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The Joint Commission announces a simplified scoring process

Credentialing Resource Center Connection, August 14, 2008

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Anne Roberts, CPMSM, CPCS, is the director of medical affairs at Children's Medical Center of Dallas, where she oversees the medical administration, graduate medical education, and medical staff services departments.

Dear credentialing colleague:

The Joint Commission announced that a new, simplified scoring and decision process for surveys will go into effect on January 1, 2009, according to the August issue of The Joint Commission Perspectives newsletter. The new scoring process grew out of the organization’s Standards Improvement Initiative (SII), which began in 2006. Specifically, it is a culmination of an intensive review and redesign focused on making the standards easier to understand and based on the premise that some requirements are more critical than others.

According to Perspectives, the initiative includes a phased approach for implementation and the initiative focused on categorizing elements of performance (EP) based on their direct impact on care. The initiative also focused on revising and reorganizing current standards and EPs to make them clearer, eliminate redundancies, and create a simpler and more logical order. 

In 2009, The Joint Commission will continue to evaluate specific measurable requirements of each EP on a three-point scale, as follows:

• 0 = Insufficient Compliance
• 1 = Partial Compliance
• 2 = Satisfactory Compliance

Some of the key changes that will affect organizations include the following:

• The more critical the issue, the shorter the time that an organization has to resolve any noncompliant standards related to the issue which they were cited for
       - Organizations will be required to submit Evidence of Standards Compliance (ESC) within 45 days for EP’s that they were cited if the EP has a ‘direct impact’ on patient care
       - Organizations will be required to submit an ESC within 60 days for EP’s that they were cited if the EP has an “indirect impact” on patient care
• Compliance problems previously cited as supplemental findings will be cited as requirements for improvement (RFI’s)
• EPs will be divided into two scoring categories:  A and C. Scoring category B will be eliminated.
       - Category A EPs are typically related to structural requirements (for example, policies and procedures), that either exist or do not exist, and are scored either a ‘0’ or a ‘2’; Category A EPs may address an issue that must be fully compliant even though it focuses on performance or outcome (i.e National Patient Safety Goals).
       - Category C EPs:  Scored based on the number of times an organization does not meet a particular EP (numerator/denominator). They are scored 2 if there are one or no occurrences of noncompliance; they are scored 1 if there are two occurrences of noncompliance; and they are scored 0 if there are three or more occurrences of noncompliance.

To obtain more information regarding the new SII, including a video clip summarizing the initiative, an outline of each chapter and a 2008-2009 standards crosswalk, visit The Joint Commission Web site at:
 http://www.jointcommission.org/Standards/SII/default.htm

As the role of MSP continues to expand and become more comprehensive, it is important for hospital-based MSPs to be familiar with all chapters of The Joint Commission’s Comprehensive Accreditation Manual for Hospitals. Several of the chapters have significant influence on the medical staff office, including, but not limited to, the leadership chapter, the new waived-testing chapter, the human resources (specifically the credentialing of non-employees & APN/PA requirements) chapter as well as the new transplant safety chapter.

Ensuring that you, as an MSP, are familiar and able to speak to the new scoring process and all standards related to the medical staff will not only benefit you professionally, but will also benefit your organization.

Remember, clear, effective communication is the key to success!

That’s all for this week.

All the best,

Anne Roberts, CPMSM, CPCS

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