Accreditation

Six steps for submitting a clarification to JCAHO

Briefings on The Joint Commission, April 1, 2005

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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."

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