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Follow the paper trail to JCAHO survey success

Experts provide tips to organize critical documents

Learning objectives: After reading this article, you will be able to

1. identify documents necessary for a JCAHO survey

2. explain how to organize meeting minutes

3. discuss when to review policies and procedures

Although the JCAHO emphasizes individual patient and system tracers, do not underestimate the importance of documentation. Documents are still key evidence to prove compliance with standards and elements of performance.

Specific documents are to be readily available for the survey planning session that will occur shortly after the surveyors arrive at your hospital. During additional sessions, a surveyor may request to see specific items (e.g., a policy, procedure, plan, or meeting minutes).

Nevertheless, it is unrealistic to attempt to maintain current copies of these documents within a single binder for continuous survey readiness-you and your staff would be forever pushing papers and playing a game of seek-and-replace. Instead, consider organizing the many documents generated from your facility's daily operations.

Meeting agenda, handout materials, and minutes

An agenda should serve as the roadmap of your meeting. Attendees should be able to review an agenda and know immediately what handout material corresponds to the topics discussed. Look around at the people in attendance: Are they continuously shuffling papers or looking for the item being discussed, or have they given up and started working on something totally unrelated to the meeting? If either is happening at your organization, it might be time to try something different.

This is an excerpt from a member only article. To read the article in its entirety, please login, subscribe, or try out BOJExtra! for 30 days.
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