ED Accreditation Update: Accreditation Q & A
Accreditation Q & A
Accreditation carries with it questions, some specific to individual organizations, but many that apply universally. In this section, ED Accreditation Update will provide experts’ answers to your accreditation questions, as well as tips from organizations fared exceptionally well during their survey process. Submit questions or suggestions for this section to Joy Daughtery Dickinson, Senior Managing Editor. E-mail: [email protected].
Q: What standard is most frequently cited for improvement during hospital surveys?
A: According to the Joint Commission, during the period from January through June of last year, 26.6% of accredited hospitals received recommendations for improvement in "Assessing each staff member’s ability to meet the performance expectations stated in his or her job description (HR. 5)."
Paula Swain, RN, MSN, CPHQ, Director of Clinical and Regulatory Review for Presby-terian Health Care in Charlotte, NC, says that particular standard poses problems for every hospital department.
"The ED manager has to understand what the [hospital’s] policy is on performance evaluation completion, and if there’s a grace period,’’ says Swain. "The Joint Commission doesn’t determine how often the evaluations must take place, but feels that staff have the right to be evaluated according to [the hospital’s] policy, and if the process doesn’t work the way it’s supposed to work, that puts you in line for a Type I recommendation."
Question: What standard is most frequently cited for improvement during hospital surveys?
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