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Joint Commission removes certain MOS provisions
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July 1, 2010
Changes to EC standards
A series of subtle switches will affect 21 elements of performance (EP) under 10 of the EC standards. The changes stem from an April 26 announcement that The Joint Commission (formerly JCAHO) has eliminated the measure of success (MOS) requirements for a variety of EPs in the Comprehensive Accreditation Manual for Hospitals.
The Joint Commission still expects organizations to comply with the EPs. However, organizations no longer need to submit MOS data.
An MOS—indicated by a circled M icon next to an EP—generally means you need to conduct an audit for an EP scored as partial or insufficient compliance during a survey, and then submit those data to The Joint Commission four months after the accreditor accepts your action plan and measures. The audit must use quantifiable measures to demonstrate that your action plan (generally, an improvement or change of process) was successful, thus providing Evidence of Standards Compliance (ESC) for the cited performance element(s).
Elimination of MOS requirements for some of the EPs should make things less painful when organizations need to provide ESC, says Steven MacArthur, safety consultant at The Greeley Company, a division of HCPro, Inc., in Marblehead, MA.
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