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CMS Approves Joint Commission's Application for Deeming Authority

Matt Phillion, for HealthLeaders Media, December 2, 2009

The Joint Commission's hospital accreditation program has been approved for continued deeming authority by CMS through July 15, 2014.

"We are honored that CMS has renewed our deeming authority. This validates their confidence in The Joint Commission, the predominant hospital accrediting body in the U.S," says Mark G. Pelletier, RN, MS, executive director of Hospital Programs and Accreditation and Certification Services at The Joint Commission.

Deeming authority means that hospitals accredited by an organization with deeming authority can elect to be "deemed" as meeting CMS requirements based on successful accreditation by the other organization.

CMS conducted an onsite administrative review of The Joint Commission's corporate policies; procedures for training, monitoring, and evaluating its surveyors; ability to investigate and respond to complaints against accredited facilities; and the survey review and decision-making process for accreditation.

CMS compared The Joint Commission's hospital accreditation requirements and survey process with the Medicare Conditions of Participation (CoP) and survey process outlined in the State Operations Manual. The Joint Commission made a number of revisions to its Elements of Performance (EP) during the application process to meet various CoP requirements. Areas include:

  • Credentialing and privileging for telemedicine

  • Medical staff requirements

  • Documentation of medical history and physical examinations

  • Reporting drug administration errors

  • Requirements regarding infection control officers

All changes made to the EPs are listed in the Federal Register.

"I'm very pleased, not only having worked for The Joint Commission, but also having watched them excel under the new leadership," said Elizabeth Di Giacomo-Geffers, RN, MPH, CSHA, a healthcare consultant based out of Trabuco Canyon, CA. "I love the changes they're making. I'm very excited they now have deeming authority, but I had no question they wouldn't—they've always excelled in advocating what's right for the patient and the organizations they accredit."

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