Joint Commission Coming Attractions

The Joint Commission is always on the move. Changes are driven by CMS and by Joint Commission initiatives focused on improving quality and patient safety. This year several features several new or revised survey activities.

Near the top of the list is the new validation survey process being tested by CMS. The new process for all accreditation organizations (AO) includes on site validation by a CMS team during a scheduled Joint Commission or other AO. The CMS team will be the same size as the AO team. The intent is for the CMS team to evaluate the work of the AO team to determine how well the AO team evaluates compliance with the Medicare Conditions of Participation. CMS participation will be unannounced to both the accrediting organization and the hospital. Not all validation surveys will be done in this manner. The others will be done in the traditional manner with a CMS team following an accreditation team within a few days or weeks.

The Joint Commission innovations include a more integrated mobile survey technology platform (MST). The new software integration is designed to encourage surveyors to use tablet devices throughout their work day to record findings as they work rather than taking notes and transcribing them later. The integration allows the surveyors to access many more resources, such as standards interpretation guidance, seamlessly. The new capability has the potential to further improve surveyor consistency and reduce the amount of time surveyors spend preparing documentation after completing the days on site.

Several standards changes are in the works. These are best tracked through the Joint Commission web site ( The proposed changes are posted for comment and, when finalized, posted with the effective date. Checking the site frequently is the best way to maintain alignment with the changing standards during the years between surveys.

The Leading the way to Zero initiative is entering version 2.0 for 2019. The updated approach is focusing on harvesting proven practices from organizations that achieve sustainable reductions in adverse patient events. The case studies will form a resource library for all accredited organizations. This will be tied into the standards for the safety culture assessment. During surveys questions are likely during the leadership conference as well as tracers. Individual staff members are likely to be asked about their knowledge of and participation in activities designed to build a strong culture of safety.

Recently published survey data shows that hospitals surveyed over the course of most of 2018 received an average of 32.4 RFI’s. The most frequently cited issue for the EC standards was EC.02.01.01 EP 1 for ligature risk issues. This is likely to be the case during 2019 as the focus on creating ligature safe environments in dedicated behavioral health units in acute care hospitals may be even more intense.

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