For many years, TJC has had a process whereby an organization can request to “clarify” a survey finding. The clarification process is used when the organization believes that it was actually in compliance with the applicable standard at the time of the survey and thus should not have been cited as noncompliant. The organization has ten business days from the date the survey report is posted to submit the clarification to TJC.
There will continue to be a clarification process but there are some significant changes to the process that go into effect for all accreditation programs effective January 1, 2017. These are as follows:
Documents not available during survey
Documents that were requested by surveyors but not available at the time of the survey will no longer be eligible as evidence for a clarification. Findings regarding documents that were unavailable at time of survey will be Requirements for Improvement (RFIs) in the survey report and will need to be addressed via the 60 day Evidence of Standards Compliance (ESC) process.
Audits to demonstrate compliance will no longer be a part of the clarification process. These audits were related to demonstrating compliance with C elements of performance. With the introduction of the SAFER matrix, the C designation for elements of performance has been eliminated. Thus, clarifications for any element of performance will all require the same format (see below) and will not require audits.
If the organizations identifies clerical errors in the Survey Findings report posted after their survey, the organization should submit a clarification requesting that the clerical error be corrected. TJC will correct the clerical error and the corrected finding will remain in the report. The corrected RFI will need to be addressed through the 60 day ESC process.
The information to be submitted for a clarification remains the same (except for the audits referenced above) and includes the following:
- WHO: Title of who approved the (relevant) policy/procedure.
- WHAT: A description of the policy/procedure/process that was in place prior to the survey.
- WHEN: The date the policy was approved; was effective; and when training occurred.
- HOW: A description of how information on the policy was disseminated to staff.
- WHY: Explanation of why the surveyor did not have access to this information at time of survey.
The new clarification instructions are posted on your TJC Connect site under the Post Survey tab and are titled SAFER Clarification Instructions.
Keep in mind that the reason for these changes is that TJC spends large amounts of time reviewing and responding to clarifications and wants to reduce that post-survey workload. So, your best approach is to try to get clarification while the surveyors are on site. Ask them to tell you the standard and EP they are planning to cite so you can be clear on what the requirements are. Use your morning briefings and your Issue Resolution time to discuss issues and bring forth additional evidence of compliance. It’s time well spent and TJC wants to resolve those issues on site as much as you do!
Learn more about how we can help with our Post Survey Support services.