A complimentary publication of The Joint Commission
May 28, 2014
In this issue
Notice: Overdue PFIs previously accepted during survey must be addressed by July 1, 2014
WHO report: The world is headed for a post-antibiotic era
Joint Commission Resources journal receives ABIM Professionalism Article Prize
New on the web
Accreditation
Notice: Overdue PFIs previously accepted during survey must be addressed by July 1, 2014
The Joint Commission is instituting a new policy, consistent with the Centers for Medicare & Medicaid
Services’ (CMS’) expectations, which requires The Joint Commission to clear Plans For Improvement
(PFIs) in a more timely manner. The Joint Commission’s Department of Engineering recently reviewed
existing PFIs, which revealed that a large number of organizations have failed to make sufficient progress
towards completion. All accredited organizations need to complete, or request an extension for, any PFIs
in their Statement of Conditions™ (SOC) that exceed the projected completion date by more than six
months. This affects only those PFIs which have been accepted during survey. Failure to address
overdue PFIs by July 1, 2014 will result in a follow-up call by a member of The Joint Commission’s
Department of Engineering. Further delay in resolving a PFI may result in an on-site survey.
To see which PFI(s) are outstanding, review the SOC on your
Joint Commission Connect™ extranet, under Plan for
Improvement, View All screen. Organizations can take one of
the following actions to address overdue PFIs:
 Close the PFI if the corrective action is complete
 Complete the resolution identified in the PFI
 Request an extension; instructions are available on the
web page with the Online Standards Submission form
Organizations use PFIs when they need more time to correct
building deficiencies identified during the Life Safety Code®
assessment (see sidebar). While the PFI is in effect,
organizations must comply with their Interim Life Safety
Measures (ILSM) policy, which is intended to provide interim
measures until deficiencies are resolved and allow the
building to remain occupied with known deficiencies.
However, patient safety can be adversely affected when
deficiencies are not corrected in a timely manner.
Accredited organizations with overdue PFIs will be sent a
series of reminder emails in the coming weeks:
 May 30: Message sent to all organizations with overdue
PFIs addressed to the organization’s primary
accreditation contact and the facilities manager.
 June 12: Message sent only to organizations that are still
not making sufficient progress addressed to the
organization’s primary accreditation contact, the facilities
manager and the CEO.
 June 23: Final message sent to organizations that have
not made progress addressed to the organization’s
primary accreditation contact, the facilities manager and
the CEO.
Background
The Statement of Conditions™ (SOC) was
developed in 1995 to assist organizations in
assessing their building’s compliance with the
National Fire Protection Association (NFPA)
Life Safety Code® (NFPA 101). If a building
deficiency can’t be fixed immediately because
it requires additional resources such as
money, materials or time, then the organization
can create a Plan For Improvement (PFI)
within the SOC that identifies when the repair
will be completed. During this time, The Joint
Commission requires the organization to be in
compliance with the Interim Life Safety
Measures (ILSM) policy (LS.01.02.01 EP 3)
until the deficiency is resolved.
Before an organization is surveyed, it can
change the PFI. Once a surveyor has reviewed
and “accepted” the PFI, the PFI can no longer
be edited by the organization and is expected
to follow through on the plan. The
“acceptance” by the surveyor becomes an
agreement between the organization and The
Joint Commission that the building deficiency
exists and that the projected completion date
and ILSM are in effect. A corrective action is
considered to be completed on time if it is
finished within six months of the projected
completion date.
To ensure that this backlog doesn’t occur again, after July 1, 2014, the Department of Engineering will
automatically be notified if a previously accepted PFI exceeds the projected completion date by more
www.jointcommission.org
Joint Commission Online
Page 2
May 28, 2014
than six months. When this happens, a member of the department will call the organization to help get it
back on track. If the PFI is not completed, an on-site survey may occur. For more information, see the
SOC on your Joint Commission Connect™ extranet. (Contact: George Mills, [email protected])
Patient safety
WHO report: The world is headed for a post-antibiotic era
The World Health Organization (WHO) has released Antimicrobial
Resistance: Global Report on Surveillance 2014, the first comprehensive
WHO report on surveillance of antibacterial resistance – when bacteria
outsmart the drugs designed to kill them. The report found that rates of
resistance for common bacteria causing serious illness are high
throughout the world and that there are significant gaps in global
surveillance. The findings are consistent with Centers for Disease Control
and Prevention’s (CDC’s) Antibiotic Resistance Threats in the United
States, 2013. To read the full report, visit the WHO website.
Joint Commission Resources
Joint Commission Resources journal receives ABIM Professionalism Article Prize
The American Board of Internal Medicine (ABIM) Foundation has awarded The Joint Commission Journal
on Quality and Patient Safety its annual Professionalism Article Prize for the article, “An Intervention
Model That Promotes Accountability: Peer Messengers and Patient/Family Complaints,” by James W.
Pichert, Ph.D., Ilene N. Moore, M.D., J.D., Jan Karrass, M.B.A., Ph.D., Jeffrey S. Jay, J.D., Margaret W.
Westlake, M.L.S., Thomas F. Catron, Ph.D., Gerald B. Hickson, M.D., published in October 2013. This
article is the first in the prize’s history to receive a perfect score. Committee members felt that this cuttingedge intervention model could successfully identify and remediate at-risk physicians, thereby improving
patient safety and addressing burnout, a clear boon to the field of medical professionalism. Links to the
winners’ abstracts, along with a comprehensive medical professionalism bibliography and information on
previous winners, can be found on the Foundation’s website.
Resources
New on the web
 New Hospice Awareness Campaign Launches
 Free Industry Report: The National State of Home Care & Hospice
 Customer Spotlight: Innovative Strategies To Improve Care and Efficiency—Season’s Hospice
 Blog posts:
o Ambulatory Buzz: Revised imaging requirements implementation date postponed
Learn more about Joint Commission Resources’ education programs and publications
at www.jcrinc.com or call 877-223-6866.
©2014 Published by the Department of Communications & Corporate Marketing
Pamela Schumacher, M.S., editor