The New Year has arrived! So, are you all squared away with the Joint Commission 2023 standards that are effective 1/1/23? Now’s the time for a final check to be sure you’re fully compliant with the new 2023 requirements.
Experience tells us when a new year kicks in, surveyors typically focus heavily on the new requirements for that year. So, let’s review some key changes for 2023 and tips for ensuring compliance.
New Joint Commission Requirements Effective 1/1/2023
Health Care Equity Requirements
These new requirements are in both the Hospital standards and the Behavioral Health Care & Human Services standards. TJC’s goal is for healthcare organizations to reduce health care disparities among patients.
The requirements include designating a leader for this initiative, collecting data, and developing an action plan. For full coverage of what TJC is requiring, see our post Joint Commission Health Care Equity Requirements.
What to Do Now: First, make sure you’ve identified a leader and team for this initiative. Next, get going on your data analysis and your action plan. Certainly, you can expect health care equity to be a high focus area in 2023. During your survey, surveyors will cover this topic during the Leadership Session.
Antibiotic Stewardship: An Organizational Priority
These new requirements are in the Hospital standards. There are 12 new and revised elements of performance under MM.09.01.01. They expand upon the existing requirements and emphasize the need for antibiotic stewardship to be an organizational priority.
What to Do Now: Carefully review TJC’s R3 Report: New and Revised Requirements for Antibiotic Stewardship. Make sure to incorporate the new requirements into your existing antibiotic stewardship policies. During survey, surveyors will cover this topic in the system tracer on Data Management, Infection Control, and Medication Management.
Sentinel Event Policy
In both the Hospital and Behavioral Health Care programs, there’s a revised definition of sexual abuse/assault. For full coverage of this topic, see our post Joint Commission Sentinel Event Definition Revised.
What to Do Now: Review the new sentinel event definition and update your policy accordingly. Also, be sure to train staff so they report all incidents that meet the expanded definition of sexual abuse/assault.
New Safety Briefing
In both the Hospital and Behavioral Health Care programs, a safety briefing is now part of the survey agenda. To learn more about this topic, see our post Joint Commission Safety Briefing: New in 2023.
What to Do Now: Develop a short briefing for your surveyors which covers any potential safety concerns that might arise during survey. Make sure to include your procedures for how the surveyors should respond to these situations.
For Hospital surveys, the only significant change to the Documents List relates to the Medical Staff Bylaws and Rules/Regulations. Specifically, TJC is now requesting you flag any changes you’ve made since your last triennial survey. Also, be sure to review the Life Safety & Environment of Care Documents List since there are some recent changes there.
For Behavioral Health Care surveys, there are no changes to the Documents List. However, be aware surveyors often request additional documents that are not on that list. For example, your suicide risk assessment policy.
Joint Commission 2023 Standards: E-dition
All these standards updates are included in the E-dition January 2023 Update to the Comprehensive Accreditation Manual for Hospitals and the Comprehensive Accreditation Manual for Behavioral Health Care and Human Services.
The E-dition is available on your Joint Commission Connect extranet site. There’s a helpful section at the front of each E-dition titled “What’s New?” This gives you a summary of the January 2023 changes.
Joint Commission 2023 Survey Activity Guides
In addition, TJC has published the 2023 Survey Activity Guides. There’s one for Hospitals and one for Behavioral Health Care organizations. These Survey Activity Guides are available on your Joint Commission Connect extranet site. They’re a critical tool for your survey preparation. So, be sure to review them carefully as you prepare for your next survey.
Barrins & Associates Consultation
We’re now in full swing with our 2023 Mock Surveys and Continuous Readiness Consultations. Be assured, our consultations cover all these updates to the Joint Commission 2023 standards and survey process. As always, we’re prepared to support your ongoing compliance and survey readiness as we launch into this new year.