Updates to JCAHO's Comprehensive Accreditation Manual for Hospitals

Accreditation Monthly, July 9, 2005

Dear Colleague,

For those hospitals keeping score, there are no fewer than 13 substantive additional requirements or edits contained in JCAHO's Comprehensive Accreditation Manual for Hospitals (CAMH) Update #2 released in May, 2005.

Recent issues of JCAHO Perspectives have included announcements of numerous substantive changes that, taken together, make it all the more challenging to achieve continuous survey readiness. Since many of the changes are effective immediately or by July 1, 2005, it has become increasingly confusing for hospitals to keep up.

I'd like to address a few of these updates:

First, in the March 2005 Perspectives JCAHO announced the addition of EP 46 and 47 to HR.1.20 for hospitals and critical access hospitals requiring primary source verification of licensure, certification or registration for all clinical licensed staff effective July 1, 2005.

Footnotes following the EPs are highly prescriptive and describe how the new requirement is applicable to CVOs and staffing agencies. Predictably these changes were included in the CAHM Update #2 released in May. However, the May issue of Perspectives announced that the implementation date for the changes is postponed to January 1, 2006. So my advice is to begin to study changes needed to comply with the EPs while awaiting further clarification in an upcoming issue of Perspectives.

Second, the June issue of Perspectives confirms that beginning with full surveys conducted July 1, 2005 organizations "should" provide the survey team the Measure of Success (MOS) data used to measure the effectiveness of any Elements of Performance (EPs) found noncompliant in the organization's first Periodic Performance Report (PPR) completed sometime between January 1, 2004 and July 1, 2005.

This appears to be the JCAHO's expectation regardless of whether the organization completed the full PPR or one of the alternative options. Although they chose to use the helping verb "should" in this instance, I suspect organizations should assume they intended to use the helping verb "shall" or "must."

Finally, the June issue of Perspectives clarified Medication Management standard MM.4.10 (review of medication orders by pharmacy) with respect to how oral contrast media used in imaging exams is to be addressed. In April 2004 and again in the January 2005 issue of the journal "Hospital Pharmacy" Darryl S. Rich, Pharm. D., MBA, and an employee of JCAHO wrote a column titled "Ask the Joint Commission" in which he answers "frequently asked questions" including one on whether, since oral contrast media is now considered a medication, will this require a pharmacist to review all orders for oral contrast media prior to it being administered.

His answers sowed some confusion in the field and now the Standards Interpretation Group at JCAHO has weighed in officially to say that the review by pharmacy is required only if pharmacy receives the order and dispenses the oral contrast media. Otherwise, a qualified health care professional (e.g., staff in imaging) operating under a medical staff approved guideline or protocol may review the contrast media for appropriateness.

So while Dr. Rich's FAQs published periodically in Hospital Pharmacy are often very helpful in providing insight into the intent of the medication management standards and offer implementation tips, his column should not be confused with the official JCAHO position on any particular issue.


John Rosing
Practice Director of Accreditation
and Regulatory Compliance
The Greeley Company

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