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Lisa Eddy
Senior Consultant
Many healthcare professionals focus their accreditation energies on Joint Commission findings from other hospitals, hearsay about surveyor preferences and list serve discussions about the TJC survey process. At Greeley, we are in the business of keeping hospitals "RFI proof." We've found hospitals and other healthcare entities dedicate entire positions (and sometimes departments) to the accreditation process in an effort to accomplish this, however, we've discovered nothing serves a hospital better at survey time, than maintaining continual compliance with TJC and CMS standards. Surveyors are human and as such, can misinterpret standards or have their own bias about what constitutes compliance. Because no one can control human bias or personal interpretation, we always recommend that our hospitals check their list serve hearsay at the door and spend their precious time and energy on looking at the actual requirement of the element of performance and answer the questions "what does this really mean, and are we in compliance?" So we encourage you to remove the fright factor from what you hear about someone else's survey, and focus on what you are really doing on a day to day basis to provide good and safe, quality patient care. Chances are, if you are doing that, you're already in compliance!
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Our interventional radiology department is having difficulty getting our radiologists to perform a history and physical before they do biopsies. What can we do to get them to comply?
Actually, you might want to sit down with the physicians and discuss the types of procedures that are conducted in the IR department. ... Read More...
