TJC Autopsy Requirements

Question:

Once upon a time, TJC used to review that we offered an autopsy to basically all families when the patient expired. Can we stop offering it to all and offer per criteria as per the TJC standard? What are the TJC autopsy requirements that we should follow?

Answer:

Interestingly, the TJC reference to autopsy was removed recently (in 2020) from the Joint Commission hospital standards because of the CMS Burden Reduction effort actually removed the whole A-Tag on autopsy from the CMS COPs.  We are including the OLD CMS language, which was removed.  

In the published burden reduction memo from CMS the writers stated that the hospitals have to adhere to the state requirements on autopsies, which were often more rigorous than the federal requirements.  You need to adhere to your own state requirements in your policy but no longer have a Joint Commission or CMS requirement.

State Operations Manual

Appendix A (Content that was deleted in 2020)

§482.22(d) Standard: Autopsies

The medical staff should attempt to secure autopsies in all cases of unusual deaths and of medical-legal and educational interest. The mechanism for documenting permission to perform an autopsy must be defined. There must be a system for notifying the medical staff, and specifically the attending practitioner, when an autopsy is being performed.

Survey Procedures §482.22(d)

Verify that the medical staff has policies requiring the practitioners to attempt to secure permission to perform autopsies, that the mechanism for documenting permission to perform an autopsy is defined, and that there is a system for notifying the medical staff, specifically the attending practitioner, when an autopsy is performed.