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Below is information based upon recent surveys and conversation with other consultants and surveyors.
Updated 12/01/04
- It has come to our attention that surveyors that discover a sentinel event will call the Joint Commission to report it and in turn request that the root cause analysis be sent to them. It is recommended that each hospital seek legal counsel to avoid compromising their peer review immunity.
- Hospitals are receiving finds for the timeout not being properly documented in the medical record. ALL five elements MUST be in the individual medical record, not just the fact that the timeout was conducted relying on the hospital policy that contain the five elements.
- Be sure and ask your survey Team Leader if they would like a formal presentation during the first Leadership Interview Orientation to the Organization. Most have supported a formal presentation and if you conduct one, be sure to give equal time to your Patient Safety Program, not just Performance Improvement. This is not a Performance Improvement Presentation.
- Several hospitals have been placed on conditional accreditation for not making satisfactory progress on their Statement of Conditions (SOC). The Surveyor signed off on the SOC during their last survey and there were not only remaining items on the updated SOC but some of the items had been corrected 18 to 24 months late. There had been no communication with the Joint Commission relating to delays, budgets, etc. It has been our experience that the Joint Commission will go to great lengths to assist a hospital if you will just communicate with them. Check with your Facilities Management Team today to see the status of the progress on the SOC.
The information, answers and interpretations are furnished for information purposes only and not intended to apply to your specific situation or meet current standard interpretation. Please feel free to call us should you have any questions or we can assist in any way. |
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