Use your full compliance data when clarifying RFIs

In my last post I talked about the advantages of using The Joint Commission’s clarification process when you receive an RFI.

Just to give you an example of how this could manifest itself, say you have a couple of off-site clinics that are visited during a hospital survey and surveyors find 10 fire extinguishers that missed a monthly inspection. (By the way, frequently survey verdicts are based on sample size—for all intents and purposes, if surveyors find three or more noncompliant conditions within an EP or standard, they have to score it as a “0” or noncompliant.)

It appears the surveyors have the hospital in a bad situation. As they might say in the U.K., “It’s a fair cop!” But, if you look at that EP (EC.5.40, EP #12), why, it’s a “C” score. Can we do something here? You betcha!

We know how many extinguishers we have in our inventory: 75 extinguishers at the main hospital and another 10 at all of the off-sites, for a total of 85 devices. Ah, but we still don’t make the mark—10 out of 85 is a compliance rate of 88.2%, which may be enough to downgrade to a supplemental citation, but not enough for outright removal of an RFI.

But is that really the case? I’m thinking perhaps not.

As you know, compliance is generally measured as a function of 12-month periods. If you take your fire extinguisher program to the 12-month parameter, you end up with a total number of monthly inspections as a function of the number of extinguishers (85) and the number of inspections per year per extinguisher (12), which yields 1,020 activities.

With that number in mind, if you only missed 10 inspections, then you still have a compliance rate of better than 99%. No RFI for you, my friend. Your compliance data is most useful in the clarification process.

One further note about auditing: You need to base the timeframe for review on the date of your survey. The only sure way to vacate an RFI is to demonstrate that you were in compliance during the survey.

Now you may say my extinguisher anecdote is an extreme example, but I can assure you that this solution absolutely works in real life (this falls under the “been there, done that” category).

But what if my hospital isn’t in any real accreditation jeopardy? What’s the point of chasing these rainbows? Well, turning once more to Joint Commission official Darlene Christianson in her remarks at the Executive Briefings conference, we learn that, beginning in 2008, the number of RFIs you receive during your triennial survey can influence how soon (or not) you can expect your next survey.

Remember, the survey window will be opening to any time from 18–39 months after your most recent survey—a mighty big window, yes? I’d rather see the 39-month-sized window.

And perhaps most importantly, do you really want to submit an “evidence of standards compliance” response and be responsible for fixing a process that wasn’t broken in the first place? Don’t you have enough to do fixing things that ought to be fixed? I thought so…