Accreditation

Q&A: Who's running things at your facility?

Briefings on Accreditation and Quality, February 27, 2017

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Editor’s note: On January 9, 2017, Joint Commission Leadership (LD) standard LD.01.03.01, element of performance (EP) 12, for home health and hospice was expanded to apply to hospitals, critical access hospitals, and ambulatory surgical centers. The following is an edited Q&A with Victoria Fennel, PhD, RN-BC, CPHQ, director of accreditation and clinical compliance at Compass Clinical Consulting, on what leadership needs to know.

BOAQ: How big an impact will the addition of EP 12 of LD.01.03.01 make on hospitals, critical access hospitals, and ambulatory surgical centers? Will this require a significant change on their part? 
    Fennel:
This brings the Joint Commission standards more in alignment with the CMS Conditions of Participation (CoP). CMS in tag A-0043 has a section that talks about the governing body’s responsibilities. CMS clearly states that the governing body must be functioning effectively and holds the ultimate responsibility for the hospital’s compliance not only with the Governing Body chapter, but with all of the CoPs.

I think this is something that most hospitals have known, but it surprises me every once and awhile in talking with members of the board, that it appears that they’ve not heard it so plainly.
As far as how this might affect organizations, it could be that when the orientation is done for new board members, it needs to be clearly stated that, “you, as a member of the governing body of this institution, are ultimately responsible for the hospital being compliant with the CoPs—all of them, all of the time.”
And this should be done not only for new members, but also for existing members to make sure that it’s very clear.

I recall an incident a colleague shared with me while conducting orientation with the board. One of the [board] members came up to her afterward and said, “You scared me to death.”
[My colleague] said, “I’m lost. What did I say?”
The board member said, “I never knew that I was responsible for all of the quality of care that is provided in the hospital. No one has ever told me that before.”

So perhaps there needs to be some plain speaking to members of the board about what their responsibilities are, what this means, and how this will impact them as decision-makers.
That’s one of the biggest changes that we’ll see. 
 

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