If and when significant changes occur within a hospital, the hospital staff must notify The Joint Commission in writing or through its Joint Commission Connect site not more than 30 calendar days after such a change is made. The staff must also notify TJC in writing or in its electronic application (e-APP) if it opens or closes any units or services.
There are three change categories addressed in the 2011 Hospital Accreditation Standards manual’s The Accreditation Process (ACC) chapter:
• Changes affecting e-APP Information
• Changes to the Site of Care, Treatment, or Services
• Mergers, Consolidations, and Acquisitions
An accredited hospital might undergo a change that modifies the information reported in its e-APP. The hospital staff must update its e-APP within 30 calendar days after such a change is made in:
• Ownership
• Location
• A significant increase/decrease in the volume of services or individuals served
• The addition or deletion of a new type of health service, program or site of care
• The acquisition of a new component
• The deletion of an existing component
The accuracy and veracity of relevant information reported in the e-APP are subject to The Joint Commission’s Information Accuracy and Truthfulness Policy and must be accurate and truthful. Falsification, which applies to both commissions and omissions in sharing information with TJC, will lead to a Preliminary Denial of Accreditation decision.
When a hospital offers at least 25% of its services/programs at a new location or in a significantly altered physical plant, the hospital staff must also complete and submit a TJC Basic Building Information (BBI) within the electronic Statement of Conditions™ (e-SOC), which is available on the hospital’s secure Joint Commission Connect site, and Plan for Improvement (PFI), should there be any Life Safety Code® deficiencies. Failure to provide timely notification to TJC of these changes could result in the hospital’s loss of accreditation.
In case of a merger, consolidation, or acquisition, TJC may decide that the hospital responsible for services must have a survey. Barring any exceptional circumstances, TJC continues the accreditation of the hospital undergoing the changes described herein until it determines whether or not an extension survey is necessary.
See also Accreditation Participation Requirements Standard APR.01.03.01: The hospital reports any changes in the information provided in the application for accreditation and any changes made between surveys. EP.1: The hospital notifies The Joint Commission in writing within 30 days of a change in ownership, control, capacity, or services offered. Note: When the hospital changes ownership, control, location, capacity, or services offered, it may be necessary for The Joint Commission to survey the hospital again. If the hospital does not provide written notification to The Joint Commission within 30 days of these changes, the hospital could lose its accreditation.
The Joint Commission accreditation is neither automatically transferred nor is it automatically continued if significant changes (as described above) occur within an accredited hospital. When such changes occur, it is imperative to notify The Joint Commission within 30 calendar days or less after any such changes are made.
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