July 1 Scoring Changes Mainly Affect Joint Commission Safety Standards

HealthLeaders Media Staff, June 4, 2009

Effective July 1, The Joint Commission will roll out a series of scoring changes to 45 elements of performance (EP) within its accreditation standards.

The majority of the amendments adjust the environment of care (EC) and life safety (LS) standards, which generally fall under the responsibilities of your safety officers and facility directors.

Other affected standards include:

  • Leadership
  • Medication management
  • Provision of care
  • Performance improvement
  • Rights and responsibilities

The Joint Commission reviewed standards scoring earlier this spring, said George Mills, FASHE, CHFM, CEM, senior engineer for the accreditor. Mills spoke during a Joint Commission Resources audio conference June 3.

Some criticality levels altered
The changes—which were published in the June issue of Joint Commission Perspectives—center on The Joint Commission's criticality scoring levels and scoring categories. Here's a quick rundown of criticality levels by number:

  • 1—Immediate threat to life, which is self-explanatory and can lead to preliminary denial of accreditation. No single EP in a standard has an immediate threat designation; instead, the status results from a combination of serious problems.
  • 2—Situational decisions rules, which are based on specific situations during a survey and can result in preliminary denial of accreditation or conditional accreditation.
  • 3—Direct impact requirements, which are likely to create immediate risks to patient safety. The risks stem from a lack of processes to offset the threats.
  • 4—Indirect impact requirements, which center on planning and evaluation of processes. Failure to resolve concerns with these processes may increase risks to patient safety over time.

Eight EPs within the EC and LS standards have been upgraded from indirect to direct impact requirements. "Occasionally we felt things were a greater risk, so we changed [them] to direct impact," Mills said.

For example, standard EC.02.03.05, EP 11 requires hospitals to test their fire pumps every 12 months and will be a new direct impact requirement as of July 1. Joint Commission officials felt this was an "extremely important test" that warranted a higher criticality ranking, Mills said. In fact, fire pump failures are often noted by Joint Commission officials as situations that would trigger criticality 1, so the connection to pump testing is clear.

From point C to point A
Other upcoming changes affect the scoring categories. These categories include either an A or C designation:

  • "A" EPs are for requirements in which a hospital either has a policy or plan, or doesn't have a policy or plan
  • "C" EPs are for requirements whose compliance is judged by the number of times a hospital does or doesn't meet a provision

For example, standard LS.02.01.34, EP 3, requires hospitals to put a fire alarm annunciator panel in a location approved by the local fire department. This EP went from a C score to an A because typically there is only one such panel in a building, thus it better meets the criteria for an A score, Mills said.

The Joint Commission discontinued B-scored items in January 2009.

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