Joint Commission forms a task force

To review standards, compliance requirements

The Joint Commission on Accreditation of Healthcare Organizations is taking a hard look at the relevance of its hospital standards and compliance requirements. An 18-member task force will pinpoint which accreditation standards are most relevant to the safety and quality of patient care with a goal of eliminating or modifying those that don’t contribute to good patient outcomes. In addition, the task force will identify redundant and overly burdensome documentation requirements for potential streamlining, and identify areas needing additional focus. Standards relating directly to Medicare Conditions of Participation (COPs) for hospitals will receive special consideration.

Assembling list of possible additions

While the task force will identify potential additions, deletions or modifications to this subset of standards, the Joint Commission recognizes that these standards are the "law of the land" and are required by the government. The task force’s ideas, however, may serve as the basis for Joint Commission discussions with the Health Care Financing Administration when it considers changing the COPs.

Led by Ken Shull of the South Carolina Hospital Association in West Columbia, the task force will include quality directors, medical records directors, nurses, physicians, engineers, risk managers, and other hospital leaders who have first-hand experience with Joint Commission accreditation standards and surveys. Doctor groups will also be enlisted to specifically review medical staff standards. Shull and his colleagues will consider the following when reviewing standards and regulations:

  • Continuing relevance in promoting patient safety or high quality care.
  • Redundancy with other external quality requirements.
  • Applicability of standards to hospital care.
  • Likelihood that compliance will be consistently evaluated.
  • Extent to which compliance can actually be measured.
  • Linkage to patient outcomes.

The Joint Commission also will ask the task force to identify common misconceptions and misinformation regarding requirements for demonstrating standards compliance. These fallacies often result in unnecessary costs for hospitals in both staff time and resources. The standard review is part of a continuing effort by the Joint Commission to change the accreditation process into something that is more continuous, consultative, and focused on performance improvement.