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Update from Executive Briefings #8: RFI Trends

Accreditation Monthly, September 11, 2008

Pat Adamski reported the following "Problem Standards" from the results of surveys conducted in 2007 and the first quarter of 2008.

EC.5.20: Life Safety Code (LSC). 2007 RFI rate: 29%; 2008 RFI rate: 45%. The increasing rate of LSC RFIs is attributed to additions to the number of surveys including a LSC specialist.

IM.6.50. Verbal orders not authenticated. 2007 RFI rate: 25%; 2008 RFI rate: 35%. At present, a single unsigned telephone order is an RFI (category A). The good news is that this issue will become a category C element of performance in 2009.

MM.2.20. Medication storage. 2007 RFI rate: 43%; 2008 RFI rate: 31%. This issue includes expired medications and medication refrigerators that are not monitored or are out of range. This issue will also move from a category A (100%) to a category C (90%) requirement.

EC.5.40. Testing of LSC devices. 2007 RFI rate: 18%; 2008 RFI rate: 30%. The increase in RFI rate probably reflects an increase in LSC engineer survey participation. Sometimes, this is merely a few missed issues or missing documentation, and the issue can be easily clarified or corrected. However, this can lead to preliminary denial of accreditation (PDA) due to immediate threat if there are significant lapses and if interim life safety measures have not been implemented. It is recommended that compliance with this issue be tacked through to the leadership level.

IM.6.10. Complete medical record. 2007 RFI rate: 26%; 2008 RFI rate: 24%. Findings tend to fall into the general area of a complete medical record and the issue of dating and authentication of medical record entries. Although CMS requires that entries be timed, The Joint Commission does not. However, The Joint Commission will survey to your policy, so if you require timing, so will they.

HR.1.20. Primary source verification. 2007 RFI rate: 15%; 2008 RFI rate: 18%. One-hundred percent compliance with this issue will continue to be required in 2009.

MM.3.20 2007 Noncompliance with medication order policies. 2007 RFI rate: 20%; 2008 RFI rate: 16%. This will remain a category C element of performance. In our experience, a hospital's intrinsic rate of compliance is about 93%, meaning that clarification rather than correction should be considered.

PC.8.10: Assessment and reassessment of pain. 2007 RFI rate: 15%; 2008 RFI rate: 16%. A large part of noncompliance with PC.8.10 is unrealistic policies for reassessing pain. We've posted several sample policies and approaches in our Center's documents library, but the bottom line is: Don't paint yourself into a corner.

EC.7.40: Emergency power generation. 2007 RFI rate: 8%; 2008 RFI rate: 16%. This is another issue in which the effect of an extra LSC surveyor can be clearly seen. Issues with emergency power generation can also lead to immediate accreditation problems due to imminent threat to patient welfare.

PC.13.20: Pre-sedation assessment. 2007 RFI rate: 18%; 2008 RFI rate: 15%. These issues can usually be traced back to requiring too much documentation. To address this, simply remember that less is more and to standardize your forms.

EC.7.50: Medical gasses. 2007 RFI rate: 6%; 2008 RFI rate: 14%. Our friendly neighborhood LSC specialists are at work again. The specter of imminent jeopardy arises when it comes to alarms being shut off.

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