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Recently, we covered the new Joint Commission PI requirements effective January 2022.

We’re now seeing a clear uptick in the amount of attention surveyors are paying to this topic. Moreover, they’re issuing Requirements for Improvement in their survey reports.

While there are some new PI requirements in 2022, many remain the same. Thus, it’s important to fully understand TJC’s expectations for data collection and how you use that data. So, here’s a recap of the data collection requirements in the Performance Improvement chapter:

Joint Commission PI Requirements: Hospital Standards

In the Hospital Manual, PI.01.01.01 lists the following data collection requirements (as applicable to psychiatric hospitals):

  • Medication errors
  • Adverse Drug Reactions
  • Results of resuscitation
  • Patient satisfaction
  • Pain assessment and pain management
  • Transfers to higher level of care

Joint Commission PI Requirements: Behavioral Health Standards

The Behavioral Health Care & Human Services Manual lists the following data collection requirements in PI.01.01.01:

  • Medication errors
  • Adverse Drug Reactions
  • Client satisfaction including
    • Whether the client was asked about treatment goals and needs
    • Whether the client was asked if these treatment goals and needs were met
    • The client’s view re how the organization can improve safety
  • High risk, high volume, problem prone process: e.g. restraint/seclusion

In addition, there are specific data collection requirements for Opioid Treatment Programs under PI.01.01.01 EP37.

Data Collection Requirements Beyond the PI Chapter

Clearly, the Joint Commission PI chapter lists the essential data collection requirements for all organizations. However, it’s important to remember there are data collection requirements embedded in other standards of both the Hospital and BH manuals.

For example, the BH standards require organizations to collect data on the outcomes of care. Specifically, CTS.03.01.09 states: The organization gathers and analyzes the data generated through standardized monitoring, and uses the results to inform the goals and objectives of the individual’s plan for care, treatment, or services as needed.”

Similarly, both manuals implicitly expect data collection on hand hygiene compliance. NPSG.07.01.01 requires you to set goals for improving hand hygiene compliance and show improvement toward those goals. Thus, it follows that you must gather baseline data and set numerical targets.

So, as you build your database, be aware of those additional data collection requirements spread throughout other chapters.

Tip: Do a search of the term “data” in the TJC E-dition of your accreditation manual. It will highlight the term “data’ anywhere it’s used in the standards.   From there, you can quickly ascertain the different data collection requirements throughout the chapters.

The PI – Leadership Connection

Both manuals make it clear that, in addition to the required measures in the PI chapter, you should collect data on the PI priorities your leaders have identified.  Specifically, LD.03.07.01 states:

“As part of performance improvement, leaders (including the governing body) do the following:
– Set priorities for performance improvement activities and patient health outcomes
– Give priority to high-volume, high-risk, or problem-prone processes for performance improvement activities
– Identify the frequency of data collection for performance improvement activities
– Reprioritize performance improvement activities in response to changes in the internal or external environment”

So, the message here is that performance improvement is not the work of just the PI Department. Rather, top leaders need to set the priorities for the organization-wide PI program. That’s why TJC surveyors cover this topic during the Leadership session as well as the Data Management session.

Current Joint Commission Survey Focus

In recent surveys, it’s clear surveyors are focusing on two key requirements. First, your written PI Plan must identify the specific processes you’ve decided need improvement.

Second, you must show you’re using an evidence-based PI methodology and tools. For example, FOCUS-PDCA, Six Sigma, Lean.

This focus has been a challenge for some organizations on recent surveys. In some instances, the surveyors have given RFIs in the PI chapter.

For example, for not having clearly defined project goals. Or, for not using adequate data analysis methods.

In other instances, the surveyors gave the organization the opportunity to rewrite their PI Plan to be in keeping with the new requirements. As a result, there were no RFIs for PI on their survey report.

Interestingly, the organizations that redrafted their PI Plans reported it helped them narrow their focus  and define how they would actually measure improvement in the processes they had selected.


Check out TJC’s R3 Report # 31: New and Revised Performance Improvement Accreditation Standards. Also, be sure to view the TJC webinar on the new PI standards. It’s available on your TJC Connect site.

Barrins & Associates

Like TJC, we’re back to business as usual. We’re busy conducting Mock Surveys and Continuous Readiness Consultations across the country.

We’ve incorporated the new PI standards into our mock survey process. As always, we’re prepared to support your ongoing survey readiness and best practices for regulatory compliance.