June 13, 2014 | | Comments 0
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When things really start to add up (and not in a particularly nice way…)

Our continuing coverage of the survey wars brings us to the June 4 edition of Joint Commission Online in which it was revealed that we can anticipate that Joint Commission survey reports are going to be bulking up over the next little while (you can determined whether that bulk is the result of banned substances). This “bulk” is being introduced as TJC strives ever harder towards alignment with the requirements (and expectations) of the folks at CMS, and I’m all a-tingle—not!

Henceforth (kind of makes it sound almost biblical), TJC will be adding a section to every survey report that will be entitled Opportunities for Improvement or OFI (to differentiate OFIs from PFIs and RFIs and any other FIs that might be swirling around the compliance world). The OFI section is going to be reserved for all those pesky little single instances of non-compliance that fall under “C” performance elements (you will no doubt recall that “A” performance elements are already balanced on a single instance of non-compliance—you either have it or you don’t. And if you don’t…).

In current survey practice, “C” performance elements, to generate an RFI, require the survey team to identify at least two instances of non-compliance. For example, during the facility tour, the LS surveyor finds a single door that does not close and latch properly. In the past, that finding would be absent from the final report, but now it will reside in the OFI section of the report. The good news here is that you will not have to submit an Evidence of Standards Compliance (ESC) for the items in the OFI section, you just have to fix them. Also, any open PFIs from previous surveys or PFIs approved by the surveyor during the survey visit will also be enumerated in the survey report. You’ll still be resolving them via the normal process, within six months of the projected completion date, etc., so that piece of it doesn’t change. I guess it’s just a means of keeping open PFIs on everyone’s radar (the likelihood of this being an offshoot of the number of overdue PFIs found in recent TJC review of eSOCs is anybody’s guess, but I’m betting… yeah, pretty much) I suppose another by-product of this “highlighting” of open PFIs is added impetus to make sure that you get things resolved prior to your triennial survey, but it is certainly not a requirement. You just have to adhere to your committed completion dates.

All that said, clearly we’ll be dealing with more “findings” on the report, which presumably means that TJC will have more evidence for CMS that it really is looking carefully at compliance issues and that it is identifying deficiencies during the survey process. I do believe that everyone in the process—the regulators and the regulated—are committed to providing safe quality care to the patients, but I guess how that care is going to be delivered is subject to interpretation. Same as it ever was…

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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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