Accreditation

Revisions to hospital deeming EPs

Briefings on Accreditation and Quality, December 1, 2018

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The Joint Commission (TJC) is revising five elements of performance (EP) following a CMS review of TJC’s EP Review Project for its Leadership (LD) chapter. The revisions go into effect starting January 1, and deal with the deeming in hospitals and critical access hospitals to better align with CMS' Conditions of Participation (CoP).

Some of the changes include specifying that if hospitals provide emergency services, they must comply with 42 CFR 482.55, and that operating rooms (OR) must have a communication system that can summon staff outside the OR. 

The affected EPs are:

  • EC.02.03.01, EP 9
  • LD.01.03.01, EP 13 (hospitals only)
  • LD.04.03.01, EP 2
  • LS.01.01.01, EP 1
  • PC.02.02.03, EP 7 (critical access hospitals only)
  • PC.03.01.01, EPs 5 and 8

You can read the prepublication changes to hospitals and critical access hospitals here.

Sue Dill Calloway, RN, Esq., AD, BA, BSN, MSN, JD, CPHRM, CCMSCP, is the president of Patient Safety and Healthcare Consulting and Education. She says she was most interested in the change to LD.01.03.01.

This is an excerpt from a member only article. To read the article in its entirety, please login or subscribe to Briefings on Accreditation and Quality.

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