Institute for Medical Quality (IMQ) and Joint Commission Ambulatory ...

[Pages:3]Institute for Medical Quality (IMQ) and Joint Commission Ambulatory Care Accreditation Standards Comparison: November 2019

Topics

Requirements for Deemed Ambulatory Surgical Centers

Governance and oversight

IMQ accreditation requirements address:

Requirements align with all CMS' Conditions for Coverage CfCs 416.2416.54 Administration

Credentialing and Human Resource Management

Performance Improvement

Medical Records Management

Patient Rights and Provision of Care

Personnel and Credentialing

Quality Programs and Peer Review Medical Records

Care and Treatment (includes patient rights and medication management)

Infection Prevention and Control, Facility and Environmental Safety

Facility and Environmental Safety (includes infection control and emergency management)

Joint Commission accreditation requirements address:

Comments

Requirements align with all CMS' Conditions for Coverage CfCs 416.2416.54 Leadership

Human Resources

Standards are comparable (Does not apply to Office Based Surgery practices)

Standards are comparable, however, Joint Commission standards also include requirements that address a culture of safety and an organization-wide patient safety program

Standards are comparable

Performance Improvement Human Resources Leadership Record of Care, Treatment, and Services Information Management Rights and Responsibilities of the Individual Provision of Care, Treatment, and Services Medication Management

Infection Prevention and Control Environment of Care Emergency Management Life Safety

Standards are comparable Standards are comparable

Standards are comparable with the exception of Joint Commission requirements that address patient restraint and medication management. Joint Commission has more standards focused on these topics than IMQ. (Joint Commission requirements that address patient restraint do not apply to Office Based Surgery practices)

Standards are comparable with the exception of IC for which TJC's standards are more comprehensive

Institute for Medical Quality (IMQ) and Joint Commission Ambulatory Care Accreditation Standards Comparison: November 2019

Topics

IMQ accreditation requirements address:

Joint Commission accreditation requirements address:

Comments

Surgical Services

Surgery, Anesthesia and Invasive Diagnostic Procedures (includes a Life Safety Code requirement)

This chapter also includes prescriptive requirements for the provision of laser and liposuction procedures.

Provision of Care, Treatment, and Services (pre-op, intra-op, and post-op care)

Rights and Responsibilities of the Individual (informed consent)

Record of Care, Treatment, and Services

Universal Protocol (timeout, site marking)

Environment of Care

Life Safety

Standards are comparable, however, Joint Commission accreditation requirements do not include prescriptive requirements for specific types of clinical procedures.

AREAS ADDRESSED IN JOINT COMMISSION ACCREDITATION STANDARDS THAT ARE NOT INCLUDED IN IMQ REQUIREMENTS:

Chapter

Requirements that address the following topics:

Infection Prevention and Control Medication Management

Selected high-risk patient safety issues

? High level disinfection ? Hand hygiene ? Influenza vaccination

? Management of high alert, hazardous and look-alike/sound-alike medications ? Medication orders ? Medication procurement, preparation and storage ? Dispensing medications ? Medication administration ? Antimicrobial stewardship (Does not apply to Office Based Surgery practices)

National Patient Safety Goals on: ? Accuracy of patient identification ? Reducing the risk of healthcare related infections ? Pre-procedure verification process ? Site marking ? Reducing harm from anti-coagulation therapy (Does not apply to Ambulatory Surgery Centers or Office Based Surgery practices)

Institute for Medical Quality (IMQ) and Joint Commission Ambulatory Care Accreditation Standards Comparison: November 2019

AREAS ADDRESSED IN JOINT COMMISSION ACCREDITATION STANDARDS THAT ARE NOT INCLUDED IN IMQ REQUIREMENTS:

Chapter

Requirements that address the following topics:

Transplant Safety

Waived Testing

Leadership Provision of Care, Treatment, and Services Life Safety

? Standardized processes for managing tissues ? Tracing tissues from supplier or donor to recipient ? Investigating adverse events related to tissue use ? Policy and procedures for waived testing ? Staff competency for waived testing ? Quality control checks for waived testing ? Record maintenance for waived testing ? Culture of safety ? Patient safety program

? Patient restraint (Does not apply to Office Based Surgery practices)

? Requirements in this chapter do not apply to Office Based Surgery practices

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