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New Joint Commission Policy Affects Survey Options for Hospitals

Matt Phillion, for HealthLeaders Media, September 8, 2009

The Joint Commission has announced a new policy for accredited hospitals seeking deemed status. This new policy will align awarding of Joint Commission accreditation with Centers for Medicare & Medicaid Services (CMS) Certification Numbers (CCN). Approximately 300 hospitals will be directly affected by this change.

CCNs, formerly known as "Medicare Provider Numbers," are provided by CMS to hospitals or groups of facilities based on specific factors or characteristics. This number has, in the past, had no effect on whether or not the hospital can be accredited by The Joint Commission. Typically, the CCN does not have an effect on Joint Commission accreditation status. Hospitals covered under the Department of Veteran Affairs are not affected as well.

What does this mean? Hospitals that are part of a system affected by this new policy will now have two survey options:

  • Individual hospitals in the system will have a survey of shared functions between facilities, and then individual hospital surveys will follow concurrently

Or

  • Each hospital in the system will have completely independent surveys

Typically, CCNs are shared throughout a hospital system, but in some cases individual hospitals within a system may receive their own CCNs.

The Joint Commission will contact each affected hospital individually on this matter.

Staffing effectiveness update

In other Joint Commission news, a second field review will take place for the revised staffing effectiveness requirements, according to an official statement by The Joint Commission. These requirements, applicable to both hospitals and long-term care facilities, have been refined following feedback during the first field review period.

The Joint Commission will be accepting feedback on the most recent round of changes until October 7, 2009.


Matt Phillion, CSHA, is senior managing editor of Briefings on The Joint Commission and senior editorial advisor for the Association for Healthcare Accreditation Professionals (AHAP).

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