There have been some significant changes to The Joint Commission’s (TJC) standards and scoring for 2009. The Emergency Management (EM) requirements have been removed from the Environment of Care chapter and incorporated into their own EM chapter. The Life Safety Code® requirements, Statement of onditions™ (SOC™), and Interim Life Safety Measures (ILSM) have all been relocated to a new Life Safety (LS) chapter. While there are purportedly no new requirements as a result of all these changes, there are some subtle nuances that may be viewed as new requirements along with items that might have been implied in the past which are now specified. However, the most significant changes can be found in the scoring.
Now all findings of less than full compliance will be cited as a “Requirement for Improvement” (RFI) and will require resolution through an “Evidence of Standards Compliance” (ESC) submission. There are no more supplemental” findings. The timeline for completing the ESC submission will depend on the “criticality” of findings and immediacy of risk. Criticality is the immediacy of the impact of noncompliance on quality care and patient safety. In the past, scoring was typically based on the number of noncompliant standards and elements of Performance (EPs) and on the volume of survey findings in relation to pre-established thresholds.
There are now four scoring categories:
Tier 1) Immediate Threat to Life (ITL): Situations identified at survey that have or may potentially have a serious adverse effect on patient health and safety resulting in a Preliminary Denial of Accreditation (PDA). Example: Inoperable fire alarm or pump without a fire watch or ILSM; Emergency generator down for extended period without backup; Lack of master alarms for medical gas systems.
Tier 2) Situational Decision Rules (SDR): Situations in which an accreditation decision of PDA or Conditional Accreditation (CA) is recommended to the TJC Accreditation Committee. Two LS Examples where failure to comply could result in PDA or CA: LS.01.01.01, EP.3, “When the hospital plans to resolve a deficiency through a Plan for Improvement (PFI), the hospital meets the time frames identified in the PFI accepted by The Joint Commission;” or LS.01.02.01, EP3, “The hospital has a written interim life safety measure (ILSM) policy that covers situations when Life Safety Code® deficiencies cannot be immediately corrected or during periods of construction. The policy includes criteria for evaluating when and to what extent the hospital ollows
special measures to compensate for increased life safety risk.” See EPs marked with the number (2) in a triangle in the accreditation manual.
Tier 3) Direct Impact Requirements (DIR): Implementation-based requirements. Example: Requirements where non-compliance is likely to create an immediate risk to patient safety or quality of care. See EPs marked with the number (3) in a triangle in the accreditation manual. evaluation-based requirements.
Tier 4) Indirect Impact Requirements (IIR): Planning and evaluation-based requirements. Example: Requirements where failure to resolve compliance issues increases risk to patient safety or quality of care over time. Most EPs in the Environment of Care, Emergency Management, and Life Safety chapters fall into this category.
Due to the significant rearranging, relocating, renumbering, and new scoring of the above-mentioned standards, this is a perfect opportunity to assess your existing policies and procedures and documentation against the Environment of Care, Emergency Management, and Life Safety chapter requirements shown in the 2009 accreditation manuals.
