Accreditation

Collaboration, staying current with policies important in complying with PC.2.120

Briefings on Accreditation and Quality, September 1, 2007

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Editor's note: This feature explores problematic Joint Commission standards with expert advice from two BOJ advisors: Jodi Eisenberg, CPMSM, CPHQ, program manager of accreditation and clinical compliance at Northwestern Memorial Hospital in Chicago, and Elizabeth Di Giacomo-Geffers, RN, MPH, CNAA, BC, a healthcare consultant in Trabuco Canyon, CA. Conducting an initial assessment in a hospital-specified time frame should be straightforward, says Di Giacomo-Geffers. PC.2.120 is mostly an issue of definition within policy. "This is the most prescriptive among the more prescriptive of the standards," she says. "It's A plus B equals C." However, that by itself may make this standard harder to comply with, because every hospital has to follow its policy and the policy, may not be current, or physicians and staff members may not be aware of policy changes; thus, practice does not follow policy, she says.

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