Your organization’s administrators may say that The Joint Commission requires adherence to a particular rule. But in many cases, those rules don’t originate from The Joint Commission, which accredits tens of thousands of health care organizations and programs. In fact, the rule may have even been put in place by your employer.
Yes, The Joint Commission does have policies and standards that health care organizations seeking the group’s accreditation must follow and meet. However, officials from The Joint Commission are also in charge of holding organizations accountable for many standards that the commission did not create. That includes local rules established by the health care organization, according to a recent addition to the AMA’s “Debunking Regulatory Myths” series.
This series provides regulatory clarification to physicians and their care teams. It is part of the AMA’s practice-transformation efforts and gives physicians and their care teams resources to reduce guesswork and administrative burdens so their focus can be on streamlining clinical workflow processes, improving patient outcomes and increasing satisfaction.
Where rules may originate
The Joint Commission leaves it to individual organizations to establish policies that meet the commission’s standards and other requirements. The Joint Commission then holds organizations accountable for following their own policies intended to improve quality and safety.
“Overinterpretation or misinterpretation of required standards for Joint Commission accreditation may lead to overly strict policies, unnecessary tasks and inefficient processes,” the AMA says. “Health care organizations may establish internal requirements well beyond Joint Commission standards. When health care organizations fall short of these more stringent, self-imposed policies and procedures, they risk being surveyed by The Joint Commission as out of compliance.”
During his recent tenure as The Joint Commission’s executive vice president of health care quality evaluation and improvement, David Baker, MD, MPH, said that he and his colleagues frequently saw organizations establish stringent requirements—and related tasks and processes—that went “well beyond” the commission’s standards. In turn, he said, such organizations can then get scores that show them as being out of compliance.
“We get blamed for this and that’s how myths arise that we require things—when we do not!” Dr. Baker said at the time.
And those burdensome tasks could originate from rules put in place by a number of other entities as well. The Joint Commission is tasked with evaluating health care organizations’ compliance with the Centers for Medicare & Medicaid Services’ (CMS) conditions of participation and other federal, state and local laws and regulations. And it also holds health care organizations accountable to manufacturer instructions of use.
So, if there is a burdensome rule you want to change, check to see whether your organization may be able to change its own rule to ease something that is an unnecessary or repetitive task in your day-to-day work or if it comes from The Joint Commission, CMS or another entity.
Earn CME credit
Learn more with the “AMA Debunking Medical Practice Regulatory Myths Learning Series,” which is available on AMA Ed Hub™ and provides regulatory clarification to physicians and their care teams. For each topic completed, a physician can receive CME for a maximum of 0.25 AMA PRA Category 1 Credit™.
Physicians are encouraged to submit questions or ideas they have about potential regulatory myths. The AMA’s experts will research the matter. If the concern turns out to be a bona fide regulation that unnecessarily burdens physicians and their teams, the AMA’s advocacy arm can get involved to push for regulatory change.
