October 30, 2012 | | Comments 0
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Q&A: The mechanics of a clarification

Q: Do you have any advice on how to format evidence for a clarification or choosing a sampling method to submit to The Joint Commission?

A: Note the following excerpted example that uses an audit submitted for a clarification by a client. It is very clear how the medical records were sampled during the audit process and it leaves no doubt as to potential bias or skewing of the data or the validity of the outcome. Of course, the data would also be submitted to support the claim. This submission leaves a perception of confidence in the organization’s ability to correctly assess and support its claim of compliance.

Sampling method: The hospital discharged more than 2,000 patients in the 30 days preceding the survey; a sample of 70 medical records was anticipated. A list of the 2,443 patients admitted on or after January 6, 2011 (30 days prior to the beginning of the survey), and discharged on or before February 4, 2011 (the day before the survey), was prepared. Every 80th patient on the list was selected for review. Nine of these records were arbitrarily omitted from the sample prior to the review, leaving 71 records in the final sample.

Calculation: The organization’s policy titled “Consents, Policy 440-34” adopted by the medical staff in June 1999 and last modified in September 2009 requires that the provider performing a high-risk procedure document informed consent either by signing the consent form or by documenting informed consent in the medical record. The policy also requires that the name of the person performing the procedure be recorded on the consent form.

The denominator for this calculation was the number of times informed consent was required by hospital policy. The numerator was the number of such occurrences where a) informed consent was documented as required by hospital policy and b) the name of the person performing the procedure was on the consent form.

Outcome: Overall performance within this sample was 97%, leading to a score of full compliance for this EP.

We respectfully request that this finding be removed based on the evidence presented.

This is an excerpt from The Joint Commission Survey Coordinator’s Handbook, 13th edition.

Editor’s Note: Do you have a question about clarifying RFIs, policy management, or survey-prep for our experts? E-mail your queries to Jaclyn Zagami at jzagami@hcpro.com and receive one-on-one advice from our experienced advisory board. Submit a question and our credible sources will provide you with a timely answer.

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Filed Under: Survey


Jackie Zagami About the Author: Jaclyn Beck is the associate director of the Association for Healthcare Accreditation Professionals (AHAP) where she manages AHAP Accreditation Connection, the annual AHAP conference, and contributes to the monthly publication Briefings on The Joint Commission.

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