Notify TJC of New Hospital Opening

We are opening a new hospital that will be affiliated with our current TJC accredited hospital.  Should we notify TJC of the opening of the new hospital?  Will it be included in our current accreditation?

The Hospital Accreditation Standards, 2011 provides direction to notifying TJC of changes.

 

Under “The Accreditation Process”  (ACC) section “Notifying The Joint Commission About Organizational Changes” the manual states: “Accreditation is neither automatically transferred nor continued if significant changes occur within a hospital.  When significant changes occur, the hospital must notify TJC in writing or through its Joint Commission Connect site not more than 30 calendar days after such change is made.  The hospital must also notify TJC in writing or in its e-App if it opens or closes any units or services.”   The chapter goes on to specify actions to be taken for: “Changes Affecting e-App Information”, “Changes to the Site of Care, Treatment, or Services”, and “Mergers, Consolidations, and Acquisitions”.

 

The section on “Changes to the Site of Care, Treatment, or Services” states: “When a hospital offers at least 25% of its services or programs at a new location or in a significantly altered physical plant, the hospital must also fill out and submit TJC Basic Building Information within the electronic Statement of Conditions (eSOC), available on the hospital’s secure Joint Commission Connect site, and Plan for Improvement, should Life Safety Code deficiencies be present.  Failure to provide timely notification to TJC of these changes may result in the hospital’s loss of accreditation.  If completion dates for a PFI cannot be achieved, the hospital is contact TJC Standards Interpretation Group’s engineering staff to request an extension.”

 

My recommendation is to notify TJC of this site and services prior to opening the facility for services.  I consider that as “timely notification”.  TJC will determine whether to survey the facility or not, based upon organizational history, publicity and their parameters for monitoring/surveying new sites.  Whether you notify them or not, if the current hospital's name is associated with the new facility, TJC will be aware of when it opens through news clipping services.  It is to your advantage to notify TJC ahead of opening the new hospital and take care of all those official applications and electronic forms.  This does buy some good will although it may be hard to see at times.