The long-awaited publication of The Joint Commission’s 2017 accreditation standards occurred on January 9th. The delay was due to the adoption of the 2012 editions of NFPA 101, the Life Safety Code® and NFPA 99, the Health Care Facilities Code ®. When the standards adoption was effective on July 5, 2016, The Joint Commission developed and rewrote multiple elements of performance in the Environment of Care (EC) and Life Safety (LS) chapters. They were submitted to CMS for their approval, and these are what you see in the January 9th publication of the standards.
Meanwhile, however, CMS was writing many additional K-tags in these chapters. Due to the time required for CMS vetting of The Joint Commission’s new standards, these issues did not make it into the published 2017 standards. There simply wasn’t time. To accommodate the scoring of these issues, required by the 2012 codes, “wild card” standards have been added to several standards in the EC chapter, and to the existing wild card standards in the LS chapter. The “wild cards” are those standards which reference “all other” requirements found within a specific code and chapter. In addition, some of the new K-Tags are also listed under the safety “general duty clause,” EC.02.06.01, EP1, which has always been somewhat of a wild card. The K-Tags used under these wild card standards can be downloaded here: 2017 TJC Wild Cards (by: MSL Healthcare).
But before you review that, there are several other changes of which you should be aware.
- Previously, it was announced that non-high risk medical equipment in an alternative equipment maintenance (AEM) program required a preventive maintenance completion rate of at least 90%. However, CMS believes that since the organization determines the AEMs, the preventive maintenance under AEM must have a 100% completion rate. The note under EC.02.04.03 EP 3 indicates that non-high risk medical equipment in an AEM program must have a 100% completion rate, but “AEM frequency is determined by the hospital’s AEM program.” Therefore, the 100% completion is required for non-high risk AEM equipment, but the organization may determine the frequency at which AEM programs must be completed, thus allowing some discretion in setting the allowable window in which to perform the maintenance.
- In LS.01.01.01 a new EP 15 has been added to state that the hospital may use alternative ILSM’s that aren’t listed in the standards. Those will be noted in the survey report. In addition, any identified life safety deficiency noted at survey will generate a discussion with the surveyor about which ILSMs will be implemented for the deficiency, and these, too, will be noted in the survey report.
All of these changes will be discussed in the coming months in EC News and Perspectives. Expect to see the K-Tags scored at the wild card standards in the 2018 Joint Commission standards as unique elements of performance.