Accreditation

Joint Commission Leadership standard now aligns with CMS

Accreditation Insider, December 27, 2016

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On January 9, 2017, Joint Commission Leadership (LD) standard 01.03.01, element of performance (EP) 12, for home health and hospice will be expanded to apply to hospitals, critical access hospitals, and ambulatory surgical centers.

The standard requires that the leadership/governance of a healthcare facility is the one ultimately held accountable for the facility’s safety, quality, and compliance. Previously, however, the Joint Commission standard didn’t have an EP that referred to leadership’s legal responsibility. In addition, the EPs varied between different types of facilities on what to do if leadership failed to meet its responsibilities.
The Joint Commission announced it was expanding EP 12 to the additional settings as a way to standardize compliance across all accredited facilities and to come into alignment with CMS’ Conditions of Participation.

Hard copy versions of accreditation manuals published after November 2016 will include the new EP, and the change will be made to the accreditor’s E-dition in January. For more information, contact Laura Smith, Joint Commission project director, at lsmith@jointcommission.org.

 



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