ILSMs--your ticket to conditional accreditation

In reviewing recent survey findings, I've noted that surveyors (especially, but not limited to, the life safety specialists) have become very skilled at identifying exactly what elements of your ILSM policy were not implemented, making it almost impossible to get a favorable decision when seeking RFI clarification.

Your policy says "A," but you didn't do "A"--welcome to conditional accreditation.

The rest of your organization could be absolutely perfect in every other facet of the survey process, and you could still be in conditional accreditation because you got boxed into a corner on your ILSM policy. How unpleasant would that be?

And you get to have someone from The Joint Commission come back to resurvey you in six months or so, just to make sure that you've got everything under control. You've already waited the whole freakin' year for them to come and now you have to wait for them to come again. That would be most stinky, don't you think?

And so, to reflect briefly on compliance mantra:

1. Do the right thing (and frequently common sense is a good indicator of the right thing)
2. Do what you say (don't shoot yourself in the foot with the policy gun)
3. Say what you do (and please don't make a policy that goes on and on and on and on--kind of like me)

Put it this way, if you have a policy that looks like it might be one of my blogs, you can probably simplify it a wee bit.

If you can get all those points covered in your practice, policy, procedure, and planning, your survey compliance is in better shape.