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Greeley Reflections

Accreditation Connection, September 14, 2009

Maintain survey readiness: A primer

Part 5

Before finalizing a policy or procedure, compare its content to the Joint Commission requirements, CMS requirements, and state regulations. Determine whether the medical staff bylaws/rules and regulations have addressed the topic, and make sure there are no conflicts between the documents. Because many RFIs are based on staff members not following their own organization’s policies, research what is minimally required by each regulatory entity and encourage leadership not to raise the bar of expectation to a level that cannot be achieved.

Assess hospital orientation programs to ensure that revised practices and accreditation requirements are being incorporated into the curriculum. Take a look at the training needs of your hospital—from physicians to line staff—drawing upon the advice of your education staff. Consider whether the staff needs knowledge-based training (e.g., refreshers on fire-drill instructions or confidentiality policies) or survey process training (e.g., a description of what to expect during unit tours).

Don’t confuse standards compliance with poor performance of job responsibilities. The accreditation coordinator does not have authority over personnel and their failure to follow policies and procedures. The Joint Commission Steering Committee or similar oversight body for accreditation readiness should not be involved in performance issues after education has been provided to staff. For example, failure to complete a dietary assessment within the defined time frame must be addressed by the manager, not the accreditation coordinator.

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