Accreditation

Revisions deeming EPs

Accreditation Insider, October 16, 2018

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Starting January 1, five revisions to The Joint Commission’s Elements of Performance (EP) will go into effect. The revisions deal with the deeming in hospitals and critical access hospitals. The changes are a result of CMS’ review of The Joint Commission’s EP Review Project for the Leadership (LD) chapter.

Some of the changes include specifying that if hospitals provide emergency services that they comply with 42 CFR 482.55 and  that operating rooms have available a communications 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 hospital and critical access hospitals here. 



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