The Joint Commission Eliminates 14% of Its Standards Across All Accreditation Programs

The Joint Commission (TJC) accredits a variety of healthcare organizations, including hospitals, critical access hospitals, ambulatory care organizations and laboratories. Many TJC-accredited healthcare organizations also rely on their TJC accreditation for “deemed compliance” with federal and state administrative agencies’ requirements for certifications or licenses without the need for separate survey. TJC’s announcement of a major reduction in its accreditation standards is especially welcomed by those healthcare organizations that achieve several regulatory authorizations through TJC accreditation.

In September 2022, TJC announced that it would review its accreditation requirements that go above and beyond the Centers for Medicare and Medicaid Services’ (CMS) Conditions of Participation or Conditions for Coverage (collectively, CoPs). In that announcement, TJC acknowledged that the stress of the COVID-19 pandemic on accredited healthcare providers was its motivation to focus on streamlining standards and decreasing administrative burdens so that only the strategies and structures that support patient safety, quality and equity are required.

Specifically, TJC assessed each of the “above and beyond” requirements that did not directly correspond to a CoP by considering whether the requirement addressed an important quality and safety issue, was redundant, or otherwise required time and resources to comply that exceeded the estimated benefit to patient care and health outcomes.

TJC also conducted quantitative analyses of scoring patterns, tests for redundancy, literature reviews, field reviews and engaged experts within the field to determine which of the implicated requirements could be eliminated or revised. CMS approved the eliminated and revised standards.

January 2023 Eliminations and Revisions

Below are links to the deleted or revised standards, effective January 1, 2023, in the order of greatest to least amount of change. Also included is a list of the implicated chapters that have deleted standards and a reference to the revised standards:

• Hospitals
  • Hospital: 56 deleted and four revised
    • Deleted standards implicate the following 11 chapters of TJC’s Hospital Accreditation Program: (i) Environment of Care, (ii) Human Resources, (iii) Information Management, (iv) Leadership, (v) Life Safety, (vi) Medication Management, (vii) National Patient Safety Goals, (viii) Provision of Care, Treatment, and Services, (ix) Performance Improvement, (x) Rights and Responsibilities of the Individual, and (xi) Waived Testing.
    • Revised: (i) Leadership Standard (Standard LD) 02.02.01 and its Elements of Performance (EP) 1-3, and (ii) Standard Waived Testing (Standard WT) .02.01.01, EP1.
  • Critical Access Hospital: 37 deleted and four revised
    • Deleted standards implicate the following 11 chapters of TJC’s Critical Access Hospital Accreditation Program: (i) Environment of Care, (ii) Human Resources, (iii) Information Management, (iv) Leadership, (v) Life Safety, (vi) Medication Management, (vii) National Patient Safety Goals, (viii) Provision of Care, Treatment, and Services, (ix) Performance Improvement, (x) Rights and Responsibilities of the Individual, and (xi) Waived Testing.
    • Revised: (i) Standard LD02.02.01 and EPs 1-3, and (ii) Standard WT.02.01.01, EP1.
• Ambulatory Care
  • Ambulatory Health Care: 20 deleted and one revised
    • Deleted standards implicate the following nine chapters of TJC’s Ambulatory Health Care Accreditation Program: (i) (i) Environment of Care, (ii) Human Resources, (iii) Information Management, (iv) Leadership, (v) Life Safety, (vi) Medication Management, (vii) National Patient Safety Goals, (viii) Performance Improvement, and (ix) Waived Testing.
    • Revised: Standard WT.02.01.01, EP 1.
  • Office-Based Surgery: 18 deleted and one revised
    • Deleted standards implicate the following six chapters of TJC’s Office-Based Surgery Accreditation Program: (i) Environment of Care, (ii) Human Resources, (iii) Leadership, (iv) Medication Management, (v) National Patient Safety Goals, Performance Improvement, and (vi) Waived Testing.
    • Revised: Standard WT.02.01.01, EP1.
  • Home Care: 10 deleted and one revised
    • Deleted standards implicate the following six chapters of TJC’s Home Care Accreditation Program: (i) Environment of Care, (ii) Leadership, (iii) Life Safety, (iv) Medication Management, (v) Provision of Care, Treatment, and Services, and (vi) Waived Testing.
    • Revised: Standard WT.02.01.01, EP1.
  • Behavioral Health Care and Human Services: Nine deleted and one revised
    • Deleted standards implicate the following four chapters of TJC’s Behavioral Health Care and Human Services Accreditation Program: (i) Leadership, (ii) Life Safety, (iii) Medication Management, and (iv) Waived Testing.
    • Revised: Revised: Standard WT.02.01.01, EP1.
• Nursing Care Center: 12 deleted and one revised
  • Deleted standards implicate the following six chapters of TJC’s Nursing Care Center Accreditation Program: (i) Life Safety, (ii) Medication Management, (iii) National Patient Safety Goals, (iv) Provision of Care, Treatment, and Services, (v) Performance Improvement, and (vi) Waived Testing.
  • Revised: Please note that the current TJC prepublication does not reflect the revised standard.
• Laboratory Services: Six deleted and one revised
  • Deleted standards implicate the following four chapters of TJC’s Laboratory Accreditation Program: (i) Environment of Care, (ii) Human Resources, (iii) Leadership, and (iv) Waived Testing.
  • Revised: Revised: Standard WT.02.01.01, EP1.

Constant Change

According to TJC’s President and CEO, Dr. Jonathan Perlin, TJC plans to keep reviewing its standards every six months to ensure performance measures are relevant to quality improvement. TJC is expected to announce a second tranche of eliminated or revised TJC standards in June 2023. Healthcare organizations should consult with internal and external resources to review the changes and assess how to update current operations and compliance efforts to ensure they are current with the new standards. Also on the horizon for hospitals and critical access hospitals, as explained in this On the Subject article, is TJC’s certification program for Health Care Equity with newly revised quality measures effective July 1, 2023.