Accreditation

JCAHO releases a slew of new FAQs

Briefings on Accreditation and Quality, June 1, 2005

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History & physical changes nearly go unnoticed

If you caught spring fever, you may have missed one of the 26 new, revised, or updated hospital frequently asked questions (FAQ) posted to the JCAHO Web site in April alone--and so might your surveyors, who were likewise not notified, according to a source close to the JCAHO.

The JCAHO develops FAQs in response to multiple requests for clarification of standards, elements of performance, or National Patient Safety Goals and requirements. Although the JCAHO cautions that advice given in FAQs is not necessarily the only way to comply, it does consider it an "authoritative clarification." In the field, FAQs are widely considered to be just as good as the only way to comply. Some surveyors use them while on surveys for standards interpretation. Unfortunately, both the field and surveyors were caught off-guard by this flurry, says the source close to the JCAHO. Many are still unaware of the changes.

FAQs are not posted according to any schedule or with much fanfare, so it's generally up to hospital survey coordinators to keep an eye on the JCAHO Web site where FAQs reside or risk being out of the loop on official standards interpretation.

The FAQs for April represent the most released in one month since January 2004. So far in 2005, two each were released in January, February, and March. At press time, only one had been released for May (see below for a complete list).

H&P changes

Although most of the standards chapters are represented in the FAQs released this spring, four pertain to history and physical (H&P) requirements under the information management, provision of care, and medical staff standards chapters.

Hospitals continue to struggle with the JCAHO's requirements for updating presurgery H&Ps. The accreditor requires all H&Ps (done up to 30 days prior to admission) to be updated within 24 hours for inpatient admissions and all operative invasive procedures whether inpatient or outpatient. This represents a change from the Centers for Medicare & Medicaid Services (CMS) requirement of seven days--the rationale for which has not been explained to the field or surveyors, according to the JCAHO source. "This is a moving target with which many physicians may have difficulty in complying," says the source.

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.

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