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How to clarify

Don’t get hung up on the clarification format. Sometimes explanations don’t fit well into the Joint Commission’s “who, when, what, how, and why” outline and your explanation won’t be clear.

Future posts will walk you through specific examples of successful clarifications, but overall you will need to demonstrate:

  • that the hospital had a process that complied with the actual requirement in place at the time of survey;
  • that the process was approved by the right folks at the hospital;
  • that the process was implemented using an effective implementation process (education, reinforcement, etc.);
  • that the process had been in place for a significant amount of time prior to survey (ideally for at least the previous year); and
  • why you believe this process complied with the requirement at the time of survey.

Do your homework

Before you decide whether to clarify what seems to be a misinterpretation of the requirement, check the facts.

  • Read the element of performance carefully. What does it really require.
  • Read the relevant portions of the CMS interpretive guidelines.
  • Read recommendations from nationally recognized standard-setting bodies such as CDC, AORN, AAPIC or other relevant entity.
  • Read recent literature.

If this homework validates that the finding is inaccurate, then please put this information into the clarification.

If this homework uncovers a disparity between your process and CMS requirements or recognized guidelines, you will want to change your process instead of trying to clarify the RFI.

What if you miss the 10-day clarification window?

The hospital has ten business days after the survey report is posted to submit a clarification. But, what if you realize that the finding was inaccurate after the ten-day window has closed? Then, reflect the existing, compliant process in your evidence of standards compliance.

After doing your homework, explain what you will do going forward to comply with the requirement. The fact that what you will do going forward is the same as the process in place at the time of survey is irrelevant. Your proposed evidence is either sufficient (shows compliance with the requirement), or it is not.

Important: balance safety, experience and efficiency

Whether clarifying a survey finding, crafting evidence of standards compliance, or fixing a problem you found yourself, it is extremely important that the process at the heart of this clarification or fix is:

  • safe (and compliant)
  • promotes a positive experience for patients, staff members and providers, and
  • is efficient.

If the fix (or the existing process) does not meet all three of these criteria, then you are not done; a better process design is indicated. (More about the three features of a reliable process in later blog posts.)

In future posts

… We will give examples of how to clarify specific common findings. Findings like medication security, care planning, abuse and neglect screening and many more.

So stay tuned.

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