Joint Commission say some standards are ambiguous

This may come as no surprise to risk managers, but the Joint Commission’s Standard Review Task Force is reporting that its first assessments show some leadership standards are ambiguous and result in "overpreparation by organizations because of uncertainty of what is required to meet the standards."

The task force is charged with reviewing nearly all Joint Commission standards to look for those that are overly burdensome, unrealistic, or ambiguous. The team will take about a year to review each chapter of accreditation standards, one by one, but the first suggestions for change already have been released.

The Leadership chapter was reviewed first, and then the task force began work on these other chapters: Improving Organization Performance, Management, and Nursing. In its initial assessment, the task force reported that "leadership standards are ambiguous, resulting in over preparation by organizations because of uncertainty of what is required to meet the standards. Currently, surveyors conduct a leadership interview and then look for evidence of clinical integration between various departments. Task force members suggest a better approach is to reverse this process — surveyors should first look for evidence of integration during visits to patient care units and staff interviews, then proceed to the leadership interview to seek an organizational response to pertinent observations."

In addition, the task force reports that many of the standards in the Improving Organization Performance chapter are related to the collection and use of data. For that reason, the task force suggests that the chapter could be condensed after pertinent unduplicated standards are integrated into the Information Management chapter. The task force also found that the material in the Management and Nursing chapters are consistent with the Leadership chapter, so relevant concepts should be integrated into the Leadership chapter and these chapters should be eliminated.

Mark Crafton, MPA, CPHU, director of state relations for the Joint Commission, says the task force is releasing its findings as soon as they finish each chapter instead of waiting for all the work to be completed. "The task force is asked to rate the standard on whether it’s relevant, how it contributes to good patient outcomes, how it contributes to patient safety and quality, the clarity, and how compliance can be consistently and effectively evaluated," he says. "We ask them to rate those issues on a one to five scale, and there also are some open ended questions like How could you best demonstrate compliance with the standard and how does that compare to what you’re currently doing?’"

Crafton says the task force probably will take about eight weeks to review each chapter. All the evaluations are expected to be completed by June.