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."
In 2008, the Medicare Improvements for Patients and Providers Act of 2008 included a provision that changed the Joint Commission's deeming authority status with CMS. The law removed a unique deeming authority given to The Joint Commission via CMS since 1965, requiring instead that the accrediting body (as well as any other accrediting bodies seeking deeming status) to apply through CMS for that authority. Fellow accrediting organizations DNV Inc., and the Healthcare Facilities Accreditation Program (HFAP) also have to undergo this application process.
In order to prevent any breaks in accreditation for Joint Commission-accredited hospitals, a two-year transition period was included in the provision for The Joint Commission to apply for deeming authority through CMS. The Joint Commission completed its application and was approved within that two-year window.
During the application process, organizations such as the American Hospital Association (AHA) urged CMS to approve The Joint Commission's application.
"The Joint Commission's set of accreditation standards go beyond the minimum requirements of the Medicare Conditions of Participation and focus on key functional areas within the hospital, such as patient rights, patient care, and infection control," Rick Pollack, executive vice president of the AHA, stated in a letter to CMS in July.
Hospitals do not need to be accredited—it is a voluntary option, as is being "deemed" through an organization like The Joint Commission. Hospitals can elect to be surveyed by state surveyors working on behalf of CMS as an alternative to an accrediting organization, such as The Joint Commission.
The Joint Commission also has deeming authority for ambulatory surgery centers, critical access hospitals, durable medical equipment suppliers, home health, hospice, and laboratories.
"The Joint Commission is proud of its tradition of collaboration with CMS to provide quality oversight of hospitals," Pelletier says. "Accreditation is a proven method for improving the care of Medicare beneficiaries."