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Six steps for submitting a clarification to JCAHO

Accreditation Connection, April 18, 2005

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 explain in detail how you do comply with the standard.

"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," he says.

Hospitals that receive up to nine RFIs have 90 days after survey to craft a response to the JCAHO, in the form of either clarifications or ESC, 45 days for hospitals surveyed after July 1, 2005.

But hospitals with 10 or more RFIs have just 10 working days to submit any clarifying information once the JCAHO complete its internal review process of its survey report.

To learn the six steps to writing a clarification, click here.

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