Every January and July, Joint Commission Submits Changes
Table of Contents
Important of Compliance Monitoring
As compliance officers, one of our roles is to ensure organizations are always up to date on regulations and rules that ensure continuous compliance. In my work on compliance teams, I have often found that a program has not updated policies and procedures in years. Due to this, they were still doing things from years ago that are no longer required. In addition, it was common to find companies not fully incorporating more recent standards in their daily practices.
Being out of compliance can spell big problems for a program. Stiff fines and other penalties are in place that can when discovered during an audit, be detrimental to the program’s operation and bottom line. Keep reading to learn more about the importance of ongoing compliance checks and updates.
The Joint Commission Summer 2023 Updates
As a rule, The Joint Commission updates its standards twice a year. Here are some of the highlights from the summer 2023 revisions:
- There are a total of twenty-nine section updates
- The leadership standard on Electronic Data Interchange (EDI) is now a National Patient Safety Goal
- There are eighty-one new requirements for the Certified Community Behavioral Health Clinic model (CCBHC), which can inform possible future updates for other services
- Waived Testing updates
- Updates and clarification on Required Written Documentation expectations
What Are the 7 Elements of a Comprehensive Compliance Program?
In the 1990s, The Joint Commission created a compliance checklist specifically for the healthcare industry. The purpose of the list of seven elements was to help curb healthcare fraud and abuse, and to address a lack of adherence at the executive level within healthcare. Since its debut, these elements are still seen as very effective in streamlining operations, optimizing organizational performance, and reducing costs.
The seven elements of compliance include:
- Implement written policies, procedures, and standards of conduct
- Designate a compliance officer and compliance committee
- Conduct effective training and education
- Develop effective lines of communication
- Conduct internal compliance monitoring and auditing
- Enforce standards through well-publicized disciplinary guidelines
- Respond promptly to detected offenses and undertake corrective action
Importance of Safety Systems Updates
Compliance professionals pay particular attention to any updates to the Safety Systems chapter and any information on High Reliability. After all, the purpose of The Joint Commission accreditation is to reduce variation, reduce risk, and improve quality. In addition, it seeks to create an integrated approach to compliance as the best way to standardize, monitor, and validate that such culture and systems exist.
The Joint Commission further defines its purpose in the following statement:
“Staff and leaders work together to eliminate complacency, promote collective mindfulness, treat each other with respect and compassion, and learn from safety events, including close calls and other system failures that have not yet led to the harm of an individual.”
This is where a comprehensive compliance program comes in. Using the seven elements to guide them, a compliance monitoring professional will:
- Ensure reliable processes are in place
- Decrease variation and defects
- Focus on achieving positive measurable outcomes
- Use evidence to ensure we are preventing, finding, and fixing all risk areas
The importance of compliance monitoring and maintaining compliance goals, by ensuring that updates and standards are recognized and adhered to, is vital to overall organizational health and prosperity.
Circa Behavioral Healthcare Solutions Compliance Officers
Let us know if Circa Behavioral Healthcare Solutions can help you get your program aligned with the standards and updates, to become a learning organization, and to be more proactive in reaching your compliance goals. Reach out today at (888) 458-6619.
