The Joint Commission has announced the beginning of a review of all organization “above-and-beyond” requirements—those that go beyond the Centers for Medicare & Medicaid Services (CMS) Conditions of Participation (CoPs) and are not on crosswalks to the CoPs.

During the COVID-19 public health emergency (PHE), CMS put many requirements on hold. As the PHE nears its end, CMS has been reviewing the waived requirements to determine whether some should be permanently retired. The Joint Commission will similarly address the necessity of its own unique requirements, says Joint Commission President and CEO Jonathan B. Perlin, MD, PhD, MSHA, MACP, FACMI.

Specifically, the Joint Commission will review each requirement to answer:

  • Does the requirement still address an important quality and safety issue?
  • Is the requirement redundant?
  • Are the time and resources needed to comply with the requirement commensurate with the estimated benefit to patient care and health outcomes?

In addition to a direct review of each requirement, the Joint Commission will conduct quantitative analyses of scoring patterns and tests for redundancy. Where necessary, the organization also will conduct literature and field reviews and engage experts within the field. 

“American healthcare still has a long way to go to fully recover from COVID-19 and to reach a new equilibrium—especially as we are now witnessing secondary effects from the pandemic,” says Perlin. “At The Joint Commission, we are committed to working with healthcare organizations and other stakeholders to help address the many challenges healthcare is facing, as well as to making our own requirements as efficient and impactful on patient safety and quality as possible.”