Compliance News: Measures of Success and Scoring Category Changes

By Dean Samet, CHSP


According to the April 28, 2010 Joint Commission Online, a number of Measures of Success (MOS) requirements have been deleted effective April 26, 2010 and several Elements of Performance (EPs) will change from a “C” to an “A” scoring category effective July 1, 2010. Compliance with affected Elements of Performance is still expected. If your organization is currently completing the MOS data submission for the affected EPs based on your last survey, go to The Joint Commission Connect extranet and enter “MOS requirement removed” in the text box and submit.

Before showing the recent changes, let’s review the particulars of what an MOS is and what the scoring categories are.


Some EPs require an MOS (as designated with a “D” in a circle in the accreditation manual) if that EP was found to be out of compliance at the time of survey or when performing a Periodic Performance Review (PPR). An MOS is a numeric or quantifiable measure, typically related to an audit, that determines whether an action is effective and sustained.

All EPs are designated as either an “A” or “C” scoring category. “A” EPs usually relate to structural requirements, e.g., policies or plans that either exist or don’t exist, and are scored either (2) or (0), respectively. The “A” EPs may also address an issue that must be fully compliant even though it focuses on performance or outcome, e.g., National Patient Safety Goals, or may also relate to a Medicare Condition of Participation that must be fully compliant. “C” EPs are frequency-based and are scored based on the number of times an organization does not meet a particular EP. These are given a score of (2) if there are one or fewer occurrences of noncompliance; (1) if there are two occurrences of noncompliance; and, (0) if there are three or more occurrences of noncompliance.

The Environment of Care (EC) standards with MOS deletions are listed below. (Note: Those designated with an asterisk will be changed from a “C” to an “A” scoring category, effective July 1, 2010.)

EC.02.01.01 EPs 7, 11
EC.02.01.03 EP 6
EC.02.02.01 EPs 7*, 8
EC.02.03.01 EP 1
EC.02.03.05 EPs 3, 4, 7*, 9*, 12*, 16*, 17*, 18*, 19*, 20*
EC.02.04.01 EP 3
EC.02.04.03 EP1
EC.02.05.01 EP 3
EC.02.05.05 EP 1
EC.02.05.07 EP 2

Go to the April 28, 2010 Joint Commission Online publication for a complete list of changes which also include the following chapters: Information Management (IM), Leadership (LD), Medication Management (MM), Medical Staff (MS), Provision of Care (PC), Performance Improvement (PI), and Record of Care, Treatment, and Services (RC).