By Ruth Elzer, RN, MS

The Joint Commission (TJC) continues to work with the Centers for Medicare and Medicaid Services (CMS)  to complete an acceptable deeming application for its hospital program. The Medicare Improvements for Patients and Providers Act for 2008 (MIPPA) revoked the Joint Commission’s statutory deeming status for its hospital program, mandating a reapplication process before its term of approval expires July 15, 2010. The changes in the Joint Commission standards and survey process over the last year—including those in January and again in March—are part of that effort.  The next phase of that process is upon us, and it’s your turn to be heard.

CMS announced today that it will accept comments from the field about the Joint Commission’s deemed status application. In today’s Federal Register, CMS calls for “public comment on whether the Joint Commission’s requirements meet or exceed the Medicare conditions for participation for hospitals.”

The comment period opens today and will close on July 27, 2009 at 5 pm. Hospitals will have the opportunity to comment on their experiences with the Joint Commission survey process and factors that may impact the deeming process with CMS. To provide comment, individuals and organizations should respond according to the instructions written in the notice, using the file code of CMS-2302-PN. In short, hospitals have the option of providing comments via one of four ways:

• Electronically by going to www.regulations.gov and selecting More Search options and follow the direction under the Find and Take Action tab.
• By regular mail using the Baltimore address listed in the notice
• By express or overnight mail to the Baltimore address listed in the notice
• By hand or courier, using either a Washington, DC or Baltimore, MD address posted in the notice.

The notices describes the criteria to be considered in evaluating the Joint Commission’s process for deemed status consideration. The major factors to be considered include reviewing the accrediting organization’s:

• Requirements for accreditation
• Survey procedures
• Resources for conducting required surveys
• Capacity to furnish information for use in enforcement activities
• Monitoring procedures for provider entities found not in compliance with the conditions or requirements, and,
• The ability to provide CMS with the necessary data for validation.

Through comments received in these specific categories, CMS will evaluate the effectiveness of Joint Commission’s methods in demonstrating that all applicable Medicare conditions are met or exceeded. While many people might share the frustrations of trying to attain the rigid requirements of National Patient Safety Goals, remember that these requirements rise above the CoPs and are not an essential component of CMS’ oversight of the Joint Commission. Here are some suggestions for preparing your comments for CMS:

1. Requirements for accreditation-This area probably will receive the largest number of comments. The question is whether the Joint Commission’s standards meet or exceed CMS Conditions of Participation. Any hospital that has undergone a validation survey can share their experiences of how well TJC surveyors identified deficiencies compared to the follow-up survey by the state. Many known gaps in the standards were remedied in the January and March standards release from the Joint Commission, but some still remain. (See “A JAYCO Tap: Privileging by Proxy.”)
2. Survey procedures- Hospitals should comment on experiences during survey, evaluating the differences between the conduct of TJC and state surveyors and related survey procedures. Inconsistencies between TJC surveyors have been a common theme of dissatisfaction shared by hospitals.
3. Resources for conducting required surveys- This deals with the Joint Commission’s ability to continue to conduct surveys, both expected “triennial” surveys, and those required by events, such as sentinel event surveys. Factors to be considered include the surveyor cadre, financial resources of the Joint Commission, and technical support.
4. Capacity to furnish information for use in enforcement activities- This commonly refers to information shared between TJC and CMS representatives at the state and regional level for the purpose of enforcement actions.
5. Monitoring procedures for provider entities found not in compliance with the conditions or requirements- This criterion sparked the change in ESC responses over the last year. All less-than-compliant findings require follow-up, consistent with CMS procedures. However, the 45/60 day follow-up procedures are unique to the Joint Commission and may spark some comments.
6. The ability to provide CMS with the necessary data for validation- This refers to information shared with CMS and the states for the purpose of validation surveys, including the dates of survey and the results of survey.

This comment period represents an opportunity for hospitals to share their thoughts on the deemed status application and suggest improvements prior to its approval in 2010. Similarly, CMS is seeking comments on the deemed status application for the Joint Commission’s Critical Access Hospital program and the American Association for Accreditation of Ambulatory Surgery Facilities survey process.  The links to the instructions for comments are listed below.

To link to the Federal Register notice for hospitals, click here.
To link to the Federal Register notice for Critical Access Hospitals, click here.
To link to the Federal Register notice for American Association for Accreditation of Ambulatory Surgery Facilities, click here.