Compliance News: Where is that “Proof of Compliance”?

By Barbie Pankoski, CHFM, CHSP

Hospitals typically have most of the documents they need for presenting to The Joint Commission; however, all too often they just can’t seem to put their hands on some of the “proof of compliance” at the time of survey. This may be due to lack of organization, employee turn over, or the “one person” who has all the answers may be on vacation. Then what happens?

Some surveyors allow only a limited amount of time to find your needed documents before they score you for non-compliance. Hospitals should plan ahead, determine where their needed documents are located, and keep at least one copy in a central location(s), ensuring that more than one employee can locate and present them to TJC at the time of survey. Go through every standard and all of the elements of performance and ask yourself, “How do I show compliance with these requirements? Is there a written policy or task sheet to show compliance? Did I cover this in my management plans? Am I sure my employees or outside contractors are doing this task correctly and are documenting appropriately? What else can I do to ensure putting my hands on this documentation if I am asked to show proof of compliance?”

The following recommendations may help:

1. Organize

2. Centralize

3. Educate

Organize:

The hospital should organize their important documentation by going through The Joint Commission Standards, Elements of Performance (EP), and other regulatory requirements one by one and putting the back-up documentation or the “the proof of compliance” in a manageable format such as in binders or electronically stored and sorted by the Environment of Care (EOC), Emergency Management (EM), and Life Safety (LS) standards, EPs and other regulatory numbers.

Centralize:

Now that documentation and “proof” have been gathered and organized, the hospital should consider where the information will be kept, for example, in the Facilities Engineering Department, Safety Office, or Accreditation/Compliance Department. It is critical that appropriate staff be informed as to the location(s) of the documentation.

Educate:

The hospital should have a backup plan just in case the “one person” who knows everything and here it’s located is not there on the survey days. Educate several staff members on the EOC, EM, and LS standards and programs, and the location of the documentation. As required, they can retrieve the documentation and present it to the surveyor(s).

If documentation is organized, centralized and the appropriate backup staff is educated, the hospital can be confident that staff can quickly retrieve the requested documentation showing “proof of compliance” with the standards and EPs resulting in a successful TJC survey!