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JCAHO 2003 and beyond: Patient safety, forms, and supplementals

Ambulatory Safety Monitor, March 21, 2003

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Patient safety--

The JCAHO is working on a new definition for rape, one of the sentinel events for which you must conduct a root-cause analysis (RCA) and report back to the accreditor. Also, the JCAHO will soon require that you perform RCAs for death due to recognized complications, says a source close to the accreditor.

The JCAHO will also announce that the unanticipated death of an infant is part of the definition of a "reportable sentinel event," and thus, subject to an RCA.

No more homework--

Effective immediately, surveyors can't give you their own forms to fill out, the observer says. For example, surveyors often develop their own forms that show maintenance dates for a facility director to better explain what they do.

TIP: If a surveyor hands you a non-JCAHO form to fill out, you can say "no," the observer says. "This will make a lot of people happy, since it has been frustrating."

No more supplementals--

The JCAHO will eliminate supplemental recommendations. You'll either receive a Type I or an "information finding" (the JCAHO didn't give this rating a formal name), which means that the JCAHO will look for information on how you improve your weak area(s). You won't be held accountable to fix information findings as you are with Type I's.

Additionally, you won't have to submit as many paperwork-heavy correction reports to the JCAHO. The accreditor will instead hold verbal discussions over the telephone on resolving only the Type I's that arose from the self-assessment. You must still send in correction reports for additional Type I's found during the triennial surveys, however.

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