By Dean Samet, CHSP
In their December 2008 The Joint Commission Perspectives, Volume 28, Number 12, The Joint Commission (TJC) reported that at its October 2008 meeting, TJC’s Accreditation Committee (AC) approved the remaining component for the 2009 accreditation decision methodology which included elimination of the use of thresholds” as determinants of Conditional Accreditation (CA) and Preliminary Denial of Accreditation (PDA). Thresholds have been used by TJC for years to determine whether to invoke or recommend CA or PDA if and when an organization had exceeded a preset number of Requirements for Improvement (RFIs).
The AC approved that program-specific thresholds should serve only as “screens” for identifying organizations whose survey findings should be subject to a more intense review by TJC Central Office staff and senior management, rather than serve as “automatic” determinants of CA and PDA decisions. Such a review would be in addition to one conducted for organizations that meet a Situational Decision Rule (SDR) for an adverse accreditation decision or for which an Immediate Threat to Life (ITL) has been declared.
The so-called “screens” for Central Office review, which are based on the number of non-compliant Direct Impact Requirements (DIR), adjust for differences in size and complexity of surveyed organizations they are now calling “bands.” The bands are based on significant differences in the number of RFIs associated with various “survey lengths” or “surveyor days.” (See December 2008 Perspectives for full details and tables explaining how “bands,” “surveyor days,” “screens,” and RFIs relate to each other.)
TJC Central Office review would result in one of the following outcomes:
• Identification of RFIs to be addressed via the submission of Evidence of Standards Compliance (ESC)
• Recommendation for Conditional Accreditation
• Recommendation for Preliminary Denial of Accreditation
Just when you thought you might have an opportunity to enjoy a simplified scoring process as a result of TJC’s Standards Improvement Initiative, the revised accreditation decision methodology described above was painstakingly developed.
