Compliance News: TJC Elminates 16 Hospital EPs

By Dean Samet, CHSP



The Joint Commission eliminated 16 elements of performance (EPs) from their hospital accreditation program with a July 1, 2010 effective date, as announced in the June 9, 2010 Joint Commission Online publication.


These and other EPs went through an extensive evaluation process as part of TJC’s internal Robust Process Improvement (RPI) initiative started in mid-2008. The RPI establishes a measurement ranking scale against which all standards for all of TJC programs will purportedly be evaluated going forward. As part of this evaluation, more than 300 hospitals were invited to provide their perceptions of what constitutes a “valuable” standard and which standards they believed contributed the least value towardquality and safety.  TJC defines a valuable standard as one that:

• Supports a health care priority that affects patient safety or quality of care
• Has a solid evidence base or an iron-clad rationale
• Has a strong relationship to clinical care
• Supports the organization’s attainment of patient safety and quality care
• Judiciously uses an organization’s resources (that is, the benefit of implementing a requirement outweighs the cost of doing so)


52 EPs were identified by the participating hospitals as being of questionable value. Included were the following:


Standard EC.02.06.01


-  EP 4. The hospital provides space for recreation and social interaction for patients who remain in the care of the hospital for more than 30 days.


-  EP 5. The hospital provides storage space to meet patient needs.


-  EP 6. When the hospital provides care for more than 30 days, it provides outside areas for patient use, suitable to the patient’s age, physical or mental condition, or other factor.


-  EP 18. Interior spaces accommodate the use of equipment, such as wheelchairs, necessary to the activities of daily living.


All of the 52 EPs were reviewed by TJC against their above-listed “valuable standard” criteria for which recommendations were made for final approval to The Joint Commission’s Hospital Professional and Technical Advisory Committee (PTAC) and also to TJC’s Standards and Survey Procedures Committee (SSPC) to keep, revise, combine, or delete the recommended requirements.


See the June 2010 issue of The Joint Commission Perspectives for the full text of the revised and eliminated requirements.