Joint Commission Revises Ambulatory Surgical Center Elements of Performance, Effective Immediately


The Joint Commission has revised three elements of performance in their Ambulatory Care Accreditation program in order to remain consistent with the Centers for Medicare & Medicaid Services Conditions for Coverage for Ambulatory Surgical Centers (ASU) on October 14, 2011. The Joint Commission (TJC) standards must align with CMS Conditions for Coverage in order for TJC to maintain their deemed status designation.

The revisions, effective immediately and applicable to ASCs using Joint Commission for deemed status, are summarized below:

LD.04.02.01. EP 6 has been revised to remove the requirement that disclosure of physician financial interest or facility ownership be provided to the patient in advance of the date of his or her procedure. Physician financial interest/facility ownership must be disclosed in writing but removal of the restrictive timeframe should allow ASCs to more readily perform same day, non- emergent procedures.
RI.01.01.03, EP 4 has been revised so that the requirement that the patient and or their surrogate decision-makers must be provided with written notice of patient rights prior to the start of the patient’s surgical procedure. The patient rights still need to be provided in a manner the patient or his/her surrogate can understand but the rights no longer have to be provided in advance of the date of the procedure.
RI.01.05.01, EP 7 has been revised so that now, the patient and or surrogate decision-maker must be provided with written information about policies on advanced directives including a description of applicable state health and safety laws and, if requested, official state advance directive forms prior to the start of the procedure. The information no longer must be provided in advance of the date of the procedure.

You will want to be sure any changes your facility makes with regard to these processes are reflected in your policies and procedures.

This entry was posted in Uncategorized. Bookmark the permalink.

Comments are closed.