Changes in TJC policies aplenty in 2011 — are you up to speed?

From new accreditation levels to an extra survey day for life safety

From new and revised standards to new levels of accreditation, this year will bring some changes in Joint Commission expectations. The new version of MS.01.01.01 now is in effect. An extra day of survey has been added to the life safety/environment of care chapter, an already problematic area for compliance. Medication reconciliation will be scored once again beginning in July 2011. Here you'll find suggestions on some of the biggest changes and how to be survey-ready and keep your policies up to date.

New accreditation categories

At the end of 2009, Hospital Peer Review reported that The Joint Commission had acknowledged confusion in the field between its Medicare condition-level follow-up survey and conditional accreditation status. Beginning in 2011, the provisional and conditional accreditation decisions have been replaced with "accredited with follow-up" and "contingent" status, respectively.

"They're important new names, which will lead to less confusion, but my read on it also is that it sounds like it is more difficult to get to contingent accreditation than it used to be to get conditional accreditation," says Kurt Patton, MS, RPh, CEO of Patton Healthcare Consulting in Glendale, AZ, and former executive director of accreditation services at The Joint Commission.

This could mean good news for hospitals, he says. "If you look at the decision rules for contingent, it says the organization fails to successfully address all requirements of the accreditation with follow-up survey, or does not have a required license or similar issue at the time of survey. So that sounds like it might be a more limited subset of issues leading to this contingent accreditation than conditional used to be," he says.

The Joint Commission was unique among accrediting bodies with its conditional accreditation, Patton says, "which was similar to academic probation." Neither CMS nor DMV has a similar category. Now, if TJC finds one or more condition-level deficiency with a condition of participation, a hospital would receive "accredited with follow-up" status. "In addition, this decision can be awarded much like the old conditional decision as a result of your onsite survey if The Joint Commission determines that you either tripped a situational decision rule, had numerous widespread findings, or if you had patterns of repeat findings," Patton says. He notes that The Joint Commission said a condition-level finding also could be given if deemed as such by onsite surveyors or as recommended by the surveyors to the central office.

The category substitutions signal another change — what will be reported on TJC's Quality Check and Quality Reports site, says Jennifer Cowel, RN, MHSA, vice president and principal, Patton Healthcare Consulting, who also previously worked for The Joint Commission for more than 17 years.

When the organization changes its accreditation decision categories, "which they don't do very often," she says, it also changes its public information policy. When it eliminated the conditional and provisional categories, it also updated this policy. "In 2004, they started releasing just for adverse decisions, the summary-level findings, adverse decisions. What's new in this new policy is that they had said that they will release standard-level findings now for accredited with follow-up, which is one of the new accreditation decisions, which makes that an adverse decision," she says.

"I guess what is notable about it is that, for you or I to receive an accreditation decision of 'accredited with follow-up,' we need only have one condition-level finding, to make my whole program 'accredited with follow-up.' And, the condition-level findings, as you know, are the CMS condition-level findings, which are slightly subjective," Cowel says. Now, every facility with a condition-level finding not only receives a follow-up survey but all of its RFIs are published on Quality Check as standard-level findings.

Because of this — more risk of public disclosure — she advises hospitals to take full advantage of the clarification period after they receive their initial report of findings. She says organizations are sometimes able to take a condition-level finding and communicate through the clarification process why that particular finding would be more appropriately scored as a standards-level finding or somewhere else so as not to trigger condition-level deficiency.

Add a day for life safety

Beginning January 2011, you can add one full day to your survey to account for an extra day to Joint Commission's life safety code survey. And since four of five of the top-cited standards in 2010 were among the environment of care and life safety chapters, Cowel says this is going to be a noticeable change for hospitals. "Now that you can have an extra day of observation by those surveyors, you would expect to see the number of RFIs continue to increase."

Why the changes? CMS surveys a certain percentage of hospitals to follow up after a Joint Commission survey. Each year the agency publishes those findings, also known as its validation report. It also publishes the discrepancy rates between its findings and TJC findings. "The area of the greatest discrepancy was the life safety code," says Cowel. TJC's response was adding a day to that part of the survey and subsequently, Cowel says, to offer hospitals more consultation and education in an area obviously ripe for more information.

One thing she notes is that many areas that are consistently cited are things you don't need an engineering degree to spot. "Certainly, when it comes to generator testing or testing of medical gas, those are things that it takes a specialist to find. But many of the frequent findings are things you or I could see if we were on the unit.

"What hospitals really should get better at doing is training the clinical staff and the nursing staff who are on the unit to be more observant of things like blocked hallways, clearances in front of emergency exit doors, exit lights that are burnt out, doors to secured rooms," she says.

With the latter, many hospitals use tape or other workarounds to prohibit the door from closing. "Those things get scored when the surveyor comes out, but those things are also things that hospitals could put on a punch list and start training their clinical staff to see them and to understand why it's important not to tape open or tape a lock — it becomes a fire hazard."

Medication reconciliation up for scoring

Beginning July 1, 2011, TJC will once again score hospitals on medication reconciliation, now within National Patient Safety Goal 3 on improving the safety of medications.

Patton outlines each EP:

  • EP 1, he says, requires a medication list for both inpatient and outpatient locations. If a patient cannot remember, staff must make a "good-faith effort" to document all medications the patient currently is taking.
  • EP 2 "appears to open up some flexibility for the organization to define the type of medication information you will collect in different settings and circumstances," Patton says.
  • EP 3 recalls the "difficult requirement" to compare and resolve any subsequent discrepancies between what the patient was taking upon admission and what was ordered for the patient while in-house. "When last we saw this requirement it meant you had to explain or document if a chronic medication is not going to be continued in the hospital. Documentation of decision making is easier if the physician uses the continue/discontinue columns on a medication reconciliation worksheet or selects or deselects each medication on a CPOE [computerized physician order entry] list," Patton says.
  • EP 4 states that upon discharge the hospital should provide the patient with a written list of medications he or she should be taking.
  • EP 5 requires that hospitals discuss with patients the importance of managing their medications.
  • "What is absent from this new safety goal is the former requirement to conduct medication reconciliation upon transfer in level of care," Patton says. Both he and Cowel suggest health care facilities not discontinue reconciliation at transfer, especially if there are already processes in place. The Joint Commission, Cowel says, was "going for more consensus at the time, what's really important, and 'Let's start with that.' But, again, if a hospital is already doing reconciliation at transfer of level of care, don't stop."

MS.01.01.01 to be scored — again

Beginning March 31, 2011, the new MS.01.01.01 standard will be up for scoring. Now that the final version is here, Cowel says hospitals should print out the entire standard and have someone from accreditation and someone from the medical staff go through each element of performance (25 new ones are included) and check that the bylaws include each requirement. Patton suggests reviewing the frequently asked question section on The Joint Commission's website.

[For more information, contact:
Jennifer Cowel, RN, MHSA, vice president and principal, Patton Healthcare Consulting. Phone: (630) 664-8401. E-mail:]