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The Joint Commission issues revised 2009 accreditation requirements
Biggest changes concern restraint and seclusion
Less than three months after releasing an addendum to its 2009 accreditation standards, The Joint Commission is telling hospitals to throw it out and refer instead to a newly revised edition.
The revisions, released March 26, were prompted by The Joint Commission's work with the Centers for Medicare & Medicaid Services (CMS), which will determine by the end of the year whether TJC will continue to enjoy deeming authority.
In a conference call announcing the revisions, Robert Wise, MD, vice president of The Joint Commission's division of standards and survey methods, said the biggest group of changes concerns the issue of restraint and seclusion. "[W]e decided to take our existing restraint and seclusion standards and remove those and replace them in a wholesale fashion with those from CMS. The reason for that is if you look at your current restraint and seclusion standards, they are driven specifically by the purpose of the restraint and seclusion — was it a medical reason or was it a psychiatric reason? — and this was in fact the way CMS set it up a few years ago.
"CMS has rethought this," Wise added, "and they have moved to a behavioral-based decision on restraint and seclusion regardless of the etiology of behavior. When we looked at the two strategies, we realized they were incompatible, and even though we believe we have good EPs [elements of performance] in restraint and seclusion, rather than mix apples and oranges we have decided to replace them with the new CMS ones. As time goes on, we will see whether there were any important criteria that were left out."
Standards, EPs decrease from 165 to 87
The Joint Commission, with guidance from CMS, evaluated the 165 standards and EPs released in January and deleted 78 that CMS believed were already included in TJC's standards and survey processes, reducing the total number of new or revised standards and EPs to 87 in the latest version of its manual. "Of the 87, they fell into two categories: About 37 include new expectations, and the others have already been handled but not to this level of specificity," Wise said.
In its evaluation, Wise said The Joint Commission used these guiding principles:
"The other [standards or elements of performance] that are new relate to an updating of the history and physical and some requirements around pre- and post-anesthesia. That represents about another 10," Wise said. "The remaining are the ones that we believe we've already been handling, but now there's greater specificity, and those are the ones related to blood infusion and the handling of infected blood."
"I don't think [the changes] will be big show-stoppers for organizations," says Kurt Patton, CEO of Patton Healthcare Consulting in Glendale, AZ, and former executive director of accreditation services at The Joint Commission. "They'll have to do some fine tuning; it's by no means like trying to implement med rec or the Universal Protocol."
He applauds the changes, in general for bringing CMS and TJC in closer alignment. Now that the approaches of both organizations "are one in the same... I think hospitals will actually embrace that. Because previously they were trying to deal with both, so it sort of makes things easier for the hospital."
Pointing to the teleconference The Joint Commission held to discuss the new document, Patton says, "I found it very curious that they added in some new elements of performance for all hospitals, including those that are not participating in Medicare." He adds "that's just curious why they need to rush that if it applies to everybody and there isn't pressure from CMS."
Of the changes, Patton highlights one requiring that controlled substance losses be reported to the CEO of a hospital. "That's sort of a change for hospitals," he says, adding that if the missing element was a truckload of substances, the CEO would definitely know about it. But "if one syringe is missing, it's probably unlikely that there's a reporting process to get that information in front of the CEO. So hospitals are going to have to design some sort of an aggregation process where they can tally that, and quarterly or every six months, get that information to the CEO of the organization."
Another change he notes is where the requirements for an H&P are placed. "The medical staff bylaws have to contain the requirements for what constitutes a history and physical. And I think many hospitals have the requirements, but they're spelled out in rules and regulations or policies or procedures of the medical staff as opposed to being in the bylaws." Why the change? Patton says "there's no real logic to it" other than the fact that when the CoPs were written in 1965, the term medical staff bylaws was used, not rules, regulations, policies, or procedures.
One "nice" change he points to, on page 12 of the hospital deeming application, centers on what constitutes a good H&P. In previous versions, he says, using the term "admission" in these EPs was confusing. "In this document, it's clear that's it's either admission for an inpatient or registration for admission as an outpatient." Generally, he thinks the elements relating to H&Ps are much clearer than before.
"The other thing that's developed that will be important for hospitals is the post-anesthesia assessment within 48 hours. That really is a new expectation from The Joint Commission. Traditionally, they've had some sort of a post-anesthesia assessment as the patients move from the OR over to the post-anesthesia care unit. And this really is requiring evaluation after the patient is totally recovered from anesthesia."
Hospitals, he says, will have to work on this, but he adds that The Joint Commission probably will have to spell out this issue as part of its education programs. "They'll probably have to make it clear that they're not talking about the evaluation the anesthesiologist does coming out of the OR. It's after recovery from anesthesia."
Another element hospitals will have to work on, he says, relates to patient rights and the complaints resolution process. Hospitals should "make sure that their policy includes informing patients that they can complain to the quality improvement organization in the state, making sure they have a ledger that has a timely response and all complaints and grievances are submitted. That might not have been well established at hospitals," Patton says.
Echoing Patton's assertion that the changes are marked mostly by nuanced differences, Sandy Burke, RN, MPH, LHRM, consultant with The Mihalik Group, says, "I don't note significant changes. There is a new requirement for a policy on how the organization will deal with potentially contaminated blood. The restraint requirements are actually a little less restrictive."
Patton says he would not necessarily characterize the requirements as less restrictive, but rather "clearer and less confusing." He says the most significant change "was the elimination of special restraint standards for psychiatric reasons in a behavioral health setting. The simplification is now two choices: restraint for medical reasons and restraint for psychiatric reasons, regardless of location." In the old standards, there were requirements for medical restraint, psychiatric restraint in a medical unit, and psychiatric restraint in behavioral health settings. In addition, PC.03.02.01 to PC.03.03.31 have been removed, Patton says.
Burke says the main difference she sees is in "the requirement for a licensed independent practitioner conducting the face to face. TJC did require that within four hours of the original order and then at least at every other order cycle. I am still cautioning people to leave it the old way until we actually get the manual update that shows those standards are deleted. The March update did not show PC.03.03.15 EP 1 or PC.03.03.19 EP 3 deleted."
As far as the alignment of CMS and TJC measures, Burke notes that the surveys each organization conducts are still quite different. "In states that have an active health department that conducts visits on behalf of CMS, organizations know the CoPs. In states the state does not visit (and yes, there are many), the organizations do not know the regulations."
So the learning curve will vary by institution.
Darla Farrell, RN, BS, MBA, FACHE, CHCQM, FAIHQ, CPHQ, president and CEO of Quality Management Consultation Services in Diamond Bar, CA, also works in the compliance department of Kindred Healthcare. What concerns her "is the PPR. The PPR is the periodic performance report that [hospitals] have to prepare and send to The Joint Commission to let TJC know where the hospital stands with standards that require measurement or standards that they identified need improvement," she says.
The Joint Commission won't be using the 87 new standards to determine accreditation until July 1, but what about hospitals that have to submit a PPR, say June 30, Farrell asks. "They haven't been measuring [the new standards] yet. Many are planning to do a small side by side to show that they are addressing the new standards. Because in actuality, July 1, TJC will begin surveying against them. So one day TJC is not scoring the standards in the accreditation process and the next day they are."
After July 1, hospitals will have to show they have a plan in place for monitoring these 87 standards, and "it would behoove them to know and understand the standards, show they have indeed monitored and addressed them, and implemented a plan if they weren't in compliance."
She adds that the automated PPR won't be ready until the end of the year, and she expects the standards to keep evolving until that point as well. "Why not wait until August when [The Joint Commission does] their new manual and put the standards into effect Jan. 1 like they usually do?" she asks. Now hospitals will have to put the standards into the PPR manually, as The Joint Commission has no provision for them yet. "That's going to be a burden," she adds.
"I don't recommend to my clients that they submit their PPR," says Burke. "My reasoning for this is that I don't believe organizations are hard enough on themselves... I believe the spirit of the PPR should be conducted to be a thorough and honest evaluation. The organization needs to conduct a mock survey. Evaluation should be done the same way that TJC will evaluate. You cannot conduct a PPR sitting in a room with policies."
Farrell concurs with both Patton and Burke that the changes don't really represent anything new, and in areas such as restraints and seclusion, the changes make it "a little more open and less stringent than what The Joint Commission had before."
The Joint Commission also released the scoring impact of the new standards, which "will assist the field to begin their improvement and compliance plans, in addition to being able to demonstrate positive outcomes when TJC begins scoring the standards after July 1," says Farrell.