Latest news and topics from The Joint Commission

1. Were You Aware? March 2013
 That you have input into proposed changes to TJC accreditation requirements and
CMS Conditions of Participation? It’s important to have input into requirements
that will affect our healthcare organizations!
o CMS is receiving comments until April 8, 2013 on proposed changes to the
COPs. These proposed revisions are designed to reduce unnecessary regulatory
burden on hospitals.
o TJC currently has several proposed revisions for certification programs posted on
its “field review” page. Keep an eye on that page and the “pre-publication” pages
for new information.
 There is increasing attention to detail by TJC when reviewing Evidence of
Standards Compliance (ESC) from healthcare organizations. Some tips to keep in
mind when developing ESC after survey:
o ESC must include review (and revision or creation as appropriate) of any policies,
procedures, forms, medical staff documents, etc. related to the Requirement for
Improvement (RFI).
o There must be one individual, identified by title, who is responsible for
implementation of, and ongoing compliance with, the ESC.
o A description of how staff job responsibilities were modified, how staff were
educated to the new process and how they will be held accountable for
compliance going forward needs to be provided.
o All activities identified in the ESC must be complete and implemented by the
time the ESC is submitted (either at 45 or 60 days).
o A description of how compliance will be sustained over time must be included.
o Evaluation methods for measures of success (MOS) must include the process for
random sampling, how the audits will be conducted and what the reporting
mechanism (i.e., committee hierarchy) will be for monitoring results.
 Infection control continues to be a focus this year for both TJC and CMS surveys.
Some key areas:
o Appropriate use of Cidex in procedural areas
o Safe handling and storage of food and medications
o All components of cleaning, disinfection and sterilization
o Temperature, humidity and air exchanges in applicable areas of the organization
o Risk analysis, development, implementation and evaluation of the Infection
Control Program
Participate in our May 20, 2013 webinar on “Tracing for Infection Control” to learn
strategies for evaluating your infection control processes