After our November 2009 newsletter hit the electronic newsstands, we received further information from TJC about its process for surveying healthcare organizations by CMS Certification Number. According to Gail Weinberger, Director of Accreditation & Certification Policy & Administration, it is the expectation of CMS that each hospital independently demonstrate compliance with TJC standards and CMS Conditions of Participation. Therefore, the concurrent survey model will not include joint surveying of shared services, but rather a system orientation, and then individual, simultaneous surveys of each CCN within the system. Ms. Weinberger noted that this an update to what had previously been reported at TJC Hospital Executive Briefings.
In addition, it should be noted that if a hospital has components, i.e., a psychiatric or other facility that has a CCN that stems from the hospital (same CCN with the exception of the last number), those components are recognized as part of the hospital and can be surveyed as such. If the CCNs are distinct, the survey and accreditation decisions will be distinct.
To provide healthcare systems that are affected by this situation the most current information; we have updated the article which first appeared last month and provide it here for your reference:
Originally featured in the C&A Newsletter, November 2009
Updated with new information from TJC in December 2009
Effective July 15, 2010, The Joint Commission (TJC) will accredit healthcare organizations (HCO) based on their Centers for Medicare & Medicaid Services (CMS) Certification Number (CCN), formerly known as Medicare Provider Number (MPN). This is in accordance with TJC’s application to CMS for deeming authority. (See the October 2009 edition of The Joint Commission Perspectives.)
Previously, a healthcare system might have had one TJC HCO number that encompassed several hospitals, home care agencies or other accredited components. In that model, the HCO would receive one accreditation decision based on combined survey activity at all locations. Effective July 15, 2010, an HCO with three hospitals with separate CCNs and one home care agency with a distinct CCN will receive four separate accreditation decisions.
Also of note, if a hospital has components, i.e., a psychiatric or other facility that has a CCN that stems from the hospital (same CCN with the exception of the last number), those components are recognized as part of the hospital and can be surveyed as such. If the CCNs are distinct, the survey and accreditation decisions will be distinct.
Using our three hospital, one home care agency HCO as an example, let’s explore what the survey process will be like after this becomes effective next July.
In this new model, surveys may either be done in a concurrent manner with each of the four entities surveyed at the same time, or in an independent manner with each entity surveyed at separate times without any joint survey activity. Both models are, of course, unannounced in accordance with CMS and TJC requirements. Exceptions to the unannounced survey are delineated in The Joint Commission’s Comprehensive Accreditation Manual for Hospitals.
In the concurrent model, survey activity for each CCN begins on the same day with a system orientation and TJC survey teams simultaneously dispatched to conduct tracer and all other survey activity at each CCN. While TJC had previously indicated it would survey shared functions, i.e., human resources and information management, together in this model, as part of its deeming application, CMS is requiring TJC to survey each CCN separately to determine its compliance with TJC standards and CMS Conditions of Participation.
In the independent model, each CCN is separately scheduled for survey without a system orientation.
In either scenario, accreditation decisions are rendered to each CCN at the conclusion of the survey. The accreditation decision of one CCN entity, regardless of survey option chosen, will not affect the decision of any other CCN entity. (See quick reference table below.)
The most significant issues HCOs need be aware of in this accreditation decision by CCN model include:
- Each CCN must have its own governing body and medical staff structure. If the healthcare system currently has one governing body and or one medical staff, it will need to demonstrate independent structure related to:
- Organizational structure (table of organization),
- Corporate bylaws,
- Medical staff bylaws, rules and regulations, credentialing and privileging policies, and
- Minutes that outline decisions related to that specific CCN.
- Ambulatory and behavioral health services on the CCN of a hospital will be surveyed using the Hospital Accreditation Program (HAP) standards.
TJC is currently working, through its Account Representatives, with the approximately 300 HCOs affected by this requirement to discuss the survey options and assist organizations in determining what will work best for their system.
So, should your organization seek a concurrent or independent survey? Some things to consider in preparation with that call with TJC:
The concurrent model might be best suited for systems that have:
- Shared leadership and a unified mission and vision,
- A system-level approach to survey readiness, i.e., a centralized survey coordination function responsible for accreditation and regulatory compliance, preparation, application and PPR response,
- The staff resources to manage simultaneous survey activity, i.e., provide surveyor escorts and scribes simultaneously to three hospitals, somewhat complex survey agenda planning and management, and
- Geographical proximity to facilitate travel between CCNs for staff that must be present for various survey activities.
The independent model might work best for systems that have:
- A more distinct leadership and operational structure for each CCN,
- A CCN-level approach to survey readiness and coordination,
- Limited resources to manage a simultaneous survey and a complicated survey agenda, and
- Disparate geography that would impede key staff participation in survey activities.
In summary, as there is no impact on the accreditation decision process related to the survey option chosen, the decision regarding which survey model to use is a matter of organizational preference and availability of resources for survey preparation and response. Organizations that are affected by this change in process are encouraged to contact their TJC Account Representative for more information.
TJC Accreditation by CCN – Survey Process Choices:
| Concurrent Survey Model | Independent Survey Model |
1. Survey of all CCNs within a system begins on the same day (within the 18-39 month window) – survey teams dispatched simultaneously to each CCN
| 1. Survey of each CCN within a system scheduled separately within the 18-39 month window
|
| 2. Shared services and functions surveyed together | 2. Shared services and functions not surveyed together |
| 3. Requires distinct governance and medical staff structures and decision-making | 3. Requires distinct governance and medical staff structures and decision-making |
| 4. Accreditation decision by CCN – survey decisions not linked | 4. Accreditation decision by CCN – survey decisions not linked |