Accreditation

Documentation: Getting the details right

Briefings on Accreditation and Quality, December 6, 2016

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The pressure is on for hospitals to organize their binders. Starting January 1, 2017, The Joint Commission is getting rid of its clarification process. That means facilities will be expected to have their documentation readily available during survey if they want to avoid a finding. Even if the documentation exists, surveyors will still consider it “not done” if you send it to them later. 

To put it in high school terms: If you finish your essay but go to class without it, the teacher will now give you an automatic F instead of letting you turn it in on Monday.

That may become an issue for the 50% of hospital accreditation programs that request clarifications, 51% of which are in the Life Safety (LS) and Environment of Care (EC) chapters.

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