ED Accreditation Update

Joint Commission to use new scoring process

A new simplified scoring process that The Joint Commission will use for all accreditation and certification programs as of Jan. 1, 2009, was created in conjunction with The Joint Commission's Standards Improvement Initiative (SII). The goals of SII are to:

  • enhance clarity and objectivity of standards and EPs (Elements of Performance);
  • tailor standards language to the characteristics of each program;
  • refine scoring and decision processes;
  • enhance manuals for ease of use.

"We wanted make sure our new scoring model would work in parallel with SII," explains Kevin Hickey, MSA, director of survey scheduling and support. "Since [standards] language was being modified, we elected to use the same time period to [revise the scoring process] from top to bottom."

Scoring changes being made for 2009 include:

  • Bulleted lists of expectations have been minimized.
  • Compliance problems previously cited as supplemental findings will be cited as requirements for improvement.
  • EPs will be divided into two scoring categories: A and C. Scoring Category B will be eliminated.

— Category A EPs: Usually related to structural requirements (for example, policies or plans) that exist or do not exist, and are scored 0 or 2. They also may be related to a Medicare Condition of Participation (CoP) that must always be fully compliant.

— Category C EPs: Scored based on the number of times an organization does not meet a particular EP. They are scored 2 if there are one or no occurrences of noncompliance; they are scored 1 if there are two occurrences of noncompliance; and they are scored 0 if there are three or more occurrences of noncompliance.

  • All findings of less-than-full compliance require resolution through an Evidence of Standards Compliance (ESC) submission. The timeline for completing the ESC submission will depend on the criticality of findings and immediacy of risk.
  • If one or more Direct Impact (on quality of care and patient safety) EPs under a standard are found to be partially or insufficiently compliant, then all EPs under that standard that have been found to be partially or insufficiently compliant must be addressed in an ESC submission within 45 days.
  • If no Direct Impact EPs under a standard are found to be partially or insufficiently compliant, then all EPs under that standard that have been found to be partially or insufficiently compliant must be addressed in an ESC submission within 60 days.

The three-point EP scoring scale will be retained, in which a 2 equals satisfactory compliance, a 1 equals partial compliance, and a zero equals insufficient compliance.