Accreditation

Learn from one case study how an imperfection can lead to conditional accreditation

Accreditation Connection, October 22, 2004

The JCAHO scoring guidelines are strict and in many cases rely on surveyor interpretation of Category A and B elements of performance. Rack up too many requirements for improvement and your hospital is in danger of a conditional accreditation or tentative denial of accreditation. Here's a possible scenario:

 

Step 1: A surveyor finds that the medication refrigeration log shows a temperature above the threshold for action. He scores this under MM.2.20. This is a Category A, or zero defect, standard. The institution receives a "requirement for improvement."

 

Step 2: The hospital has 45 days (effective July 1, 2005) to correct this and all other issues identified during the survey. For years, the hospital has experienced problems with fluctuations in refrigeration temperatures, and now it must find a way to permanently fix that problem.

 

Step 3: The hospital measures its level of performance for four consecutive months. If a medication refrigerator log reflects a temperature that is too high or a staff member finds a single multidose vial of insulin on the countertop, the hospital is again noncompliant and the accreditation status slips to "provisional."

 

Step 4: The hospital measures its level of performance for another four consecutive months. This time, lack of consistent compliance triggers "conditional accreditation."

 

Step 5: The hospital measures its level of performance for another four consecutive months. This time, lack of perfect compliance triggers "tentative denial of accreditation."

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