The Joint Commission previously announced that it would review accreditation requirements that are above and beyond the Centers for Medicare & Medicaid Services (CMS) Conditions of Participation (CoPs). This initiative aims to help their customers address the many challenges that healthcare is facing by eliminating requirements that do not add value to accreditation surveys so that healthcare organizations and surveyors can focus on other strategies and structures that support quality and safety.
The review began with hospital elements of performance (EPs) that met all of the following criteria:
- The EP does not support a CMS CoP or state regulation.
- The EP has been in effect for at least three years.
- The EP has been scored five times or less during full triennial surveys between 2017 and 2019 (the three years prior to the COVID-19 public health emergency).
Staff across multiple divisions reviewed each of the selected EPs and reported the possible reasons why scoring was low, including organizations are compliant with the requirement because they have adopted it as a standardized practice, the EP is redundant to another requirement, and the EP is difficult to assess compliance objectively and consistently during surveys. As a result of this review, 56 hospital EPs were identified for deletion, and 4 EPs needed minor revisions to make them more effective. Many of these EPs were also accreditation requirements for other programs, and these were deleted or revised from those programs as well.
