• E-mail
• Print
• RSS

What does the JCAHO expect with its new scoring guidelines?

Accreditation Connection, November 19, 2004

Do you have a perfect staff (no one makes mistakes and they never will)? If you answer "yes," then you'll easily stay compliant with the JCAHO's new scoring guidelines for many Category A and B elements of performance (EP). If not, there are issues you need to know-right now.

In the August Perspectives, the JCAHO clarified that it expects perfect performance for a subset of the EPs, including but definitely not limited to the National Patient Safety Goals. Therefore if your hospital is less than perfect and if a surveyor finds even one mistake, you will receive a score of noncompliance.

If you feel like the odds are stacked against you, you're not alone. Bud Pate, REHS, the director of clinical operations improvement for The Greeley Company, a division of HCPro, in Marblehead, MA, is working with concerned parties to encourage the JCAHO to rethink the guidelines, which he describes as unrealistic. "None of us are capable of perfect performance all of the time-not even the JCAHO," he says.

Watch out for the flaws

A preliminary review of the hospital EPs will uncover many requirements with zero tolerance.

If you look hard enough, you'll find flaws at almost any institution. The JCAHO leaves the de-termination of "appropriate," "secure," and other variation-prone judgments up to the individual surveyor.

If a surveyor finds any of the following situations-and many more not covered here-your hospital will be noncompliant with a standard, triggering the need for an evidence of standards compliance report within 45 days after survey (effective July 1, 2005):

·  A single refrigerator log that shows medication storage temperatures out of range (MM.2.20 EP.2)

·  A single unsecured IV bag, tube of ointment, vial of lidocaine, or any other medication (MM.2.20 EP.3)

·  Carbon dioxide (CO2) levels are not continuously monitored during moderate sedation-assuming that the surveyor believes CO2 monitoring is the appropriate monitor of ventilation (PC.13.30 EP 1)

·  A single expired medication (MM.2.20 EP.5)

·  A single unapproved abbreviation in the progress note of one medical record (IM.3.10 EP 2)

·  A single order for medical restraint is not renewed during one day of a multiday restraint episode (PC.11.40 EP 6)

• E-mail to a Colleague
• Print
• RSS
• Archive