Two Reasons to Read Perspectives Carefully

Accreditation Monthly

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February 12, 2008

The January 2008 issue of Joint Commission Perspectives contained two seemingly small announcements, each of which carries big implications for hospital organizations that include a home health/hospice/DME and/or physician practice component(s) in their triennial survey.

The first announcement involves home health care. If your organization uses Joint Commission accreditation as the deeming authority for demonstrating compliance with Centers for Medicare & Medicaid Services (CMS) requirements, The Joint Commission will no longer recognize supplemental findings in your final accreditation survey report. Now all findings, including those that in the past had been scored as supplemental findings, will be categorized as requirements for improvement and thus require full follow-up through the evidence of standards compliance process and, importantly, will contribute fully to the thresholds used to determine whether an organization achieves full accreditation or conditional or preliminary denial of accreditation. 

Faced with this new and undesired implication of selecting a Joint Commission deemed status survey for their home health programs, many organizations should consider forgoing the deemed status choice when completing their e-application for Joint Commission survey. To do so, simply leave the deemed status cell blank on the e-application and choose instead to receive an annual visit from a state-agency CMS team.

The second announcement in the January 2008 Perspectives was carried on the last page below a headline that read "Reminder"- when, in fact, the announcement seems like a new expectation to many survey coordinators. The "reminder" specifies that critical access hospitals must include physician practices in an accreditation survey if one or both of the following is true:
1. The physician practice is included in the hospital's Medicare cost report as a provider-based (that is, not freestanding) practice
2. The physician is employed by the hospital, and the hospital or the physician practice positively portrays to the public that the physician practice is part of the hospital

Survey coordinators are usually more familiar with the accreditation process rules governing the tailored survey policy rules, which state that the applicant (for survey) organization must acknowledge, and subject to a full accreditation survey, any component (home care agency, physician practice, etc.) for which:
1. There are Joint Commission standards that are applicable to the component
2. It is determined that the component is organizationally and functionally integrated into the applicant organization 

Organizational and functional integration is determined on a case-by-case basis by applying criteria outlined by The Joint Commission. A determination is made to require that the component be surveyed if at least one of the two organizational criteria is met and three of the eight functional criteria are met.

It's important to note that the physician practice criteria discussed in the January Perspectives have been published in the manual since 2002 (although they have not been as well publicized as the organizational and functional criteria) and supersede the organizational and functional integration criteria with respect to physician practices.

In recent years, The Joint Commission has permitted hospitals with extensive ambulatory care programs, including clinics and physician practices, to obtain ambulatory care accreditation in addition to their hospital accreditation. This does not establish a separate organization in the Joint Commission database, but rather tailors your hospital with ambulatory accreditation. Many hospitals appreciate the ambulatory experience and approach used by the ambulatory surveyors, the ambulatory focus of the standards, and the unique suggestions that these experts can make. In addition, the hospital obtains detailed but separate findings for its inpatient and outpatient programs and two unique accreditation decision thresholds. This method appears to be a win-win for both the hospital and its ambulatory care programs.

Remember, there is risk in failing to report surveyable hospital or ambulatory volume. For example, if your non-reported clinic volume exceeds 25% of the total outpatient volume reported on your application, an extension survey could result. And a poor outcome on an extension survey will affect your entire hospital accreditation negatively.
 
There is no process for a grace period while you sort this out. As the rules are written currently, The Joint Commission expects immediate compliance with applicable standards at the time an organization acquires a new service. Because of this, many hospitals are having a consultant conduct a preacquisition survey-readiness assessment. The purchase price is predicated on how much it will take to bring the acquisition into standards compliance. 

Speaking on behalf of my colleagues at The Greeley Company, any one of us would be happy to help you sort though these issues to chart the best course of action for your organization. We specialize in helping to craft Joint Commission-compliant policies and effective processes designed specifically to fit your organization. It may also be time to schedule an "unannounced survey vulnerability visit" by one of our Greeley consultation teams. For more information, please call Robin Flynn, client relations manager, at 888/749-3054.

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