This book provides the guidance an organization needs to successfully complete any Joint Commission postsurvey process. While standards requirements have not changed with the rollout of the Standards Improvement Initiative in 2009, postsurvey requirements have changed slightly. For the first time, noncompliance with any element of performance (EP) or other Joint Commission requirement automatically generates a Requirement for Improvement (RFI).

This book offers helpful instructions on how to propose an effective clarification or how to develop and evaluate Evidence of Standards Compliance (ESC) and Measures of Success (MOS) to ensure standards compliance and help your organization receive a positive accreditation decision. An unresolved RFI can ultimately lead to loss of accreditation. This book can help your organization avoid that situation.

A Guide for Addressing RFIs After Your Joint Commission Survey is a guide that can help all health care organizations navigate post-survey activities.

--- Evidence of Standards Compliance (ESC) Examples ---

A corrective Evidence of Standards Compliance (ESC) shows postsurvey changes you made and completed to address a Requirement for Improvement (RFI) your organization received during your Joint Commission survey. The following examples are actual ESCs submitted by organizations to The Joint Commission. Names of organizations in the examples have been omitted or changed to preserve anonymity. More examples of corrective ESCs appear in the book.

Acceptable Corrective ESC Example
This example includes the specific corrective actions (Who, What, When, and How) taken by the organization to address its Requirement for Improvement (RFI). This Evidence of Standards Compliance (ESC) submission was found acceptable by The Joint Commission.

Corrective ESC with Acceptable MOS Example
This example shows a Requirement for Improvement (RFI) that includes a Measure of Success (MOS). It includes the specific corrective actions (Who, What, When, and How) taken by the organization to address its RFI. This Evidence of Standards Compliance (ESC) submission was found acceptable by The Joint Commission.

Corrective ESC with Unacceptable MOS Example
This example shows a Requirement for Improvement (RFI) that includes a Measure of Success (MOS). However, certain information was missing from this Evidence of Standards Compliance (ESC) submission, which made it unacceptable to The Joint Commission. Italicized remarks in brackets indicate what was missing.

Self-Assessment: How Does Your Organization Compare?

The Joint Commission regularly collects data on organizations’ compliance with its standards and requirements so that it can identify trends and focus education on its most challenging requirements. Click on the following links to see bar graphs showing which Joint Commission standards, National Patient Safety Goal (NPSG) requirements, Universal Protocol (UP) requirements, and Accreditation Participation Requirements (APRs) were most frequently identified as “not compliant” from January 1, 2008, through June 30, 2008, for each of the eight accreditation programs. The percentage of organizations in each program that received Requirements for Improvement (RFIs) is displayed in the bar corresponding to the requirement number. Look in your 2008 accreditation or certification manual for the full text of the requirements.

Note: The requirements listed in each bar graph are from 2008. Through the Joint Commission’s Standards Improvement Initiative for 2009, some of these requirements were renumbered, split into multiple requirements, consolidated, revised, or deleted. Please refer to the history tracking reports provided on CD-ROM with your 2009 manual or check your online electronic manual (E-dition) to track the requirements from 2008 to 2009.

Ambulatory Care
Behavioral Health Care
Critical Access Hospital
Home Care
Hospital
Laboratory
Long Term Care
Office-Based Surgery

--- The Accreditation Decision Process ---

This overview of The Joint Commission’s accreditation decision process serves as a refresher on how The Joint Commission assigns Requirements for Improvement (RFIs) and determines an organization’s accreditation decision.