JCAHO Eliminates 168 Standards

JCAHO Eliminates 168 Standards To Help Relieve Healthcare Organizations

By: Breann Kakacek  BSN, RN

The Joint Commission recently announced it will be reducing standards for its accreditation. These changes are being made to meet standards similar to other entities. Starting January 1, 2023, 14%  of The Joint Commission’s standards and quality measures were reduced, and accreditation fees were frozen to provide relief to healthcare organizations. The first portion of changes includes a total of 168 standards that will be eliminated, and another 14 standards will be revised across the accreditation programs.

The Joint Commission is a not-for-profit organization that was created to evaluate and improve healthcare organizations. Currently, they oversee 22,000 facilities and organizations in the United States, including home health care, laboratories, surgery centers, hospitals, and more.

The Joint Commission surveyors consist of,

• Doctors
• Nurses
• Technologists
• Hospital administrators

During surveys, the experts select patients randomly for review to evaluate the facility’s quality of care and compliance with standards. They check for things such as infection control, readmission rates, medical errors, education, and competency of staff members. Each type of facility is upheld to specific criteria that qualify them for accreditation and certification.

The quality measures they hold healthcare organizations accountable for are to protect public safety when seeking care. Quality measures are population-focused common conditions such as receiving certain medication after a heart attack or stroke, preventing pressure ulcers when hospitalized, and using venous thromboembolism prevention items.

Certifications are reevaluated every 2 to 3 years, depending on the type of facility. The facility can gain a positive reputation and display compliance with The Joint Commission’s safety standards. With the reduction of standards, some may wonder how this will affect patient care and the daily practices of nurses.

Why are These Changes Being Made?

The changes being made are the requirements that are above the current standards of Centers for Medicare & Medicaid Services (CMS) Conditions of Participation (CoPs). This is occurring to eliminate requirements that do not add value to the accreditation to facilities that can focus on other areas that benefit the quality and safety of patients. CMS worked with The Joint Commission and approved the discontinued and revised standards ensuring they do not diminish the CMS requirements.

The changes made are considered to be “above-and-beyond” requirements from the CMS CoPs, were deemed not to address quality and safety issues, are considered redundant, and use of time and resources do not benefit patient care and outcomes. The Joint Commission also analyzed their scoring patterns and reviewed for any redundancies that needed to be removed.

The president and CEO of The Joint Commission, Jonathan B. Perlin, MD, Ph.D., MSHA, MACP, FACMI, stated, “The standards reduction will help streamline Joint Commission requirements, as well as provide some much-needed relief to healthcare professionals and organizations as they continue to recover from the pandemic. Our goal is to eliminate any standard that no longer adds value. We want to have fewer but more meaningful requirements that best support safer, higher-quality, and more equitable health outcomes.”

What Changes are Occurring?

14% of The Joint Commission’s standards have been eliminated, which accounts for 168 total removed and another 14 standards that needed revisions to streamline requirements. Hospital elements of performances that did not support CMS CoP and state regulations,  were over three years old, and scored five times or less on triennial surveys before COVID-19 was reviewed for change.

Effective February 19, 2023, these are the new standards for each area:

• Ambulatory Health Care (AHC)– 20 eliminated  standards and 1 revised standard
• Behavioral Health Care and Human Services (BHC)– 9 eliminated standards and 1 revised standard
• Critical Access Hospital (CAH)– 37 eliminated and 4 revised standards
• Hospital (HAP)– 56 eliminated and 4 revised standards
• Laboratory (LAB)– 5 eliminated standards and 1 revised standard
• Nursing Care Centers (NCC)– 12 eliminated standards and 1 revised standard
• Office-Based Surgery (OBS)– 18 eliminated standards and 1 revised standard
• Home Care (OME)– 10 eliminated standards and 1 revised standard

Each area was specifically reviewed for its performance elements and reasons for low scoring. It was determined that if the performance measures were redundant to other requirements or difficult to assess, they were changed or removed.

A Few of the Most Notable Changes

With so many changes being made across the healthcare spectrum, some are more notable than others.

Retired Elements:

• Standard EC.02.01.03 The hospital prohibits smoking except in specific circumstances. EC.02.01.03, EP 1 The hospital develops a written policy prohibiting smoking in all buildings. Exceptions for patients in specific circumstances are defined.

Note: The scope of this EP is concerned with all smoking types—tobacco, electronic, or other.

• Standard HR.01.07.01 The hospital evaluates staff performance.
  HR.01.07.01, EP 5 When a licensed independent practitioner brings a nonemployee individual into the hospital to provide care, treatment, and services, the hospital reviews the individual’s competencies and performance at the same frequency as individuals employed by the hospital.

Note: This review can be accomplished either through the hospital’s regular process or with the licensed independent practitioner who brought staff into the hospital.

• Standard MM.05.01.19 The hospital safely manages returned medications. MM.05.01.19, EP 1 The hospital determines under what circumstances unused, expired, or returned medications will be managed by the pharmacy or the hospital.

Note: This element of performance is also applicable to sample medications.

• MM.05.01.19, EP 3 The hospital determines if and when outside sources are used for the destruction of medications.

Note: This element of performance is also applicable to sample medications.

• PC.01.01.01, EP 24 If a patient is boarded while awaiting care for emotional illness and/or the effects of alcoholism or substance abuse, the hospital does the following: – Provides a location for the patient that is safe, monitored, and clear of items that the patient could use to harm themselves or others. (Refer to LD.04.03.11, EP 6; NPSG.15.01.01, EPs 1 and 2) – Provides orientation and training to any clinical and nonclinical staff caring for such patients in effective and safe care, treatment, and services (for example, medication protocols, and de-escalation techniques). (Refer to HR.01.06.01, EP 1) – Conducts assessments and reassessments, and provides care consistent with the patient’s identified needs.
• Standard PC.02.02.03 The hospital makes food and nutrition products available to its patients.PC.02.02.03, EP 9, When possible, the hospital accommodates the patient’s cultural, religious, or ethnic food and nutrition preferences unless contraindicated.

Currently, a second round of standards is up for review for elimination and revisions to reduce burdens on healthcare facilities. The Joint Commission plans to keep reviewing its standards every six months to ensure performance measures are up to date and not obsolete. Healthcare facilities and nurses must review these measures to ensure they are current with the new standards. In July 2023, The Joint Commission will release a new certification for Health Care Equity for the new quality measures.