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Project REFRESH: The Joint Commission’s New Accreditation Process

by Mary Lou Weden on Sep 6, 2016 11:03:13 AM


The Joint Commission recently announced that it is revamping the accreditation process in an initiative called Project REFRESH. This initiative is an internal process improvement activity seeking to demonstrate more clearly the intersection between the established standards and patient safety. 

The new accreditation process is being guided by four core principles: simplification, relevance, innovation and transparency. These principles are factors in the building, revising and implementing stages concerning the new accreditation process.

The revision process was completed through consultations with accredited organizations and involvement of other stakeholder groups. In regards to implementation, all changes related to the project will be divided into phases, which started with the first phase in June 2016 and the rest running through 2017.

According to the Joint Commission, the initiative aims to improve consistency in standard interpretation, enhance and streamline the post-survey process, utilize mobile technology for a more interactive process and decrease the actual number of standards and elements of performance.

Throughout the review process, the organization spent significant time analyzing the standards and eliminating as many as possible. As a result of this effort, 131 Elements of Performance (EPs) have been eliminated. However, the Joint Commission stresses that the elimination of EPs does not mean the survey process will be less rigorous in comparison to the past and that the Joint Commission will continue to hold all organizations to a high standard. The main difference is that now the new focus will be on patient safety and risk management. The changes are aimed at making it easier for the organizations surveyed to understand the findings and create plans to mitigate issues.

New Scoring Methodology

The survey process currently conducted by the Joint Commission uses a “criticality model”. The criticality model assesses the risk to patients and the quality of care if there is non-compliance with a requirement. Currently, this model uses a four level score to assess that risk. However, that model is now being replaced with “The Survey Analysis for Evaluating Risk” evaluation matrix, or more commonly known as the SAFER matrix. The changes to the model are geared toward making the assessment more closely tied to the potential impact on safety. Additionally, the modifications will provide more information to organizations to prioritize resources and focus their corrective action plans on the areas that have the most significant impact on the patients they serve.

In the past, organizations stated that they had difficulty reviewing their survey reports and identifying the most critical areas. With the SAFER matrix implementation, organizations will be ensured that all reporting processes will be much clearer. This reporting implementation began with psychiatric facilities surveyed in the beginning June 2016. Other programs going through the survey process will begin seeing the Matrix reporting starting in January 2017.

Additionally, surveyors will begin utilizing mobile technology to document findings and place deficiencies into the SAFER matrix in real time. Where they place the item will depend on the impact to safety, how likely the situation is to occur and the scope in which the issue was observed. These combined efforts will determine where on the matrix the item falls and will more clearly indicate risk.

The New Post-Survey and Clarification Processes

Another component of the revision focuses on the post-survey process. The SAFER matrix results will directly determine what level of post-survey follow-up is taken by the Joint Commission. The new process will eliminate the current “A” and “C” designations. Thus, the timeline for follow-up reporting Evidence of Compliance will inevitably be changed. In the new process, all deficiencies cited must be corrected within 60 days. Deficiencies with a higher risk level will have additional requirements related to sustainment of the corrective actions taken. The process for deficiencies deemed “Immediate Threats to Life” will not change with the implementation.

Another major revision is the clarification process for organizations related to survey findings. In the past, this process has been a long, consuming valuable resources from organizations and the Joint Commission. However, the process has been revised to allow clarification to occur in real time during the survey process. The adoption of this new process provides more clarity for all involved. 

For more information regarding the new accreditation process, the Joint Commission will be providing educational opportunities to become more familiar with the new process and tools to be used. They stress the fact that they are not just creating new standards and that organizations do not need to change their preparations for upcoming surveys. In the end, the ultimate goal is to ensure the survey process is more meaningful for the organization and its constituents. 


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This post was written by Mary Lou Weden

Mary Lou Weden is a product manager, business solution - Systems at Intermedix.

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