Accreditation

Six steps for submitting a clarification to JCAHO

Briefings on Accreditation and Quality, April 1, 2005

This is an excerpt from a member only article. To read the article in its entirety, please login or subscribe to Briefings on Accreditation and Quality.

Hospitals continue to struggle with writing clarifications of how they comply with a standard despite being cited during a survey as "not compliant."

What is it?

A clarification is similar to an evidence of standards compliance (ESC) in that it explains how the hospital complies with the standard for which it received a requirement for improvement (RFI). However, with a clarification you're saying you are in compliance with the standard and here's how.

"Basically you're saying, 'at the time of survey, we were in compliance, and here's how' " says Bud Pate, REHS, practice director of clinical operations improvement for The Greeley Company, a division of HCPro, Inc., which publishes BOJ.

Resist saying a surveyor was wrong, advises Steven W. Bryant, practice director of accreditation and credentialing and privileging for The Greeley Company. "Even if they are wrong, it's your word against a surveyor's. Just address the issue aggressively with the JCAHO. Do your best to give evidence and show how you were meeting the intent of the standard."

This is an excerpt from a member only article. To read the article in its entirety, please login or subscribe to Briefings on Accreditation and Quality.

Most Popular