Rumor has it that the Joint Commission removed the option to clarify survey findings. This rumor is not true. It is more important than ever to make sure that corrective actions are based on accurate findings lest we get off track by trying to fix things that are not broken.
What went away at the first of 2017:
There are no more rate-based or “Type C” elements of performance in the Joint Commission’s Hospital standards manual. Therefore, there is no longer the opportunity to “audit” a finding away by measuring performance at the time of the survey to prove that the defect observed was present less than 10% of the time. So, type C rate-based clarifications are gone, along with measures of success that were required to demonstrate and 90% or higher rate of compliance over a four-month period. (Hooray!)
There is also no opportunity to clarify a RFI based on a document that was found by hospital personnel after the survey was complete. It therefore behooves the hospital to have required documents at the ready and to dedicate resources during the survey for last-minute scavenger hunts. This, too, makes sense.
However, if a finding is just wrong, the hospital can and should clarify. You damage yourself, and, you damage the institution, by trying to fix something that is not broken.
We’ve helped clients with hundreds of survey reports of all kinds in the last decade, and we know that most survey reports have some level of inaccuracy … this is not a criticism of the survey process, it’s just a recognition of the human condition: “to err is human …”
When to clarify
- Clarify when the observation documented in the survey report is not accurate.
- Clarify when the observation is accurate, but the hospital nevertheless complies with the standard.
Even if there are 20 observations under one element of performance and only 1 of them is wrong, clarify. Say thank you for the 19 observations that were accurate, but get the 20th inaccurate observation removed. Why? Well, the RFI may not go away, but your post survey improvement efforts will focus on real issues.
Don’t fall into the trap of thinking that the Joint Commission is offended by clarifications.
Some of us are loathe to object to a survey finding. Don’t be. The Joint Commission doesn’t mind. Be courteous and respectful for sure, but don’t hesitate to let the Joint Commission know when you think a survey finding is wrong. There are two possible outcomes as a result of submitting a clarification:
- You will get the errant finding removed from the report (or, if you miss the formal clarification window, the citation will be “corrected” by merely demonstrating the compliance of existing systems), or
- You will be educated about why what you thought was an erroneous finding was actually correct.
Either way, the discussion is worth having. The next post will focus on how to clarify Joint Commission findings.