Accreditation

JCAHO increases number of allowable RFIs during surveys

Briefings on The Joint Commission, May 1, 2006

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Distinction made between small and large hospitals

Learning objectives: After reading this article, you will be able to

1. define what the JCAHO considers the difference between a large and small hospital

2. recite the number of requirements for improvement (RFI) that small and large hospitals may receive for conditional accreditation and preliminary denial of accreditation

The number of RFIs that hospitals may receive has increased, further relaxing the revised thresholds the accreditor released in December 2005.

The change came as a surprise to the field and even to JCAHO surveyors, who say they had been using the recently revised thresholds and were unaware that the JCAHO was planning to revise them again, and so soon. Since the January 2004 changeover to the new survey pro-cess, the thresholds have been re-vised annually.

The number of RFIs that a hospital can receive before landing in conditional (CON) or preliminary denial of accreditation (PDA) was released to JCAHO surveyors on March 27 in an e-mail from Joseph Cappiello, JCAHO vice president of accreditation field operations. Multiple copies of the e-mail were obtained by HCPro, Inc., and confirmed by the JCAHO. Since then, the JCAHO has notified hospitals about the change via e-mail and its JaycoT extranet site.

The change took effect immediately and was retroactive to January 1. It was widely believed that this would mean an overturn of CON or PDA status for hospitals that may have received either this year. But of the more than 400 unannounced full surveys completed since January 1, none has resulted in an ad-verse decision because final accreditation decisions were being held, according to JCAHO spokesperson Mark Forstneger.

The JCAHO's Accreditation Committee made the change during its March 21 meeting.

"These hospitals are now being notified of their accreditation decisions based upon these modified thresholds," Forstneger said. A follow-up inquiry into when it was made public that threshold changes were coming again was not immediately answered.

Important distinctions made

For the first time, a distinction was made between small and large hospitals.

The distinction was made based on RFI data from the 1,449 hospital surveys conducted during 2005, according to Cappiello's announcement to surveyors. The data showed a "statistically significant" difference in the average number of RFIs between the two groups (see below for some historical data and more about adverse decisions).

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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