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Help On the Way for Conditional or Preliminary Denial of Accreditation Decisions

Accreditation Monthly, February 14, 2006

Dear Colleague,

Did you know that about 60 hospitals surveyed by JCAHO will receive Conditional or Preliminary Denial of Accreditation (PDA) based on their 2005 survey? Did you know that the number will likely double in 2006, to about 120 hospitals!? Why? Because JCAHO reduced the threshold for conditional accreditation making it easier for hospitals to fail.

Experiencing such a poor showing in a JCAHO survey is obviously a significant threat looming over any organization expecting an unannounced triennial survey in 2006. If an organization is notified that a recommendation is to be made to the Joint Commission's Accreditation Committee for either Conditional Accreditation or Preliminary Denial of Accreditation, the organization has only 10 business days to provide information to clarify any of the requirements for improvement cited in its Accreditation Report or the decision sticks.

But help is a phone call away. I am pleased to report that, with a swat-team-like response, experts at The Greeley Company have assisted many hospitals over the last few years right their ship in the immediate wake of their stormy survey, and through a process JCAHO calls "Clarification," successfully reversed a sufficient number of erroneous or flawed surveyor findings such that each hospital ultimately improved their standing to full accreditation. We also have deep experience preparing material for JCAHO's Accreditation Committee and Review Hearing Panels.

In the January 2006 issue of Perspectives JCAHO announced the 2006 thresholds for the number of Requirements for Improvement that will trigger Conditional or Preliminary Denial of Accreditation. For hospitals 10-14 RFI will trigger Conditional Accreditation (10 RFI is 1.5 standard deviations above the mean rather than the former 2 standard deviations above the mean) while 15 or more will trigger Preliminary Denial (3 standard deviation above the mean.) Although the difference may sound small, in actuality, the number of hospital finding themselves in hot water will virtually double.

If you are one of these hospitals, or if this happens at the organization of a respected colleague, call us immediately.

Experience teaches us that the number of valid RFIs (those that remain following clarification) is often only half the number originally cited by the survey team.

Of course, the best way to avoid trouble is to invite our experts in early, prior to your unannounced survey, so we can pre-test your compliance readiness and help fill any compliance gaps with our time-tested solutions that ensure sustained execution and a constant state of readiness. Help is but a phone call away.

Sincerely,

John Rosing
Practice Director of Accreditation
and Regulatory Compliance
The Greeley Company

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