The regulatory and accreditation requirements for health care organizations continue to change as health care evolves and adjusts to accommodate advances in health-related sciences and safety sciences. Absent of these necessary changes, our healthcare delivery systems would quickly become antiquated and fail at its very mission of protecting lives. Keeping a finger on the pulse of all of these changes can be daunting. Our article this month focuses on some of the expected survey process changes organizations should expect to experience during their TJC Hospital Accreditation Survey in 2025.
Changes to The Joint Commission Survey Process
Virtual Document Review
Expect some time in 2025, that TJC will roll out a virtual document review process. The creation of a shared repository location so that HCO’s can upload all of the requested documents prior to their triennial survey is moving along. This may allow your survey team the opportunity to review documents, identify areas where further exploration is warranted and develop inquiries which may lead to a more targeted survey.
More Standardized Assessments
TJC Leadership stated during their Executive Briefings session in September 2024, that a core competency process is underway to ensure more consistency in how organizations are surveyed. The use of standardized checklists such as the Kitchen Tracer Survey Guide checklist may actually be used by the surveyor to both assess the topic and record their findings.
Physical Environment Chapter
Effective January 2025, the Environment of Care and Life Safety Chapters are being merged in a new chapter to be known as the Physical Environment Chapter. Expectations are that the standards and elements of performance will be reviewed and streamlined to eliminate any redundancies.
Survey Outcomes
TJC Executives share that between January 2024 and July 2024, 466 hospitals were surveyed. 54% of those resulted in Medicare Deficiency Surveys, meaning the organization was found to be out of compliance at a condition level for one or more CMS Condition of Participation, and 4.9% of surveys resulted in the need for an Accreditation with Follow-up survey. This reinforces the pressure that CMS is placing on all accrediting organizations to strictly and consistently assess organizations for their compliance with the CMS Conditions of Participation when there is a deemed status relationship in place. In 2025, we believe that similar performance data will continue to occur.
Top Scoring Problematic Standards
Interestingly, when you compare the various lists of Top Scoring Standards within the Hospital Accreditation Program, top CMS COP compliance issues and other similar types of lists, the same vulnerabilities or opportunities continue to populate these lists. Will 2025 be the year when accrediting organizations and CMS take firmer actions to motivate organizations to finally mitigate these issues?
Potential Refocus of Patient Safety & Quality & Equity
As each healthcare organization delves deeper into their own data related to disparities and inequities in health care, it is anticipated that the Federal Government will create specific requirements for obstetrical care and potentially for Age Friendly Care. Few details are available but we would expect initial drafts to be released sometime mid-2025.
Emergency Management
The past several years has certainly put our Emergency Preparedness and Management processes to the test. The Emergency Management Chapter has been rewritten for each and every The Joint Commission Accreditation Program. The end result for each program is a more consolidated, better aligned chapter setting forth clear expectations. The end goal of the rewrite process was to help organizations develop and implement more comprehensive programs for the Emergency Management Readiness and Execution. We anticipate that Emergency Preparedness and Management will be a focus area for future surveys.
Ensuring that your organization has a well-written plan that defines the expectations is divided into 6 key areas. Those six areas are:
- Communications
- Resources and assets
- Safety and security
- Staff responsibilities
- Utilities management
- Patient clinical and support activities
Organizations need to remember to continually reassess the greatest risks to both their organization and the community, and evaluate their Emergency Preparedness to ensure their plan will deliver as they expect.
Disease Specific Certification Surveys
Effective January 1, 2025, the disease specific certification process will become a virtual or “off-site” survey for several of the core disease specific certification programs. Note that initial certification surveys will still be conducted on-site. Organizations that would like to keep their review process as “on-site” should contact their account executive.
Courtemanche & Associates has conducted virtual or “off-site” mock surveys for numerous clients with various disease specific certifications and the process works very well provided the organization is using an electronic health record and has good connectivity to the internet.
Texting of Patient Care Orders
We expect that with the publication of CMS QSO 24-05 Hospital/Critical Access Hospital on February 8, 2024, announcing the revision of their policy to permit texting of order through a HIPAA compliant platform and in compliance with the CoPs at 42 CFR Part 482.24 and 41 CFR Part 485.638 that accrediting organizations include, The Joint Commission will begin to query organizations regarding the policies and procedures defining both the administrative aspects and the delivery of care aspects of the process. Administratively the platform must be secure, encrypted, and ensure the integrity of the author identification to minimize patient privacy and confidentiality risks. Organizations should be prepared to share the frequency at which they are testing their platforms for security and integrity along with validation that texted orders are reaching their intended destination and are dated, timed, accurately written, authenticated, promptly captured by the Electronic Health Record, completed, properly filed and retained within the EHR, and accessible as a component of the medical record. Organizations are encouraged to utilize the patient tracer methodology to verify that their processes are fulfilling all these expectations which are designed to mitigate patient safety issues.
Nothing is permanent except change, and we dislike it because it is change. There is a comfort in knowing and being aware of the good and the bad and when change occurs our comfort level is challenged.
But keep in mind, change is also the only path to progress, to improvement, to better ways and outcomes.
For questions or to learn more contact the C&A team at 704-573-4535 or email us at info@courtemanche-assocs.com.
