October 17, 2007 | | Comments 0
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Butter isn’t the only thing you can clarify…

Okay, Elvis has left the building (picture a Joint Commission surveyor with sideburns, sunglasses and a big ‘ol belt buckle-bell-bottoms optional) and you’re the proud owner of a handful of EC RFIs.

You tried, tried, tried to negotiate a favorable result during the survey, but a couple of things would not go away. Adding insult to injury, your organization is looking at an adverse decision of conditional accreditation (CON) or even preliminary denial of accreditation (PDA) and the rest of the team is giving you the hairy eyeball because you were supposed to have everything under control-right?!?

Well, the departure of the survey team does not signal the end of things. And, importantly, if your organization is facing an adverse accreditation decision, you need to start digging yourself out of that CON or PDA hole.

The best tool for the job? The clarification process.

But don’t spend too much time moping around because the clock is ticking.

Organizations faced with an adverse decision have a mere 10 business days from your final report to submit clarifications for findings during survey. You need to carefully analyze each finding to identify any RFIs for which clarifying evidence will reverse one or more citations. But which one (or ones) do you choose?

At a recent Joint Commission Executive Briefings conference, Darlene Christianson, executive director of accreditation and certification services at the Joint, urged the audience at a minimum to perform a post-survey audit on all RFIs involving C elements of performance and submit the results as a clarification if the audit demonstrates 90% compliance or better.

What’s that? A score of 90% is all I need? Yes, my friends, you heard it right. And, to sweeten the clarification pot even more, an audit compliance percentage of 80%-89% can, in certain cases, result in a reduction from an RFI to a supplemental recommendation.

So I ask-what are you waiting for? More on this in my next posting . . .

Steve Mac.


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Steve MacArthur About the Author: Steve MacArthur is a safety consultant with The Greeley Company in Danvers, Mass. He brings more than 30 years of healthcare management and consulting experience to his work with hospitals, physician offices, and ambulatory care facilities across the country. He is the author of HCPro's Hospital Safety Director's Handbook and is contributing editor for Briefings on Hospital Safety. Contact Steve at stevemacsafetyspace@gmail.com.

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