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Among the last-minute steps that can be taken just before a Joint Commission on Accreditation of Healthcare Organizations survey begins, none is more important than a final review of record keeping. In part, that’s because the document-review process begins just two hours after the first interview.
"The order or accessibility of the information that they need in that document review really sets the tone for the survey," asserts Regina Walczak, director of organizational performance at Saddleback Memorial Medical Center in Laguna Hills, CA. "If they get what they want in that document review, there is a comfort level that the hospital understands the standards." After that, Walczak says, surveyors mainly seek to confirm that through interviews.
According to Walczak, the more clearly the documents are tagged using the Joint Commission’s standard numbers rather than words, the better. "You have to talk their language and not expect them to know your language. At the very least, you have to educate them as to what your language is."
Susan Goodwin, a consultant with the Hospital Company in Nashville, TN, notes that the Joint Commission routinely sends its guidelines to hospitals scheduled for surveys. She says some hospitals respond by assembling all their policies and procedures for every single standard in massive books. But in reality, she says, surveyors really want to look at a handful of key documents.
"They don’t have a document on their list that is going to match up to every single standard in the chapter," she explains. "You want to simply follow the instructions in the survey guidelines to make it as easy as possible."
Goodwin points to one hospital that assembled all the key documents in one notebook that was tabbed by function for each of the three surveyors. "The surveyors loved that because they each had their own book, and they didn’t have to share materials," she reports.
She says the other key ingredient is to have a functional team or standing groups that are responsible for ongoing compliance and that can look over the documents to make sure that everything is complete and up-to-date. That will avoid having somebody get his or her hands on an outdated policy that later ends up in the documents review book.
Walczak says the other import ingredient in the document review is to think of materials that would convey compliance, such as patient rights, which may demonstrate that patients are informed about their privacy. That means not only showing them a policy that demonstrates that patients understand their rights but other evidence as well.
"You can assemble letters, pamphlets, brochures, and anything that you think will convey compliance so they know that you are thinking outside the box," she explains.
Walczak also points to "nonconventional" patient care areas. For example, at her hospital, when a patient goes into a bed, staff fill out an interdisciplinary patient assessment form (IPA) that explains what the patient’s needs are. "If you just stick that IPA in a book and say that this is evidence of our patient assessment practice, that won’t always work."
It might work for a medical/surgical patient but not for an emergency room patient or a patient who is in partial hospitalization, Walczak explains. Likewise, she points to patients who come in for same-day surgery and newborns, who may lack that documentation.
"What we found is that not every patient or every department has an IPA," says Walczak. "Where we were short, we had to come up with an equivalent form to demonstrate how we evaluated these patients."
"You have to slice and dice your population and think of other alternative types of documents that demonstrate compliance," she adds. "Your bread-and-butter’ materials will not necessarily cover that in same way."