Physicians invited to play a larger role in standards process

Surgeons and other physicians know The Joint Commission for its accreditation of hospitals and development of the standards that guide many aspects of an institution’s daily operations and have an impact on physicians. Because the guidelines affect physicians, The Joint Commission strives to include them in the standard-setting process.

The Joint Commission’s goal is to help health care institutions—and the practitioners in those facilities—to improve the quality and safety of patient care. That rationale should underlie every standard The Joint Commission sets. The evidence for this rationale comes both from formal studies and from the experience of experts in practice—surgeons, other physicians, nurses, pharmacists, and so on.

Making certain that surgeons and their physician colleagues understand the reason for relevant standards and that they have a clear understanding of the meaning of the standards is a goal of a number of initiatives that The Joint Commission is undertaking. These efforts include engaging physicians about their experience with the standards through focus groups and other outreach efforts to inform staff when changes are needed. Physicians also can influence the development of new or revised standards by participating in the field review or submitting questions via an online standards question form.

Physicians are encouraged to take advantage of the form and send their thoughts about specific standards to The Joint Commission.

Summary of the standards development process

  • New or revised requirements are identified through the scientific literature or The Joint Commission’s standing committees and advisory groups, accredited organizations, professional associations, and consumer groups, and input from physicians, health care workers, or others.
  • The draft standards are developed using input from external task forces, focus groups, experts, and other stakeholders.
  • Technical Advisory Panels (TAPs) are assembled when complex technical or controversial issues are involved.
  • The draft standards are reviewed by relevant Joint Commission Professional and Technical Advisory Committees (PTACs) composed of outside experts and the Standards and Survey Procedures (SSP) Committee, a committee of the Board of Commissioners, both of which include experts from the American College of Surgeons.
  • The draft standards are distributed nationally for review and made available for comment on the Standards Field Review page of The Joint Commission website.
  • If needed, the draft standards are revised and again reviewed by the TAP, other experts, and relevant PTACs.
  • The draft standards are approved by the SSP Committee and provided to the Board for a comment period. Once that period of time has passed, the standards are final unless the Board seeks further discussion.
  • Surveyors are educated about how to assess compliance with the standards.
  • The approved standards are published. Prepublication versions of the standards are posted on the website until they are published in the printed accreditation manuals or The Joint Commission E-dition, the electronic version of the accreditation and certification manuals.
  • Once a standard is in effect, ongoing feedback is sought through a Comment on a Standard form for the purpose of continuous improvement.

Physician questions

Most questions and concerns about standards that come to The Joint Commission from physicians fall within the following categories:

  • Standards not related to quality and safety. The Joint Commission has heard from physicians that certain standards do not support the quality and safety of patient care. For example, the requirement to create a summary list for recurring outpatients by the third visit has been problematic in terms of implementation and frequently questioned as to how it contributes to quality and safety when the outpatient areas in question do not provide primary care-type services. A frequently asked questions (FAQ) document was developed to explain the limits of the requirement’s applicability. The Joint Commission staff systematically review any standard that is thought not to support quality of care and to determine if the standard needs to be updated or deleted.
  • Standards that generate ongoing debate. In some cases, there are divergent opinions on what would be the best requirement. For example, a number of standards in the “Medical Staff” chapter of the hospital and critical access hospital accreditation manuals have been vigorously debated among physicians. Topics covered in this chapter include guidelines for determining which clinicians are allowed to complete the admitting history and physical examination, the relationship between the organized medical staff and the medical staff executive committee, and the use of volume of procedures performed in the privileging process. The Joint Commission often finds that issues that elicit ongoing, passionate debate tend to be based less on data and more on strong opinions. Although it is impossible to satisfy all stakeholders, The Joint Commission attempts to elicit all major points of view and to create a clear rationale for the final requirement.
  • Relationship of The Joint Commission standards to Conditions of Participation (CoP) established by the Centers for Medicare & Medicaid Services (CMS). A number of The Joint Commission requirements are actually CMS CoP and must be addressed through accreditation standards and/or elements of performance if accreditation is to qualify the organization for Medicare payments. Changes in CoP sometimes necessitate revisions in The Joint Commission standards language to maintain alignment between the requirements. For example, The Joint Commission has made changes in the Medication Management and Leadership chapters for hospitals and critical access hospitals to reflect revised CoP. The Joint Commission engages in ongoing dialogues with CMS about ways they can work together to help health care organizations improve patient care and patient outcomes.
  • Misinterpretation of requirements within a standard. On occasion, the intent of a standard is misunderstood. One example is the standard associated with physician privileging and re-privileging, which uses a combination of Ongoing Professional Practice Evaluation and Focused Professional Practice Evaluation. These two processes are used to address separate issues in privileging and are quite different. The most common misinterpretation is the level of complexity required in these two evaluations. Occasionally, The Joint Commission finds interpretations of these requirements that go significantly beyond the intent. While an organization may implement processes that exceed The Joint Commission requirements, different methods to reduce misunderstandings of the requirements themselves are under review.

Standards development

Physicians also often ask questions such as, “Why is this standard phrased the way it is? What does this standard have to do with quality and safety? How was this standard developed?”

The standards are based on available scientific evidence with extensive input of experts in the topic area and from the field. New and revised standards undergo an extensive vetting process that can take one year or more to complete. During this time, opportunities are provided for physicians and others to voice their opinions about the proposed standards. A summary of the standards development process appears in the sidebar.

The Joint Commission provides a Standards Online Question form as one of the means of soliciting questions about the standards. Physicians are also invited to visit the Standards page on The Joint Commission website for more information.

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