Joint Commission Releases New Scoring Information

Matt Phillion , April 13, 2009

Accreditation professionals across the country have known for months that revisions to Joint Commission standards will go into effect on July 1. One unanswered question has stood out among others, however: how will hospitals be scored on the various changes The Joint Commission has announced?

Now we have an answer. The Joint Commission has released scoring guidelines for the current list of revisions the accrediting body is expected to implement on July 1.

Four days after The Joint Commission's 2009 standards went into effect, the organization released an update intended to help bring existing standards in line with the Centers for Medicare & Medicaid Services Conditions of Participation. Since that time, the field has seen the release of a second update with proposed revisions to the standards, cutting the number of revisions in half.

The Joint Commission is currently undergoing the application process for continued deeming authority with CMS. These latest revisions came about following discussions with CMS where certain new or revised standards were found to be covered elsewhere in the standards and thus unneeded.

"Discussions with CMS are a routine part of the deeming application process," says Elizabeth Zhani, media relations specialist with The Joint Commission.

Can we expect any further changes before the July 1 implementation date?

"The Joint Commission submitted its deeming application to CMS in March," says Zhani. "Throughout the deeming application process The Joint Commission will continue to work with CMS. It is difficult to predict if there will be additional changes based on these discussions."

Experts in the field note that this latest round of information will help to identify which standards will have the greater bearing on potential adverse decisions following a Joint Commission survey.

"It looks like they've made some of the more frequently cited issues—Histories and Physicals, timing and dating of orders, authentication of verbal orders—non-direct impact level Elements of Performance, which technically means these should not roll up into any adverse decision Requirements for Improvement (RFI) for the hospital," says Lisa Eddy, RN, CPQH, CSHA, senior consultant with The Greeley Company, a division of HCPro, Inc.

Eddy notes that the standard listing what The Joint Commission requires included in the medical record is a direct impact standard (Level 3)—which means if, for example, allergies are not listed in the medical record the hospital can be hit with a Level 3 RFI. Pre- and post-anesthesia assessment and evaluation suffer a similar challenge, Level 3 direct impact standards which would count towards the total number of RFIs, which could lead towards an adverse action directed at the hospital's accreditation.

"The restraint Elements of Performance dealing with use of restraint only for appropriate reasons have the direct Level 3 impact category attached, as does ordering of restraints," says Eddy. "However, many other [standards] that tend to get facilities into trouble do not."

Crosswalks between the various rounds of revisions and additional supporting documents can be found on Joint Commission Web site.

Matt Phillion, CSHA, is senior managing editor of Briefings on The Joint Commission and senior editorial advisor for the Association for Healthcare Accreditation Professionals. E-mail him at

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