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The Joint Commission revised accreditation standards as of July 1, 2024, to eliminate 200+ Elements of Performance (EPs) which measure the effectiveness of how organizations comply with standards. The current Joint Commission changes aim to create less, but more meaningful standards to provide “compliance relief” as healthcare organizations face inflationary pressures and labor shortages.
The revisions result from the comprehensive review taken by the Joint Commission, which began in September of 2022 to eliminate EPs that go beyond CMS Conditions of Participation (CoPs) or OSHA workplace safety standards. The process includes appropriately reviewing, eliminating, and updating standards to align with the CMS Strategic Plan and the 2024 National Patient Safety Goals.
Changes To TJC Standards, Requirements, and Guidance
TJC reworked, modified, or updated standards, requirements, or guidance for specific types of organizations in five areas:
- Emergency Management Standards: Changes for ambulatory care organizations (ACOs) include reducing the number of elements of performance, broadening from an emergency plan to an emergency program, and increasing focus on an all-hazard approach.
- Infection Prevention and Control Requirements: The hospital-specific IC chapter underwent a complete rewrite and will replace the current one for both accreditation programs. The revised standards now require a qualified “infection preventionist” or infection control professional to oversee planning, training, and documentation.
- Workplace Violence Prevention: For behavioral healthcare, a worksite analysis will be required as part of TJC’s workplace violence prevention program for the first time. Healthcare organizations must appoint an individual(s) to oversee violence prevention measures, enforce policies and procedures, analyze trends, and provide a process to report incidents.
- Responsible Use of Health Data: Though not required for accreditation, TJC encourages healthcare organizations to join its Responsible Use of Health Data™ program to help reduce threats to personal health information and other sensitive information.
- Total Hip and Knee Replacement: TJC revised its total hip and knee replacement guidelines to align with the American Academy of Orthopedic Surgeons clinical practice guidelines released in December 2022.
Get a list of The Joint Commission accreditation standards that require training - and a course list.
Emergency Management Standards Changes
The Joint Commission is cutting the number of elements of performance by more than 40% for ambulatory care organizations (ACOs) and eliminated redundant requirements for office-based surgery practices (OBSPs).
The emergency management (EM) chapter (for ambulatory health care accreditation) now clearly states that an organization “must have a comprehensive emergency management program that utilizes an all-hazards approach.” The change from using “plan” to “program” indicates TJC is encouraging a broader approach to emergency management, with requirements for specific plans as part of the program. The requirements are also clearly stated (to include, but not limited to):
- Leadership structure and program accountability
- Mitigation and preparedness activities
- Emergency operations plan and policies and procedures
- Education and training
- Exercises and testing
- Continuity of operations plan
- Disaster recovery
- Program evaluation
TJC is placing more emphasis on staffing with enhanced requirements for managing staff and volunteers during an emergency or disaster. Plans should include, if applicable, use of integrated staffing agencies, volunteer resources, off-duty staff, and employees from other healthcare facilities to ensure patient care and safety are maintained if an emergency or disaster occurs.
The EM chapter for office-based surgery practices also requires an all-hazard vulnerability analysis to determine which types of emergencies or disasters are most prevalent in their areas. OBSPs are then required to create an all-hazards emergency operations plan (EOP) that includes, but is not limited to:
- Communications plan
- Maintaining, expanding, decreasing, or closing operations
- Sheltering in place
- Evacuating
- Safety and security
Practices must provide all staff with emergency management training and education and conduct an annual exercise to test its EOP.
Hospital Infection Control and Prevention Requirement Changes
TJC reworked the infection control and prevention (IC) chapter and included the requirement for hospitals to appoint a qualified “infection preventionist(s) or infection control professional(s).” This goes beyond just appointing a person to lead, but specific the individual(s) must be “qualified through education, training, experience, or certification in infection prevention to be responsible for the infection prevention and control program.”
The Joint Commission requirement changes also clearly state that training and education expectations place an emphasis on competency-based training, including testing staff’s ability to “demonstrate the skills and tasks specific to their roles and responsibilities.”
Training is not limited to industry or regulatory standards but also for competencies for staff who implement protocols for specific tasks like “donning/doffing of personal protective equipment or the ability to perform high-level disinfection processes.
Get strategies to maintain infection control in a changing world.
Greater Emphasis on Workplace Violence Prevention
The Joint Commission also announced new and revised workplace violence prevention requirements for accredited behavioral healthcare and human services organizations.
“Workplace violence” is now listed in the environment of care (EC) chapter with traditional issues such as occupational illness, injuries to staff, and fire safety management. For the first time, organizations must conduct an annual worksite analysis related to their workplace violence prevention efforts, and be sure their incident reporting system accounts for these types of incidents.
In the leadership (LD) chapter, organizations must designate an individual who collaborates with a multidisciplinary team on policies and procedures, incident and trend analysis, and follow-up with victims or witnesses to workplace violence.
The human resources (HR) chapter notes that workplace violence prevention programs must now include training, education, and resources for new employees, annual updates, or when changes to policies and procedures occur. TJC is leaving it up to organization leaders to determine what individuals receive which training, but education programs must include:
- What constitutes workplace violence
- Education on leadership, clinical staff, security personnel, and external law enforcement roles and responsibilities
- Training in de-escalation, nonphysical intervention skills, physical intervention techniques, and response to emergency incidents
- The reporting process for workplace violence incidents
Protecting Personal Health Information and Other Data
TJC also called out its Responsible Use of Health Data™ Certification program to help healthcare organizations use data responsibly to “improve the safety, quality, and equity of care, develop new technologies, and discover new therapies benefiting all patients.” Though not required, the commission recommends accredited and non-accredited organizations embrace the program as threats to personal health information (PHI) and other data reach an all-time high.
The certification program provides participating organizations with an objective evaluation of PHI use, best practices, and if protocols are in place regarding transparency, limitations of use, and patient engagement.
Responsible Use of Health Data certification covers:
- Oversight Structure: Establish a governance structure for the use of de-identified data.
- Data De-Identification: Comply with HIPAA.
- Data Controls: Establish data controls to protect against unauthorized re-identification of data.
- Limitations on Use: Prohibit the misuse of data.
- Algorithm Validation: Have processes to manage internally developed algorithms.
- Patient Transparency: Communicate with key stakeholders about the secondary use of de-identified data.
How to Pivot Quickly When Regulations and Standards Change
Change is a natural part of TJC accreditation standards. Keeping up with those changes is another matter. When major revisions are made to regulations or standards, healthcare leaders must pivot their organizations into “more meaningful” compliance by updating policies, educating staff, and providing training. Conscientious staff may be reluctant to embrace the changes without clearly understanding how it impacts their role and responsibilities. Technology shines here by facilitating changes, updating processes, and quickly distributing information.
Managing Education Changes
A learning management system (LMS) keeps your employees updated on the latest regulations and best practices. A healthcare-specific system should update courses well in advance of requirement changes and enable you to upload facility-specific training. With access to an entire course library, the workplace violence or infection prevention courses that are now required may already be available to you, and you just need to assign them. If you don’t have an LMS, look for a vendor offering modular courses and many healthcare-specific options.
Easing the Burden of New Policies and Procedures
Technology makes it much easier for healthcare staff to adapt to a change in processes or procedures. Full-cycle policy management software makes it easy to upload revised policies and send them to all employees for acknowledgment or signature. Workflows can keep staff on track with automatic escalation or reminders of the next step in the process.
Reducing Tedious Processes
Making changes to the incident reporting template used to be nearly impossible. Staff were using the old forms months — or even years — later. With a digital incident reporting system, you can update the templates in minutes to reflect new incident types (such as workplace violence) or additional data to be recorded. Plus, having multiple templates makes it easier for staff to complete the necessary information. With this round of TJC changes and the emphasis on reporting workplace violence incidents, online incident reporting could be a game changer for behavioral health facilities.
Adapting to change doesn’t have to be complicated. See how MedTrainer’s enterprise-grade compliance platform can help you quickly implement these TJC changes — and more! Get in touch.