Accreditation Process Issues
| Issue | Summary Description | Impact/Explanation |
| Key Dates | 1/1/09 SSI Improvements | Implementation of revised scoring and decision methods for all programs. |
| New Terms | Criticality | The immediacy of risk to patient |
| Direct Impact Requirement | These are “Implementation” based requirements with a short resolution time frame | |
| Indirect Impact Requirement | These are “Evaluation” based requirements with longer resolution time frame | |
| “egregious” non compliance | This was not clearly defined in the “Perspectives” article | |
| D | A “D” Icon with a circle around it in the standards indicates documentation is required | |
| New Concepts | Accreditation Decision | Was based on volume of findings, to be based on premise that some standards are more critical than others (more direct patient impact). # of RFI’s and criticality decide outcome. |
| Supplemental findings eliminated | All findings will be RFI’s, no supplemental findings. All receive RFI and require ESC | |
| “B” Type EP’s eliminated | There will be no more “B” classified EP’s. All EP’s will be A or C Type | |
| Eliminate vague wording | Hard to measure words such as adequate, appropriate, as needed, assure, considers, might, should, significant, sometimes, and timely, eliminated or minimized in standards. | |
| 4 levels of criticality | Immediate Threat to Life, Situational Decision Rules, Direct Impact, Indirect Impact | |
| Criticality Tagging | Relevant standards will be “tagged” with a 2 or 3 in a triangle in the standards, indicating if they are Situational Decision Rules, or Direct Impact Requirements. | |
| Findings Clarification | Within 10 business days of the report being posted, the organization may move to “clarify” findings based on evidence not previously available to the surveyors, (but in place at the time of survey). | |
| What Remains | Standard/EP structure | There will still be standards and elements of performance for each standard |
| EP scoring | Elements of performance still scored on a 0 -2 point scale | |
| RFI | Requirement for improvement (criteria change somewhat) | |
| ESC | Evidence of standards compliance required when and RFI is identified | |
| MOS | Measure of success required for cited element of performance when a standard fails | |
| Immediate Threat to Life | ||
| Situational Decision Rules | Several modifications have been made to rules for issues leading to various types of Preliminary Denial and Conditional Accreditation, etc. | |
| Unknown | # allowable RFI’s & criticality | To be determined at TJC Board Meeting in August 2008 |
