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February 14, 2018

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The Joint Commission Updates Hospital COP-related Requirements

May 12, 2009:

The Joint Commission has refined the scoring and decision process for the Hospital Accreditation Program, as detailed in a March addendum to its accreditation standards.

The Commission made some changes to its accreditation processes beginning January 1, 2009, as part of its application to Centers for Medicare & Medicaid Services for continued hospital deeming authority and as part of a collaborative effort with CMS to more closely align these conditions of participation (COP) standards with those of CMS.

Originally 165 new and revised requirements were proposed for the ambulatory, critical access hospital, home care, hospital, and office-based surgery programs. A number of those requirements were considered already addressed in the survey process so the number of changes was reduced to 87, and many of these changes add only additional specificity to existing requirements.

The addendum including these COP-related changes, posted to the Joint Commission website March 26, replaces the version posted on January 5, 2009. Hospitals will be surveyed on these requirements from April 6 through June 30, 2009, during which time noncompliance will not affect accreditation decisions; rather, surveyors will review compliance with any new requirements beginning January 1, 2009, but these will not be scored until July 1. Hospitals will receive separate feedback on their efforts to meet these requirements. Beginning July 1, 2009, however, noncompliance will affect the accreditation decision.

The updated requirements and a comparison between the standards posted in January 5 and the March addendum can be found on the Joint Commission website at: http://www.jointcommission.org/Standards/.

Sarah A. Serling, CPC, CPC-H, CPC-I, CCS-P, CCS
Clinical/Technical Editor


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