It can’t be emphasized enough that you should consider which issues have the potential for successful clarification as soon as you are aware of the findings. Start your research as soon as you suspect there is an issue. Don’t waste valuable time waiting for the final report to be posted to your extranet site. Because clarification audits are very time-consuming and must be completed within 10 days of the survey, any extra time you can buy for the data review process is helpful. Focus on the key issues and problem areas, especially direct impact findings.
Important Note: If you feel you can successfully clarify a specific issue and you will need to go beyond the ten days allowed, consider asking your accounting representative for an extension. Organizations have stated that The Joint Commission is open to an extension, so asking for one can work to your advantage.
Think about how you would respond to the actual requirements. This means noting surveyor scoring errors (yes, they do still occur). Avoid responding to a surveyor’s misunderstanding of a standard or his or her preference in how it “should” work in your organization. The Joint Commission has been very careful in standards development and interpretation to allow organizations the flexibility in implementing them. However, your process should parallel acceptable practices, such as those recommended by the U.S. Centers for Disease Control and Prevention (CDC) or specialty societies, for example. Many organizations and some consultants even preach “best practices” for all, but in reality, patient issues and resources may vary across the United States, and you need to find the process that works for you while being compliant.
Consider all sources of information from The Joint Commission, such as the actual EPs in the standards manual and the officially published Perspectives and standards FAQs on the Internet.
Editor’s note: This blog post is an excerpt from The Joint Commission Survey Coordinator’s Handbook, Thirteenth Edition, by Jean S. Clark, RHIA, CSHA, and Jodi Eisenberg, MHA, CPHQ, CPMSM, CSHA