In July of 2018, Joint Commission International (JCI) announced the implementation of a new extended look back – known as a 36-Month Look-Back requirement – to the accreditation survey process. Over the past 2-plus years, the 36-Month Look-Back has also been referred to as a 3-Year Look-Back and Continuous Compliance. This requirement to show evidence of continuous compliance through a 36-month look back process was scheduled to be included in the survey process for all hospitals with an accreditation survey beginning on or after 1 January 2021.
We recognize that due to the COVID-19 pandemic, hospitals are focused on ensuring safe, quality patient care and may have altered the services normally provided to patients within their community. We know that these are very stressful times. As such, JCI has decided to postpone the implementation of the 36-month look back indefinitely.
This announcement pertains only to the new extended look-back process that was first announced in July 2018 and was scheduled for implementation on 1 January 2021.
To clarify, the original look-back process remains effective for all hospitals and academic medical centers and will remain in effect for surveys conducted in 2021. The original look-back process for all hospital and academic medical centers is as follows:
- A 12-month look-back period of compliance for triennial surveys
- A 6-month look-back period of compliance for initial surveys
- No look-back period for a follow up survey; sustainability of improvement is used to evaluate compliance.
The Joint Commission International Hospital Standards are intended to promote continuous, systematic and organization-wide improvement in daily performance and in the outcomes of patient care. It is understood that during these incredibly challenging times, interruptions in non-critical activities, such as data collection, aggregation and analysis, inspection and maintenance of non-critical equipment, and other non-essential activities may be temporarily suspended. However, it is JCI’s expectation that all hospitals will maintain compliance with the JCI standards in such a way as to provide safe, quality patient care during the pandemic and develop a plan of action to address the return to continuous compliance with the JCI standards in the near future.
For more detailed information about the look-back period and scoring implications, please refer to the “Joint Commission International Survey Process Guide for Hospitals, 6th Edition.”
The “Joint Commission International Survey Process Guide for Hospitals, 7th Edition” will be updated to reflect the original look-back policies in the form of errata.
Please contact with any further questions.
