Maintaining Joint Commission accreditation is considered the gold standard in healthcare, often necessitating efforts that surpass basic regulatory requirements. This includes comprehensive training programs tailored to the specific needs of an organization.
The Joint Commission, a recognized leader in healthcare accreditation, has implemented significant changes to its standards as of July 1, 2024. In an effort to streamline processes and provide some "compliance relief," over 200 Elements of Performance have been eliminated. These EPs previously helped measure how effectively healthcare organizations adhered to standards amidst challenging economic times marked by inflation and workforce shortages.
This decision stemmed from an exhaustive review that started in September 2022. The Joint Commission sought to refine the EPs that exceeded the requirements set by CMS Conditions of Participation (CoPs) or OSHA workplace safety standards. This alignment not only simplifies compliance but also integrates the CMS Strategic Plan and the 2024 National Patient Safety Goals into everyday healthcare practices.
In this article, we delve into the nuances of the Joint Commission's 2024 updates and explore what these changes mean for your organization, helping you stay ahead in the evolving landscape of healthcare compliance.
Revised Standards and Guidelines from The Joint Commission for 2024
The Joint Commission has introduced pivotal updates to its standards, requirements, and guidance, targeting specific areas to enhance healthcare practices across various types of organizations. Here’s a detailed look at the changes introduced in 4 key domains:
For ambulatory care organizations, the updates streamline the number of performance elements, shifting the focus from an emergency plan to a more comprehensive emergency program. This shift emphasizes a broad, all-hazard approach to readiness, ensuring organizations are prepared for any type of emergency.
The Infection Control (IC) chapter for hospitals has been completely rewritten. This overhaul requires the appointment of a qualified “infection preventionist” or an infection control professional to manage all aspects of infection control, including planning, training, and maintaining rigorous documentation. This ensures a proactive stance against infection risks within hospital settings.
This update marks the first time a worksite analysis is mandated as part of workplace violence prevention program. Healthcare organizations are now required to designate one or more individuals responsible for overseeing violence prevention strategies, enforcing policies, analyzing trends, and creating a robust process for reporting incidents.
While not a requirement for accreditation, TJC is encouraging healthcare organizations to participate in its Responsible Use of Health Data™ program. This initiative is designed to help organizations safeguard personal health information and other sensitive data, mitigating risks associated with data breaches and misuse.
Let's delve into each of these updates in detail, exploring how they impact various aspects of healthcare operations and what organizations need to do to align with the new standards.
Updates to Emergency Management Protocols by The Joint Commission
The Joint Commission has revamped its emergency management standards, significantly reducing the number of performance elements for ambulatory care organizations by over 40%, and streamlining requirements for office-based surgery practices. This update is part of a broader shift towards enhancing emergency preparedness across healthcare settings.
In a significant change, the emergency management chapter now mandates that ACOs develop a comprehensive emergency management program that adopts an all-hazards approach, moving away from the narrower focus of a singular emergency plan. This program should encompass a variety of components, including:
- A defined leadership structure and clear accountability for the program.
- Activities focused on mitigation and preparedness.
- An emergency operations plan supplemented by specific policies and procedures.
- Ongoing education and training initiatives.
- Regular exercises and testing to validate the effectiveness of the plan.
- A continuity of operations plan to ensure service stability in all conditions.
- Disaster recovery strategies to restore services post-emergency.
- Continuous evaluation to improve the emergency management program.
Furthermore, there's a new emphasis on the management of staffing during emergencies. The updated standards now require plans that may include the use of integrated staffing agencies, volunteer resources, off-duty staff, and employees from other facilities to maintain patient care and safety during crises.
For office-based surgery practices, the EM chapter has introduced a requirement for an all-hazard vulnerability analysis. This analysis helps identify the most likely emergencies or disasters in their area, forming the basis for a robust all-hazards emergency operations plan (EOP). This EOP should address various scenarios and include strategies for:
- Effective communication during emergencies.
- Decisions on maintaining, expanding, reducing, or ceasing operations based on the situation.
- Procedures for sheltering in place or evacuating if needed.
- Ensuring safety and security during all phases of the emergency.
All staff in these practices must receive emergency management training and education, and the practice must conduct an annual exercise to test the effectiveness and readiness of its emergency operations plan. This proactive approach aims to ensure that healthcare providers are well-prepared to handle emergencies efficiently and effectively, safeguarding both patient and staff safety.
New Requirements in Hospital Infection Control and Prevention
The Joint Commission has made significant revisions to the infection control and prevention (IC) chapter, notably including the new requirement for hospitals to designate a qualified “infection preventionist(s) or infection control professional(s).” The qualifications for these roles are stringent, requiring individuals to have the appropriate education, training, experience, or certification in infection prevention to oversee the hospital's infection control program effectively.
These changes are part of a broader move to ensure that hospitals are not only complying with the necessary regulations but are also fostering a culture of excellence in infection control practices. The updated requirements emphasize competency-based training, underscoring the need for hospital staff to demonstrate proficiency in the skills and tasks that pertain specifically to their roles. This includes practical, hands-on competencies such as the proper donning and doffing of personal protective equipment and executing high-level disinfection processes.
The goal of these revisions is to enhance the overall effectiveness of infection control programs in hospitals, ensuring that all personnel are not only familiar with the protocols but are also proficient in implementing them in their daily responsibilities. This shift reflects The Joint Commission’s commitment to elevating the standards of infection prevention and control across healthcare settings, aiming to reduce infection risks and improve patient outcomes.
Enhanced Focus on Preventing Workplace Violence
The Joint Commission is intensifying its focus on workplace violence prevention within accredited behavioral healthcare and human services organizations. This growing concern is now incorporated into the environment of care (EC) chapter, traditionally reserved for issues like occupational illnesses, staff injuries, and fire safety management. For the first time, organizations are required to perform an annual worksite analysis specifically aimed at enhancing their workplace violence prevention strategies, ensuring that their incident reporting systems adequately capture these types of events.
In addition to these requirements, the leadership (LD) chapter mandates the appointment of a designated individual responsible for collaborating with a multidisciplinary team. This team’s responsibilities include developing and refining policies and procedures, analyzing incidents and trends, and providing support to victims or witnesses of workplace violence.
Moreover, the human resources (HR) chapter has been updated to include provisions for comprehensive training and education programs that are essential for new and existing employees. These programs are designed to address workplace violence and are required upon hiring, annually, or whenever significant changes to policies occur. While it is up to the organization's leaders to decide who receives specific training, the educational content must cover several critical areas:
- Understanding what constitutes workplace violence.
- Roles and responsibilities of leadership, clinical staff, security personnel, and external law enforcement.
- Skills training in de-escalation and non-physical intervention, along with physical intervention techniques and responses to emergency incidents.
- Procedures for reporting incidents of workplace violence.
These enhancements to the standards are part of The Joint Commission's broader commitment to ensuring a safe and secure working environment across all healthcare settings, aiming to mitigate the risks of workplace violence and enhance overall safety for both staff and patients.
Safeguarding Health Data: The Joint Commission's Latest Initiatives
The Joint Commission is spotlighting its Responsible Use of Health Data™ Certification program as a vital resource for healthcare organizations aiming to responsibly manage and leverage data. This initiative underscores the importance of using health information to enhance the safety, quality, and equity of care, alongside fostering the development of new technologies and therapies that benefit all patients. While participation is not mandatory, the commission strongly encourages both accredited and non-accredited organizations to adopt this program, especially as threats to personal health information (PHI) and other sensitive data escalate to unprecedented levels.
The certification program offers organizations an unbiased assessment of their use of PHI, aligning with best practices and established protocols concerning data transparency, usage limitations, and patient engagement. The key components of the Responsible Use of Health Data certification include:
- Oversight Structure: Setting up a governance system to oversee the use of de-identified data, ensuring it aligns with organizational goals and regulatory requirements.
- Data De-Identification: Adhering strictly to HIPAA regulations to maintain the anonymity of health data.
- Data Controls: Implementing robust controls to prevent unauthorized re-identification of de-identified data, safeguarding patient privacy.
- Limitations on Use: Enforcing strict rules to prevent the misuse of sensitive data, ensuring it is used solely for intended and ethical purposes.
- Algorithm Validation: Establishing procedures to manage and validate algorithms developed internally, ensuring their accuracy and fairness.
- Patient Transparency: Engaging with patients and key stakeholders transparently about how their de-identified data may be used beyond direct healthcare delivery.
This initiative by The Joint Commission aims to ensure that health data is handled with the utmost integrity, contributing to a trust-based healthcare environment where data aids in advancement without compromising privacy.
Adapting to Regulatory Changes Efficiently
Adapting swiftly to changes in The Joint Commission (TJC) accreditation standards is crucial for healthcare organizations aiming to maintain compliance. As TJC evolves its standards to make them more relevant and focused, healthcare leaders must ensure their organizations are equally agile in updating policies, educating staff, and implementing necessary training. This may initially meet resistance from staff wary of changes affecting their daily responsibilities. Here, technology plays a pivotal role by streamlining updates, enhancing processes, and ensuring swift communication.
- Managing Education Changes
A CE Management System that offers updates when new requirements take effect will be beneficial. This ensures that necessary courses, such as those for workplace violence or infection prevention won't go unnoticed by your staff, enhancing compliance..
- Easing the Burden of New Policies and Procedures
Technological solutions greatly simplify the adoption of new processes or policy changes within a healthcare setting. Policy management software, for instance, enables effortless uploading, distribution, and acknowledgment of updated policies across the organization. Automated workflows help keep staff aligned with new procedures by providing reminders and escalations.
- Reducing Tedious Processes
Revising incident reporting templates used to be a cumbersome task, often leading to prolonged use of outdated forms. Digital incident reporting systems now allow for quick updates to reflect new types of incidents, such as workplace violence, or to capture additional required data. The availability of multiple tailored templates simplifies the completion process for staff, ensuring accurate and efficient reporting.
How Credsy Supports Healthcare Organizations Amid Changing Regulations
In the rapidly changing landscape of healthcare regulations, staying ahead can be daunting for organizations. Credsy simplifies this challenge by providing a robust credentialing and compliance management platform. As healthcare regulations evolve, such as those outlined by The Joint Commission, Credsy's tools enable organizations to efficiently manage and update their provider credentials and ensure compliance with new standards.
Credsy's platform automates the credentialing process, reducing the administrative burden and minimizing errors. This is particularly valuable when dealing with changes in regulations that affect credentialing requirements or when updating policies to comply with new standards. For instance, when The Joint Commission introduces new training requirements, Credsy’s system can help track which employees have completed the necessary training and which are due, ensuring no gaps in compliance.
Moreover, Credsy enhances transparency and accountability. It offers a centralized database that provides real-time insights into the credentialing status of all providers, making it easier to manage compliance across large teams and multiple facilities. This centralization is crucial when institutions need to pivot quickly due to regulatory changes, as it ensures that all stakeholders have access to the most current and relevant information.
For healthcare organizations navigating the complexities of data protection and patient privacy, Credsy also supports compliance with HIPAA regulations. Its security features ensure that sensitive data is handled correctly, protecting against unauthorized access and data breaches.
By integrating Credsy into their operational framework, healthcare organizations can not only meet current regulatory demands but also prepare for future changes. This proactive approach to compliance and credentialing not only safeguards patient safety and data privacy but also enhances the overall efficiency and reliability of healthcare services.