Joint Commission accredited organizations must now provide advance written notice of significant changes

The Joint Commission (TJC) recently revised its policy regarding notification of changes. Accredited organizations were historically required to notify TJC within 30 days after a significant change occurred. Effective October 1, 2016, TJC accredited organizations must now provide written notice to TJC in advance, when significant changes are contemplated, so that TJC has time to assess the potential impact to the organization’s accreditation, such as the need for an on-site survey. 

The revised policy states that “an organization is considered to have ‘contemplated’ a change when leadership within the organization has approved moving forward with the proposed change and identified a time frame for implementing that change.” Significant changes include:

• A change in ownership
• A change in location
• A significant increase or decrease in the volume of services or individuals served
• The addition of a new type of health service, program, or site of care
• The deletion of an existing health service, program, or site of care
• The acquisition of a new component
• The deletion of an existing component

While the policy’s explanation of when a significant change is “contemplated” leaves many questions unanswered, TJC accredited organizations should take steps to ensure that sufficient advance notice is given to TJC in accordance with the new policy. 

The revised policy clarifies that this advance notice is separate and in addition to updating the electronic application for accreditation (E-App), which is to be done only after the change has actually occurred. The revised policy states, “[o]nce the change has actually occurred, the organization must update its E-App within 30 calendar days.”

The revised policy provides that TJC may conduct an additional survey at a later date if it discovers that a change was not reported, but TJC may also survey any unreported services and sites addressed by its standards during the survey as appropriate.