In September of 2019, CMS issued the Burden Reduction Final Rule that reset some of the requirements and expectations related to Performance Improvement within Critical Access Hospitals. Several of the required changes have taken effect within The Joint Commission Critical Access Hospital Accreditation Program but several additional changes that reside within the Leadership Chapter took effect March 30, 2021.
LD 01.03.01 EP 21 expands the scope of QA-PI and/or Performance Improvement Program to encompass all departments and services provided by both the organization and any of those services that are provided via a contractual relationship. This standard assigns the governing body with the responsibility to ensure that the program addresses all the complexities within the organization and that they use objective measures to complete the evaluations. Objective measures can look at processes, functions and/or services. As organizations provide more and more services via a contractual agreement, it is essential that the QA-PI process include an assessment of those services to determine the quality and safety of services provided. The element of performance continues to provide clear direction related to those critical access hospitals that offer either rehabilitation or psychiatric distinct units. The use of a QIO (Quality Improvement Organization) is not required provided the organization establishes its internal program that is of equal robustness.
The revisions at LD 03.02.01 continue to align the QA-PI program expectations for critical access hospitals with the expectations set for hospitals. It is here that the expectation for use of patient care data, and the setting of Organizational Goals for the Performance Improvement Program reside and focus on* creating a culture of safety and quality, *set the expectation that decisions will support safety and quality and, *focus the organization on identifying, analyzing, and responding to internal and external forces of change. This standard goes one-step further to set the expectation that the overarching program will focus on both outcomes but also on prevention and reduction of medical errors, adverse events, and unplanned readmissions.
The last new requirement embeds key components of high reliability into The Joint Commission’s expectations. This entails the setting of priorities for PI activities using external data sources that are predictive of desired patient outcomes, more commonly referred to as “Evidence-Based Best Practices” along with using a methodology that helps to identify organizational priorities. This methodology can be as simple as “High Risk – High Volume – Problem Prone” to more complex matrices used to assess risk. The last change in the standards carries another key principle of high-reliability within it, that is building into the organization a resiliency and nimbleness to be able to respond and redirect itself to changes within the internal and external environment. The Covid-19 pandemic is a perfect example of a change in the external environment that caused organizations to respond and redirect their organization operationally while developing new metrics to measure the organization’s performance.
Resources: TJC Pre-publications Standards March 30, 2021 Interoperability and Burden Reduction
