According to the 2019 HFAP Quality Review, incomplete processes and insufficient documentation were the most-cited standards during 2018 on-site surveys at acute care hospitals, critical access hospitals, laboratories, and ambulatory surgery centers.
Element of performance (EP) 3 requires that the suicide risk assessment include risk factors, which TJC describes as “a combination of individual, biological, psychological, familial, community, cultural, and/or societal characteristics or factors that may contribute to the risk of suicide.”
The proposed rule establishes a process AOs with Medicare-approved accreditation programs must follow if there is a sale, transfer, and/or purchase of assets related to the ownership of an AO.
The added emphasis on suicide comes at a time of national concern about suicides in hospitals and is meant to complement the “Zero Suicide” campaign, an effort by several outreach groups to eliminate suicide in healthcare facilities nationwide, according to Joint Commission literature.
Released in the April issue of Perspectives, the list covers the top Joint Commission requirements that surveyors found to be noncompliant most often during 2018.
The proposed law, which became known as “Question 1” because of its position on the referendum ballot, was soundly defeated in the November 2018 election, with about 70% of Massachusetts poll-goers voting “no.” An industry-backed campaign from hospital executives spent around $27 million exhorting voters to turn down the measure.
CMS published a request for information in mid-December, asking the public to weigh in on whether accrediting organizations that also offer consulting services have, or at least create, a public perception of conflict of interest.
All the changes are listed in R3 Report 19 and will take effect July 1, 2019. The update applies to all TJC-accredited hospitals, critical access hospitals, nursing care centers, and medical centers accredited under the ambulatory healthcare program.
On December 18, the federal agency pre-published a request for information on “Medicare Program: Accrediting Organizations Conflict of Interest and Consulting Services.”
The latest list, published in the September issue of Perspectives, shows the standards scored most frequently as “not compliant” during Joint Commission accreditation surveys and certification reviews from January 1 through June 30, 2018.