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Intracycle Monitoring Process Fact Sheet

Helps organizations with continuous standards compliance. Every accredited organization has access to an Intracycle Monitoring Process or ICM Profile on its Joint Commission Connect® extranet.

The ICM Profile includes a list of high-risk topics and related standards, as well as resources and solutions to contemporary healthcare service challenges. Located within the ICM Profile, the Focused Standards Assessment (FSA) provides organizations with an easy-to-use, interactive standards self-assessment scoring tool. The FSA lists applicable standards customized to an organization’s accredited programs and services; standards linked to high-risk topics are displayed with an "R" icon for easy recognition. The FSA tool workspace permits an organization to develop and monitor corrective plans of action to sustain standards compliance.

ICM Profile Submission Options

To support accredited organizations with their continuous compliance efforts, The Joint Commission offers the ICM application during the interim years of the accreditation cycle. The ICM Profile is designed to help accredited organizations incorporate Joint Commission standards as part of routine operations and ongoing quality improvement efforts.

The FSA tool is available to accredited organizations as an optional self-assessment aid. Accredited organizations that receive a PDA02 decision rule are required to participate in the ICM submission process. These organizations will be required to submit either the Full ICM Profile option (see below) with a call with Joint Commission staff or on-site survey, Option 2.

Full

The organization uses the FSA tool to assess and score compliance with elements of performance (EP) for applicable standards. At least the minimum subset of R-icon standards must be scored. Data entered into the FSA tool is copied to a historical submission record for future reference by the organization.

For each EP scored not compliant, the organization creates a Plan of Action (POA) to restore the standard to full compliance, identifies an individual as the ‘Person Responsible’ for developing and implementing a Plan of Action, and identifies a Plan of Action compliant-by date.

Option 1

The organization submits an attestation to affirm it has completed a standards self-assessment process, including the development of appropriate POAs.

While organizations are encouraged to use the FSA tool to facilitate standards self-assessment activities, any data entered into the FSA tool is not copied to a historical submission record.

Option 2

The organization submits a request for an on-site ICM survey that includes documented findings (additional fees apply).

A surveyor assists the organization in the review of organization-identified high-risk areas. Standards compliance issues are documented in the FSA tool for the organization’s follow-up action.

Within 30 calendar days after the on-site event, the organization submits POA information for standards identified by the surveyor as not compliant.

Option 3

The organization submits a request for an on-site ICM survey that does not include documented findings (additional fees apply).

A surveyor assists the organization in the review of organization-identified high-risk areas but does not enter data in the FSA tool.

Standards compliance information is provided to the organization through an oral exit briefing; there is no documented record of any event findings.

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