Does a hospital or a hospital system need to do restructuring so that each hospital is accredited in accordance with their CCN?
To the degree possible, we would hope not. Through the years, hospitals have formed “systems” to standardize and integrate their services to improve their delivery of patient care; we wouldn’t want to interfere with this positive effort. Nonetheless, each facility in a “system” which has enrolled separately in Medicare and has its own CCN must be able to demonstrate compliance with the CoPs independent of other hospitals in the “system.” Joint Commission staff will work with each affected hospital/”system” to help them understand the requirements and any actions they may wish to pursue to be in compliance. Hospital systems also have the option of changing the way in which their member facilities are enrolled in Medicare, in order to match they way in which they are accredited. Such decisions may have complex ramifications, for example in terms of the number of Medicare graduate medical education slots available to the system. Hospital systems, therefore, should carefully consider what
