Accreditation 360: How much structure do you have to have?

As I see it, the current changes to the Joint Commission accreditation process that are barreling at us with almost alarming speed (it will be January before you know it—and I’m keeping close tabs on that, let me tell you) represent a significant opportunity to streamline the oversight processes for managing conditions in the physical environment. And, with the melding of the JC standards into a more clearly matched set with the CMS Conditions of Participation, this allows you the opportunity to/luxury of paring things down to the essential elements. That said, there is still a little bit of work to do, as it appears that any restructuring to programmatic elements will need to be (more or less) justified. The “word” from Chicago is that it will be up to the organization to demonstrate compliance (more on that in a moment).

Of all the requirements that have crisscrossed the annals of compliance over the years, the one that still gives me the worst case of intellectual indigestion is the requirement for written management plans. Regulatorily, there is no basis for the management plans and the fact that we’ve had to deal with them for so long (seems like forever) is what I consider the second greatest misspending of resources. (No. 1 is, and always will be, the attempts to eradicate cardboard from the firmament, but I have yapped about that enough times in the past). The newly unveiled standards have removed the requirements for management plans, but JC’s Survey Process Guide (SPG) still calls out the management plans as documents to be reviewed. It would seem that the SPG inclusion is tantamount to a typographical error and will likely be removed from next year’s Process Guide.

At any rate, as a pursuit that has been in place for many a long year, the decision to forego maintaining the management plans is at the determination of each organization; you can’t really expect to abandon such a programmatic fundamental without some sense of analysis, etc. My suggestion would be to include the determination to discontinue the management plans as part of the annual evaluation; maybe even as a programmatic goal with the intent of ensuring the ongoing effectiveness of your physical environment management program. By the way, regulatorily, the annual evaluation is somewhat amorphous, but, as part of the Quality Assurance and Performance Improvement (QAPI) that is required of organizations, I think it makes perfect sense to continue that tradition. I’ve never had an issue with the annual evaluation process—how else are you going to keep score?

Interestingly enough, as something of a by-product, the standards language that specifically requires something akin to an Environment of Care (EOC) committee has also been shed. This change also allows for some self-determination, with the caveat that if you choose to break up the EOC committee band, you must be prepared to demonstrate how you are effectively managing the physical environment without one. I’m not saying you can’t, particularly at smaller, less-complex organizations, but the physical environment has become too complicated an undertaking to forego structured oversight. Maybe you could “blend” it into another committee, but I would think long and hard about it before embarking in that direction.

Next time, I think we’ll take a sprint through the most frequently cited physical environment conditions and practices—it wouldn’t be Fall without some sort of recap of what’s being found during surveys. I’d like to say that you’ll be surprised with what’s on tap, but if you’ve been here for a while, I think you will find things almost eerily familiar.

About the Author: Steve MacArthur is a safety consultant with The Chartis Group. 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 an advisory board member for Accreditation and Quality Compliance Center. Contact Steve at stevemacsafetyspace@gmail.com.