8/12/2019 Accreditation Participation Requirement (APR) section of the new 5th edition accreditation manual - April2014 Req

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9 December 2013/bh

The Accreditation Participation Requirement (APR) section of the new 5thedition accreditation manualconsists of specificrequirements for participation in the Joint Commission International accreditation process and for maintaining an accreditationaward. The requirement APR.7 requires hospital seeking accreditation the first time or already-accredited hospitals to be incompliance with the Library of Measures requirement effective with 1 April 2014 inpatient discharge medical records. Please referto the table below for the Library of Measures current and 1 April 2014 requirement details:

CurrentRequirements

Accreditation Participation Requirement (APR).7 Library ofMeasures

Applicable to: Startdate/effective

dateMinimumnumber ofselectedmeasures

The hospitals leadership selects five measuresfrom the Library ofMeasures that are applicable to the organizations patientpopulation and clinical service areas.

Initial, Triennial,and FocusedSurveys

April 1, 2011-continued

Specificationsand supportingresources usedto developmeasurement

plan andimplementation

The hospital applies the current Library of Measure Specifications,version 2.0and supporting data collection resources as indicated onthe Library of Measuresweb page in the development of theorganizations measurement plan and implementation process.

NOTE:JCI accredited and central office-approved applicanthospitals are provided direct access to the Library web resources.

Initial, Triennial,and FocusedSurveys

January 1,2013 -continued

Data collection

and aggregation

A JCI accredited hospital collects data for the five selected Library

measures and at minimum aggregates data quarterly and accordingto the measure specifications.

EXCEPTION:An organization under-going its initial JCI surveyis temporarily exempt from the Library measure data collectionrequirement. Data collection is required to begin when anorganization is granted initial JCI Accreditation.

Triennial and

Focused Surveys

October 1,

2011 -continued

Submission ofLibrary measuredata to JCI

To be determined and announced at a later date To bedetermined

To bedetermined

Proposed non-Librarymeasures

For special patient population hospitals that do not provideclinical services that are addressed in the Library of Measures,hospitals notify JCI Measurement Associate Director through the

JCI Measurement mailbox link below. Hospitals are required tomeet the five measure requirements by proposing evidence-based replacement measures for JCI approval.

Initial, Triennial,and FocusedSurveys

October 1,2011 -continued

Measure dataavailability

Library data are evaluated through all phases of accreditation andavailable upon request by surveyors on-site and during thecontinuous accreditation process.

Triennial andFocused Surveys

October 1,2011 -continued

Library ofMeasures data

validation

Hospitals utilize one of the two following validationcomparison/calculation methodologies found in thespecifications, Appendix G, to assess inter-rater reliability.

Triennial andFocused Surveys

January 1,2013 -continued