Krieg DeVault


Practice and Industry Teams

Joint Commission Updates Medication Management Element of Performance

October 5, 2017

By: Thomas N. Hutchinson

The Joint Commission is enhancing provider Element of Performance (“EP”) protocols regarding patient medications in response to the nation’s ongoing opioid crisis. Specifically, the Joint Commission has revised its Medication Management (MM) EPs “to assure the standards continue to reflect evidence-based practices and quality and patient safety issues that emerged from the healthcare field in recent years.”[1] Joint Commission-accredited providers impacted by the finalized changes include:

- Hospitals

- Ambulatory care

- Behavioral care

- Home care

- Nursing care centers

- Critical access hospitals

- Accredited office-based practices

The updated Medication Management EPs implement both revisions to existing standards and entirely new standards. The new EPs are effective January 1, 2018, and include the following:

1) Implement a policy to provide emergency backup for essential medication dispensing equipment identified by the organization

2) Implement a policy to provide emergency backup for essential refrigeration for medications as identified by the organization

3) Add “wasting” of medications to the required written policy addressing the control of medications between when they are received by an individual health care provider and when they are administered

4) Implement a policy that describes the types of medication overrides that will be reviewed for appropriateness and the frequency of the reviews when automatic dispensing cabinets are used

5) Record, in the patient’s clinical record, the date and time of any medication administered.

The Joint Commission details the new Medication Management EPs on its website in “prepublication status,” meaning the standards will soon be available in provider’s print manuals and the Joint Commission’s online “E-dition.”[2]

Provider types included in the list above need to review the new EP standards and confirm that relevant policies, procedures, and clinical workflows support the new requirements. While many of the new EPs require providers to revise policies to address the new standards, providers must be prepared to demonstrate the new standards in clinical settings as well (e.g., evaluation of EMR patient medication interface).      

Joint Commission surveys are a stressful time for providers, but understanding and implementing the new Medication Management EPs is a provider’s clearest path to survey success. Krieg DeVault’s Health Care Practice Group provides expert guidance to its clients regarding provider accreditation and is prepared to assist in these changes. Please contact Tom Hutchinson at (317) 238-6254 or should you have any questions. 




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