Accreditation

To comply with public notice policy, keep it simple

Briefings on The Joint Commission, April 1, 2006

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Accreditation Participation Requirement (APR) 8 is seemingly straightforward: Hospitals must continuously provide public notice about how anyone-including staff-can contact the Joint Commission if concerns about patient care or safety in the hospital aren't being addressed. But your colleagues at several hospitals recently visited by the JCAHO say surveyors are not glossing over APR 8. Therefore, they recommend investing time and attention to APR 8 to ensure compliance during survey and not be cited for something that they believe is straightforward.

Surveyor scrutiny

"We were just surveyed, and I was astonished [by] how hard they were surveying [APR 8]," says Maureen Barnes, vice president for risk management and insurance at Cooper University Hospital in Camden, NJ. The facility was surveyed February 14-17.

Barnes estimates that surveyors quizzed 25 employees on how the hospital complies with APR 8. And although Cooper was in the clear, Barnes advises other facilities that it's not enough to simply educate employees about APR 8 or for them to know where to locate information. "They must also be able to verbalize [that] they know they will not be subject to disciplinary action if they do report something." Barnes also suspects that APR 8 is an area at which surveyors are encouraged to look because it's new for the unannounced survey process. It replaced the old system of requiring notification postings 30 days prior to survey date. Now, because survey dates are not known, notice must be available 24/7.

One source close to the JCAHO doesn't believe that all surveyors scrutinize APR 8 and says surveyors have not been told to do so. The source says some surveyors actually give hospitals a little slack because it's new.

Complying with APR 8

APR 8 is one of 14 requirements hospitals must meet to participate in the accreditation process and maintain accreditation status. All of the APRs are outlined in the Comprehensive Accreditation Manual for Hospitals ( CAMH ).

APRs are scored as either compliant or noncompliant. And although most APRs are straightforward, noncompliance with some (e.g., APR 10 [falsification of information]) can thrust a facility into preliminary denial of accreditation. Noncompliance with APR 8 will only earn a facility a requirement for improvement (RFI), but hospitals are only allowed 10 RFIs during an entire survey before meeting conditional accreditation and 15 for preliminary denial of accreditation, according to the JCAHO. It's not worth overlooking APR 8 and winding up with an RFI when there are many other standards to be assessed.

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

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