Accreditation

Post survey advice: Take advantage of the opportunity to clarify (overturn) RFIs

Accreditation Monthly, September 14, 2007

In the period of time following your Joint Commission (JC) (formerly JCAHO) survey, be certain to take full advantage of your opportunity to clarify some or all of the requirements for improvement (RFI) noted in your final JC survey report. A clarification is really your attempt to refute, reverse, overturn, or diminish RFI findings (i.e., reduce an RFI to a supplemental finding).

If you are facing an adverse decision of conditional accreditation (CON) or preliminary denial of accreditation (PDA), you most certainly want to carefully analyze each finding to identify those RFI for which clarifying evidence will reverse one or more findings, thus bringing your total number of findings below the threshold for CON or PDA. In these circumstances, clarifications need to be submitted over your secure extranet site within 10 business days of the final report being posted to the extranet. In our considerable experience assisting clients facing an adverse decision, we have been very successful overturning RFIs in numbers sufficient to move the client to a more favorable accreditation status (e.g., from PDA to conditional or from conditional to accredited).  We swoop in with SWAT team-like speed, efficiency, and effectiveness to assist you in investigating the facts that gave rise to the finding while building a case, through data collection or other evidence, to prove that the organization was actually in compliance with the cited standard(s) during the survey.

But what should you do if your hospital's JC triennial survey results in a decision of full accreditation with seven or eight RFIs and a handful of supplemental findings? Rest on your laurels? Concede defeat on those RFIs? Not according to Darlene Christianson, executive director of accreditation and certification services at JC. Instead, you should also seek to clarify these RFIs early in your 45-day evidence of standards compliance (ESC) or measure of success (MOS) period to arrive at the most accurate assessment of your organization's compliance with JC standards. Speaking at the annual JC Executive Briefings conference two weeks ago in Chicago, Christianson urged the audience to, at a minimum, perform postsurvey audits on all RFIs involving C elements of performance (EP) and submit the results as a clarification if it was able to demonstrate 90% compliance or better. (Additionally, in some cases 80%-89% compliance will reduce an RFI to a supplemental finding.) 

The A and B EP findings also lend themselves to clarification and reversal. In fact, Greeley consultants have had great success helping dozens of clients reverse C EPs through audit, and A and B EP findings through carefully crafted arguments that demonstrate the organization's full compliance with the applicable standard. The numbers can be quite startling. We've had success moving a hospital in PDA with 21 RFIs to full accreditation with nine RFIs. Or consider the hospital that achieved full accreditation with nine RFIs having their RFI count reduced to two RFIs. 

Everyone understands why the client in adverse action would want to fight for their lives and clarify findings, but why would a hospital that achieved full accreditation want to rock the boat and submit RFI clarifications? According to Christianson, beginning in 2008 the number of RFIs you have during any triennial survey will influence (increase) your priority focus process (PFP) point total, and this along with other data will make it more likely that your next survey will fall sooner than later in your 18-39 month window for when your next survey will be scheduled. And why go through the exercise of creating an ESC or MOS in which you identify how you fixed a process that was not broken in the first place? Doing so is a waste of precious time and resource and often results in tampering with (and increasing the error rate of) an otherwise well-functioning process.

So regardless of whether your JC survey results in a decision of full accreditation or adverse action, I suggest that you give us a call to ask for advice about how to clarify RFIs. Joint Commission rules dictate how clarifications are to be submitted and The Greeley Company consultants have the tools, know-how, and skills you'll need to submit successful clarifications. And remember, if you are a JCR client your Continuous Survey Readiness (CSR) consultant is barred by the JC conflict of interest firewall from assisting you with post survey clarifications. For more information, please call Stacey Koch, director of client relations, at 888/749-3054.

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