A JCAHO Progress Note
On May 18, BWH submitted six Requirements for Improvement to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).
These requirements were the result of the February survey. Under the new survey process, all issues identified at the time of survey must be addressed and have a corrective action plan in place within 90 days. Once the submitted plans are reviewed by JCAHO, BWH's accreditation status will be finalized.
Under the six Requirements for Improvement, all patient care providers must be consistent with BWH policies related to patient assessment in all settings (inpatient, outpatient, anesthesia induction and pre-procedure); advance care directives; informed consent; using two identifiers in patient care; and not using prohibited abbreviations, asoutlined in the Patient Safety Goals.
Interdisciplinary teams were established, and met over the past three months, to address the six Requirements for Improvement. These teams were not only responsible for creating corrective action plans addressing each of the RFI’s, but also for implementing those plans within the 90-day time frame.
BWH staff are currently conducting mandatory random audits to measure the success of the corrective action plans. These audits will continue through August with the results to be submitted to JCAHO in September. A rate of 90 percent compliance is required for these plans to be deemed acceptable.
For more information around the new survey process, the Patient Safety Goals, or to view survey findings, visit the ”Compliance Corner” at www.bwhpikenotes.org