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While very few hospitals are denied accreditation after a Joint Commission survey (less than 1% in 2007), many are issued preliminary denial or provisional or conditional accreditation pending corrective action. How should a facility proceed after receiving a poor Joint Commission rating? Here several experts offer advice on corrective actions, managing public image and staff morale, and the value of the appeals process.
Common Faults
Wayne Jenkins, CBET, biomed manager for Carroll Hospital Center in Westminster, MD, says the most common areas for improvement noted in surveys of clinical engineering (CE) departments involve not consistendy following policies and procedures and proving to surveyors that "you are doing what you say you are doing."
He feels the current survey process has actually improved conditions in the biomedical arena. "We are able to set our own inspection standards that work for our individual hospital," he says, "as long as we can show just cause for why we do what we do and that we are following our own standards."
A major issue departments face is making sure surveyors understand exacdy how a facility's CE program is managed and the reasoning behind it. "It's important to have a well-designed management plan in place with complete documentation to back it up," says Baretich Engineering, Inc. President Matt Baretich. He stresses that communicating a plan in simple, easy-to-follow language is key. "CE managers should review their written material from the perspective of a surveyor. For example, ask if...