The Joint Commission updates policy for physician practices in hospital survey

The Joint Commission has revised its policy for inclusion of physician practices in hospital and critical access hospital accreditation surveys. Previously, Joint Commission policy required that a physician practice be included in the hospital’s survey if at least one of two criteria were present:

  1. The physician practice is included in the hospital’s Medicare cost report as a provider-based practice. This criterion aligns with CMS’ requirement that all services reported on a hospital’s cost report meet all hospital Conditions of Participation.
  2. The hospital or physician practice portrays to the public that the practice is part of the hospital.

Effective immediately for hospitals achieving initial accreditation, and effective January 1, 2014, for currently accredited hospitals, the second criterion is no longer required for including physician offices in a hospital or critical access hospital survey. A hospital-affiliated physician practice not included on the hospital’s Medicare cost report that requests a Joint Commission survey may choose to be surveyed under the standards for either the Hospital (or Critical Access Hospital) Accreditation Program or the Ambulatory Care Accreditation Program, according to The Joint Commission.