Organizations surveyed after July 1, 2014 will see a change in how their findings are written up in their TJC survey reports. There will now be an Opportunities for Improvement section included in the survey report. Included in this OFI section will be single observations of non-compliance with Category C elements of performance (EPs.)

A bit of explanation regarding scoring: Category C EPs are frequency based requirements and are scored based on the number of times an organization is found not to be compliant with a particular EP. In the past, if a surveyor had only one observation of non-compliance with a Category C EP (such as pain screening), that EP would be scored as 2 (satisfactory compliance) and this finding would NOT be included in the survey report. If there were two observations of non-compliance, that EP would be scored as 1 (partial compliance) and if there were three observations of non-compliance, that EP would be scored as 0 (insufficient compliance.) The findings with scores of 1 (partial compliance) and 0 (insufficient compliance) were included in the survey report.

The change is that now just one observation of non-compliance with a Category C EP will result in a finding that will be included in the survey report as an Opportunity for Improvement. Although the OFI will be included in the survey report, it will not require Evidence of Standards Compliance (ESC) follow-up by the organization. Also, the organization will not be allowed to submit a Clarification to attempt to have the finding removed from the survey report. We have seen survey reports this month with the new OFI section and it is worded as follows:

[tblock title=”Opportunities for Improvement” tag=”h2″/]

“Observations noted within the Opportunities for Improvement (OFI) section of the report represent single instances of non-compliance noted under a C category Element of Performance. Although these observations do not require official follow up through the Evidence of Standards Compliance (ESC) process, they are included to provide your organization with a robust analysis of all instances of non-compliance noted during survey.”

So, the bottom line is that survey reports will have more findings than in the past but the nature of the official response to TJC will not change.