like this occur, confusion about which standards the ASC must meet can occur. Especially when building requirements are involved, the appli- cation of standards after the building has been built and outfitted, can be particularly problematic. Generally, when CMS issues a rule, whether a new rule or an updated ver- sion of a rule, all the requirements apply to every provider. The normal expectation is that the providers will keep up with the changes and adapt. In this case, several ASCs have been con- fused by CMS’ requirements for exist- ing facilities. The distinction between existing and new facilities is a distinc- tion within the 2012 edition of the Life Safety Code. Existing does not mean that facilities built before the adoption of the 2012 edition of the Life Safety Code on July 5, 2016, fall under the authority of the previous 2000 edition. Within the 2012 edition of the Life Safety Code, there are distinctions between the requirements for new facil- ities and existing facilities, with July 5, 2016, as the differentiating line. Facili- ties with plans that were approved prior to July 5, 2016, must meet the require- ments for existing facilities within Chapter 21 of the 2012 edition. Obvi- ously, facilities permitted after July 5 must meet the new occupancy require- ments contained in Chapter 20 of the 2012 edition. Do not be confused by the term existing. All ASCs must meet the requirements under one of the two classifications in the 2012 edition of the Life Safety Code.


Please do not hesitate to contact AAAASF at reception@aaaasf.org with compliance questions on the top- ics above or any accreditation-related topics or visit www.aaaasf.org.


Thomas S. Terranova is the director of accreditation at American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF) in Gurnee, Illinois. Write him at tterranova@aaaasf.org.


The Journey of Continuous Improvement


The Joint Commission implements changes to its accreditation process BY MICHAEL KULCZYCKI


Health care organizations are in a constant cycle of focusing


on operational


excellence and overall process improvement. As


health care makes significant advances, so too must the industry’s best practic- es, patient care standards and processes. Thousands of health care organiza- tions use Joint Commission accredi- tation as the cornerstone of their pro- cess improvement efforts. Therefore, The Joint Commission believes it is imperative to continuously review data and conduct research to improve its standards and methods to advance the accreditation process for the organiza- tions that rely on it.


As a direct result of research and


extensive discussions with accredited organizations, last year, The Joint Com- mission launched Project REFRESH, a multi-phase process improvement proj- ect aimed at simplifying and moderniz- ing various aspects of the accreditation process. The Joint Commission believes the changes introduced in Project REFRESH will help all ambulatory care providers, including surgery centers: ■■


advance ■■ ■■ their ment journey,


provide for a better accreditation experience, and


demonstrate more clearly the rela- tionship between accreditation stan- dards and improved patient safety. Four core objectives guided The Joint Commission’s discussions with accredited organizations and stake- holder groups to improve the accred- itation process: simplification, rele- vance, transparency and innovation. The rollout of Project REFRESH was divided into phases that started in


process improve-


June 2016 and will be completed by the end of 2017. The overall goals of Project REFRESH are: ■■


■■ ■■ ■■


simplify aspects of pre-survey, on- site survey, and post-survey;


enhance relevance to accredited organizations;


increase transparency within the accreditation process; and


enrich the customer’s experi ence through innovative approaches and technology.


Simplify the Accreditation Process ASCs are busier than ever and need to dedicate their time to delivering high-quality patient care, not fulfill- ing irrelevant standards. As a part of Project REFRESH, The Joint Com- mission spent significant time ana- lyzing its standards and eliminating those requirements that are not key to advancing patient safety, quality and high reliability. First, it eliminated Ele- ments of Performance (EPs) that were duplicative. Then, it eliminated EPs that were less relevant due to contem- porary changes in operations and laws. In the end, it eliminated 85 Elements of Performance in Ambulatory Care. The deletions went into effect on July 1, 2017, and should help organi- zations focus on the standards and ele- ments of performance that are most important to improving patient safety. In future phases of Project REFRESH, The Joint Commission will continue to consolidate and improve standards affecting the Ambulatory Care Accredi- tation program. For more information, visit https://www.jointcommission.org/ standards_information/prepublication_ standards.aspx.


continued on page 12 ASC FOCUS SEPTEMBER 2017 |www.ascfocus.org 11


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