What do summer haircuts and TJC have in common?
It’s all about taking a little off the top!
In reviewing the July issue of The Joint Commission’s Perspectives, the top story (if you will) deals with the ongoing reduction of standards and performance elements as we approach the Nirvana that is a direct reflection of the Conditions of Participation (CoPs—there’s probably a mantra that could be extracted for that).
There’s a smattering of changes relative to the EC standards in a number of different accreditation programs (Ambulatory Care, Behavioral Health, Critical Access Hospitals, Laboratories, Nursing Care Centers, Office-Based Surgery, Home Care—you can click through to your heart’s desire here: https://www.jointcommission.org/standards/prepublication-standards/select-retired-and-revised-accreditation-requirements/ ), mostly what I would characterize as consolidation of processes (pre-construction risk assessments, the management of the physical environment as a performance improvement activity).
For those of you with office-based surgery practices in the mix—a number that I suspect is going to grow over time—unless everyone starts throwing up ambulatory surgery centers—I think the consolidation of general environment considerations is a good thing (it would be nice if the hospital standards followed likewise). Though it may be more of an effort to consolidate surveyor focus—only time will tell. At any rate, I would do a quick run-through of the changes to see what’s what. It may be that this will be an indicator of what processes are next for greater survey scrutiny.
Another item in the July Perspectives is the regular column dealing with consistent interpretations and, this month, the new National Patient Safety Goal on health care equity. This one’s a little unusual in that (officially) the requirements were not to be surveyable until July 1, 2023, so I’m not sure of the intent (how many interpretations—or inconsistent interpretations can there be at this point), though I am really starting to lean towards this column being more for the benefit of the surveyors in the field.
There’s definitely a lot of “have to” processes involved, a fair amount of written documentation, etc., so this could probably be considered a warning shot across the bow of the good ship Leadership. Not really clear on how this one might (or might not) swing out into the environment, but it’s definitely going to be an organizational-specific undertaking, and since there’s not much that doesn’t somehow/somewhere/somewhy impact the management of the environment, it’ll be interesting to watch this unfold.
I know it’s (hopefully) a short week for you, so I will break it off there. There are a couple more pending changes for critical access hospitals that will take effect in August, so I think that will be our topic for next week as there are some implications to the environment. Hope you have/had a safe, happy and healthy Independence Day!
About the Author: Steve MacArthur is a safety consultant with Chartis Clinical Quality Solutions (formerly known as The Greeley Company) in Danvers, Mass. He brings more than 30 years of healthcare management and consulting experience to his work with hospitals, physician offices, and ambulatory care facilities across the country. He is the author of HCPro's Hospital Safety Director's Handbook and is contributing editor for Healthcare Safety Leader. Contact Steve at stevemacsafetyspace@gmail.com.