Accreditation

Wiping away RFIs during survey is possible, one hospital discovers

Briefings on The Joint Commission, September 1, 2006

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.

After reading this article, you will be able to

1. -describe why it's important to challenge surveyors on a finding if you feel that it was made in error

2. list three tips for wiping away RFIs

3. -outline ways to train staff to feel more comfortable talking to surveyors

By Patricia Dolan's count, her facility avoided at least three requirements for improvement (RFI) during its unannounced survey simply because she decided to speak up and take surveyors to task on some of their findings.

"It's my hospital," says Dolan, RN, BSN, MSN, chief nursing officer at Saint Mary's Regional Medical Center in Russellville, AR. "I know how it runs, the processes that are in place, and I know the [JCAHO] standards."

So when surveyors took issue with areas that Dolan was sure that Saint Mary's was in compliance with, she didn't keep quiet and worked to clarify the issues on the spot.

"It's part ownership or self-preservation-I'll be the one writing the evidence of standards compliance for that RFI," she says. Another factor is that "surveyors don't know the process in this hospital. You have to educate them. You can't be passive about what they're finding."

Dolan says the two surveyors who spent four days at her 170-bed facility were amenable to her approach because she kept it professional and timely.

"It's important to ask that an issue be discussed during the special issue resolution time on the daily schedule. Be prepared with data to support your position," she says.

The RFIs that got wiped away

"We should have had more [RFIs]," Dolan says. The following were the issues about which she challenged surveyors and won:

  • In an outpatient area, a surveyor was looking at home medication lists (the first step in medication reconciliation) and a discharge sheet read "continue home medications," which is not acceptable to meet the goal's requirements. The surveyor indicated that it would be a finding. However, Dolan challenged the surveyor that the rule didn't apply in this area because the patient was in for an endoscopy procedure. Those physicians don't change patient medications, pharmacists aren't used to profile their medications, and further, nothing had changed for the patient. The surveyor was adamant, but so was Dolan. They called the JCAHO's standards interpretation group (SIG). The SIG sided with Dolan, and the potential finding never materialized as an RFI.
  • A surveyor found an operative note that wasn't timely, which could lead to an RFI. Dolan didn't dispute the finding, but said she believed that it was an anomaly. Staff reviewed every chart on the unit and didn't find any other notes that weren't timely. Staff showed the surveyor the findings. The surveyor agreed to let it go.
  • A surveyor found that a nurse missed checks on pain assessment and was about to write an RFI. But, as with the operative note, Dolan knew that her facility was in compliance with pain assessments. Staff reviewed a half dozen charts and showed the surveyor the findings. The surveyor agreed that it was probably just a "blip," Dolan says, and did not write an RFI.

    • 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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