The Joint Commission (TJC) is launching a new Telehealth accreditation program (TEL) effective July 1, 2024 designed for health care organizations that provide care through telehealth or offer telehealth services to another organization’s patients. Recognizing the rapid expansion of telehealth across various health care settings and specialties, The Joint Commission created this program to ensure the necessary structures and processes for delivering safe, high-quality telehealth care. The accreditation requirements cover multiple areas, including leadership, human resources, emergency management, information management, care provision, record-keeping, and patient rights. While most standards apply universally, some requirements are specific to the telehealth modality and services provided.

The Joint Commission Telehealth Accreditation is a standalone three-year accreditation called “Telehealth Accreditation.”  It is no longer incorporated within another accreditation program.  Joint Commission accredited Telehealth organizations meet regulatory requirements for telemedicine credentialing and are qualified to conduct credentialing by proxy.  

Eligibility

Any organization that is 100% telehealth is eligible for this accreditation.  This includes all telehealth modalities such as real-time interactive, asynchronous or remote monitoring.  The key criterion is that the organization must be entirely telehealth focused. Organizations offering a mix of telehealth and in-person care as part of an integrated approach are not eligible for this specific accreditation.  These organizations can still gain accreditation under traditional hospital, behavioral, or ambulatory manuals, as they involve physical locations and on-site care.

Requirements

The Telehealth Accreditation standards were developed through consensus from a technical advisory panel of telehealth experts, current customers, industry experts, and feedback from both internal and external stakeholders, Many of the telehealth standards will look familiar to current Joint Commission accredited organizations, as they align with the current requirements of other Joint Commission accredited programs.

In addition, the standards also address some of the top topics relevant to telehealth as highlighted by CMS, states, and payers. These include credentialing and privileging, information management structures and processes, leadership structure and governance, medication management, patient identification, and documentation in the record of care.

Additionally, over the years, and with feedback from external advisory panels, TJC has curated a specific set of standards targeting the most current and pressing quality and safety concerns specific to telehealth. These include equipment, devices, and connectivity, streamlined emergency management requirements, expanded requirements regarding written agreements and policies with organizations to whom you provide telehealth services, and new standards relevant to provider and patient education regarding the receipt and delivery of care via telehealth.

Safe, High Quality Telehealth Services

The TJC standards provide a framework to address the structure and processes that organizations need to provide safe, high-quality care, treatment, and services using a telehealth platform.  The Joint Commission recognizes that not all telehealth organizations are the same, and this isn’t a one-size-fits-all program. The applicability of standards varies based on the modality you’re using or the services you’re providing. To address this, TJC has developed a standards applicability grid that filters the standards to ensure they are the most relevant and practical for your organization.

Excluded Standard Chapters

TJC did not include the typical standards found in their accreditation manuals related to Environment of Care such as physical environment, fire safety, and utilities, as these are not applicable to telehealth organizations without brick-and-mortar facilities. Additionally, TJC omitted traditional infection prevention and control standards.

Included Standard Chapters

Emergency Management

Emergency management is a prime example of how TJC adapted existing standards to suit telehealth organizations. While preserving key components of emergency management, TJC tailored the standards specifically for telehealth.  Their goal is to ensure that these requirements are flexible and meet the diverse needs of various telehealth models.

For instance, organizations are still required to perform a hazard vulnerability analysis to identify potential emergencies, similar to their expectations for any accredited organization. However, TJC recognizes that telehealth organizations are structured differently. Therefore, TJC included provisions to incorporate business occupancy locations and remote provider sites into the hazard vulnerability analysis.

Communication plans during an emergency are also essential. TJC expects all organizations to have robust communication processes, but in the Telehealth program, they emphasize the importance of notifying office staff at business occupancy locations, clinical staff, and any external entities receiving services under contractual agreements. 

Organizations should have a plan for providing care and clinical support that focuses on how the organization transfers patient care to another entity during an emergency or disaster incident. It should address the sharing of information and medical documentation with different organizations or providers, tailored to the specific nature of the emergency and the structure of the telehealth organization.

Human Resources Management

Similar to information management, leadership and performance improvement, the telehealth organization in this accreditation program will adhere to many of the same requirements as other programs, including staff qualification, credentialing, and privileging.  Many organizations want to maintain consistency with TJC’s expectations across multiple accreditation programs offered by TJC, ensuring compliance with credentialing and privileging requirements similar to the hospitals, and other settings they may partner with. The credentialing and privileging requirements for the Telehealth program are identical to those in TJC’s current accreditation for ambulatory care.  The behavioral healthcare and human services standards encompass all original behavioral healthcare requirements.  

The Joint Commission added the need to train staff on the use of telehealth platforms and software applications. This ensures that staff can optimize telehealth encounters and provide effective care in a virtual environment.  Your organization can identify the necessary educational topics. What’s more, how your staff receives training in these areas will interest the surveyors.

Care, Treatment, and Services

Clinical practice guidelines are a legacy standard incorporated into several of the program manuals over the years. This standard has been adapted to the telehealth environment.  TJC recognizes that for some settings and specialties, there may not be existing clinical practice guidelines or industry recommendations. However, when these guidelines are available, TJC wants to ensure their accredited organizations incorporate them into their processes.  All programs have existing standards related to accepting patients for care, treatment, and services. 

In addition, the organization should accept a patient for care, treatment, and services delivered via telehealth based on whether the scope of services can meet the patient’s needs. This involves creating and developing criteria for which patients to treat via telehealth and identifying those outside the scope of your services.  The Joint Commission is not prescriptive on patients/clients admission practices.  Rather, the TJC surveyors will want to understand the criteria you use to accept patients and your process for handling cases where patients do not meet these criteria and you cannot provide services at that time.

NEW Equipment, Devices, and Connectivity

This chapter replaces the old Environment of Care section, focusing on what is crucial for telehealth organizations regarding equipment and devices provided to staff or patients, as well as managing and responding to connectivity disruptions.

The new standards emphasize procedures for handling disruptions in connectivity. This includes processes for rescheduling or transferring patients to another provider if a disruption occurs or if a telehealth encounter needs to convert to audio-only. These requirements have a flexible design, allowing organizations to tailor them to their specific services.

Information Management

This chapter focuses on an organizations technical infrastructure, ensuring organizations can transfer information between locations to meet their needs. TJC does not specify exact technical requirements, recognizing that different organizations have varied needs and modalities. Thus, TJC has left room for flexibility, allowing organizations to determine their technical needs. The surveyors are interested in understanding your technical capabilities and how you maintain the infrastructure to provide care, treatment, and services via telehealth.

Leadership

The written agreements standard is particularly relevant for organizations providing telehealth to another organization’s patients. These are elements that you should include in the contract:

• Scope of Services: Define the services you will provide to the other organization’s patients.
• Performance Metrics: Establish expectations and metrics to measure your performance, such as provider availability, timeliness of care, and adherence to clinical guidelines.
• Data Collection and Measurement: Detail how you will collect and measure data and identify opportunities for service improvement.
• Provider Competencies: Specify the required competencies for your providers.
• Communication Processes: Outline procedures for communicating unexpected incidents or adverse events with the organization where the patient is located and detail your involvement in analyzing these events.
• Contractual Details: Clarify what is included in the contract and how the relationship is established.
• Performance Improvement: Describe how your organization evaluates and improves the care provided.

To facilitate ease of use, the Joint Commission has grouped the standards by modality, with specific standards for tele-behavioral healthcare (BHC) organizations, given their unique requirements.  When you access the standards in your E-dition, you can filter them based on your modality or BHC. This ensures you see only the standards relevant to your organization, without being overwhelmed by requirements that do not apply.

For example, the standard on assessing, reassessing, and notifying patient locations of changes in condition may not apply to organizations that do not operate in environments requiring immediate care notifications.

However, for behavioral healthcare, there is a standard about having a process to notify the patient’s emergency contact or local emergency services if there is a change in condition requiring additional assistance. This standard is crucial for BHC organizations but not relevant to all other modalities.

Survey Process

TJC utilizes an off-site, virtual survey process for the Telehealth Accreditation. This allows for real-time review and analysis of your organization’s compliance with Joint Commission standards and regulations.  A secure, unique survey SharePoint site is set up between your organization and the Account Executive. 

Next, your organization will need to upload all requested or required documents for surveyor review. This pre-survey review allows for a more focused and engaging real-time event. The surveyor will arrange an off-site platform call through Microsoft Teams to conduct the survey.

The Joint Commission utilizes individual and system tracers to assess your organization. The goal is to identify risk points and safety concerns, providing a thorough review of these topics in discussions with the surveyors. The system tracers include:

• Equipment, Devices, and Connectivity
• Emergency Management
• Competence and Credentialing of Staff
• Leadership and Data Use Involvement

Preparing for Your Survey:  Tips for Success

• Review Standards: Use self-assessment prompts and checklists to identify gaps in compliance.
• Share Findings:  Communicate self-assessment findings and develop a plan to address non-compliance. Use evidence-based resources when possible.
• Integrate Preparation into Routine: Make quality and safety routines part of everyday activities.
• Involve Your Team: Include direct participants and ancillary teammates in the survey process.
• Communicate the Process: Discuss accreditation with everyone, creating champions to participate and share information widely.
• Develop a Roadmap: Work with your Account Executive to create a roadmap for accreditation and share it with your organization.
• Utilize Storage Points: Use a centralized location for tools and documents to ease access and sharing.
• Engage with Business Development and Standards Interpretation Staff: Contact TJC resources to clarify standards and offer examples of best practices.  

To view the new Telehealth Standards email ahcquality@jointcommission.org or visit the TJC website Request Prepublication Requirements for Telehealth | The Joint Commission.

Barrins and Associates Consulting

Barrins can help you to achieve initial accreditation with the Joint Commission Telehealth Accreditation program.  We conduct a comprehensive gap analysis, policy, procedure and document development, and an evaluation of your compliance with telehealth accreditation standards and regulatory requirements.   By conducting mock surveys, providing access to our repository of best practices, and offering tailored strategies for optimizing your compliance, we empower your organization to embrace the future of telehealth care. Let us guide you in seamlessly integrating telehealth solutions, propelling your organization towards this exciting frontier of healthcare.  

Barrins & Associates – “Your Path to Accreditation Success: Our Experts Know Every Step!”