There can be a reluctance to clarify (appeal) the findings of a Joint Commission final accreditation report, especially as there’s not a lot of information available regarding the process to follow. However, if an organization believes that it was compliant with one or more requirements for improvement at the time of survey and has the data to prove its case, then it should submit an Evidence of Standards Clarification plan.
The timeline is tight, though — staff members have only 10 business days to gather all of the supporting documentation, including any audits. The good news is that some organizations may find an easy way to remove the RFIs.
When an organization receives the official report from a TJC accreditation survey with one or more RFIs, it has a choice on how to respond: Appeal the findings by submitting clarification plans or develop and submit compliance plans. Both take a lot of work to prepare; however, if the clarification plans are accepted, the RFIs will be removed, and no additional information has to be submitted to TJC. Typically, clarification plans are submitted to provide supporting information that, for various reasons, was not presented or not accepted during the survey. The key to submitting a credible clarification plan is that the organization has to be compliant at the time of survey. Submitting a clarification plan is an optional process with a tight timeline.
On the other hand, compliance plans are submitted within 45 or 60 days after the official accreditation report is posted. The timing is based on the designated impact of the RFI as being a direct finding (45 days to respond) or indirect finding (60 days to respond). The compliance plans detail the actions taken to bring the organization into compliance with the standards/elements of performance that were identified as being partially or non-complaint during the survey. If the standard/element of performance is a "C" standard, the organization will need to develop a plan of correction, collect and analyze data for four months and attain a compliance rate of 90 percent — not always an easy feat.
4 essential elements of a well-designed appeal
Before beginning the clarification (appeal) process, organizations need to know that they will be on dual tracks: clarification and compliance. While the clarification track seeks to remove an RFI by submission of evidence that the organization was compliant at the time of the survey, the compliance track provides evidence of compliance after the survey. Once the evidence is submitted for clarification, the organization cannot submit a corrective action plan until the Joint Commission Standards Interpretation Office has evaluated the information submitted. TJC may respond by removing the RFI or by upholding the finding, in which case, organizations are then required to submit compliance plans.
When submitting an appeal, organizations should note these four essential elements of a well-designed appeal:
- Follow the TJC format to answer "who," "what," "when," "why" and the "evaluation method."
- Answer the questions accurately, briefly and completely.
- Use existing data whenever you can, such as audits conducted for the Focused Standards Assessment.
- Submit your response online as soon as possible, but prior to 10 days following the official posting of your accreditation report.
Format
TJC has a specific format for hospitals to follow when submitting an evidence of standards clarification plan on their extranet site:
- Who
- Identify who was responsible for the implementation of the process (indicate title — not a name — of a single individual who has overall responsibility).
- What
- Describe the policy/procedure or process, training, existing data that demonstrate that the organization was compliant at the time of survey, refer to the evaluation method (audit) section below.
- When
- Indicate process/policy/procedure approval or implementation dates prior to survey.
- How
- Explain how information was disseminated to staff prior to survey.
- Why
- Provide a detailed explanation of why information was not presented to surveyors or why it was not accessible during the survey.
Evaluation method (audit)
The amount and kind of data submitted to TJC is dependent on whether the standard/element of performance was a patient care standard related to documentation or whether it was an environment of care standard.
- If the finding is related to documentation, use records from 30 days prior to survey.
- If the finding is related to the environment of care, use data from 12 months prior to survey.
Focused Standards Assessment
When it comes to submitting data for clarification, organizations may find that their Focused Standards Assessment will pay off. Instead of having to initiate new audits, they may be able to use the data collected as part of their FSA to make their appeal.
The data gathered for a Focused Standards Assessment can be valuable when facing the tight timeline for submitting the clarification plan. Below are two examples of how organizations could use this data to successfully submit a clarification plan to TJC.
Example I
In this first example, surveyors found unsecured oxygen tanks in two locations of a hospital. The TJC standard cited as non-compliant was EC.02.01.01 EP 3 "C" "R." The letters "EC" indicate that the finding came from the Environment of Care chapter, and the numbers refer to the standard number; "EP" means "Element of Performance." The symbol "C" refers to the type of standard designation and means that it is scored based on the number of times an organization is found out of compliance with an EP. The "R" symbol indicates that TJC has identified specific risks associated with this EP.
Because the hospital had conducted an FSA for the past couple of years and had been conducting internal rounds of the environment of care, they had existing data. Storage and security of oxygen tanks was one of the areas audited during the quarterly environment of care rounds. In this instance, the clarification plan submitted to TJC demonstrated that the hospital had maintained compliance with the standard/EP above the minimum requirement of 90 percent for the past 12 months.
Corrective action plan
Who:
Chairperson, Environment of Care Committee
What:
The hospital’s Environment of Care Committee conducts quarterly rounds of the clinical departments using a checklist. Items audited during these rounds focus on facilities' management of the environment, employee safety, infection control and environmental services that have been identified in TJC Focused Standards Assessment as potential "risks." The storage/security of oxygen cylinders is one of the items reviewed on the checklists during quarterly rounds. Additionally, shift engineers routinely inspect storage and security of the compressed gas tanks located in facilities on machine rounds.
When:
Results of findings from EC quarterly rounds are documented, analyzed and reported to the hospital safety committee. Inspections by the shift engineers are conducted three times per day.
How:
The multidisciplinary EC team uses a checklist when inspecting patient care units and enters findings in an electronic computer program. Results from the focused safety inspections are entered on a spreadsheet and disseminated to managers of the units and at the hospital’s safety committee. The shift engineers correct any issues related to compressed gas tanks at the time of inspection.
Why:
The findings from the quarterly rounds were in the documents for the life safety and the administrator surveyors to review. Overall results of the quarterly rounds were discussed during the EC interview; however, specific results relating to inspecting oxygen cylinders were not discussed at that time. The findings from the shift engineer's inspections were not formalized.
Evaluation method:
1Q/yyyy, 99% (1394/1400) oxygen tanks were secured correctly
2Q/yyyy, 99% (1398/1400) oxygen tanks were secured correctly
3Q/yyyy, 99% (1391/1400) oxygen tanks were secured correctly
4Q/yyyy, 99% (1399/1400) oxygen tanks were secured correctly
Example II
This second example illustrates how an organization could use its FSA data from chart audits to provide supporting data of compliance with documenting required elements in a medical history and physical examination. A similar clarification plan could be used for other RFIs related to documentation, such as initial nursing assessments, pain assessments, or abuse assessments.
In this hypothetical situation, the hospital is cited as non-compliant with standard PC.01.02.03 EP 4, "C" "R" "M" because there were three instances in which an H&P was not available in the chart (paper or electronic) in the designated timeframe. PC indicates that the finding came from the Provision of Care Chapter. This standard is classified as "C" and "R." The "M" symbol indicates that a measure of success (monitor/audit) is required if the organization is found to be out of compliance during a survey or during an internal audit, such as the FSA.
As part of its monthly chart audits, the hospital monitored H&Ps for completeness, completion dates, and quality of the assessment. This information was used in the completion of the FSA to help the hospital assign its score of "satisfactory compliance," "partial compliance" or 'insufficient compliance" with this standard/EP. In this situation, if a hospital received an RFI during a survey, it would already have the data needed to demonstrate compliance with the standard/EP and would be able to quickly and easily submit it as part of its clarification plan.
Who:
Chief Medical Officer
What:
The hospital's medical staff's rules and regulations state that the medical history and physical examination must be completed within 24 hours following an inpatient admission or registration, but prior to surgery or a procedure requiring anesthesia services. The rules and regulations also state that if a previous history and physical examination will be used, it must be no more than 30 days old and updated upon admission and prior to surgery or a procedure requiring anesthesia services.
When:
The medical staff rules and regulations have an unknown origination date and were last revised mm/yyyy. Chart audits are conducted monthly to assess the H&P for accuracy, completeness, and timeliness.
How:
Medical staff rules and regulations are developed and reviewed by the Medical Executive Committee. Monthly chart audits are conducted by a multi-disciplinary committee. Using screening criteria, the chair of the chart audit committee refers H&Ps to the appropriate medical staff department committee for additional review when there is a question regarding the accuracy/justification of medical necessity of the H&P note. Overall results are submitted to the hospital’s Nursing Advisory Committee, MEC and the Quality Steering Committee and are used in scoring compliance with TJC standards.
Why:
The surveyor requested that the hospital submit its evidence to TJC for clarification.
Evaluation method:
Per TJC instructions for sampling, the hospital is required to audit a minimum of 50 charts, as its average daily census is 272, and the average number of outpatients registered for surgery or invasive procedures involving anesthesia per day is 50. Because the hospital collects data through monthly chart audits and has data from the month prior to the survey, the hospital respectfully requests that TJC consider this data as evidence of compliance. The numerator represents the number of charts in which the H&P was timely (less than 30 days old; completed within 24 hours of inpatient admission/registration, but prior to surgery or a procedure requiring anesthesia services). The denominator represents the number of H&Ps reviewed for inpatients and outpatients at the time of the audit: 98 percent (294/301) charts monitored in mm/yyyy showed a timely H&P was present on the chart. This exceeds the goal of 90 percent set for this standard/EP.
Conclusion
Hospitals often have data from routine quality improvement activities and from audits that have been implemented as a result of the FSA process. These audits may be an overlooked source of data that can be used to support compliance with a specific standard when the hospital receives an RFI.
Victoria May Fennel has more than 20 years of healthcare leadership experience. She has spent the majority of her career in nursing leadership roles and brings expertise in evidence-based practice, nursing education, quality management, performance improvement, accreditation, risk management, patient safety and patient-centered care. As director of accreditation and clinical compliance for Compass Clinical Consulting, Ms. Fennel manages the quality of accreditation and compliance engagements and directs client education and advisement.