The Joint Commission Announces Changes to Accreditation Process

Matt Phillion, for Briefings on the Joint Commission , January 7, 2009

The Joint Commission has announced that, as part of its application to the Centers for Medicare & Medicaid Services, a number of changes will be made to the accreditation process.

Many of the changes have resulted in added specificity to existing standards, though others have required the creation of entirely new standards. The new standards were released January 5, 2009, but went into effect January 1, 2009. These requirements will not be scored, however, until July 2009. The Joint Commission has a policy that it will, when possible, give its accredited organizations six months notice for new requirements.

Among the chapters hardest hit by these changes are the Leadership (LD) and Provision of Care, Treatment, and Services (PC) chapters. Record of Care, Treatment, and Services (RC) and Rights and Responsibilities of the Individual (RI) were also extensively reworked.

Industry experts have noted that many of the changes are requirements hospitals already meet due to existing state or other regulatory requirements. According to The Joint Commission's announcement, many of the requirements are already being met by accredited facilities.

"A lot of these [requirements] are current law or regulation," says Elizabeth Di Giacomo-Geffers, RN, MPH CNAA, BC, CSHA, a healthcare consultant in Trabuco Canyon, CA, and former Joint Commission surveyor.

Di Giacomo-Geffers suggests facilities compile a list of the changes to see which changes the hospital already complies with--a checklist of yes, no, or not applicable.

"If the answer is no, you're not complying with the requirement, then ask, what do we need to make this happen?" she says.

“Fortunately, at least on the Environment of Care side of things, the overarching take is that this is all stuff that is already (or should already be) in place by any organization that can be surveyed directly under the Conditions of Participation,” says Steve MacArthur, a consultant with The Greeley Company, a division of HCPro, Inc., Marblehead, MA.

For instance, MacArthur notes, the expansion of consideration of radiation as a hazardous material under EC.02.02.01 is a direct reflection of section 482.53(c) under the Physical Environment section of the COPs; likewise the change in language relating to equipment management and the qualifications of staff in the inspection, testing, etc. of nuclear medicine equipment.

Other experts see this as a black mark on The Joint Commission from the perspective of accredited hospitals.

"This type of action is what is going to be the catalyst in getting hospitals to go with another accrediting body," says, Dean Samet, CHSP, director of regulator compliance services at Smith Seckman Reid, Inc., based in Nashville.

The Joint Commission's official announcement can be found at The new requirements can also be downloaded.

Look for continuing coverage of this and other issues online at and

This article first appeared as a breaking news item from the editors of Briefings on The Joint Commission, a monthly newsletter from HCPro, Inc.

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