Transitioning from Conditions of Participation to Joint Commission Standards

A healthcare facility is interested in pursuing Joint Commission accreditation. Senior management has asked departments to submit reports about implementation of applicable Joint Commission standards in their areas of responsibility. You are the HIM director who will draft a report for implementation of procedures to comply with standards related to Information Management (IM) and Record of Care, Treatment and Services (RC). Using the terms below do an internet search to locate the standards and Condition of Participation needed. Create a document, spreadsheet or table that compares the COP and Joint Commission standards, and address differences in preparation (e.g. accreditation cycles, resources needed) and training and preparing of staff. The report should also include how compliance is reported to and monitored by the Joint Commission.

Joint Commission Standard IM

Joint Commission Standard RC

Conditions of Participation 42 CFR 482.24 Medical Record Services

Here are a couple of links to help get you started in the right direction (these are for Illinois, but you are welcome to use  your own state as well):

  • http://www.dph.illinois.gov/topics-services/provider-partner-resources/public-health-standards
  • http://www.dph.illinois.gov/topics-services/health-care-regulation/facilities
  • http://www.dph.illinois.gov/licensing-certification