The 2008 elimination of the four-month "track record" for initial accreditation surveys has created some questions regarding the best way to approach the initial accreditation process for hospitals. Historically, The Joint Commission (TJC) required that each new hospital demonstrate a four-month "track record" of compliance in order to be eligible for a full initial accreditation survey. For hospitals relying on TJC accreditation for CMS-deemed status purposes, four months represents a significant stall in the Medicare certification process.
To speed things up, TJC previously provided two "early survey" policy options, both of which required hospitals to undergo two initial surveys. Under "Early Survey Policy Option 1," the first survey, which was a partial survey, could be conducted up to two months prior to opening with the result being "preliminary accreditation" status for the hospital, a designation not recognized by CMS for deemed status purposes. A second survey was conducted four months later, and if successful, the hospital was awarded full accredited status at that time.
The first survey under "Early Survey Policy Option 2," was not conducted until the hospital had been in operation at least one month, treated a minimum of ten patients and had at least one patient in active treatment at the time of survey. Because the first survey under Option 2 was a full initial survey, a successful hospital could receive full accredited status recognized by CMS for deemed status purposes at that time. A follow-up survey was conducted four months later, at which time TJC would confirm the hospital's track record and standards compliance.
Two significant revisions were made during 2008 to the initial survey process outlined in TJC's Comprehensive Accreditation Manual for Hospitals. First, TJC eliminated the track record requirement, such that a new hospital is now eligible for a full initial accreditation survey as soon as it has treated a minimum of ten patients, with one patient in active treatment at the time the survey is conducted. The eligibility determination is made only with regard to the minimum patient requirement and no longer is dependent upon the amount of time the hospital has been in operation. The second significant revision eliminated Early Survey Policy Option 2. Comprehensive Accreditation Manual for Hospitals: The Official Handbook (2009).
Because Early Survey Policy Option 1 remains in the Manual, if read together with the elimination of the track record requirement, the result is surprising. If a hospital chooses the remaining Early Survey Policy Option, it would assume that full accreditation is not available until four months following the first survey. However, if the hospital forgoes the Early Survey Policy altogether, a full initial accreditation survey now is possible as soon as the minimum number of patients is reached.
New hospitals should be able to work with TJC to obtain a full accreditation survey when the patient threshold is met, even if the Early Survey Policy is chosen. While not required, obtaining a preliminary survey prior to opening, pursuant to the Early Survey Policy, may assist the hospital in identifying and addressing any facility issues prior to the full accreditation survey.