Quality & Patient Safety

Joint Commission Changes to Align with CMS

Accreditation Monthly, March 11, 2009

On January 6, The Joint Commission announced the addition of 165 new elements of performance (EP) for hospitals that use Joint Commission accreditation for deemed status purposes. The intent is to more closely align the standards with CMS' Conditions of Participation. The majority of the new EPs have little effect on existing processes. Approximately 35% will require a change in practice. I will mention a few select standards that do have an impact and what that means to your organization. I recommend that you review all 165 EPs to see how they affect your organization.

HR.01.02.01, EP 19: If blood transfusions and intravenous medications are administered by staff other than doctors of medicine or osteopathy, the staff members have special training for this duty.
Impact: Maintain documentation of training and competencies for staff members administering blood and IV medications.

MS.13.01.01, EP 1: All licensed independent practitioners who are responsible for the patient's care, treatment and services via telemedicine link are credentialed and privileged to do so at the originating site according to standards MS.06.01.03 through MS.06.01.16.
Impact: This now requires Nighthawk and similar contractors to be fully credentialed by the hospital.

NR.02.03.01, EP 11: A registered nurse supervises and evaluates the nursing care of each patient.
Impact: The RN scope of practice should include the oversight of patients assigned to LPNs and other non-RN nursing staff. Nursing staff should be able to articulate this practice.

PC.03.01.07, EP 7: A post-anesthesia evaluation is completed and documented by an individual qualified to administer anesthesia no later than 48 hours after surgery or a procedure requiring anesthesia services.
Impact: It is unclear how The Joint Commission will interpret this, because unlike CMS, The Joint Commission has an "expansive" definition of anesthesia services. At a minimum, there should be a post-anesthesia note for all inpatient post-op patients receiving anesthesia.

PC.03.05.03, EP 2: The use of restraint or seclusion is in accordance with a written modification to the patient's plan of care.
Impact: This requirement has not existed in Joint Commission requirements.

PC.03.05.05, EP 1: A physician or other authorized LIP primarily responsible for the care of the patient's ongoing care orders the use of restraint or seclusion in accordance with hospital policy and law and regulation.
Impact: This eliminates the "12-hour rule" to get an order for medical restraints. The following is from the CMS interpretive guidelines:… in (these) emergency application situations, the order must be obtained either during the emergency application of the restraint or seclusion, or immediately (within a few minutes) after the restraint or seclusion has been applied. The failure to immediately obtain an order is viewed as the application of restraint or seclusion without an order.

PC.03.05.05, EP 3: The attending physician is consulted as soon as possible, in accordance with hospital policy, if he or she did not order the restraint or seclusion.
Impact: This should be part of your hospital policy and the notification documented in the medical record.

PC.03.05.09, EP 2: Physicians and other LIPs authorized to order restraint or seclusion (through hospital policy in accordance with law and regulation) have working knowledge of the hospital policy regarding the use of restraint and seclusion.
Impact: This imposes a training burden for the general medical staff.

RC.01.01.01, EP 19: All entries in the medical record, including all orders, are timed.
Impact: The Joint Commission, until now, only required medical record entries to be dated.

RC.02.03.07, EP 4: Verbal orders are authenticated within the timeframe specified by law and regulation. If there is no State law that designates a specific timeframe, the verbal orders are authenticated within 48 hours.
Impact: New for The Joint Commission. (Although not stipulated, if the authentication is not dated and timed, it is not possible to determine whether the 48-hour time frame was met.)

RC.02.03.07, EP 6: Documentation of verbal orders includes the time the verbal order was received.
Impact: New for the Joint Commission

EP 1:
The hospital establishes a complaint and grievance resolution process.

EP 2: The hospital informs the patient and his or her family about the complaint and grievance resolution process.

EP 4: The hospital reviews and, when possible, resolves complaints and grievances from the patient and his or her family.

EP 6: The hospital acknowledges receipt of a complaint or grievance that the hospital recognizes as significant and notifies the patient of follow-up to the complaint or grievance.

EP 7: The hospital provides the patient with the phone number and address needed to file a complaint or grievance with the relevant state authority. (See also MS.09.01.01, EP 1)

EP 10: The hospital allows the patient to voice complaints or grievances and recommend changes freely without being subject to coercion, discrimination, reprisal, or unreasonable interruption of care.

EP 17: The governing body reviews and resolves grievances unless it delegates this responsibility, in writing, to a grievance committee.

EP 18: In its resolution of grievances, the hospital provides the individual with a written notice of its decision, which contains the following:

  • The name of the hospital contact person
  • The steps taken on behalf of the individual to investigate the grievance
  • The results of the process
  • The date of completion of the grievance process

EP 19: The process for resolving grievances includes a mechanism for timely referral of patient concerns regarding quality of care or premature discharge to the Quality Improvement Organization (QIO).

EP 20: The governing body approves the complaint and grievance resolution process.
Impact:These standards are new to the Joint Commission but not CMS. The hospital must now have a procedure, approved by and overseen by the governing body. It will be necessary to track the steps of the process.

Most hospitals already follow these new Joint Commission standards if they receive Medicare and Medicaid reimbursement for services. However, this is a good time to review current policies and practice to be sure the standards are met.

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