Joint Commission Modifies Process for Preliminary Denial of Accreditation Decisions

by dawnconrey

Joint Commission Modifies Process for Preliminary Denial of Accreditation Decisions

by dawnconrey

by dawnconrey

The May 2016 issue of The Joint Commission Perspectives describes an important change in how they are handling preliminary denial of accreditation decisions, or PDA02. This is a particularly good news story, because TJC has found a way to not drive organizations all the way to a review hearing panel, providing they can quickly correct the issues found on survey. In the past a hospital that had a PDA02 decision had to submit their ESC, had to go through an ESC implementation verification survey, and had to then convince the Accreditation Committee not to uphold the PDA decision, and if not successful next go to a review hearing panel in Chicago to plead their case. This has become much simpler and less threatening.

Now if a hospital has a PDA02 decision they will have to submit their ESC in 30 days, must go through an ESC implementation verification survey, and if applicable must go through their COP level survey in 45 days. However, the really good news is if the hospital gets their act together quickly and they pass these surveys and make the corrective actions, the Joint Commission will change their accreditation status to Accreditation with Follow up, or AFS. That means one more survey at the 4-6-month point to verify that corrective actions are sustained, but you avoid the appeal to the accreditation committee and the in-person review hearing panel. In addition, these new rules will require senior leadership to participate in the intracycle monitoring process or ICM. Furthermore, TJC will schedule a telephone conference call with leadership to “review areas of risk and available Joint Commission resources.” We noted the small “R” in resources, so we assume this really means Joint Commission resources, not the Joint Commission Resources consultation services. TJC has many online tools, like the leading practice database and the Targeted Solutions Tool that hospitals make insufficient use of today that may provide helpful guidance in implementing corrective actions. Having worked with many organizations that had this onsite PDA decision, they all made swift corrective actions, but had an anxiety provoking 6-month period working their way through this, and hoping for the right decision from the accreditation committee, which in the past factored in only status at the time of survey, not the improvements. So this is very good news. There is one important additional step in this process; the next full survey will moved up in the schedule (e.g., at the 19-month mark instead of the normal 33-36-month mark from the previous survey decision) and if that survey should turn out with a PDA decision, its potentially “lights out” as the Joint Commission would up-score a second PDA to DA, or denial of accreditation. Thus the importance of sustainable corrective actions.

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