New Clinical Care Program Certification Eligibility Requirements Now In Effect

Joint Commission International’s (JCI’s) governing board approved eligibility requirements for Clinical Care Program Certification (CCPC) programs in which the host organization is not JCI accredited at its 29 June 2010 meeting.

The clinical care programs are grouped into one of three categories, depending upon the degree of patient risk and the degree of the program’s integration into the host organization. Therefore, the analysis of the 15 clinical areas eligible for the CCPC program application are divided into groups A, B and C below.

Group A	Group B	Group C
Programs that are primarily outpatient in nature and rely on the host organization for little or no direct patient support. The program may use the credentialing process of the host, the pharmacy and patient record and other administrative processes however, not diagnostic and therapeutic services or invasive and surgical procedures.	Programs that are primarily outpatient in nature, but do rely on the host organization for direct patient support such as for blood banking, laboratory analysis and diagnostic imaging (but not for invasive procedures and surgical procedures).	Programs that are primarily in-patient in nature and include invasive and surgical procedures.
Evaluation of host organization: These programs will have a one day on-site risk analysis review prior to the CCPC program survey. The risk analysis will use standards derived from the current edition of the International Standards for Hospitals (3rd edition standards for surveys through 31 December 2010; 4th edition standards from 1 January 2011 forward) and include standards related to credentialing, medication management and other standards appropriate to the integration of the CCPC program into the host organization.	Evaluation of host organization: These programs will have a two day on-site risk analysis review prior to the CCPC program survey. The risk analysis will use standards derived from the current edition of the International Standards for Hospitals (3rd edition standards for surveys through 31 December 2010; 4th edition standards from 1 January 2011 forward) and include standards related to credentialing, clinical laboratories, diagnostic imaging, and other standards appropriate to the integration of the CCPC program into the host organization.	Evaluation of host organization: These programs can only be surveyed if the host organization/hospital is currently accredited by JCI.
Example: A home care based palliative care program.	Example: A hospital based outpatient Diabetes Mellitus management program.	Example: An organ transplant, joint replacement, Acute Myocardial Infarction, primary stroke, traumatic brain injury, chronic kidney disease programs.

The intent of this requirement is to ensure that JCI does not accept an application from, nor certify, a CCPC program within an organization for which little is known as to the quality and safety of the host environment. The general premise is that even a program of exceptional quality requires an environment focused on quality of care and patient safety to sustain a high level of performance.

JCI will determine which category a program belongs in using the following criteria:

• The description of the scope of the CCPC program contained in the certification application. This is the primary source.
• The content and scope of the clinical practice guidelines that have been selected to guide the program’s scopes and services. The guidelines are submitted with the application and would specify, for example, if any outpatient chronic disease management programs or if the applicant program also follows and provides services to the patient if they become acute and require inpatient care.
• Any contractual relationship between the applicant program and host organization, such as for laboratory diagnostic work, as well as the frequency of any applicant program and host interaction, for example, all patients or only in the event of an emergent patient need.

The standards selected from the International Standards for Hospitals will guide the separate evaluation of the host would relate to the services provided by the host organization (e.g., diagnostic radiology) and to the safety of the physical environment, the processes for ensuring competency of staff, quality monitoring processes, and patient rights.

Even when the host organization is JCI accredited, the certificate of certification will be quite clear as to the scope of the certified program.

* JCR is the parent organization for JCI, so the JCR Board of Directors approves all JCI standards, accreditation policies and procedures, and other significant initiatives.

Read an article on these standards and this certification program in an earlier edition of JCInsight

Read more about or order the Clinical Care Program Certification Standards