Misinformation on Shared Visions–New Pathways
Organizations not affiliated with the Joint Commission produce products and sponsor education programs related to JCAHO accreditation. At times, the information provided in these products and programs is misleading or inaccurate.
The Fact on Fiction column identifies this misinformation with the intent of preventing confusion and correcting misperceptions in the field. This column is included in Perspectives on an “as needed” basis, whenever misleading or inaccurate information on JCAHO initiatives is published.
Addressing recommendations
The January 7, 2003, issue of HCPro Express from Briefings on JCAHO states that, in 2004, health care organizations will not be able to “challenge Type Is except when you can prove that surveyors didn’t look at enough of a sample size, such as six medical records rather than 30.”
This statement is misleading in that beginning in 2004 there will no longer be a need for a recommendation revision process. Instead, for
any recommendation, the organization is to provide evidence of compliance within 30 days. This evidence may be either
- to show that it was in compliance with the standard in question at the time of survey; or
- to show what staff has done to come into compliance with the standard since their survey.
For example, if the organization believes that a surveyor’s finding is in error because it was based on too small a sample, it could demonstrate it is in compliance by taking a larger sample. Health care organizations will have the opportunity to address their recommendations—whether they agree with them or not—under the new 2004 accreditation process, Shared Visions–New Pathways.