Phase I of the Standards Improvement Initiative (SII) was implemented on January 1, 2009. When the SII was launched in August 2006, it was designed in two phases with the focus of each phase on different accreditation programs. The purpose of the SII was to revise and re-organize the standards and elements of performance in a manner that would provide the accreditation programs with more user-friendly materials regarding the accreditation process. The revisions are intended to enhance the clarity and objectivity of the standards and elements of performance, making scoring easier; and to better tailor the requirements to the characteristics of each accreditation program. The SII revisions also include a re-organization of the manuals, and a re-numbering of the standards and elements of performance in an effort to provide a logical sequence within each chapter.

The SII revisions have not introduced any new requirements. The revisions have eliminated compound requirements, and similar standards and elements of performance have been consolidated.

Phase I, now in effect, includes the revised standards and elements of performance for Ambulatory, Critical Access Hospitals, Home Care, Hospitals and Office-Based Surgery. Although they were part of the proposed Phase II program, the creation of six new chapters has also been added. These are: Emergency Management, Equipment Management (Home Care only), Life Safety, Record of Care, Treatment and Services, Transplant Safety, and Waived Testing.

Take note that the revised scoring and decision methods will be effective on January 1, 2009, for all accreditation programs, not just those in Phase I. Phase II revisions to the standards and elements of performance are on target to be implemented in January 2010. The programs affected by the 2010 revisions include: Behavioral Health Care, Laboratory and Long Term Care. JCAHO has created a computer based edition of the manual that can be accessed through it’s web site ― www.jcaho.org. Each program will receive a one time password to access the manual and thereafter will need to purchase access rights.

For further information, please contact Linnea L. Schramm or your regular Hinshaw attorney.

This alert has been prepared by Hinshaw & Culbertson LLP to provide information on recent legal developments of interest to our readers. It is not intended to provide legal advice for a specific situation or to create an attorney-client relationship.