Accreditation

Three strikes and you're out

Briefings on Accreditation and Quality, March 1, 2005

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Surveyors will now score two National Patient Safety Goal (NPSG) requirements that no longer require 100% compliance with a "three-strikes," frequency-based rule.

The requirements do not allow prohibited abbreviations (Goal #2b) and mandate hand hygiene (Goal #7a), and they require 90% compliance. Organizations will be in compliance as long as surveyors observe no more than two strikes.

Surveyors learned about the scoring change in January during their annual conference in Chicago . One source close to the JCAHO says surveyors were after the conference sent the two-page scoring guidelines to be used in the field.

Three strikes and you're out- of compliance

The number of observations a surveyor conducts may affect compliance, says Robert Marder, MD, practice director of quality and patient safety for The Greeley Company in Marblehead, MA, a division of HCPro, Inc., which publishes this newsletter.

For example, if surveyors observe 20 incidents and find three strikes, the organization is at 85% compliance.

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