Medical Staff

Consistent levels of care a focus for JCAHO

Executive Briefings Digest, January 20, 2003

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The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) standard LD.1.6, which requires organizations to offer the same level of care to all patients, is a particular focus during surveys these days. Variations are easier to spot because surveyors study standards compliance by walking through the entire care process of each patient, from admission to discharge.

The following steps will help you limit the amount of variation in how you treat patients-to not only avoid a bad survey score, but also to decrease the chance of error and improve patient outcomes:

  1. Create a board policy mandating that all patients receive a single level of care.
  2. Review a sample of medical records and the results of monitoring and evaluation activities to ensure that staff members comply with the board policy.
  3. Periodically review medical records of patients with similar diagnoses to confirm whether both the nursing care plans and nursing care provided are consistent among patients.
  4. Review board reports regarding quality to determine whether the board routinely receives information about the quality of care provided to patients of all types—Medicare, Medicaid, private-pay, health maintenance organization, and no-pay-and to patients of all ages and sexes with similar health problems in all settings.
  5. Review the organization's information management resources. Are they integrated to permit the assessment of care provided across the hospital?
  6. Review education and training documentation to ensure that you equivalently train different staff members who provide the same aspects of care.

Source: Briefings on JCAHO,
http://www.hcmarketplace.com/Prod.cfm?id=16&S=EEBD



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