The Accreditation Process (ACC)

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1 The Accreditatio Process (ACC) Notices The Joit Commissio Coect extraet site is the primary meas of commuicatio by The Joit Commissio. Ay required otices to be give to a orgaizatio shall be set to the orgaizatio via the orgaizatio s secure Joit Commissio Coect extraet site. ACC Chapter Cotets This chapter itroduces the Joit Commissio s accreditatio process, begiig with geeral iformatio about eligibility for accreditatio ad the applicatio process, accreditatio policies, ad types of surveys. Details are the provided o what orgaizatios ca expect before, durig, after, ad betwee accreditatio surveys. Fially, the chapter eds by listig the accreditatio decisio rules ad outliig review ad appeal procedures. This outlie provides a way to easily avigate the chapter ad fid iformatio quickly. This list cotais a ico ext to sectios that have cotet of special iterest to hospitals that use Joit Commissio accreditatio for deemig purposes. Notices... ACC 1 ACC Chapter Cotets... ACC 1 Overview... ACC 3 Geeral Eligibility Requiremets... ACC 3 Eligibility Requiremets for Iitial Surveys... ACC 5 Scope of Accreditatio Surveys... ACC 6 Accreditatio Policies... ACC 6 Tailored Survey Policy... ACC 6 Orgaizatioal ad Fuctioal Itegratio... ACC 8 Iclusio of Physicia Practices i Survey... ACC 11 Multiorgaizatio Optio... ACC 11 Cocurret Survey Optio... ACC 11 Cotracted Services... ACC 12 Shadig idicates a chage effective Jauary 1, 2018, uless otherwise oted i the What's New. CAMH Update 2, Jauary 2018 ACC 1

2 Comprehesive Accreditatio Maual for Hospitals Itegrated Care Certificatio Optio... ACC 12 Primary Care Medical Home Certificatio Optio... ACC 13 Patiet Blood Maagemet Certificatio Optio... ACC 14 Accreditig i Accordace with CMS Certificatio Numbers... ACC 15 Survey Postpoemet Policy... ACC 15 Iformatio Accuracy ad Truthfuless Policy... ACC 15 Good Faith Participatio i Accreditatio/Certificatio... ACC 17 Public Iformatio Policy... ACC 18 Process for Respodig to a Complait... ACC 24 Early Survey Policy... ACC 25 Before the Survey... ACC 28 A Orgaizatio s Secure Joit Commissio Coect Site... ACC 28 Role of the Accout Executive... ACC 29 Electroic Applicatio for Accreditatio (E-App)... ACC 29 Accreditatio Cotract ad Busiess Associate Agreemet... ACC 30 Aual ad Survey Fees... ACC 31 Durig the Survey... ACC 32 Survey Notificatio... ACC 33 Iitial ad Full Survey Team Compositio... ACC 35 Survey Ageda... ACC 36 Tracer Methodology... ACC 41 Immediate Threat to Health or Safety... ACC 46 The Summary of Survey Fidigs Report... ACC 50 After the Survey... ACC 50 The Scorig Process... ACC 50 The Accreditatio Decisio Process... ACC 53 Evidece of Stadards Compliace (ESC) Process... ACC 57 Accreditatio Award Display ad Use... ACC 59 Medicare Certificatio Recommedatio Letter... ACC 60 Betwee Accreditatio Surveys... ACC 61 Duratio of Accreditatio Award... ACC 61 Cotiuous Compliace... ACC 61 Itracycle Moitorig... ACC 62 Focused Stadards Assessmet (FSA)... ACC 62 Setiel Evet Follow-up... ACC 65 Notifyig The Joit Commissio About Orgaizatio Chages... ACC 66 Shadig idicates a chage effective Jauary 1, 2018, uless otherwise oted i the What's New. ACC 2 CAMH Update 2, Jauary 2018

3 The Accreditatio Process Accreditatio Status of Orgaizatios That Cease Services After a Disaster... ACC 67 Accreditatio Status of Orgaizatios That Cease Services or Do Not Have Patiets for a Period of Time... ACC 69 Reeterig the Accreditatio Process... ACC 70 Additioal Surveys... ACC 70 Decisio Rules for Orgaizatios Seekig Iitial Accreditatio... ACC 73 Decisio Rules for Orgaizatios Seekig Reaccreditatio... ACC 76 Process for Orgaizatios That Meet Decisio Rule PDA02 for Patiets Placed at Risk for Serious Adverse Outcomes Due to Sigificat ad Pervasive Patters, Treds, ad/or Repeat Fidigs... ACC 81 Process for Orgaizatios That Meet Decisio Rule PDA04... ACC 83 Review ad Appeal Procedures... ACC 84 Overview The policies, procedures, ad explaatios of process described i this chapter apply to ay health care orgaizatio iterested i Joit Commissio accreditatio, whether it is applyig for the first time or seekig cotiued accreditatio. All orgaizatios must follow the policies ad procedures listed i this chapter to participate i the accreditatio process. Failure to follow the policies ad procedures described i this chapter ca result i deial of accreditatio. Because this iformatio is reviewed ad revised as ecessary o a cotiuous basis, all accredited hospitals are resposible for keepig track of chages to these policies ad procedures. Chages made to accreditatio requiremets betwee maual updates ca be viewed at The Joit Commissio Requiremets page o The Joit Commissio website at The Accreditatio Participatio Requiremets (APR) chapter also icludes specific requiremets for accreditatio participatio. The APRs are existig policies ad are curretly effective for accreditatio purposes. Cross-refereces to the APRs are oted i the applicable sectios of this chapter. Geeral Eligibility Requiremets Ay health care orgaizatio may apply for Joit Commissio accreditatio if all the followig requiremets are met: Shadig idicates a chage effective Jauary 1, 2018, uless otherwise oted i the What's New. CAMH Update 2, Jauary 2018 ACC 3

4 Comprehesive Accreditatio Maual for Hospitals The orgaizatio is i the Uited States or its territories or, if outside the Uited States, is owed or operated by the US govermet or uder a charter of the US Cogress. If required by law (for all programs), the orgaizatio has a facility licese or registratio to coduct its scope of services. The orgaizatio ca demostrate that it cotiually assesses ad improves the quality of its care, treatmet, ad/or services. This process icludes a review by cliicias or other qualified idividuals, icludig those kowledgeable i the type of care, treatmet, ad/or services provided at the orgaizatio. The orgaizatio idetifies the services it provides, idicatig which care, treatmet, ad/or services it provides directly, uder cotract, or through some other arragemet. The orgaizatio provides services that ca be evaluated by The Joit Commissio s stadards. If the orgaizatio uses its Joit Commissio accreditatio for deemed status purposes, the orgaizatio meets the Ceters for Medicare & Medicaid Services (CMS) defiitio of a hospital as set forth i Appedix A: Medicare Requiremets for Hospitals (AXA); see Appedix B: Special Coditios of Participatio for Psychiatric Hospitals (AXB) for iformatio about psychiatric hospitals that use accreditatio for deemed status purposes. The orgaizatio meets parameters for the miimum umber of ipatiets/volume of services required for orgaizatios seekig iitial or cotiued Joit Commissio accreditatio; that is, 10 ipatiets served, with oe active at the time of survey. A hospital that is seekig Medicare Certificatio must have oe active ipatiet case at the time of survey. o If the hospital s average daily cesus (ADC) is 21 or more, or if the hospital is a specialty hospital (cardiac, orthopedic, or surgical), the hospital must be able to provide ipatiet records for at least 10% of the ADC, but ot less tha 30 ipatiet records at the time of survey. o If the hospital s ADC is less tha 21 (1 20), the hospital must be able to provide 20 ipatiet records. The tests, treatmets, or itervetios provided at the orgaizatio are prescribed or ordered by a licesed practitioer i accordace with state ad federal requiremets. Shadig idicates a chage effective Jauary 1, 2018, uless otherwise oted i the What's New. ACC 4 CAMH Update 2, Jauary 2018

5 The Accreditatio Process Eligibility Requiremets for Iitial Surveys A orgaizatio that is seekig Joit Commissio accreditatio for the first time, is udergoig a iitial survey for deemed status purposes, or has ot bee deied accreditatio by The Joit Commissio durig the previous four moths is eligible for a iitial uaouced survey if it serves the required miimum umber (defied below) of patiets regardless of how log the orgaizatio has bee i operatio. The full scope of applicable stadards is reviewed durig the survey. The Joit Commissio s policy for assessig ad moitorig orgaizatios ew to the accreditatio process is as follows: If a orgaizatio ew to the accreditatio process demostrates compliace with applicable Joit Commissio accreditatio requiremets, the orgaizatio will receive accreditatio. All orgaizatios ew to the accreditatio process that become accredited after their iitial survey will be icluded i a 2% pool of orgaizatios udergoig a radom uaouced o-site validatio survey of their Evidece of Stadards Compliace (ESC) (see the Radom Validatio of Evidece of Stadards Compliace sectio for more iformatio). The orgaizatio has a sufficiet umber of ipatiet records to review to adequately determie compliace equal to 10% of the average daily cesus but ot fewer tha 30 ipatiet records, or for small geeral hospitals (with a average daily cesus of 20 patiets or less) ot fewer tha 20 ipatiet records. Specialty hospitals (such as cardiac, orthopedic, or surgical hospitals) have a miimum of 30 ipatiet records regardless of average daily cesus. The orgaizatio meets parameters for the miimum umber of patiets/volume of services required for orgaizatios seekig Joit Commissio accreditatio for the first time, that is, 10 ipatiets served, with oe active at the time of survey, if the hospital is ot usig Joit Commissio accreditatio to meet deemed status requiremets. The accreditatio effective date for a orgaizatio that udergoes a iitial survey is the date o which a acceptable ESC was submitted, if the orgaizatio has a Requiremet for Improvemet (RFI). If there are o RFIs, the effective date is the day after the last day of the survey. Shadig idicates a chage effective Jauary 1, 2018, uless otherwise oted i the What's New. CAMH Update 2, Jauary 2018 ACC 5

6 Comprehesive Accreditatio Maual for Hospitals Scope of Accreditatio Surveys The Joit Commissio evaluates all health care services provided by the orgaizatio for which The Joit Commissio has stadards ad makes a accreditatio decisio for each accreditatio program surveyed. The survey results are documeted by the surveyor(s) ad left o site (with the exceptio of for-cause surveys) i the prelimiary Summary of Survey Fidigs Report. Durig a survey, a orgaizatio must be prepared to provide evidece of its compliace with each applicable stadard. To attai accreditatio, a orgaizatio must demostrate compliace with the stadards ad their elemets of performace (EPs). I additio to usig stadards ad EPs, The Joit Commissio also surveys orgaizatios by usig APRs, performace measuremet data (whe applicable), ad the Joit Commissio Natioal Patiet Safety Goals (see the APR, Performace Measuremet ad the ORYX Iitiative [PM], ad Natioal Patiet Safety Goals [NPSG] chapters, respectively). Used i cojuctio with the stadards, these requiremets help assess a orgaizatio s performace. Accreditatio Policies This sectio provides iformatio o the policies that gover the accreditatio process for hospitals ad describes how The Joit Commissio shares iformatio about a idividual orgaizatio. Tailored Survey Policy The public expects all of the programs or services delivered uder the auspices of a accredited orgaizatio to have bee evaluated. As such, The Joit Commissio applies its Tailored Survey Policy to compoets (for which there are applicable Joit Commissio stadards), icludig laboratory services, that are orgaizatioally ad fuctioally itegrated with the health care orgaizatio applyig for accreditatio (see the Orgaizatioal ad Fuctioal Itegratio sectio). The Joit Commissio will iclude aother service, program, or related etity (that is, compoet), whether providig programs or services directly or through a cotractual arragemet *, i the survey of the applicat orgaizatio uder the followig circumstaces: * Cotractual arragemets are evaluated for tailorig applicability o a case-by-case basis. Shadig idicates a chage effective Jauary 1, 2018, uless otherwise oted i the What's New. ACC 6 CAMH Update 2, Jauary 2018

7 The Accreditatio Process There are Joit Commissio accreditatio/certificatio requiremets applicable to the compoet. There is orgaizatioal ad fuctioal itegratio betwee the compoet ad the applicat orgaizatio. The Joit Commissio survey, assumig satisfactory compliace, provides oe accreditatio award for each accreditatio program surveyed (for example, ambulatory physical health care, behavioral health care, home care, ursig care ceters, ad so forth). Ay service, program, or related etity that is a compoet of a accreditatio-eligible orgaizatio may idepedetly seek accreditatio if it ca meet Joit Commissio survey eligibility requiremets. The results of such a separate accreditatio survey will ot affect the overall orgaizatio s decisio. If the service, program, or related etity seeks separate accreditatio, the Tailored Survey Policy does ot require the larger complex orgaizatio to be separately accredited. Complex Orgaizatio Survey Process The complex orgaizatio survey process is applied to orgaizatios that are govered by the Tailored Survey Policy. The Joit Commissio coducts a complex orgaizatio survey based o the services or programs provided by the orgaizatio, as reported i its electroic applicatio for accreditatio (E-App). After completig its E-App, the orgaizatio is able to view which mauals are applicable to the accreditatio survey o the Applicable Mauals tab. Because a complex orgaizatio survey process ivolves stadards i more tha oe of the accreditatio mauals, The Joit Commissio provides the orgaizatio with access to the electroic editios of the mauals to be used i the survey before it is coducted. The Joit Commissio surveys ad, assumig satisfactory compliace, provides oe accreditatio award for each program surveyed. The laboratory must meet the requiremets of decisio rule FOC01 for the orgaizatio to be successfully accredited. See the Oe-Moth Survey sectio i the Accreditatio Decisio Rules for the full requiremet. A complex orgaizatio refers to a orgaizatio that is surveyed uder more tha oe accreditatio maual. Shadig idicates a chage effective Jauary 1, 2018, uless otherwise oted i the What's New. CAMH Update 2, Jauary 2018 ACC 7

8 Comprehesive Accreditatio Maual for Hospitals Orgaizatioal ad Fuctioal Itegratio Orgaizatioal ad fuctioal itegratio refers to the degree to which a compoet is oversee ad maaged by the applicat orgaizatio that is either seekig accreditatio or curretly accredited. A compoet is a service, program, or related etity that delivers care, treatmet, or services ad is eligible for survey uder oe of The Joit Commissio s accreditatio programs listed i the INTRO chapter. Orgaizatioal itegratio exists whe a applicat orgaizatio s goverig body either directly or ultimately cotrols budgetary ad resource allocatio decisios for the compoet or, where idividual corporate etities are ivolved, there is greater tha 50% commo goverig board membership for the applicat orgaizatio ad o the board of the compoet. Fuctioal itegratio exists whe the etity meets at least three of the followig eight criteria: 1. The applicat orgaizatio ad the compoet do the followig: Use the same process for determiig membership of licesed idepedet practitioers i practitioer paels or medical or professioal staff ad/or Use the same process for credetialig ad assigig of privileges or cliical resposibilities to licesed idepedet practitioers ad/or Share a commo orgaized medical or professioal staff betwee the applicat orgaizatio ad the compoet 2. The applicat orgaizatio s huma resources fuctio hires ad assigs staff at the compoet ad has the authority to do the followig: Termiate staff at the compoet Trasfer or rotate staff betwee the applicat orgaizatio ad the compoet Coduct performace appraisals of the staff who work i the compoet 3. The applicat orgaizatio s policies ad procedures are applicable to the compoet, with few or o exceptios. 4. The applicat orgaizatio maages sigificat operatios of the compoet (that is, the compoet has little or o maagemet authority or autoomy idepedet of the applicat orgaizatio). 5. The compoet s medical records are itegrated ito the applicat orgaizatio s medical record system. 6. The applicat orgaizatio applies its performace improvemet program to the compoet ad has authority to implemet actios iteded to improve performace at the compoet. Shadig idicates a chage effective Jauary 1, 2018, uless otherwise oted i the What's New. ACC 8 CAMH Update 2, Jauary 2018

9 The Accreditatio Process 7. The applicat orgaizatio bills for services provided by the compoet uder the ame of the applicat orgaizatio. 8. The applicat orgaizatio ad/or the compoet portrays to the public that the compoet is part of the orgaizatio through the use of commo ames or logos; refereces o letterheads, brochures, telephoe book listigs, or websites; or represetatios i other published materials. A checklist to help determie whether orgaizatioal ad fuctioal itegratio exists is provided i Figure 1. Shadig idicates a chage effective Jauary 1, 2018, uless otherwise oted i the What's New. CAMH Update 2, Jauary 2018 ACC 9

10 Comprehesive Accreditatio Maual for Hospitals Figure 1. Checklist to determie orgaizatioal ad fuctioal itegratio. Shadig idicates a chage effective Jauary 1, 2018, uless otherwise oted i the What's New. ACC 10 CAMH Update 2, Jauary 2018

11 The Accreditatio Process Iclusio of Physicia Practices i Survey Physicia practices are icluded i a accreditatio survey oly if the physicia practice is icluded i the hospital s Medicare cost report as a provider-based practice. Note: For those physicia practices ot icluded i the Medicare cost report, The Joit Commissio does ot ecessarily require the iclusio of physicia practices i survey; however, orgaizatios may choose to iclude them. Multiorgaizatio Optio The Joit Commissio offers a multiorgaizatio system that ows or leases at least two orgaizatios the optio of usig a modified survey process. This optio has the followig three compoets: 1. A corporate orietatio held at the begiig of the year 2. Surveys of participatig orgaizatios with the same survey team leader 3. A corporate summatio after the last orgaizatio i the system is surveyed A system may choose a corporate orietatio, a corporate summatio, or both or either of these optios. The orietatio sessio provides a opportuity for corporate staff to oriet the surveyor or survey team to the structure ad practices of the system. The surveyor or survey team also surveys cetralized corporate services, documetatio, ad policies ad procedures applicable to Joit Commissio requiremets. The corporate summatio provides a overall aalysis of the system s stregths ad weakesses. It also provides cosultatio ad educatio related to accreditatio survey fidigs across the system. There is a separate fee for both the corporate orietatio ad corporate summatio. Through the multiorgaizatio optio, The Joit Commissio accredits the idividual health care orgaizatios that are part of a multiorgaizatio system, ot the system itself. Therefore, each orgaizatio withi a system receives its ow accreditatio decisio ad Accreditatio Survey Fidigs Report. The fidigs ad decisio for oe orgaizatio withi a system have o bearig o those of aother orgaizatio withi the system. Cocurret Survey Optio The Joit Commissio offers a cocurret survey optio for health care systems with more tha oe accredited etity icluded i a sigle system eve if the orgaizatios maitai distict CMS Certificatio Numbers (CCNs). This optio provides a structure across the etire system ad has the followig compoets: Shadig idicates a chage effective Jauary 1, 2018, uless otherwise oted i the What's New. CAMH Update 2, Jauary 2018 ACC 11

12 Comprehesive Accreditatio Maual for Hospitals Uaouced surveys of participatig orgaizatios occur at the same time. Each participatig orgaizatio must demostrate compliace with all Joit Commissio requiremets idepedet of ay other orgaizatio withi the system. Each orgaizatio with a distict CCN will receive a separate survey report ad accreditatio decisio. The cocurret survey process works best whe coducted i systems where 12 or fewer etities wish to be surveyed at the same time. Cotracted Services The Joit Commissio evaluates a orgaizatio s maagemet ad oversight of the quality of care, treatmet, ad services (for which there are Joit Commissio stadards) provided uder cotractual arragemets, icludig laboratory services provided uder cotract. The Joit Commissio reserves the right to evaluate, as part of its survey, the care, treatmet, ad services provided by aother orgaizatio or provider o behalf of the applicat orgaizatio. It may survey performace issues betwee the cotracted orgaizatio ad the applicat orgaizatio, regardless of the accreditatio decisio of the cotracted orgaizatio. The Joit Commissio also surveys care, treatmet, ad services provided o site uder cotract to the applicat orgaizatio. Itegrated Care Certificatio Optio Itegrated Care Certificatio evaluates how well a orgaizatio itegrates key processes ad coordiates care as a patiet moves across the cotiuum of care. The certificatio program is a optioal process ope to etities that are itegratig patiet care across the cotiuum: A hospital or health system that is itegratig with a physicia practice (freestadig or hospital based) or a ambulatory orgaizatio A physicia practice (freestadig or hospital based) or a ambulatory orgaizatio itegratig with a hospital Home care providers ad/or ursig care ceters that are itegratig with ay of the above etities or with other home care ad/or ursig care ceters At least oe of these etities must be accredited by The Joit Commissio at the time that a itegrated program applies for certificatio. The orgaizatio(s) must be workig toward improvig outcomes through itegratio ad coordiatio of care. Shadig idicates a chage effective Jauary 1, 2018, uless otherwise oted i the What's New. ACC 12 CAMH Update 2, Jauary 2018

13 The Accreditatio Process The certificatio review will evaluate compliace with the Itegrated Care Certificatio stadards, which are desiged to be flexible to accommodate differet models ad sizes of orgaizatios. The requiremets will help orgaizatios develop a foudatio for usig data to idetify their risk poits ad the determie ways to maage those risks. The review will also utilize the tracer methodology, which will follow the experieces of a select umber of patiets as they move betwee the itegrated care orgaizatio s care providers. Whe ready to apply for Itegrated Care Certificatio, a orgaizatio ca use the applicatio to describe the itegrated programs ad also the specific sites to be reviewed. The results of Itegrated Care Certificatio, which is valid for three years, will have o effect o a orgaizatio s accreditatio status. For further iformatio, please itegratedcare@joitcommissio.org or visit The Joit Commissio website at /itegrated_care_certificatio.aspx. Primary Care Medical Home Certificatio Optio The Joit Commissio s Primary Care Medical Home (PCMH) certificatio optio helps hospitals provide patiet-cetered, comprehesive, accessible, ad coordiated care delivered by a primary care cliicia workig with a iterdiscipliary care team. This volutary certificatio is achieved by demostratig compliace with all hospital stadards, plus a additioal set of PCMH-oly requiremets that support the five operatioal characteristics of the PCMH model (see the Primary Care Medical Home Certificatio Optio [PCMH] chapter). PCMH certificatio is a optioal selectio available as part of the applicatio for accreditatio; that is, hospital accreditatio is required for a orgaizatio to be eligible for PCMH certificatio. Certificatio is awarded at the idividual site level for those cliics/practices seekig PCMH certificatio ad ot for all cliics associated with the applicat orgaizatio. A hospital may elect to have the PCMH certificatio for all or oly some of its eligible cliics/practices. As with a iitial hospital accreditatio survey, all PCMH iitial surveys are uaouced, with the evaluatio of PCMH requiremets beig itegrated as part of the o-site survey process. PCMH certificatio ca also be added to a already existig hospital accreditatio through a extesio survey. I a extesio survey, the surveyor will coduct a uaouced o-site survey prior to the hospital s ext resurvey. Shadig idicates a chage effective Jauary 1, 2018, uless otherwise oted i the What's New. CAMH Update 2, Jauary 2018 ACC 13

14 Comprehesive Accreditatio Maual for Hospitals Additioal iformatio about the PCMH certificatio optio for hospitals is available o The Joit Commissio website at /primary_care_medical_home_certificatio_optio_for_hospitals.aspx. The Joit Commissio also offers similar certificatio for ambulatory care orgaizatios, behavioral health care orgaizatios, ad critical access hospitals. Orgaizatios that are requestig or that have achieved PCMH certificatio may access the Provider Iformatio Tool via their E-App or Joit Commissio Coect extraet site. This optioal tool eables orgaizatios to idetify cliical providers who serve as staff at eligible PCMH sites. Depedig o the locatio of the orgaizatio, this iformatio may be used by payers for reimbursemet or fudig purposes. Patiet Blood Maagemet Certificatio Optio The Patiet Blood Maagemet certificatio program is a collaborative effort betwee AABB ad The Joit Commissio. The AABB Joit Commissio Patiet Blood Maagemet Certificatio is desiged to promote patiet safety ad quality ad to help hospitals realize the maximum beefits of establishig a comprehesive patiet blood maagemet program. This volutary hospital certificatio, which is based o the AABB Stadards for a Patiet Blood Maagemet Program, is ew; hospitals already accredited by AABB are ot automatically certified. Joit Commissio accreditatio is required for a orgaizatio to be eligible for Patiet Blood Maagemet certificatio, which is awarded at a site level. Orgaizatios with multiple sites uder the same health care orgaizatio umber may choose to apply for Patiet Blood Maagemet certificatio for selected sites. To be certified, sites must be able to meet all of the certificatio program s requiremets. A Patiet Blood Maagemet certificatio review is scheduled to last oe day. If the hospital is accredited by AABB for blood bakig ad/or trasfusio services, a Joit Commissio surveyor will coduct the review. If the hospital is ot AABB accredited, the review will be coducted by both a Joit Commissio surveyor ad a AABB assessor. Certificatio is valid for two years. For further iformatio, or to access a complimetary trial editio of the stadards for Patiet Blood Maagemet Certificatio, please cotact or visit The Joit Commissio website at Shadig idicates a chage effective Jauary 1, 2018, uless otherwise oted i the What's New. ACC 14 CAMH Update 2, Jauary 2018

15 The Accreditatio Process Accreditig i Accordace with CMS Certificatio Numbers Uder Medicare rules for The Joit Commissio s deemig authority, The Joit Commissio accredits a hospital i accordace with its CCN. Each hospital must meet all requiremets as specified i the CMS defiitio of a hospital (as set forth i Appedix A: Medicare Requiremets for Hospitals [AXA] of this maual; see also Appedix B: Special Coditios of Participatio for Psychiatric Hospitals [AXB] of this maual). Accordig to CMS, each hospital with its ow CCN must demostrate full compliace with all applicable Joit Commissio stadards separately ad idepedetly of ay relatioship or affiliatio with ay other hospital or health care orgaizatio. Survey Postpoemet Policy I rare circumstaces, it may be appropriate to request a survey postpoemet. A orgaizatio should direct a request for a postpoemet to its accout executive. A request to postpoe a survey may be grated if a major uforesee evet has occurred that has totally or substatially disrupted operatios, such as the followig: A atural disaster or major disruptio of service due to a facility failure The orgaizatio s ivolvemet i a employmet strike The orgaizatio s cessatio of admittig or treatig patiets The orgaizatio s iability to treat ad care for patiets ad its trasfer of patiets to other facilities or orgaizatios The Joit Commissio may, at its discretio, approve a request to postpoe a survey for a orgaizatio ot meetig ay of the criteria described above. The orgaizatio may be charged a fee to defray costs. Iformatio Accuracy ad Truthfuless Policy The accuracy ad veracity of relevat iformatio, whether actually used i the accreditatio or certificatio processes, are essetial to the itegrity of the Joit Commissio s accreditatio ad certificatio processes. Falsificatio, as the term is used i the Joit Commissio s Iformatio Accuracy ad Truthfuless Policy, applies to both commissios ad omissios i sharig iformatio with The Joit Commissio. Iformatio provided at ay time by the orgaizatio must be accurate ad truthful (see APR i the APR chapter). Such iformatio may be furished i ay of the followig maers: Provided verbally or i writig Shadig idicates a chage effective Jauary 1, 2018, uless otherwise oted i the What's New. CAMH Update 2, Jauary 2018 ACC 15

16 Comprehesive Accreditatio Maual for Hospitals Obtaied through direct observatio or iterview by Joit Commissio surveyor(s) or reviewer(s) Derived from documets supplied by the orgaizatio to The Joit Commissio, icludig, but ot limited to, a orgaizatio s comprehesive systematic aalysis (for example, a root cause aalysis) i respose to a setiel evet or a orgaizatio s request for accreditatio/certificatio Electroically trasmitted data or documets icludig, but ot limited to, data or documets provided as part of the E-App process A attestatio that the orgaizatio does ot curretly ad kowigly use Joit Commissio full-time, part-time, or itermittet surveyors or reviewers to provide ay accreditatio- /certificatio-related cosultig services icludig, but ot limited to, the followig: o Helpig a orgaizatio meet Joit Commissio accreditatio/certificatio requiremets o Helpig a orgaizatio with ay itracycle moitorig process o Coductig mock surveys for a orgaizatio o Helpig a orgaizatio i the ESC process Policy Requiremets The Joit Commissio s Iformatio Accuracy ad Truthfuless Policy icludes the followig: 1. A orgaizatio must ever provide The Joit Commissio with falsified (as defied below) iformatio relevat to the accreditatio/certificatio process. The Joit Commissio costrues ay effort to do so as a violatio of the orgaizatio s obligatio to egage i the accreditatio/certificatio process i good faith. 2. Falsificatio is defied for this policy as the fabricatio, i whole or i part, ad through commissio or omissio, of ay iformatio provided by a applicat or accredited orgaizatio/certified program to The Joit Commissio. This icludes, but is ot limited to, ay redraftig, reformattig, or cotet deletio of documets. 3. The orgaizatio may submit additioal material that summarizes or otherwise explais origial iformatio submitted to The Joit Commissio. These materials must be properly idetified, dated, ad accompaied by the origial documets. 4. The Joit Commissio coducts a evaluatio whe it has cause to believe that a accredited orgaizatio/certified program may have provided falsified iformatio to The Joit Commissio relevat to the accreditatio/certificatio process. Except as otherwise authorized by the presidet of The Joit Commissio, the evaluatio may iclude a uaouced o-site survey. This survey uses special protocols desiged Shadig idicates a chage effective Jauary 1, 2018, uless otherwise oted i the What's New. ACC 16 CAMH Update 2, Jauary 2018

17 The Accreditatio Process to address the iformatio determied by The Joit Commissio to costitute possible falsificatio. It assesses the degree of actual orgaizatio compliace with the stadards ad EPs that are the subject of the allegatio, if appropriate. 5. The Joit Commissio takes actio to dey accreditatio/certificatio to a orgaizatio/program wheever The Joit Commissio is reasoably persuaded that the orgaizatio/program has provided falsified iformatio. 6. The Joit Commissio may otify resposible federal ad state govermet agecies of ay orgaizatio/program subject to such actio. 7. If a orgaizatio/program is deied accreditatio/certificatio because it provided falsified iformatio, The Joit Commissio prohibits it from participatig i the accreditatio or certificatio process for a period of oe year. The presidet of The Joit Commissio, for good cause oly as determied i his/her sole discretio, may waive all or a portio of this waitig period. If a orgaizatio requests to participate i the accreditatio/certificatio process prior to the completio of the oe-year prohibitio period ad the presidet of The Joit Commissio does hoor the request, executive leadership will be so otified. Good Faith Participatio i Accreditatio/ Certificatio The Joit Commissio requires each orgaizatio seekig (re)accreditatio or (re)certificatio to egage i the process i good faith. The Joit Commissio may dey accreditatio or certificatio to ay orgaizatio that fails to participate i the process i good faith. The followig are examples of actios iterferig with good faith participatio: Deceivig The Joit Commissio. Compliace with the Iformatio Accuracy ad Truthfuless Policy requires a commitmet o the part of the accredited orgaizatio/certified program ot to deceive The Joit Commissio i ay aspect of the accreditatio/certificatio process, such as durig the completio of a applicatio for accreditatio/certificatio, durig the Itracycle Moitorig (ICM) process, or durig a survey/review. Deceivig the public. A accredited orgaizatio/certified program is ot actig i good faith if it misleads the public about the meaig ad limitatios of accreditatio/certificatio. Also, a accredited orgaizatio/certified program must ot iaccurately suggest to the public that its accreditatio/certificatio award applies to ay uaccredited affiliated or otherwise related activities. Shadig idicates a chage effective Jauary 1, 2018, uless otherwise oted i the What's New. CAMH Update 2, Jauary 2018 ACC 17

18 Comprehesive Accreditatio Maual for Hospitals Retaliatio. The Joit Commissio ivites ope commuicatio from ay accredited orgaizatio s/certified program s staff ad recipiets of care, treatmet, ad services about ay stadards compliace or other issues related to the accreditatio/ certificatio process. A orgaizatio s/program s good faith participatio i the accreditatio/certificatio process is questioed if the orgaizatio/program does ay of the followig: o Attempts to discourage such commuicatio for example, by takig discipliary steps agaist a employee solely because that employee provides iformatio to The Joit Commissio o Threates those who commuicate with The Joit Commissio with a defamatio lawsuit based solely o what was said to The Joit Commissio o Allows the treatmet or access to services of ay idividual or staff member to be adversely affected by his or her or a family member s commuicatio with The Joit Commissio Stadards compliace. If a orgaizatio s/program s coduct reflects a lack of commitmet to stadards compliace, issues of good faith may be raised. For example, a itetioal refusal to attempt to comply with a stadard could suggest a cavalier view of the accreditatio/certificatio process. The good faith participatio requiremet applies cotiuously throughout the accreditatio/certificatio process. Public Iformatio Policy Itroductio The Joit Commissio is committed to makig relevat ad accurate iformatio about health care orgaizatios available to iterested parties. Iformatio regardig a health care orgaizatio s quality ad safety ca help orgaizatios improve their services. This iformatio may also help educate cosumers ad health care purchasers i makig iformed choices about health care. At the same time, it is importat that cofidetiality of certai iformatio be maitaied to ecourage cador i the accreditatio ad certificatio processes. The Joit Commissio s primary vehicle for providig public iformatio are Quality Check ad Quality Reports. This policy meets the requiremets of the Health Isurace Portability ad Accoutability Act of Shadig idicates a chage effective Jauary 1, 2018, uless otherwise oted i the What's New. ACC 18 CAMH Update 2, Jauary 2018

19 The Accreditatio Process Quality Check. Quality Check is The Joit Commissio s website for makig available descriptive ad performace iformatio about accredited orgaizatios ad certified programs. Quality Reports. The Quality Reports located o Quality Check are publicly available ad iclude relevat ad useful iformatio about the quality ad safety of care provided i idividual Joit Commissio accredited orgaizatios ad certified programs. Quality Reports are created at the orgaizatio level ad cotai iformatio reflectig a orgaizatio s accreditatio ad/or certificatio status, its compliace with Natioal Patiet Safety Goals, ad performace measuremet results, as appropriate. Publicly Available Accreditatio ad Certificatio Iformatio Joit Commissio Quality Reports for each accredited orgaizatio ad/or certified program iclude the followig iformatio: The date of a orgaizatio s/program s most recet full o-site survey/review, ad if the orgaizatio/program has had ay subsequet surveys/reviews sice its last full survey/review The accreditatio/certificatio decisio based o the most recet full o-site survey/ review, as well as ay subsequet updates to the decisio o Orgaizatios that are successful i obtaiig accreditatio followig a iitial survey will be posted o the Quality Check website. o Programs that achieve certificatio will be posted o the Quality Check website. For orgaizatios i the accreditatio reewal process, with a accreditatio decisio of Prelimiary Deial of Accreditatio or Deial of Accreditatio, the stadards with Requiremets for Improvemet leadig to the decisio Services icluded withi the scope of the orgaizatio s accreditatio ad/or certificatio decisio A list of a orgaizatio s previous accreditatio ad/or program s certificatio decisios ad the effective date of those decisios for the past seve (7) years o If the orgaizatio had a previous decisio of Prelimiary Deial of Accreditatio, the stadards with Requiremets for Improvemet The receipt of atioal quality recogitio awards, as recogized by the Board of Commissioers Deial of Accreditatio decisios, for orgaizatios that were i the accreditatio reewal process, will be posted o the Quality Check website for a duratio of oe year from the rederig of the accreditatio decisio. Shadig idicates a chage effective Jauary 1, 2018, uless otherwise oted i the What's New. CAMH Update 2, Jauary 2018 ACC 19

20 Comprehesive Accreditatio Maual for Hospitals Attaimet of Top Performer o Key Quality Measures desigatio from The Joit Commissio, if the program is active Compliace with Natioal Patiet Safety Goal requiremets Performace agaist Natioal Quality Improvemet Goals (core measures) Each accredited orgaizatio/certified program is afforded the opportuity to prepare a commetary of up to two pages regardig its Quality Report. The commetary will accompay ay orgaizatio/program Quality Reports distributed by The Joit Commissio, whether via hard copy or The Joit Commissio s website. Whe performace measuremet data is icluded i Quality Reports, such data will be accompaied by iformatio regardig its source or derivatio; accuracy, reliability, ad validity; ad appropriate uses of the data. A orgaizatio s Quality Report may be obtaied via the Customer Service Departmet or through Quality Check. See The Joit Commissio Quality Report (QR) chapter of this maual for more details. Release of Aggregate Data The Joit Commissio reserves the right to publish or release aggregate data. Protected health iformatio will ot be made publicly available. Performace data displayed o Quality Check are available to ay iterested party at o cost ad may be dowloaded electroically i a series of predefied report formats through a liked webpage called Quality Data. Iformatio That Is Publicly Disclosed o Request Release of Accreditatio ad Certificatio Iformatio. I additio to iformatio provided i Quality Reports, the followig iformatio may be obtaied by writig or callig The Joit Commissio: For orgaizatios that were previously deied accreditatio, are o loger certified, or withdrew from the accreditatio/certificatio process: o The orgaizatio s accreditatio ad/or certificatio history o Stadards for which The Joit Commissio had o or isufficiet evidece of resolutio whe a orgaizatio withdrew from accreditatio ad was subsequetly deied accreditatio Setiel Evet Iformatio. As applicable, cofirmatio of the occurrece of a setiel evet at a accredited orgaizatio for the three-year period prior to the date of the request ad The Joit Commissio s itet to apply its Setiel Evet Policy or other applicable procedures to this occurrece. Shadig idicates a chage effective Jauary 1, 2018, uless otherwise oted i the What's New. ACC 20 CAMH Update 2, Jauary 2018

21 The Accreditatio Process Release of Aggregate Complait-Related Iformatio. The Joit Commissio addresses all icidets that pertai to alleged patiet safety or quality of care issues withi the scope of Joit Commissio stadards. Iformatio about complaits # may be forwarded by the Ceters for Medicare & Medicaid Services (CMS) or other federal or state agecies havig oversight resposibilities for health care orgaizatios, federal or state legislators or legislative committees o behalf of costituets, or may be received directly from patiets, families, payers, or health care professioals. As used here, the term complait icludes potetially relevat reports that are received from federal or state agecies, idetified i the media, or otherwise obtaied by The Joit Commissio. The Joit Commissio will oly disclose patiet-idetifiable iformatio if authorized by the patiet, as cosistet with its busiess associate obligatios, or otherwise authorized by law. For ay party other tha the authorizig complaiat, The Joit Commissio will ot disclose patiet ame or idetifiable iformatio, per the Health Isurace Portability ad Accoutability Act (HIPAA) of Upo request from ay party, The Joit Commissio releases the followig aggregate iformatio relatig to complaits about a accredited orgaizatio or a certified program for the three-year period prior to receipt of the request: Whe a uaouced or uscheduled survey/review is based o iformatio derived from a complait or public sources, a summary of the stadards areas ** for which Requiremets for Improvemet were issued as a result of The Joit Commissio s evaluatio activities. Release of Specific Complait-Related Iformatio The Joit Commissio also provides the followig iformatio as appropriate to complaiats regardig their complaits (ad those authorized by the complaiat), or other idividuals who have kowledge regardig a specific complait: Cofirmatio of the receipt of the complait ad that it will be reviewed to determie what, if ay, Joit Commissio actio is warrated Ay determiatio that the complait is ot related to Joit Commissio requiremets If The Joit Commissio has decided ot to take actio regardig a orgaizatio s accreditatio/a program s certificatio decisio, the complaiat is to be so advised. # The term complait refers to a alleged adverse evet, usafe coditio, or cocer. ** The term stadard area refers to the focus area of the complait review as it relates to The Joit Commissio s stadards. Depedig o the review status or outcome of the complait review, the level of iformatio provided may vary. Shadig idicates a chage effective Jauary 1, 2018, uless otherwise oted i the What's New. CAMH Update 2, Jauary 2018 ACC 21

22 Comprehesive Accreditatio Maual for Hospitals If the complait is related to Joit Commissio requiremets, upo completio of review, the course of actio that was take regardig the complait, icludig the stadards areas that were evaluated If The Joit Commissio has decided ot to take actio regardig a orgaizatio s accreditatio/a program s certificatio decisio as a result of the complait review, the complaiat is to be so advised. If The Joit Commissio has take actio regardig a orgaizatio s accreditatio/ a program s certificatio decisio as a result of a o-site complait review, the ocompliat stadards leadig to that decisio will be made publicly available o Quality Check. Data Release to Govermet Agecies ad Orgaizatios with Which The Joit Commissio Performs Coordiated Survey Activities The Joit Commissio makes available to federal, state, local, or other govermetal certificatio or licesig agecies or public health agecies, or ay other appropriate eforcemet agecy, specific accreditatio-related iformatio uder the followig circumstaces: Whe The Joit Commissio idetifies a serious situatio i a orgaizatio that may jeopardize the health or safety of patiets or the public ad immediately takes actio to dey accreditatio Whe The Joit Commissio idetifies a serious situatio, or a sigificat patter of risk i a orgaizatio that may have jeopardized the health or safety of previous patiets or the public, or that represets risk that exteds beyod the orgaizatio, such as a icidet ivolvig the reuse of cotamiated istrumets If the health care orgaizatio or other idividual reports the issue to the appropriate authorities, The Joit Commissio will evaluate whether it, too, should report the issue. Sectio 92, PL , the Omibus Budget Recociliatio Act of 1980, requires that Medicare providers iclude, i all their cotracts for services costig $10,000 or more i ay 12-moth period, a clause allowig the Secretary of the US Departmet of Health ad Huma Services (DHHS), the US Comptroller Geeral, or their represetatives to examie the cotract ad the cotractor s books ad records. The Joit Commissio herei stipulates that if its charges to ay such orgaizatio amout to $10,000 or more i ay 12-moth period, the cotract or ay agreemet o which such charges are based ad ay of the Joit Commissio s books, documets, ad records that may be ecessary to verify the extet ad ature of Joit Commissio costs will be available to the Secretary of DHHS, the Comptroller Geeral, or ay of their duly authorized represetatives for four years after the survey. The same coditios will apply to ay subcotracts The Joit Commissio has with related orgaizatios if the paymets uder such cotracts amout to $10,000 or more i ay 12-moth period. Shadig idicates a chage effective Jauary 1, 2018, uless otherwise oted i the What's New. ACC 22 CAMH Update 2, Jauary 2018

23 The Accreditatio Process Additioal iformatio is made available whe a orgaizatio is certified for participatio i a federal or state program or licesed to operate by a state agecy o the basis of its accreditatio. I additio, The Joit Commissio may make available iformatio to orgaizatios with which The Joit Commissio performs coordiated survey activities. The Joit Commissio may advise the orgaizatio s chief executive officer ad will provide timely otice to local, state, ad federal authorities havig jurisdictio. The iformatio available to govermet agecies ad orgaizatios with which The Joit Commissio performs coordiated survey activities icludes the followig: Notificatio of official decisio to reder Accreditatio with Follow-up Survey, Prelimiary Deial of Accreditatio, or Deial of Accreditatio, icludig the ratioale for the decisio Complait iformatio requested by CMS i accordace with The Joit Commissio s deemig authority, icludig the cotet of the complait submitted to The Joit Commissio Complait iformatio, icludig the cotet of the complait submitted to The Joit Commissio, is shared with: o CMS i accordace with The Joit Commissio s deemig authority o A state regulatory agecy that has etered ito a writte iformatio-sharig agreemet o A orgaizatio with which The Joit Commissio coducts coordiated survey activities Upo request from CMS, the followig iformatio is shared: o All fial Requiremets for Improvemet o A statemet, if ay, from the orgaizatio regardig its views o the validity of Joit Commissio survey fidigs o A copy of the corrective actio submitted by the orgaizatio o The results of ay follow-up survey, if warrated For govermetal agecies, otificatio of upcomig full surveys ad retrospective dates of other surveys coducted, such as radom uaouced or for-cause surveys, oly if the govermetal agecy eters ito a iformatio-sharig agreemet with The Joit Commissio ad agrees to maitai the cofidetiality of the survey dates A copy of the Official Accreditatio Decisio Report ad decisio letter o For CMS upo request respectig deemed status determiatios o For state agecies that have etered ito specific iformatio-sharig agreemets that permit provider-authorized release of such reports to the state agecy Shadig idicates a chage effective Jauary 1, 2018, uless otherwise oted i the What's New. CAMH Update 2, Jauary 2018 ACC 22a

24 Comprehesive Accreditatio Maual for Hospitals This page is blak due to revisios through the CAMH update. Shadig idicates a chage effective Jauary 1, 2018, uless otherwise oted i the What's New. ACC 22b CAMH Update 2, Jauary 2018

25 The Accreditatio Process o Upo request from state agecies that are actig o behalf of CMS as cotractors The Joit Commissio will report to CMS or the Office of the Ispector Geeral, as appropriate, i the evet that there is credible evidece of potetial idetificatio of fraud ad abuse, or other crimial or civil law violatio ad upo otice to the health care orgaizatio. Data Release to Cooperative Accreditig Bodies The Joit Commissio makes available to accreditig bodies with which it has formal cooperative agreemets relevat portios of Official Accreditatio Decisio Reports ad complait-related iformatio pertiet to the accreditig activities of the cooperative parter. Judgmets as to pertiece are made solely by The Joit Commissio. (For a list of orgaizatios with which The Joit Commissio has cooperative agreemets, see _iitiative/.) Joit Commissio Right to Clarify The Joit Commissio reserves the right to clarify iformatio, eve if the iformatio ivolved would otherwise be cosidered cofidetial, whe a orgaizatio dissemiates iaccurate iformatio regardig its accreditatio/certificatio. Cofidetial Iformatio The Joit Commissio keeps iformatio received or developed durig the accreditatio/certificatio process cofidetial, such as: The Official Accreditatio Decisio Report, uless its submissio is required by a govermetal agecy (see Data Release to Govermet Agecies ad Orgaizatios with Which The Joit Commissio Performs Coordiated Survey Activities ), is required by orgaizatios with which The Joit Commissio performs coordiatig surveys, or is requested by a accredited body with which The Joit Commissio has a formal agreemet (see Data Release to Cooperative Accreditig Bodies ) Iformatio leared from the orgaizatio before, durig, or followig the accreditatio survey, which is used to determie compliace with specific accreditatio stadards A orgaizatio s comprehesive systematic aalysis ad related documets prepared i respose to a setiel evet or i respose to other circumstaces specified by The Joit Commissio All other materials that may cotribute to the accreditatio/certificatio decisio Writte staff aalyses ad executive leadership miutes ad ageda materials Shadig idicates a chage effective July 1, 2017, uless otherwise oted i the What's New. CAMH Update 1, July 2017 ACC 23

26 Comprehesive Accreditatio Maual for Hospitals Ay data from a orgaizatio s participatio i the itracycle moitorig process ad related corrective actio pla The idetity of ay idividual who files a complait about a accredited orgaizatio, except whe the complait is shared by The Joit Commissio with a govermetal etity, a orgaizatio with which The Joit Commissio performs coordiated surveys, or accreditig orgaizatios with which The Joit Commissio has formal complait-sharig agreemets ad the receivig orgaizatio has agreed to maitai the cofidetiality of the complaiat. I istaces whe the receivig orgaizatio caot assure the cofidetiality of the complaiat, ay complaiatidetifyig iformatio shall be redacted by The Joit Commissio prior to sharig. This policy applies to all orgaizatios with a accreditatio ad/or certificatio history, subject to ay requiremets of ay applicable laws. Process for Respodig to a Complait The Joit Commissio s Office of Quality ad Patiet Safety (OQPS) triages ad reviews complaits, cocers, ad iquiries related to accredited health care orgaizatios, as received from a variety of sources. These complaits may be submitted by patiets, families, ad health care providers; by state ad federal agecies i the form of reports; or through iformatio from the media. The term complait therefore covers a broad spectrum of iformatio received by the OQPS. Upo Joit Commissio review of a complait, a umber of actios may result. These iclude recordig the iformatio for tredig purposes ad possible actio i the future, obtaiig the ivolved health care orgaizatio s respose to the complait, ad/ or coductig a immediate for-cause survey. If The Joit Commissio determies that the orgaizatio should respod to the complait, the orgaizatio will be so otified. The request for a respose will be ed to the orgaizatio s CEO ad posted to the orgaizatio s Joit Commissio Coect extraet site (a secure, password-protected website iteded oly for Joit Commissio accredited or certified orgaizatios ad key stakeholders). The orgaizatio s respose to the complait also takes place through its extraet site. The complait iformatio posted o the Joit Commissio Coect site may be either of the followig: The complait itself, if the complaiat has give permissio to do so A summary of the complait, if the complaiat requested aoymity Shadig idicates a chage effective July 1, 2017, uless otherwise oted i the What's New. ACC 24 CAMH Update 1, July 2017

27 The Accreditatio Process If a accredited orgaizatio is required to respod to the complait, it is usually required to do so withi 30 busiess days of beig otified. For more serious issues, the orgaizatio may be required to respod to the complait withi 7 busiess days of beig otified, or sooer. Whe a respose i a short time frame is required, the orgaizatio will be so otified. Oce a respose is received, it is evaluated for compliace with the Joit Commissio s stadards, Natioal Patiet Safety Goals, ad APRs, as applicable. If additioal iformatio is required, the orgaizatio will be otified. Whe the orgaizatio s respose is complete ad has bee accepted, a letter idicatig acceptace is ed to the CEO, ad the case is cosidered closed. Early Survey Policy A orgaizatio seekig Joit Commissio accreditatio for the first time may choose the Early Survey Policy optio. A orgaizatio surveyed uder the Early Survey Policy will have two surveys. Sidebar 1 lists key features of the Early Survey Policy. Sidebar 1. Early Survey Policy First Survey Coducted up to two moths before opeig or operatig Licesed (accordig to law ad regulatio) or i licesig process Buildig idetified, costructed, ad equipped CEO or admiistrator, director of cliical or medical services (medical director), ad urse executive idetified Idetified opeig date Aouced Limited set of stadards (physical plat, policies ad procedures) Outcome: Limited, Temporary Accreditatio Secod Survey Ready date for survey selected by the orgaizatio withi six moths of the first survey Uaouced Full iitial survey cotiued o ext page Shadig idicates a chage effective July 1, 2017, uless otherwise oted i the What's New. CAMH Update 1, July 2017 ACC 25

28 Comprehesive Accreditatio Maual for Hospitals Sidebar 1. Early Survey Policy (cotiued) Outcome: Chage i Limited, Temporary Accreditatio decisio to Accredited or Deial of Accreditatio. The effective date of the accreditatio decisio is the day after the secod survey if the orgaizatio does ot receive ay Requiremets for Improvemet (RFIs). If the orgaizatio receives at least oe RFI ad therefore must submit a ESC that resolves all RFIs, the effective date of the accreditatio decisio is the date the successful ESC is submitted. If at six moths the orgaizatio is ot ready for the secod survey, the orgaizatio s Limited, Temporary Accreditatio decisio will expire. Note: Limited, Temporary Accreditatio is ot recogized by CMS for Medicare certificatio purposes (but it may be required for state licesure). Eligibility for Limited, Temporary Accreditatio The Early Survey Policy is available to ay orgaizatio that is curretly ot accredited except for those that have bee deied accreditatio. A orgaizatio must declare durig the applicatio process that it wishes to be surveyed uder this policy. The First Survey. Whe a orgaizatio chooses to be surveyed uder the Early Survey Policy, The Joit Commissio coducts two o-site surveys. The Joit Commissio ca coduct the first survey as early as two moths before the orgaizatio begis its operatios, provided that the orgaizatio meets the followig criteria: It is licesed (accordig to law ad regulatio) or i the licesig process. The buildig i which the services will be offered or from which the services will be coordiated is idetified, costructed, ad equipped to support such services. It has idetified its CEO or admiistrator, its director of cliical or medical services, ad its urse executive, if applicable. It has idetified the date it will begi operatios. Geerally, the first survey uses a limited set of stadards ad assesses oly the orgaizatio s physical facilities, policies ad procedures, plas, ad related structural cosideratios. For this reaso, orgaizatios surveyed uder this policy are ot recogized by CMS as meetig the requiremets for Medicare certificatio util the secod (full) survey has bee coducted ad a decisio of Accredited has bee achieved. Limited, Temporary Accreditatio Decisio. The Joit Commissio grats Limited, Temporary Accreditatio to a orgaizatio that is i satisfactory compliace with the limited set of stadards ad EPs assessed i the first of the two surveys Shadig idicates a chage effective July 1, 2017, uless otherwise oted i the What's New. ACC 26 CAMH Update 1, July 2017

29 The Accreditatio Process coducted uder the Early Survey Policy (see the Early Survey Policy Optio [ESP] chapter for a list of these requiremets). Sice a Limited, Temporary Accreditatio decisio does ot reflect a orgaizatio s compliace with the full set of Joit Commissio stadards, the orgaizatio caot use the Joit Commissio s Gold Seal of Approval. A orgaizatio that is ot i satisfactory compliace must reapply ad begi the accreditatio process agai. The Limited, Temporary Accreditatio decisio icludes assigmet of a additioal uaouced survey agaist the full set of applicable stadards withi six moths of the first survey. The survey assesses the orgaizatio s compliace with all applicable EPs. For orgaizatios surveyed uder the Early Survey Policy: If a orgaizatio does ot receive ay RFIs durig the first survey, the effective date for its Limited, Temporary Accreditatio decisio is the day after the survey is coducted. If the orgaizatio receives at least oe RFI durig the first survey ad therefore must submit a acceptable ESC report that resolves all RFIs, the effective date for Limited, Temporary Accreditatio is the date of the acceptable ESC submissio. The Limited, Temporary Accreditatio decisio remais i effect util the orgaizatio has completed the secod of the two surveys coducted uder the Early Survey Policy (which is a uaouced full survey) or util The Joit Commissio has withdraw the Limited, Temporary Accreditatio. The Joit Commissio may withdraw Limited, Temporary Accreditatio i the followig situatios: If a orgaizatio that was ot providig services at the time of the first survey does ot begi providig services whe expected If a orgaizatio does ot meet the survey eligibility criteria If a orgaizatio fails to accept the secod survey If a orgaizatio is foud to be ot i satisfactory compliace with the applicable stadards ad their EPs I ay of these cases, the orgaizatio must begi the accreditatio process agai. The Secod Survey. The secod survey uder the Early Survey Policy is a uaouced, full, iitial accreditatio survey. The Joit Commissio coducts this survey withi six moths after the first survey. If at six moths the orgaizatio is ot ready for the secod survey, the orgaizatio s Limited, Temporary Accreditatio decisio will be removed ad the orgaizatio will ot be accredited. Based o survey results, the orgaizatio s accreditatio decisio the chages to oe of the followig: Shadig idicates a chage effective Jauary 1, 2018, uless otherwise oted i the What's New. CAMH Update 2, Jauary 2018 ACC 27

30 Comprehesive Accreditatio Maual for Hospitals Accredited Deial of Accreditatio See Decisio Categories for Orgaizatios Seekig Accreditatio Reewal for descriptios of accreditatio decisios. The effective date of the accreditatio decisio is the day after the secod survey if the orgaizatio does ot receive ay RFIs. If the orgaizatio receives at least oe RFI ad therefore must submit a acceptable ESC report that resolves all RFIs, the effective date is the retroactive to the date of the acceptable ESC submissio. The orgaizatio s accreditatio cycle begis the day after the secod survey was coducted, uless The Joit Commissio reached a decisio to dey accreditatio. Before the Survey This sectio provides iformatio o the steps leadig to a full accreditatio survey. These steps iclude the applicatio process, the role of a accout executive, ad the Focused Stadards Assessmet (FSA) process. A Orgaizatio s Secure Joit Commissio Coect Site A key feature of The Joit Commissio s accreditatio process is use of techology. The use of techology better eables The Joit Commissio ad accredited orgaizatios to commuicate accreditatio-related iformatio i a more efficiet ad timely maer. The Joit Commissio provides each orgaizatio with a secure, password-protected website o The Joit Commissio s extraet site for accredited orgaizatios, Joit Commissio Coect. Joit Commissio Coect is the primary meas of commuicatio betwee The Joit Commissio ad accredited orgaizatios. Full access to this site ca oly be grated through the use of the orgaizatio s password. This site permits a orgaizatio to complete its E-App ad FSA electroically. I additio, shortly after a orgaizatio s survey, the orgaizatio s survey fidigs report ad its ESC report are posted o the orgaizatio s secure site. (See the Stimulate Improvemet sectio i the INTRO chapter for more details about what is available o Joit Commissio Coect.) While full access to Joit Commissio Coect ca oly be grated via a orgaizatio s password, employees with a address from their Joit Commissio accredited or certified health care orgaizatio ca register themselves for guest access. Guest access Shadig idicates a chage effective Jauary 1, 2018, uless otherwise oted i the What's New. ACC 28 CAMH Update 2, Jauary 2018

31 The Accreditatio Process eables viewers to see the Leadig Practice Library, the Core Measure Solutio Exchage, ad stadards BoosterPaks. Guest access does ot iclude etry to ay orgaizatio-specific data or reports. Role of the Accout Executive The Joit Commissio assigs a accout executive to a orgaizatio after receivig its E-App ad orefudable deposit. This perso serves as the primary cotact betwee the orgaizatio ad The Joit Commissio. He or she coordiates survey plaig ad hadles policies, procedures, accreditatio issues or services, ad iquiries throughout the accreditatio cycle. A applicat orgaizatio ca fid cotact iformatio for its accout executive o its Joit Commissio Coect site or by callig Electroic Applicatio for Accreditatio (E-App) Whe a orgaizatio otifies The Joit Commissio that it wats to become accredited, The Joit Commissio provides the orgaizatio with iformatio explaiig how to access ad complete the E-App o the orgaizatio s secure Joit Commissio Coect extraet site. (A applicat should cotact Busiess Developmet at for iitial access to Joit Commissio Coect.) Iitial applicatios are valid for oe year. A orgaizatio eeds to complete ad submit its E-App upo iitial applicatio for survey, ad will be asked to verify the iformatio aually. A orgaizatio ca provide updates to the E-App at ay time. (See the Chages Affectig E-App Iformatio sectio for more iformatio o otifyig The Joit Commissio of sigificat chages withi a orgaizatio.) The applicatio provides essetial iformatio about the orgaizatio, icludig owership, demographics, ad types ad volume of services provided. The E-App does the followig: Describes the orgaizatio seekig accreditatio i terms of size ad scope of services Requires the orgaizatio to make available to The Joit Commissio all official records ad reports of public or publicly recogized licesig (for example, state liceses), examiig, reviewig, or plaig bodies durig the iitial o-site survey (see APR i the APR chapter) Authorizes The Joit Commissio to obtai ay records ad reports ot possessed by the orgaizatio Whe accepted, establishes the terms of the relatioship betwee the orgaizatio ad The Joit Commissio Shadig idicates a chage effective Jauary 1, 2018, uless otherwise oted i the What's New. CAMH Update 2, Jauary 2018 ACC 29

32 Comprehesive Accreditatio Maual for Hospitals Idetifies a orgaizatio s applicable stadards based o programs/services provided Drives the aticipated umber of survey days, umber ad type of surveyors, ad survey ageda activities (see the Survey Ageda sectio) Accuracy of the Applicatio Iformatio The Joit Commissio schedules surveys based o iformatio provided i a orgaizatio s E-App. With the iformatio provided, The Joit Commissio determies the umber of days required for a survey ad the umber ad type of surveyors. Iaccurate or icomplete iformatio i the E-App may ecessitate a additioal survey, which could delay the processig of survey fidigs ad rederig of a accreditatio decisio. It may also cause the orgaizatio to icur additioal survey charges. Forfeiture of Survey Deposit A orefudable, otrasferable deposit toward accreditatio fees is required for iitial customers. The Joit Commissio applies the deposit to the orgaizatio s ope ivoices util the deposit is exhausted. A orgaizatio scheduled for a iitial survey forfeits its deposit if its survey is ot coducted withi oe year of submittig its applicatio. The orgaizatio must the reapply ad submit a ew deposit to begi the accreditatio process agai. Note: If it receives approval from The Joit Commissio to postpoe a iitial survey (less tha 20 days prior to a scheduled iitial survey), the orgaizatio will be charged a fee to defray costs. Accreditatio Cotract ad Busiess Associate Agreemet Orgaizatios seekig Joit Commissio accreditatio for the first time or reaccreditatio with The Joit Commissio must submit oe siged accreditatio cotract ad a siged Busiess Associate Agreemet. The cotract outlies the resposibilities of both the orgaizatio ad The Joit Commissio relative to the accreditatio process. This cotract is separate from the E-App. I accordace with the requiremets of the Health Isurace Portability ad Accoutability Act of 1996 (HIPAA) Privacy ad Security Rules, ad modified by the HITECH (Health Iformatio Techology for Ecoomic ad Cliical Health) provisios of the The Joit Commissio does ot charge a deposit for accredited health care orgaizatios that are seekig a ew tailored (or certificatio) program. Also, i istaces where a ower of multiple health care orgaizatios has at least five accredited etities i good stadig, that etity will be eligible for a deposit waiver. Shadig idicates a chage effective Jauary 1, 2018, uless otherwise oted i the What's New. ACC 30 CAMH Update 2, Jauary 2018

33 The Accreditatio Process America Recovery ad Reivestmet Act of 2009, a health care orgaizatio ad The Joit Commissio must have a siged Busiess Associate Agreemet before the orgaizatio s survey ca begi. This Busiess Associate Agreemet outlies the access, use, ad disclosure of ay patiet-protected health iformatio betwee The Joit Commissio ad the health care orgaizatio. A orgaizatio will ot be scheduled for survey util it sigs a accreditatio cotract ad Busiess Associate Agreemet. Whe this happes, The Joit Commissio will proceed with the orgaizatio s survey plas uless the orgaizatio otifies The Joit Commissio i writig of its itet to withdraw from accreditatio ad termiate the accreditatio cotract. Notificatio i writig is ecessary to termiate the accreditatio cotract, cease survey schedulig, ad avoid a fial decisio of Deial of Accreditatio. If a orgaizatio fails to otify The Joit Commissio i writig of its itet to withdraw from accreditatio ad termiate its accreditatio cotract before a survey, The Joit Commissio s decisio rules provide for a fial decisio of Deial of Accreditatio. Aual ad Survey Fees The Joit Commissio uses a subscriptio billig system for all accreditatio programs. Fees are determied aually ad are based o the eed to secure sufficiet resources to cover the costs of operatio. The Joit Commissio geerally bases idividual orgaizatio aual fees o the volume ad type of services provided ad the sites to be icluded i the orgaizatio s accreditatio survey. Questios about all fees ca be directed to the Pricig Uit (priciguit@joitcommissio.org) or by callig The Joit Commissio s fee structure icludes a orefudable, otrasferable aual fee, which recogizes the provisio of substatial accreditatio-related services o a cotiuous basis betwee o-site surveys. The aual fees, billed each Jauary, are determied by the orgaizatio s size ad complexity. The aual fee for orgaizatios applyig for accreditatio for the first time will be prorated, based o the quarter i which the applicatio is submitted. I additio to aual fees, orgaizatios are also billed a o-site fee withi two days after the survey has bee coducted. The o-site fee is desiged to cover the direct costs of performig a survey. Orgaizatios requirig additioal surveys, such as to evaluate a patiet safety evet, will be assessed a separate survey fee. Shadig idicates a chage effective Jauary 1, 2018, uless otherwise oted i the What's New. CAMH Update 2, Jauary 2018 ACC 31

34 Comprehesive Accreditatio Maual for Hospitals Electroic ivoices will be posted to the orgaizatio s secure Joit Commissio Coect site ad are due upo receipt. The Joit Commissio accepts paymet for all fees i ay of the followig ways: Electroic paymet usig Visa, MasterCard (credit or debit), America Express, Discover, or e-check by loggig o the orgaizatio s Joit Commissio Coect accreditatio home page ad clickig o the What s Due tab or by callig Accouts Receivable staff at Check or moey order by mail to PO Box 92775, Chicago, IL , or overight to Oe Reaissace Boulevard, Oakbrook Terrace, IL Wire trasfer by callig Accouts Receivable staff at Failure to provide timely paymet of ay Joit Commissio fees may result i the loss of accreditatio. Letters of opaymet are posted to the health care orgaizatio s Joit Commissio Coect extraet site. Failure to pay overdue amouts will result i a loss of accreditatio with o opportuity for appeal or reistatemet. For help i makig a paymet, please cotact Accouts Receivable staff at Durig the Survey Durig a accreditatio survey, The Joit Commissio evaluates a orgaizatio s performace of fuctios ad processes aimed at cotiuously improvig patiet outcomes. The survey process focuses o assessig performace of importat patietcetered ad orgaizatio fuctios that support the safety ad quality of care, treatmet, ad services. This assessmet is accomplished through evaluatig a orgaizatio s compliace with the applicable requiremets i this maual, based o the followig activities ad iformatio: Tracig the care, treatmet, ad services delivered to patiets Verbal ad writte iformatio provided to The Joit Commissio O-site observatios ad iterviews by Joit Commissio surveyors Review of documets provided by the orgaizatio Uder this accreditatio process, the full survey is the o-site evaluatio piece of a cotiuous process. The accreditatio process ecourages orgaizatios to embed the requiremets ito routie operatios to achieve ad maitai excellet operatioal systems o a ogoig basis. Iitiatives such as the aual FSA facilitate this ad also help idetify ad maage risk. Shadig idicates a chage effective Jauary 1, 2018, uless otherwise oted i the What's New. ACC 32 CAMH Update 2, Jauary 2018

35 The Accreditatio Process A survey is desiged to be idividualized to each orgaizatio, to be cosistet, ad to support the orgaizatio s efforts to improve performace. The Joit Commissio determies the legth of a survey based o iformatio supplied i the E-App that describes the orgaizatio s size ad scope of services. I additio, Joit Commissio surveyors may coduct some survey activities durig early morig, eveig, ight, ad weeked hours, as ecessary. These off-shift visits do ot occur before the opeig coferece at the start of the survey. Survey Notificatio The Joit Commissio geerally coducts uaouced surveys betwee 18 ad 36 moths after a orgaizatio s previous full survey, except for situatios i which it would ot be logical or feasible to coduct a uaouced survey. Table 1 outlies specific exceptios to uaouced surveys. Table 1. Exceptios to Uaouced Trieial Surveys Subject Early Survey Policy 1st survey Orgaizatios udergoig ICM Optio 2 ad Optio 3 surveys Departmet of Defese facilities Exceptio Aouced Aouced (uless the orgaizatio requests the survey to be uaouced) Aouced (with 7 busiess days otice) With a uaouced survey, a accredited orgaizatio will receive o otice of its survey date prior to the start of the survey. I cocert with the uaouced survey process, the followig procedures will be implemeted: Accredited orgaizatios will be able to idetify, i their 27-moth E-App, up to 15 days i their survey eligibility rage (betwee 18 ad 36 moths after their last full survey) i which a uaouced survey should be avoided. Oce the 27-moth E-App has bee submitted, these dates caot be modified. These 15 days should ot iclude federal holidays but may iclude regioal evets durig which it may be difficult to coduct a survey. The Joit Commissio will make every effort to accommodate the orgaizatio regardig avoidig these 15 days. However, The Joit Commissio reserves the right to coduct a survey durig a avoid period. Shadig idicates a chage effective Jauary 1, 2018, uless otherwise oted i the What's New. CAMH Update 2, Jauary 2018 ACC 33

36 Comprehesive Accreditatio Maual for Hospitals A orgaizatio is required to demostrate how it commuicates o a ogoig basis to its public that if members of the public have ay quality-of-care or safety cocers, they should otify The Joit Commissio (see APR i the APR chapter). If a orgaizatio kows of a surveyor who works (or has worked) at the orgaizatio or a competig orgaizatio or has had persoal experiece with the survey or that represets a potetial coflict, the orgaizatio is asked to idetify the idividual(s) i its E-App or otify The Joit Commissio via phoe or as soo as possible so that aother surveyor may be assiged. Orgaizatios are otified of upcomig Joit Commissio surveys accordig to which of the followig three types of survey they are goig to receive: 1. Uaouced Evets. O the day of the uaouced survey, by 7:30 A.M. i the orgaizatio s local time zoe (for orgaizatios withi the Uited States ad its territories), The Joit Commissio will post o the orgaizatio s secure Joit Commissio Coect site the letter of itroductio, the survey ageda, ad the biography ad picture of each surveyor assiged to coduct the evet. Oce the otificatio which serves as the official otice of the upcomig evet has bee posted, a otificatio will be set to the idividuals listed as chief executive officer, primary accreditatio/certificatio cotact, ad corporate cotact (if applicable) o the orgaizatio s extraet. This will advise that a evet has bee scheduled for that day ad istruct the cotact(s) to log i to the Joit Commissio Coect site to view the evet details. 2. Aouced Evets. Thirty days prior to the scheduled aouced evet, The Joit Commissio will post o the orgaizatio s secure Joit Commissio Coect extraet site the letter of itroductio, the survey ageda, ad the biography ad picture of each surveyor assiged to coduct the evet. Oce this otificatio which serves as the official otice of the upcomig evet has bee posted, a otificatio will be set to the idividuals listed as chief executive officer ad primary accreditatio/ certificatio cotact o the orgaizatio s extraet. This will advise that a evet has bee scheduled ad istruct the cotact(s) to log i to the Joit Commissio Coect site to view the evet details. The orgaizatio will also receive a separate by 7:30 A.M. i the orgaizatio s local time zoe (for orgaizatios withi the Uited States ad its territories) o the morig of the evet with the same iformatio listed above. These iclude all evets coducted for Medicare certificatio purposes through The Joit Commissio s available deemed status or Medicare recogitio optios. Shadig idicates a chage effective Jauary 1, 2018, uless otherwise oted i the What's New. ACC 34 CAMH Update 2, Jauary 2018

37 The Accreditatio Process 3. Short-Notice Evets. Seve busiess days prior to the scheduled evet, The Joit Commissio will post o the orgaizatio s secure Joit Commissio Coect site the letter of itroductio, the survey ageda, ad the biography ad picture of each surveyor assiged to coduct the evet. Oce the otificatio which serves as the official otice of the upcomig evet has bee posted, a otificatio will be set to the idividuals listed as chief executive officer ad primary accreditatio/certificatio cotact o the orgaizatio s extraet. This will advise that a evet has bee scheduled ad istruct the cotact(s) to log i to the Joit Commissio Coect site to view the evet details. The orgaizatio will also receive a separate by 7:30 A.M. i the orgaizatio s local time zoe (for orgaizatios withi the Uited States ad its territories) o the morig of the evet with the same iformatio listed above. Orgaizatios that are eligible for short otice will o loger receive a phoe call from a Joit Commissio represetative otifyig them that the evet has bee scheduled. Iitial ad Full Survey Team Compositio Based o the size ad complexity of the orgaizatio beig surveyed, a accreditatio survey may be coducted by oe surveyor or a team of surveyors, with a miimum of at least oe cliical surveyor assiged to the evet. The compositio of a orgaizatio s survey team is based o the iformatio provided i its E-App. O surveys with more tha oe surveyor, oe of the surveyors is desigated as the team leader. The team leader is resposible for itegratio, coordiatio, ad commuicatio of o-site survey activities. I additio to beig oe of the surveyors coductig the survey, the team leader serves as the primary poit of o-site cotact betwee the orgaizatio ad The Joit Commissio. Amog other resposibilities, the team leader leads the opeig coferece ad the daily ad exit briefigs. Life Safety Code Surveyor Scope of Service A Life Safety Code Surveyor will be part of every hospital survey. The Life Safety Code Surveyor is resposible for evaluatig specific eviromet of care ad Life Safety Code accreditatio criteria ad educatig the orgaizatio durig the survey about related compliat ad ot compliat areas, opportuities for improvemet, ad remedial actio that may be required. The Life Safety Code Surveyor is always accompaied by at least oe cliical surveyor durig the iitial ad full survey evets. Shadig idicates a chage effective Jauary 1, 2018, uless otherwise oted i the What's New. CAMH Update 2, Jauary 2018 ACC 35

38 Comprehesive Accreditatio Maual for Hospitals Survey Ageda The Joit Commissio reviews the data i a hospital s E-App ad posts a sample ageda o the orgaizatio s secure Joit Commissio Coect site. Also available o the secure site is the Survey Activity Guide, which icludes a list of iitial materials that the surveyor will request to review at the oset of the survey. The orgaizatio s Joit Commissio accout executive will cotact the hospital ad provide the aticipated umber of days ad umber of surveyors that will be assiged for the o-site survey. O the first day of a o-site survey, the surveyor(s) will work with the hospital to esure the schedule cosiders the orgaizatio s operatios ad eeds. Durig the survey, the surveyor(s) will work to miimize ay disruptio to patiet care whe coductig survey activities. The o-site survey process focuses o cotiuous operatioal improvemet i support of safe, high-quality care, treatmet, ad services. The survey ageda will iclude the elemets described i the followig paragraphs. Surveyor Arrival ad Prelimiary Plaig Sessio. Upo arrival, surveyors will check i with receptio, preset their idetificatio, ad idicate their purpose for visitig. Staff should be prepared with a pla ad istructios for how to proceed. The surveyor(s) will wat to get settled i ad begi reviewig the documetatio idetified i the Documet List as soo as possible. Opeig Coferece ad Orietatio to the Orgaizatio. Durig the opeig coferece, the surveyor(s) describes the structure ad cotet of the survey to orgaizatio staff. Surveyors will take time to itroduce your orgaizatio to the revised clarificatio procedures ad ew Survey Aalysis for Evaluatig Risk (SAFER ) reportig process. Durig the time desigated for the orietatio, staff provide the surveyor(s) with iformatio about the orgaizatio. At this time, the hospital will briefly explai its structures, missio, visio, ad relatioship with the commuity. This provides the surveyor(s) with baselie iformatio about the orgaizatio that ca help focus subsequet survey activities. Surveyor Plaig Sessio. Durig this sessio, the surveyor(s) will review data ad iformatio about the hospital to pla the survey ageda. This will iclude ay iformatio from previously coducted Joit Commissio activities ad other hospital Please see the Survey Activity Guide o the Joit Commissio Coect site or at for more detailed iformatio o the survey process. Shadig idicates a chage effective Jauary 1, 2018, uless otherwise oted i the What's New. ACC 36 CAMH Update 2, Jauary 2018

39 The Accreditatio Process documets that have bee gathered for review. The surveyor(s) will select the first patiets for tracig based o what he or she lears from the review of data ad iformatio durig this sessio. Idividual Tracer Activity. Durig the idividual tracer activity, the surveyor(s) will do the followig: Follow the course of care, treatmet, or services provided to the patiet by the hospital from preadmissio through post-discharge Assess the iterrelatioships amog disciplies ad services/programs ad the importat fuctios i the care, treatmet, or services provided Evaluate the performace of processes relevat to the care, treatmet, or service eeds of the patiet, with particular focus o the itegratio ad coordiatio of distict but related processes Idetify vulerabilities i the care processes See the Tracer Methodology sectio for more iformatio about idividual tracer activity. System Tracers. System tracers are iteractive sessios with the surveyor(s) ad orgaizatio staff that explore the performace of importat patiet-related fuctios that cross the orgaizatio. The surveyor(s) will explore critical risk poits with orgaizatio staff ad provide educatio whe idicated durig the system tracer sessios. System tracers may iclude the followig: Data maagemet Ifectio cotrol Medicatio maagemet, if withi the scope of the orgaizatio Program-specific areas (see the Accreditatio Program Specific Tracers sectio) As surveyors perform idividual tracers (see sectio above) to determie stadards compliace as it relates to care delivered to the selected patiet, they also begi to lear about the orgaizatio s overall systems. Iformatio gathered durig idividual tracers is the cosidered from a multi-patiet, cross-orgaizatioal perspective durig system tracers for high-risk processes. See the Tracer Methodology sectio for more iformatio. Program-Specific Tracers. Program-specific tracers will be coducted if they apply to the orgaizatio beig surveyed ad at the surveyor s discretio. These program-focused activities take place durig the time oted o the ageda for idividual tracer activity. See the Tracer Methodology sectio for more iformatio. Shadig idicates a chage effective Jauary 1, 2018, uless otherwise oted i the What's New. CAMH Update 2, Jauary 2018 ACC 37

40 Comprehesive Accreditatio Maual for Hospitals Issue Resolutio. This sessio provides a opportuity for the surveyor(s) to follow up o potetial fidigs that could ot be resolved i other survey activities. Surveyor Team Meetig/Plaig Sessio. This time is reserved for the surveyor(s) to review ad aalyze the iformatio gathered throughout the day ad pla for upcomig survey activities. Daily Briefigs. Durig the daily briefig sessio, surveyors will commuicate to orgaizatio staff their observatios o the previous day s survey fidigs ad ay sigificat patters or treds that are becomig evidet i the survey, if requested to do so. Durig the daily briefig, the surveyor(s) will do the followig: Facilitate leaders uderstadig of the survey process ad the fidigs Report o fidigs from the previous day s survey activities, icludig the placemet of fidigs up to that poit o the SAFER Matrix (ote that placemet of fidigs o the matrix is subject to chage as the survey progresses ad there may be additioal fidigs) Emphasize patters or treds of sigificat cocer that could lead to ocompliace determiatios Highlight ay positive fidigs or exemplary performace Allow the orgaizatio to supply additioal iformatio that would demostrate compliace with a stadard that a surveyor has idicated may be a RFI Review the ageda for the survey day ahead ad make ay ecessary adjustmets based o hospital eeds or the eed for more itesive assessmet of a issue If the orgaizatio has additioal iformatio that would demostrate compliace with a stadard that a surveyor has idicated may be a RFI, the orgaizatio should supply that iformatio to the surveyor(s) as soo as possible. Medical Staff Credetialig ad Privilegig. This activity will help the hospital ad the surveyor(s) idetify specific issues ad do the followig: Evaluate the process the hospital uses to collect relevat data for decisios for credetialig ad privilegig Evaluate the cosistet implemetatio of the credetialig ad privilegig process Evaluate processes for the gratig of ad the appropriate delieatio of privileges Determie whether practitioers practice withi the limited scope of delieated privileges Lik results of peer review ad focused moitorig to the credetialig ad privilegig process Idetify vulerabilities i the credetialig, privilegig, ad appoitmet process Shadig idicates a chage effective Jauary 1, 2018, uless otherwise oted i the What's New. ACC 38 CAMH Update 2, Jauary 2018

41 The Accreditatio Process Evaluate ogoig professioal practice evaluatio (OPPE) ad focused professioal practice evaluatio (FPPE) processes Competece Assessmet. This review activity focuses o the hospital s processes for esurig the appropriate kowledge ad competece of staff providig patiet care, treatmet, ad services. The surveyor(s) ad the orgaizatio will discuss ad review topics such as these: Processes for verifyig required professioal liceses, registratios, ad certificatios Orietatio ad traiig process for staff Methods for assessig competece of staff I-service ad other educatio ad traiig activities for staff Surveyors will request a sample of persoel records represetig a variety of disciplies ecoutered throughout the survey. With authorized orgaizatio staff, the surveyor will review these records to validate through documetatio what they have heard from both leaders ad staff related to the topic of iitial ad ogoig competece assessmet. Eviromet of Care. This sessio is a opportuity for the surveyor ad hospital to review ad evaluate the followig: The processes i place for maagig risk i the physical eviromet (for example, safety ad security, fire safety, hazardous materials ad wastes, medical equipmet) Emergecy Maagemet. This survey activity will allow the orgaizatio ad the surveyor(s) to do the followig: Discuss the four phases of emergecy maagemet: mitigatio, preparedess, respose, ad recovery Review ad discuss orgaizatio plas for maagig critical areas of their operatios so that they ca effectively respod regardless of the emergecy Review emergecy maagemet processes, such as idetifyig risks, iteractios with other health care orgaizatios, iteractios ad commuicatio with the commuity, ad drills, critiques, ad performace improvemet Facility Orietatio Life Safety Code Surveyor. This survey activity is performed by a Life Safety Code Surveyor. I additio to assessig the mai fire alarm pael ad becomig familiar with the buildig layout, the surveyor will evaluate the effectiveess of processes for the followig: Idetifyig ad resolvig Life Safety Code problems Developig ad implemetig activities to protect occupats durig periods whe a buildig does ot meet the Life Safety Code or durig costructio periods Shadig idicates a chage effective Jauary 1, 2018, uless otherwise oted i the What's New. CAMH Update 2, Jauary 2018 ACC 39

42 Comprehesive Accreditatio Maual for Hospitals Maitaiig fire safety equipmet ad fire safety buildig features Maitaiig ad testig emergecy power systems Maitaiig ad testig medical gas ad vacuum systems Life Safety Code Buildig Assessmet. This sessio icludes a buildig tour that will help the Life Safety Code Surveyor determie the degree of compliace with relevat Life Safety Code requiremets. The surveyor will assess the followig: Pressure relatioships i operatig rooms Required fire separatios Required smoke separatios Hazardous areas (ad spaces above their ceiligs) such as soiled lie rooms, trash collectio rooms, ad oxyge storage rooms Fire exits Kitche grease producig cookig devices ad laudry ad trash chutes Emergecy power systems ad equipmet Medical gas ad vacuum system compoets Leadership Sessio. Durig the leadership sessio, surveyors will explore leadership s resposibility for creatig ad maitaiig the orgaizatio s systems, ifrastructure, ad key processes that cotribute to the quality ad safety of patiet care, treatmet, or services. The sessio is iteded to be iteractive; therefore, surveyors ad orgaizatio leaders will egage i a discussio, usig orgaizatio-specific examples, of the followig topics: Leadership commitmet to improvemet of quality ad safety Creatig a culture of safety Robust Process Improvemet Observatios that may be idicative of system-level cocers Surveyor Report Preparatio. The surveyor(s) will use this time to compile, aalyze, ad orgaize the data he or she has collected throughout the survey ito a prelimiary Summary of Survey Fidigs Report reflectig the orgaizatio s compliace with stadards (see the Summary of Survey Fidigs Report sectio). Exit Briefig ad Orgaizatio Exit Coferece. The surveyor will offer to meet with the most seior leader, usually the CEO or admiistrator, or the leadership team to coduct a private Exit Briefig. Durig the Exit Briefig, the surveyor will preset the survey fidigs ad review the prelimiary Summary of Survey Fidigs Report Shadig idicates a chage effective Jauary 1, 2018, uless otherwise oted i the What's New. ACC 40 CAMH Update 2, Jauary 2018

43 The Accreditatio Process (icludig the SAFER Matrix results), discuss ay cocers seior leaders have with the report, ad determie the eed for ay special arragemets for the Orgaizatio Exit Coferece. Durig the Orgaizatio Exit Coferece the surveyor(s) will review the survey fidigs (if desired by seior leaders), review the issues of stadards compliace that have bee idetified durig the survey, ad review required follow-up actios, as applicable. Tracer Methodology The tracer methodology is the corerstoe of The Joit Commissio o-site survey. The tracer methodology icorporates the use of iformatio the orgaizatio supplies i the E-App to follow the experiece of care, treatmet, or services for a umber of idividuals through the orgaizatio s etire health care delivery process. Tracers allow the surveyor(s) to idetify performace issues i oe or more steps of the process, or i the iterfaces betwee processes. Tracer types are described i the followig sectios. Accreditatio Program Specific Tracers The goal of the program-specific tracer activity is to idetify safety cocers withi differet levels ad types of care, treatmet, or services. Program-specific tracers focus o importat issues relevat to the orgaizatio (for example, cliical services offered ad high-risk, high-volume patiet populatios). Topics for the program-specific tracers were idetified through a review of expert literature, research, iput from the field, ad subject matter expertise. Accreditatio program specific tracers evaluate program-specific issues ad compliace with relevat stadards that impact patiet safety. Table 2 cotais hospital-specific tracer activities, icludig applicability ad objectives. Note: Program-specific tracers, which occur durig the Idividual Tracer Activity, are coducted oly if they apply to the orgaizatio beig surveyed. Table 2. Hospital-Specific Tracer Applicability ad Objectives cotiued o ext page Shadig idicates a chage effective Jauary 1, 2018, uless otherwise oted i the What's New. CAMH Update 2, Jauary 2018 ACC 41

44 Comprehesive Accreditatio Maual for Hospitals Table 2. (cotiued) Tracer Applicability Objectives Laboratory Itegratio All hospitals To evaluate the cosistet applicatio of processes related to laboratory testig throughout the hospital To evaluate the exchage of iformatio ad itegratio of the laboratory process i the hospital settig (for example, specime collectio ad hadlig, specime idetificatio) To evaluate the ivolvemet of laboratory persoel i importat processes withi the hospital, such as poit-of-care testig Patiet Flow All hospitals To look for orgaizatio awareess ad improvemets i patiet flow To evaluate process issues throughout the hospital cotributig to patiet flow cocers Suicide Prevetio All hospitals To evaluate the effectiveess of the orgaizatio s suicide prevetio strategy To idetify processes ad system-level issues cotributig to suicide attempts Idividual Tracer Activity The idividual tracer activity is coducted durig a o-site survey ad is desiged to trace the care experieces that a patiet had while at the hospital. The tracer methodology is a way to aalyze a hospital s system of providig care, treatmet, or services usig actual patiets as the framework for assessig stadards compliace. The surveyor(s) will use the followig geeral criteria to select iitial idividual tracers: Patiets whose tracers would allow for the evaluatio of idetified program-specific risk areas/categories (EPs with the ico). Patiets who cross programs (for example, home care patiets discharged from a hospital or idividuals served by behavioral health care orgaizatios who preset at a ambulatory care facility i complex orgaizatios) Shadig idicates a chage effective Jauary 1, 2018, uless otherwise oted i the What's New. ACC 42 CAMH Update 2, Jauary 2018

45 The Accreditatio Process Patiets who will cotribute greater uderstadig to system tracer topics (see the System Tracer Activity sectio), such as ifectio cotrol or medicatio maagemet Patiets receivig complex services, such as surgery or treatmet i a itesive care uit ## Patiets selected for iitial idividual tracer activity will likely be those whose diagosis, age, or type of services received may eable the best i-depth evaluatio of the hospital s processes ad practices. I coductig a patiet s tracer, the surveyor(s) will follow specific patiets through the hospital s processes. A surveyor will ot oly examie the idividual compoets of a system but will also evaluate how the compoets of a system iteract with each other. I other words, a surveyor will look at the care, treatmet, or services provided by each departmet/uit/program ad service, as well as how departmets/uits/programs ad services work together. The surveyor(s) usually starts where the patiet is curretly located. He or she ca the move to where the patiet first etered the orgaizatio s systems; a area of care provided to the patiet that may be a priority for that orgaizatio; or to ay areas i which the patiet received care, treatmet, or services. The locatio ad order will vary. Alog the way, the surveyor(s) will speak with the health care staff member(s) who actually provided the care to that idividual tracer patiet or, if that staff member(s) is ot available, will speak with aother staff member(s) who provides the same type of care, treatmet, or services. Surveyors use idividual patiet tracers ad systems tracers to review patiet medical records. For hospitals seekig deemed status, surveyors will review ipatiet records for 10% of the average daily cesus but ot fewer tha 30 ipatiet records, or for small geeral hospitals (with a average daily cesus of 20 patiets or less) ot fewer tha 20 ipatiet records. For specialty hospitals (such as cardiac, orthopedic, or surgical hospitals), the miimum is 30 ipatiet records regardless of average daily cesus. Based o the fidigs of the surveyor(s), he or she may select similar patiets to trace. The tracer methodology permits surveyors to further ivestigate if there is a reaso to believe that a issue eeds further exploratio. ## Please see the Survey Activity Guide o the Joit Commissio Coect site for more detailed iformatio o other program-specific criteria for tracer selectio. Shadig idicates a chage effective Jauary 1, 2018, uless otherwise oted i the What's New. CAMH Update 2, Jauary 2018 ACC 43

46 Comprehesive Accreditatio Maual for Hospitals Risk Areas A surveyor coductig ay type of tracer at a hospital might otice somethig that requires a more i-depth look. At that poit, the surveyor will look at all processes at a system level by askig more detailed questios or spedig more time lookig at a particular risk area. The focused evaluatio icludes processes or procedures that, if ot plaed or implemeted correctly, have sigificat potetial for affectig/impactig patiet safety. Surveyors will assess ad display the risk associated with fidigs by utilizig the SAFER Matrix. Survey fidigs will be plotted o the SAFER Matrix accordig to the likelihood the RFI could cause harm to patiets, staff, ad/or visitors ad the scope at which the RFI was observed. Topics i hospitals that surveyors might eed to explore i more detail iclude, but are ot limited to, the followig: Assessig, plaig, ad coordiatig care Emergecy maagemet Eviromet of care Ifectio cotrol Life safety Medical staff Medicatio maagemet Operative ad ivasive procedures Restraits System Tracer Activity System tracers explore oe specific system or process across the orgaizatio, focusig, whe possible, o the experieces of specific patiets or activities relevat to specific patiets. This differs from idividual tracers i that durig idividual tracers, the surveyor(s) follows a patiet through his or her course of care, evaluatig all aspects of care as opposed to a system. Durig the system tracer sessios, the surveyor(s) evaluates the system or process, icludig the itegratio of related processes ad the coordiatio ad commuicatio amog disciplies ad departmets i those processes. A system tracer icludes a iteractive sessio (ivolvig a surveyor ad relevat staff members) i tracig a system withi the orgaizatio based o iformatio from idividual tracers. Poits of discussio i the iteractive sessio iclude the followig: Shadig idicates a chage effective Jauary 1, 2018, uless otherwise oted i the What's New. ACC 44 CAMH Update 2, Jauary 2018

47 The Accreditatio Process The flow of the process across the hospital, icludig idetificatio ad maagemet of risk poits, itegratio of key activities, ad commuicatio amog staff/uits ivolved i the process Stregths i the process ad possible actios to be take i areas eedig improvemet Issues requirig further exploratio i other survey activities A baselie assessmet of stadards compliace Educatio by the surveyor, as appropriate The three topics evaluated with system tracers are data maagemet, ifectio cotrol, ad medicatio maagemet. Whether all system tracers are coducted varies based o survey legth, but the data use system tracer is performed o every hospital survey. If survey legth does ot permit the coduct of a ifectio cotrol or medicatio maagemet system tracer, the give area is assessed through other survey activities. Data Maagemet. The data maagemet system tracer focuses o how the hospital collects, aalyzes, iterprets, ad uses or maages data to improve patiet safety ad care. Ifectio Cotrol. The ifectio cotrol idividual-based system tracer explores the hospital s ifectio cotrol processes. The goals of this sessio are to assess the hospital s compliace with the relevat ifectio cotrol stadards, idetify ifectio cotrol issues that require further exploratio, ad determie actios that may be ecessary to address ay idetified risks ad improve the safety of patiets. Medicatio Maagemet. The medicatio maagemet idividual-based system tracer explores the hospital s medicatio maagemet processes while focusig o subprocesses ad potetial risk poits (such as hadoff poits). This tracer activity helps the surveyor(s) evaluate the cotiuity of medicatio maagemet from procuremet of medicatios through the moitorig of their effects o patiets. The Role of Staff i Tracer Methodology To help the surveyor(s) i the tracer methodology process, staff will be asked to provide the surveyor(s) with a list of active patiets, icludig the patiets ames, curret locatios i the hospital, ad diagoses/coditios, as appropriate. The surveyor(s) may request assistace from hospital staff for selectio of appropriate tracer patiets. As the surveyor(s) moves aroud a hospital, he or she will ask to speak with the staff members who have bee ivolved i the tracer patiet s care, treatmet, or services if available. If those staff members are ot available, the surveyor(s) will ask to speak to aother staff member who would perform the same fuctio(s) as the member who has cared for or is Shadig idicates a chage effective Jauary 1, 2018, uless otherwise oted i the What's New. CAMH Update 2, Jauary 2018 ACC 45

48 Comprehesive Accreditatio Maual for Hospitals carig for the tracer patiet. Although it is preferable to speak with the direct staff member, it is ot madatory because the questios that will be asked are questios that ay staff member should be able to aswer i providig care, treatmet, or service to the patiet beig traced. Immediate Threat to Health or Safety The Joit Commissio defies Immediate Threat to Health or Safety as a threat that represets immediate risk ad has or may potetially have serious adverse effects o the health or safety of the patiet, residet, or idividual served. Such a situatio may occur aywhere i a orgaizatio. (See Accreditatio Participatio Requiremet [APR] ) For orgaizatios usig the deemed status optio, the fidig(s) that cotributes to the Immediate Threat situatio will be documeted as a Medicare Coditio-level deficiecy. If a surveyor idetifies ay coditio that he or she believes poses a serious threat to public or patiet health or safety, he or she will otify the orgaizatio s CEO ad Joit Commissio headquarters staff immediately. The presidet of The Joit Commissio, or his or her desigee, ca the issue a expedited Prelimiary Deial of Accreditatio decisio based o the threat. A orgaizatio otified of a Prelimiary Deial of Accreditatio decisio *** due to a Immediate Threat to Health or Safety situatio does ot have a right to clarify the survey fidigs relative to the situatio. Sice a Prelimiary Deial of Accreditatio is a official accreditatio decisio category, the decisio is posted o Quality Check. The orgaizatio s CEO ad appropriate govermetal authorities are iformed of this decisio ad the fidigs that led to this actio. I deemed status scearios where the survey is utilized to demostrate compliace with the Medicare Coditios of Participatio, The Joit Commissio will provide writte otificatio of the immediate threat to CMS withi 2 busiess days of cofirmig the immediate threat ad subsequetly withi 10 caledar days with additioal iformatio cocerig the immediate threat. After otificatio of the Prelimiary Deial of Accreditatio decisio, a orgaizatio has up to 72 hours to do the followig: Elimiate the Immediate Threat to Health or Safety situatio etirely or *** After the Prelimiary Deial of Accreditatio decisio has bee cofirmed by the Joit Commissio s executive leadership, the orgaizatio has five days to otify The Joit Commissio if it wishes to appeal the decisio. If this is the case, The Joit Commissio s Review ad Appeal Procedures apply. Shadig idicates a chage effective Jauary 1, 2018, uless otherwise oted i the What's New. ACC 46 CAMH Update 2, Jauary 2018

49 The Accreditatio Process If the situatio is such that it will take the orgaizatio more time to fully elimiate it (such as situatios ivolvig buildig costructio), the the orgaizatio must implemet emergecy itervetios to abate the risk to patiets (for example, cease performig a certai procedure, implemet additioal safety measures) withi 72 hours. If the situatio is ot fully elimiated withi 72 hours, the orgaizatio will have a maximum of 23 caledar days to do so. At its ext meetig, executive leadership ca either cofirm or reverse the Prelimiary Deial of Accreditatio decisio by the presidet or his/her desigee. Executive leadership may take ito cosideratio a orgaizatio s corrective actios or resposes to a serious threat situatio. The orgaizatio ca provide iformatio to demostrate that a serious threat to health or safety has bee corrected prior to executive leadership s cosideratio of the Prelimiary Deial of Accreditatio decisio. I these situatios, the corrective actio is cosidered whe a sigle issue leads to the adverse fidig ad the orgaizatio demostrates that it did the followig: Took immediate actio to completely remedy the situatio Adopted systems chages to prevet a future recurrece of the problem If the orgaizatio demostrates that it has take corrective actio, The Joit Commissio will coduct a abatemet survey to validate the implemetatio of the corrective actio ad that the immediate threat situatio is o loger preset. The results of the abatemet survey will help The Joit Commissio determie whether to remove the Prelimiary Deial of Accreditatio decisio (assumig there are o other reasos for the Prelimiary Deial of Accreditatio). Therefore, the sooer a orgaizatio elimiates the Immediate Threat to Health or Safety situatio, the shorter the period of time the orgaizatio may be i Prelimiary Deial of Accreditatio. Upo resolutio of a Immediate Threat to Health or Safety situatio, the orgaizatio s accreditatio status may chage from Prelimiary Deial of Accreditatio (PDA) to a time-limited PDA ad Accreditatio with Follow-up Survey ad remai as such util a accreditatio follow-up survey is coducted to assess the orgaizatio s sustaied implemetatio of appropriate corrective actios. Emergecy itervetio refers to ay safety measure implemeted to preserve life, whether related to Life Safety Code deficiecies or aother Immediate Threat to Health or Safety situatio. Whe referrig to specific Life Safety Code issues, these itervetios would be called iterim life safety measures, which are defied as a series of 11 admiistrative actios iteded to temporarily compesate for sigificat hazards posed by existig Natioal Fire Protectio Associatio Life Safety Code deficiecies or costructio activities. Shadig idicates a chage effective Jauary 1, 2018, uless otherwise oted i the What's New. CAMH Update 2, Jauary 2018 ACC 47

50 Comprehesive Accreditatio Maual for Hospitals See Figure 2 for a visual represetatio of the process flow for Immediate Threat to Health or Safety situatios at orgaizatios seekig reaccreditatio. Immediate Threat to Health or Safety Durig Iitial Survey There are oly two possible outcomes Accredited or Deial of Accreditatio for a orgaizatio udergoig its first, or iitial, Joit Commissio survey; therefore, iitial orgaizatios that have a Immediate Threat to Health or Safety situatio will receive a Deial of Accreditatio decisio with o opportuity for a appeal. Oce the Immediate Threat to Health or Safety situatio is idetified, the orgaizatio will ot be able to withdraw from the accreditatio process. I additio, The Joit Commissio will otify CMS (if the orgaizatio had plaed o usig its Joit Commissio accreditatio for meetig deemed status requiremets) or other licesig authority havig jurisdictio that the orgaizatio was deied accreditatio due to the Immediate Threat to Health or Safety. If the orgaizatio decides to reapply after the appropriate time iterval (a miimum of four moths), it will udergo a survey to demostrate that it has abated the Immediate Threat to Health or Safety. This survey may be coducted before or i cojuctio with the full survey. Shadig idicates a chage effective Jauary 1, 2018, uless otherwise oted i the What's New. ACC 48 CAMH Update 2, Jauary 2018

51 The Accreditatio Process Process Flow for Immediate Threat to Health or Safety (ITHS) Situatios Survey is coducted Durig survey, surveyors idetify a ITHS situatio Surveyor cosults with The Joit Commissio s cetral office staff Cetral office staff discusses the situatio with The Joit Commissio s presidet or his desigee The Joit Commissio presidet agrees with the ITHS ad places the orgaizatio i Prelimiary Deial of Accreditatio (PDA) NO Orgaizatio receives alterative accreditatio decisio based o survey fidigs YES NO PDA process cotiues PDA decisio is preseted to executive leadership The orgaizatio is otified of PDA decisio ad ITHS process is explaied Orgaizatio otifies The Joit Commissio that it has abated the ITHS situatio The Joit Commissio coducts a abatemet survey ITHS situatio o loger exists Executive leadership cofirms PDA decisio PDA decisio is posted o Quality Check ad govermetal/licesure agecies are otified Orgaizatio is otified of Executive YES leadership s decisio Orgaizatio YES ad its right to appeal appeals PDA provided The Joit decisio Commissio is otified withi five days Appeal process YES PDA decisio is chaged to Accreditatio with Follow-up Survey (AFS) decisio AFS process is ivoked NO NO Orgaizatio receives alterative accreditatio decisio Deial of Accreditatio becomes fial after 5 days Figure 2. Process flow for Immediate Threat to Health or Safety (ITHS) situatios at orgaizatios seekig reaccreditatio. Shadig idicates a chage effective Jauary 1, 2018, uless otherwise oted i the What's New. CAMH Update 2, Jauary 2018 ACC 49

52 Comprehesive Accreditatio Maual for Hospitals The Summary of Survey Fidigs Report Followig evaluatio of a orgaizatio s performace of fuctios ad processes, the surveyor (or survey team) reviews the results of itegrated idividual fidigs. The, with the use of laptop-based support software, the surveyor (or survey team) posts the orgaizatio s prelimiary Summary of Survey Fidigs Report to the orgaizatio s extraet site. Icluded i this prelimiary report is the Survey Aalysis for Evaluatig Risk (SAFER ) Matrix, which gives a visual represetatio of the risk level of each RFI. If requested, the surveyor (or survey team leader) ad the orgaizatio s CEO meet prior to the closig coferece to determie how the report will be shared (i terms of detailed, summary, or geeral commets) at the closig coferece. The surveyor (or survey team) uses the report cotets i makig closig coferece presetatios. Shortly after a survey, a orgaizatio s report of survey fidigs is posted o the orgaizatio s secure Joit Commissio Coect site. The report icludes RFIs, as appropriate. Each RFI will be plotted o the SAFER Matrix accordig to the risk level of the fidig that is, the likelihood of the fidig to cause harm to patiets, staff, ad/or visitors ad the scope at which the RFI was observed. If a hospital does ot receive ay RFIs, its accreditatio decisio is redered at the same time that the hospital s prelimiary Summary of Survey Fidigs Report is available, ad it is effective the day after the completio of the survey. If a hospital does receive RFIs, the its accreditatio decisio is redered followig the submissio of a acceptable ESC report. (See the Accreditatio Effective Date sectio ad the Evidece of Stadards Compliace [ESC] Process sectio for more iformatio.) After the Survey This sectio icludes iformatio relevat to a orgaizatio that has recetly participated i a accreditatio survey. Material icludes iformatio o scorig, the types of accreditatio decisios, the ESC ad clarificatio processes, how to request the review of a accreditatio decisio, how to appeal a accreditatio decisio, ad how to use ad display a accreditatio award. The Scorig Process The performace expectatios for determiig if a stadard is i compliace are icluded i its Elemets of Performace (EPs). If a EP is determied to be out of compliace, the it will be cited as a Requiremet for Improvemet (RFI). Each RFI is placed i the SAFER Matrix accordig to how likely it is that the RFI will harm a patiet(s), staff, ad/ Shadig idicates a chage effective Jauary 1, 2018, uless otherwise oted i the What's New. ACC 50 CAMH Update 2, Jauary 2018

53 The Accreditatio Process or visitor (low, moderate, high) ad the scope, or prevalece, at which the RFI was cited (limited, patter, widespread). As the risk level of a fidig or a observatio icreases, the placemet of the stadard ad EP moves from the bottom left corer (lowest risk level) to the upper right corer (highest risk level). Figure 3 is a represetatio of the SAFER Matrix. Immediate Threat to Life LIKELIHOOD TO HARM HIGH (Harm could happe at ay time) MODERATE (Harm could happe occasioally) LOW (Harm could happe but would be rare) LIMITED PATTERN WIDESPREAD (Uique occurrece that is ot represetative of routie/regular practice ad has the potetial to impact oly oe or a very limited umber of patiets/visitors/staff) (Multiple occurreces of the deficiecy, or a sigle occurrece that has the potetial to impact more tha a limited umber of patiets/visitors/staff) SCOPE (Deficiecy is pervasive i the facility, or represets systemic failure, or has the potetial to impact most or all patiets/ visitors/staff) Figure 3. Survey Aalysis for Evaluatig Risk (SAFER) Matrix. The SAFER Matrix is the visual represetatio of risk associated with survey fidigs. If a stadard is ot applicable (NA) to the orgaizatio, it will be marked NA ad ot placed withi the SAFER Matrix. How Accreditatio Decisios Are Made Accreditatio decisios are made based o the premise that the immediacy of risk to quality of care ad patiet safety as show by ocompliace with Joit Commissio stadards ad EPs varies. All ocompliat EPs will be cited as RFIs. I additio, all RFIs must be addressed via the ESC submissio process. The time frame for completig Shadig idicates a chage effective Jauary 1, 2018, uless otherwise oted i the What's New. CAMH Update 2, Jauary 2018 ACC 51

54 Comprehesive Accreditatio Maual for Hospitals the ESC submissio is withi 60 caledar days. However, orgaizatios recommeded for Prelimiary Deial of Accreditatio decisio PDA02 (as a result of patiets beig placed at risk for a serious adverse outcome due to sigificat ad pervasive patters, treds, ad/or repeat fidigs) are required to submit a Pla of Correctio (POC) withi 10 busiess days istead of a ESC. A validatio survey will be required withi 60 days to cofirm that the orgaizatio has implemeted the POC ad is i full compliace. The orgaizatio s accreditatio decisio will be held i abeyace pedig submissio of ESC withi the established time frame. For situatios that costitute more immediate risks to quality of care ad patiet safety, a more severe accreditatio status will be applied. I these scearios, the two accreditatio classificatios defied below will be utilized: Immediate Threat to Health or Safety Decisio Rules Immediate Threat to Health or Safety. Immediate Threat to Health or Safety situatios that are idetified o site have or may potetially have serious adverse effects o the health or safety of patiets. Upo resolutio of a Immediate Threat to Health or Safety situatio, the orgaizatio s accreditatio status may chage from Prelimiary Deial of Accreditatio to Accreditatio with Follow-up Survey ad remai as such util a follow-up survey is coducted to assess the orgaizatio s sustaied implemetatio of appropriate corrective actios. Immediate Threat to Health or Safety situatios are cited at Accreditatio Participatio Requiremet APR , EP 1. Decisio Rules. Decisio rules determie a accreditatio decisio that appropriately represets a orgaizatio s overall performace as measured by ocompliace with the applicable stadards. Decisio rules are applied whe a heighteed risk to patiet care ad safety is determied as a result of o-site survey fidigs. There are times whe situatios will automatically trigger a recommedatio for Prelimiary Deial of Accreditatio or Accreditatio with Follow-up Survey based o such issues as loss of facility licesure, provisio of care by ulicesed idividuals who require such a licese, ad failure to implemet corrective actio i respose to idetified Life Safety Code deficiecies. I follow-up to these situatios, orgaizatios must demostrate resolutio of the situatio through the ESC process. A o-site survey is coducted to validate implemetatio of corrective actio. Shadig idicates a chage effective Jauary 1, 2018, uless otherwise oted i the What's New. ACC 52 CAMH Update 2, Jauary 2018

55 The Accreditatio Process For more iformatio regardig decisio rules, see the Decisio Rules for Orgaizatios Seekig Reaccreditatio ad Decisio Rules for Orgaizatios Seekig Iitial Accreditatio sectios later i this chapter. The Accreditatio Decisio Process The goal of the accreditatio decisio ad reportig approach is to focus attetio o the issues that pose the greatest risk to quality of care, treatmet, ad services ad to patiet safety. Key elemets of the accreditatio decisio process iclude the followig: Levels of ocompliace with Joit Commissio stadards are idetified o the SAFER Matrix. The surveyor(s) leaves a prelimiary Summary of Survey Fidigs Report o site. (For special surveys, o report is left o site.) The Accreditatio Survey Fidigs Report is posted o the hospital s secure extraet site withi 10 busiess days of the survey s completio. If RFIs are cited, the orgaizatio has a 60-day widow to submit a ESC report to address correctio of the RFIs. Orgaizatios that receive a PDA02 decisio must submit a POC (istead of a ESC) withi 10 busiess days; a validatio survey is coducted withi 60 days to cofirm that the POC has bee implemeted ad the orgaizatio is i full compliace. The Joit Commissio Fidigs sectio of the Accreditatio Survey Fidigs Report icludes RFIs ad associated fidigs cited durig the o-site survey. I additio, Joit Commissio EPs that are iitially idetified as less-tha-fully compliat but corrected before the coclusio of the survey are desigated as Observed but Corrected O-site. Although the idicator recogizes issues as havig bee fixed before the coclusio of the survey, these RFIs remai i the survey report; that is, a ESC still eeds to be completed for these fidigs. Decisio Categories for Orgaizatios Seekig Accreditatio Reewal The Joit Commissio s decisio categories are desiged to help distiguish orgaizatios with serious patters ad treds i the provisio of care, treatmet, or services which require follow-up more quickly from those with less serious compliace issues. There are four possible decisio categories for orgaizatios udergoig a Joit Shadig idicates a chage effective Jauary 1, 2018, uless otherwise oted i the What's New. CAMH Update 2, Jauary 2018 ACC 53

56 Comprehesive Accreditatio Maual for Hospitals Commissio survey for reaccreditatio. Figure 4 illustrates the cotiuum of accreditatio decisios possible followig resurvey activity. The Joit Commissio s four accreditatio decisio categories for orgaizatios seekig reewal of accreditatio are as follows: 1. Accredited. The orgaizatio is i compliace with all applicable requiremets at the time of the o-site survey or has successfully addressed all RFIs i a ESC withi 60 days followig the postig of the Accreditatio Survey Fidigs Report ad does ot meet ay other rules for other accreditatio decisios. 2. Accreditatio with Follow-up Survey. The orgaizatio is i compliace with all stadards as determied by a acceptable ESC submissio. A follow-up survey is required withi six moths to assess sustaied compliace. 3. Prelimiary Deial of Accreditatio. There is justificatio to dey accreditatio to the orgaizatio as evideced by A Immediate Threat to Health or Safety to patiets or the public, ad/or Submissio of falsified documets or misrepreseted iformatio, ad/or Lack of a required licese or similar issue at the time of survey, ad/or Failure to resolve the requiremets of Accreditatio with Follow-up Survey, ad/or Sigificat ocompliace with Joit Commissio stadards. I some circumstaces, a decisio of Prelimiary Deial of Accreditatio is subject to review ad appeal prior to the determiatio to dey accreditatio. (See the Appeal Procedures sectio.) 4. Deial of Accreditatio. The orgaizatio has bee deied accreditatio. All available review ad appeal opportuities have bee exhausted. There is a fifth decisio category for orgaizatios seekig iitial accreditatio: Limited, Temporary Accreditatio. As explaied i the Early Survey Policy sectio earlier i this chapter, a orgaizatio receives this decisio if it demostrates compliace with the limited set of stadards surveyed i the first survey uder the Early Survey Policy. Shadig idicates a chage effective Jauary 1, 2018, uless otherwise oted i the What's New. ACC 54 CAMH Update 2, Jauary 2018

57 The Accreditatio Process Figure 4. Cotiuum of survey activity outcomes for orgaizatios seekig reewal of accreditatio. Decisio Outcomes for Orgaizatios Seekig Iitial Accreditatio For orgaizatios udergoig their full first, or iitial, Joit Commissio survey, the decisio process may result i oly two possible outcomes Accredited or Deial of Accreditatio. Iitial orgaizatios receive a Accredited decisio whe they are i compliace with all applicable requiremets at the time of the o-site survey or whe they have successfully addressed all RFIs i a ESC withi 60 days; if they do ot successfully address all RFIs i a ESC withi 60 days, they receive a Deial of Accreditatio decisio. Durig the 60-day time frame, the decisio is pedig ad the process is as follows: Orgaizatios foud out of compliace with Joit Commissio requiremets durig their iitial survey may volutarily withdraw from the accreditatio process with o decisio redered if they have ot yet submitted their ESC i the allotted time. If they do ot withdraw, iitial orgaizatios must submit corrective actio through a ESC. A successful ESC will the result i a Accredited decisio. If a ESC is uacceptable because it does ot demostrate compliace, a decisio of Deial of Accreditatio with o opportuity to appeal will result. Shadig idicates a chage effective Jauary 1, 2018, uless otherwise oted i the What's New. CAMH Update 2, Jauary 2018 ACC 55

58 Comprehesive Accreditatio Maual for Hospitals Orgaizatios foud with Coditio-level deficiecies durig their iitial survey are required by CMS to udergo a secod iitial Medicare survey. If o deficiecies whether related to Joit Commissio requiremets or Medicare Coditios of Participatio are foud durig this secod iitial Medicare survey, the orgaizatio receives a Accredited decisio. If Coditio-level deficiecies are foud durig the secod iitial Medicare survey, the orgaizatio receives a Deial of Accreditatio decisio. However, if the secod Medicare survey results i fidigs of deficiecies with Joit Commissio requiremets oly, the orgaizatio s decisio is agai pedig the submissio of corrective actio through a ESC. A successful ESC will the result i a Accredited decisio; a usuccessful ESC at this poit will result i a decisio of Deial of Accreditatio with o opportuity to appeal. Accreditatio Effective Date For accredited orgaizatios udergoig a resurvey, the effective date of the accreditatio decisio varies. (See the Evidece of Stadards Compliace [ESC] Process sectio for more iformatio.) For orgaizatios that do ot receive ay RFIs, the accreditatio decisio will be effective the day after the last day of survey. Otherwise, a accreditatio decisio is redered oce all RFIs have bee resolved followig the submissio of a acceptable ESC ad evidece of a successful Medicare deficiecy follow-up survey if Medicare Coditio-level deficiecies are idetified, which is retroactive to the day after the last day of the full survey. The accreditatio effective date for a orgaizatio that udergoes a iitial survey is the date o which the last acceptable ESC was submitted, if the orgaizatio has a RFI. If there are o RFIs, the effective date is the day after the last day of the survey. Whe a orgaizatio s accreditatio decisio becomes official, it is publicly disclosable ad is posted o Quality Check. I additio, the Requiremets for Improvemet will be posted for those orgaizatios that receive a Prelimiary Deial of Accreditatio. Withdrawig or Closig After Udergoig a Resurvey A accredited orgaizatio s request to withdraw from the accreditatio process after udergoig a resurvey (or that closes after udergoig survey), but before a fial decisio has bee made, does ot termiate the decisio-makig process. The Joit Commissio the issues a fial accreditatio decisio. Shadig idicates a chage effective Jauary 1, 2018, uless otherwise oted i the What's New. ACC 56 CAMH Update 2, Jauary 2018

59 The Accreditatio Process Withdrawig from Iitial Survey A orgaizatio has the opportuity to withdraw from a iitial survey up util the time it submits a ESC which could be o site or shortly thereafter. If the orgaizatio requests to withdraw from the survey after it submits a ESC, the request will be deied ad the orgaizatio will receive a decisio of Deial of Accreditatio with o opportuity to appeal. Evidece of Stadards Compliace (ESC) Process A ESC is a report submitted by a surveyed hospital that details the actio(s) that it took to brig itself ito compliace with a stadard. The ESC report is available for completio o the hospital s secure Joit Commissio Coect site at the same time that the hospital s Summary of Survey Fidigs report is posted. After the survey, the surveyor(s) trasmits his or her survey fidigs to the Joit Commissio s Cetral Office. The orgaizatio s official Accreditatio Survey Fidigs Report will be posted o its secure Joit Commissio Coect site withi 10 busiess days of completig a survey. Every stadard foud ot i compliace at the time of survey will geerate a RFI. Whe a hospital receives a RFI, it ca choose to go directly to corrective actio or to try ad clarify the accuracy of the RFI. The hospital must submit either a successful clarificatio or a corrective ESC for every RFI cited i a hospital s Accreditatio Survey Fidigs Report (see the Stadards Clarificatio sectio). Challegig specific surveyor observatios will ot result i the automatic removal of a RFI. The time frame for submittig a corrective ESC is 60 days. A corrective ESC must address compliace at the EP level for all applicable correctios. For those fidigs of a higher risk level, additioal fields will be required withi the ESC for the orgaizatio to provide a more detailed descriptio of the leadership ivolvemet ad prevetive aalysis that will assist i sustaiig the compliace pla. I additio, these higher risk fidigs will be provided to surveyors for possible review or o-site validatio durig ay o-site surveys up util the ext full trieial survey occurs. The SAFER Matrix iformatio i Figure 5 provides a represetatio of possible ESC followup activities for RFIs of varyig risk levels. Shadig idicates a chage effective Jauary 1, 2018, uless otherwise oted i the What's New. CAMH Update 2, Jauary 2018 ACC 57

60 Comprehesive Accreditatio Maual for Hospitals Figure 5. SAFER Matrix placemet ad required follow-up activities. Stadards Clarificatio After a survey evet, orgaizatios have the opportuity to submit clarifyig ESC if they believe that their orgaizatio was i compliace with a particular stadard at the time of survey. (This process does ot iclude EPs iitially idetified as ocompliat but corrected before the survey s coclusio. Also ot icluded i this process is the placemet of a fidig withi the SAFER Matrix; that is, a orgaizatio ca clarify the fidig as a whole but caot chage where the fidig is placed withi the matrix.) The clarificatio is part of the ESC process ad must be submitted withi 10 busiess days followig the postig of the orgaizatio s report o the Joit Commissio Coect site. The submissio of a clarificatio does ot egate the requiremet for submissio of a corrective ESC withi 60 days if the clarificatio does ot remove the RFI, or does it provide a orgaizatio with additioal time to submit its ESC. Therefore, if a orgaizatio submits clarificatio ad still has to submit a ESC, the orgaizatio will have up to 60 days i total to submit both the clarificatio ad the corrective ESC. Whe submittig clarifyig ESCs after a survey evet, it is importat to follow the directios i the submissio tool. Address each prompt, detailig why the orgaizatio was i compliace at the time of survey. Remember to address the EP as well as the actual Shadig idicates a chage effective Jauary 1, 2018, uless otherwise oted i the What's New. ACC 58 CAMH Update 2, Jauary 2018

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