The Joint Commission has announced two changes to its Preliminary Denial of Accreditation (PDA) decision— the elimination of one rule and revision of another.
Rule PDA06, which addresses the need to have a license, certificate, or permit, has been altered.
Previously, if an organization was found to lack certain specific licenses, certificates, or permits at the time of survey, the organization would receive a PDA decision. This lack of license or permit often was the result of the organization being unaware such a permit was needed, and would result in immediately obtaining the permit (or, if the permit application is already in process, demonstrating during the survey that steps to apply for the permit have been taken).
Under this change, however, the organization lacking the license must now show an acceptable Evidence of Standard Compliance demonstrating that the organization has received the necessary license, certificate, or permit—until that time the organization receives an accreditation decision pending receipt of this documentation and receive a Requirement for Improvement (RFI).
In order to assure The Joint Commission that appropriate processes or policies are in place for obtaining this license or permit (and thus it will be renewed in the future in a timely manner), the RFI will remain in the survey report.
Additionally, the accreditation organization has completely eliminated rule PDA07, which was invoked after a healthcare organization received a Preliminary Denial decision on two consecutive full surveys.
Performance measurement update
In other Joint Commission news, the organization will introduce a new set of Perinatal Care core measures on April 1, 2010. This new set will be in addition to existing measure sets hospitals can use to fulfill ORYX reporting requirements.
The new Perinatal Care set replaces "Pregnancy and Related Conditions," which will be retired March 1, 2010. The measure set will include the following:
- Elective deliveries
- Cesarean sections
- Antenatal steroids
- Healthcare associated bloodstream infections in newborns
- Exclusive breast milk feeding
As before, the choice of measure sets is up to the hospital, depending upon appropriate services provided as well as patient population data.