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10 Requirements for Improvement

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Introducing the first-of-its-kind resource to help you address Joint Commission noncompliance findings and maintain your accreditation status.

If you're surveyed in 2006, you'll have to address Joint Commission requirements for improvement (RFI) on the double—literally

As if the new unannounced survey process weren't enough to digest, you now have to start dealing with RFIs immediately to avoid losing your accreditation when the 90-day window to submit evidence of standards compliance shrinks to 45 days.

Learn to address RFIs as quickly and easily as possible

HCPro—the premier provider of information resources for the healthcare industry—is pleased to introduce Requirements for Improvement: The Essential Guide to JCAHO Standard Citations. This book combines expert field analysis with inside information that will help your organization maintain its accreditation in the face of even the most difficult surveyors.

You have two choices: Work around the clock without a safety net; or, keep a Joint Commission standards expert on your desktop. You decide!

Meet our authors

Deborah J. Thoman, MA, RHIA, CHP, is a senior assistant director, the compliance/privacy officer, and the Joint Commission coordinator at University of Iowa Hospitals and Clinics. Previously, Ms. Thoman was the director of health information management and associate director of clinical outcomes and resource management at the University of Iowa Hospitals and Clinics. She has more than 20 years experience in the health information management field. She is a past president of the Iowa Health Information Management Association and a past chair of the American Health Information Management's Legislative Committee. Ms. Thoman helped to write questions for the American Health Information Management Association's National Privacy Officer exam. She frequently lectures and writes on Health Information, Joint Commission, compliance and privacy issues.

Claude (Bud) Pate, REHS, joined The Greeley Company after 15 years at Kaiser Permanente. Mr. Pate was responsible for a wide range of regional quality and compliance initiatives during his tenure at Kaiser in Southern California. He was responsible for standards and survey processes established by the Joint Commission, CMS, the California Department of Health Services (DHS), and the Office of State-wide Health Planning and Development (OSHPD). Mr. Pate also had leadership roles in Kaiser teams that developed industry-leading processes for the integration of health plan and hospital credentialing, moderate and deep sedation and best-practice-driven assessments of emergency departments.

Throughout this book, the authors drill down into the topics that will have you compliant with the Joint Commission's requirements in no time. Check out our table of contents:

Section 1: Introduction and definitions
Section 2: Activities before and during survey
Section 3: Communicating with surveyors and the Joint Commission
Section 4: The real work begins after survey
Section 5: Samples: Clarifying Evidence of Standards Compliance, Evidence of Standards Compliance, Measure of Success Compliance

If your hospital receives 10 or more RFIs—the typical organization receives at least four per survey—it starts down a dangerous path to losing its lifeblood: Joint Commission accreditation.

A scathing government report accusing the Joint Commission of rubber-stamping accreditation has put the organization on the defensive and RFIs on the rise. That means your organization is in danger of receiving conditional accreditation—or worse, preliminary denial of accreditation.

Requirements for Improvement: The Essential Guide to JCAHO Standard Citations is the resource you need to prepare your organization to anticipate possible RFIs before survey, address surveyor findings during survey and possibly avoid RFIs, and then mobilize resources after surveyors leave your facility to address RFIs in their preliminary report—before you receive the final report from the Joint Commission's Central Office.

If worries about RFIs are enough to keep survey coordinators awake at night, HCPro's new resource will help you rest easy. This invaluable resource includes

• dozens of real, sample evidence of standards compliance, clarifying evidence of standards compliance, and measure of success compliance, courtesy of The Greeley Company, HCPro's consulting affiliate
• expert advice and information from a field expert who went through survey and successfully eliminated RFIs on the spot or submitted clarifying evidence after survey, that resolved RFIs without further incident
• timely information, helping you prepare for—and recover from—the new unannounced survey process
• strategies to address RFIs more efficiently, making the 45-day window seem like plenty of time

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