Accreditation

Implications of the Joint Commission's 2016 deletions for staff education and training requirements for 2017

Briefings on Accreditation and Quality, April 28, 2017

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Editor’s note: This article was written by Marlene K. Strader, RN, PhD, and Elizabeth Di Giacomo-Geffers, RN, MPH, CSHA, a healthcare consultant in Trabuco Canyon, California, and a former Joint Commission surveyor.
 
In the first quarter of 2016, there were 46 topics that were required for education and training of hospital staff, including physicians, nurses, and other allied healthcare personnel. In May 2016, The Joint Commission deleted many standards and elements of performance (EP), reducing the number to around 40. A few of those deletions impact the Human Resources (HR) chapter as well as other chapters.

Some of us who have been around for many years can remember when one of the recent deletions, population-specific education and competency, was in the top 10 most-cited standards. Over the years, the population-specific requirement changed from age-specific competency whereby hospitals struggled to find objective measures to fit into the various age categories (i.e., neonate/infant, pediatric, adolescent, adult, and geriatric) to education and training specific to meet needs of the patient population served by the hospital.

There were many varieties of definitions hospitals used to describe this population. Some hospitals defined it as ICU patients, while others thought returning veterans from wars were more appropriate, or patients who did not speak English. Thus, there was no universal definition of population-specific competency. Often surveyors surveyed to the organizational definition. The Joint Commission has some well-designed criteria used to evaluate standards, and deleting a standard is done through a rigorous process.

In May 2016, the population-specific requirement was deleted. Many hospitals cheered, as it was becoming a burden to define actual requirements, and others appeared hesitant to eliminate it. Before decisions are made to ignore this requirement, there should be some considerations as to the rationale for keeping it. For example, in some hospitals, patient population on one floor may not be homogenous. A unit may primarily be set as a labor and delivery suite, but due to space or other considerations, it also admits pediatric patients. Thus, hospitals are responsible to make sure staff are trained in the care of population-specific patients.

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