The Joint Commission (TJC)

January 23, 2012
Letter to TJC Regarding Revised Standards Related to Overuse of Treatments, Procedures, and Tests

ACEP supports the development of the National Patient Safety Goal on overuse and appreciate the flexibility for each hospital to determine area(s) of focus. Many reviewers noted that to have a significant impact on overuse it should be acknowledged that liability concerns play a role in overuse and failure to diagnose is a leading reason for medical liability suits.

January 19, 2012
Comments on Revised TJC Standards Related to Patient Flow in ED

While ACEP supports the proposed definition including the four hour timeframe opinions among members are varied. Some voiced concern that including the four hour timeframe may result in a four hour delay for all admitted patients.

May 18, 2011
TJC Provides FAQs on Use of Unlicensed Persons Acting as Scribes
The Joint Commission published Frequently Asked Questions about the use of scribes, unlicensed people hired to enter information into the electronic medical record (EMR) or chart at the direction of a physician. The FAQs include what TJC surveyors will expect to see if scribes are employed in your emergency department.

January 24, 2011
ACEP Reviews NPSG on ventilator-associated pneumonia (VAP) and catheter-associated urinary tract infections (CAUTI)
The Joint Commission is revising the National Patient Safety Goals addressing ventilator-associated pneumonia (VAP) and catheter-associated urinary tract infections (CAUTI) for the Hospital. ACEP reviewed the draft revisions and submitted comments.

May 10, 2010
ACEP Reviews NPSG on Medication Reconciliation
Joint Commission is revising the National Patient Safety Goal on medication reconciliation (NPSG.03.07.01). ACEP and ENA have submitted a joint letter. While we support the flexibility for the hospital to define the types of medication information that is collected in each setting and the elimination of the need to create a separate list, there were some remaining concerns. Recommended revisions focused on clarification of terminology and addition of the phrase "when clinically indicated" for EP2.

March 31, 2008
ACEP Reviews Draft TJC Medication Management Standards (MM.4.10 and MM.8.10 and New Standard MM.4.15)
TJC revised the standards due to concerns regarding the review of medication orders by a pharmacist prior to dispensing and administration.  These concerns included work flow issues, the nature of urgent situations, and manpower. Based on input from the field and The Joint Commission’s Medication Management Expert Panel, revisions are proposed for Standards MM.4.10 and MM.8.10 in their applicability to the emergency department.  Additionally, new Standard MM.4.15 is proposed for the emergency department.

December 18, 2007
ACEP Reviews Draft TJC Primary Stroke Center Certification Standards
ACEP reviewed proposed revisions by The Joint Commission (TJC) and the American Stroke Association (ASA) for the Primary Stroke Center Certification. The proposed revisions focused on IV thrombolytic therapy administration to eligible patients and the infrastructure that supports the safe administration of IV thrombolytic therapy.

Joint Commission Revises Medication Standards, Provides Relief for EPs

November 29, 2007
College calls for The Joint Commission to reverse its position preventing the use of nurse initiated protocols
ACEP, ENA, and AAEM jointly express serious concerns with  TJC's interpretation of MM.3.20 EP1 whereby nurses in the ED are being prevented from implementing evidence-based medical staff approved protocols prior to the examination of a patient by a physician . The group is asking TJC to immediately reverse its position and to publicize this determination so that timely, safe and effective care can continue to be offered to ED patients.

June 12, 2007
The Joint Commission has once again changed its standard requiring first dose, prospective pharmacy review -- a move that should provide some relief to emergency departments nationwide.

The revised standard now allows for an exception to the rule "in urgent situations," and frees the emergency physician from actually being required to order, prepare and administer the medication by allowing a registered nurse to process and administer the medication if a physician is in the proximity of the patient.

The revisions came after several months of ACEP representatives working with the Joint Commission to find a solution to the concerns facing emergency departments with the standard. ACEP joined forces with AAEM and ENA, and wrote several letters to the Joint Commission since the standard begin Jan. 1. A Joint Commission task force that includes ACEP members will continue to monitor the standard.

"We are pleased that the Joint Commission heard the concerns of the emergency physicians," said Marilyn Bromley, RN, ACEP’s Director of EM Practice. "We believe these changes still keep the standard’s intent of providing patient safety, but allow for a process in the ED that still manages patient throughput and minimizes treatment delays."

Revision to Medication Reconciliation Standard

The Joint Commission clarified its expectation of medication reconciliation in the emergency department. In a January 2007 update to its National Patient Safety Goals FAQs, the Joint Commission said it would accept three levels of intensity of the medication reconciliation process in the ED:

  1. "Screening reconciliation" for all ED patients should include routinely obtaining from each patient at each ED visit a list of the patient’s current medications (usually done by the triage nurse)
  2. "Focused reconciliation," as directed by the emergency physician, based on medical relevance, should include seeking additional information about the patient’s medications (exact drug list, dosage/route, etc.) from the patient’s pharmacy, primary care physician, family, etc.
  3. "Full reconciliation" for admitted patients should be completed by the receiving inpatient unit and pharmacist.

This information is current as of January 2007 and the Joint Commission may change or amend the FAQs at any time. Please confirm the latest information by visiting the Joint Commission's Web site.

This revision was the consensus recommendation from ACEP, the American Academy of Emergency Medicine (AAEM) and the Emergency Nurses Association (ENA). Comments from these groups were jointly submitted in May 2006, November 2006 and April, 2007.


Joint Commission - Frequently Asked Questions 

Guidelines for Implementing the Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery 

Universal Protocol For Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery 

ACEP Input on Joint Commission Issues

As one of their ongoing objectives, ACEPs Emergency Medicine Practice Committee is asked to review and comment on behalf of the College on various proposed standards and standards revisions such as Joint Commission Field Reviews. Whenever a topic comes up that is relative to another committee or section, staff facilitates a comprehensive review by soliciting responses from them as well. These responses are then presented to ACEPs President for approval and signature prior to submission to the Joint Commission.

Listed below are some of the reviews that have been completed on behalf of ACEP in the last year.

  • Proposed 2009 National Patient Safety Goals, February 2008 
  • Proposed 2008 National Patient Safety Goals Field Review, January 2007 
  • Proposed Hospital Disruptive Behavior Standards, January 2007 
  • Proposed Revisions to Emergency Management Standards, January 2007 
  • Proposed Revisions to Standard MS.1.20, October 2006 
  • Second Field Review for the Leadership Standards, May 2006 
  • Proposed Venous Thromboembolism (VTE) Performance Measures Field Review, February 2006 
  • 2007 National Patient Safety Goals Field Review, December 2005 
  • Medical Staff Credentialing and Privileging Standards Field Review, November 2005 
  • Contracted Services Standards Field Review, November 2005 
  • Leadership Standards Field Review, October 2005 
  • ICU - SEPSIS Core Measure Set, Request for Public Comment, July 2005 
  • Feedback to JCAHO regarding current pain management requirements, in response to CR 21(04): Pain Control, July 2005 
  • Proposed Standards HR.1.25 Disaster Job Responsibilities & HR 4.35 Disaster Privileging for Licensed Independent Practitioners, JCAHO Field Review, July 2005 
  • Proposed Revisions to the Testing of Emergency Management Plans, JCAHO Field Review, June 2005 
  • Proposed 2006 National Patient Safety Goals, JCAHO Field Review, February 2005 
  • Review and Provide Comment on the Conclusions of the Medical Abbreviations Summit, February 2005 
  • Proposed 2006 Medication Management Standards, JCAHO Field Review, January 2005 
  • Proposed Standards Revision, Individuals Working Under a Licensed Independent Practitioner, January 2005 

Please note that JCAHO announced a name change in January 2007. They should be referred to as "The Joint Commission." 

[ Feedback → ]