Greeley Reflections

Accreditation Connection, August 31, 2009

Maintain survey readiness: A primer

Part 3

Involve the unit clerks in tracers. They are instrumental in assembling and filing various components of the medical record, and an organized medical record is the first step of a successful tracer. Let them know how valuable they are in relocating misfiled documents, alerting staff to forms that are missing signatures, ensuring that patient identification is contained on each page within the record, and ensuring that the record tabs are in consistent order.

Often performance improvement (PI) data is generated from other sources, such as the hospital’s PI program, but is not shared with the accreditation coordinator. Connect with your PI director and dialogue about the types of data that could assist the organization in monitoring standards compliance. If an inventory of data collection is available, request to be copied on results.

The Standards Compliance Action Plan should be dynamic and be the basis for leadership to know at any time how compliant the organization is with the Joint Commission standards. Realistic time frames for corrective action should be documented with an individual accountable for each step.

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