By David Stymiest, PE, CHFM, CHSP, FASHE
A recent article placed in both the EC News and TJC Perspectives clarified TJC requirements for management plans. Written for the June 2013 issues by TJC Department of Engineering Director George Mills for the Clarifications and Expectations segment of both publications, the article clarified some issues that have been resulting in TJC requirements for improvement (RFIs) during survey.
Mr. Mills reiterated previous guidance that management plans should not necessarily state how things are done, but could refer to policies or procedures for more specificity. The article provided background and explanatory material on the following major points:
- Don’t cite the standards (although it can be helpful to have a copy of each plan annotated with standards and element of performance numbers to facilitate responding to survey questions.)
- Determine overall management plan format – 6 separate EC plans vs. 1 master plan covering multiple areas vs. other approaches
- Keeping management plan structures consistent
- Listing supporting material such as policies and procedures
- Indicating where the organization is complying with not only TJC’s requirements but also with stricter requirements of another authority having jurisdiction (AHJ) and naming that AHJ
- Identifying other related requirements (from other chapters of the TJC Hospital Accreditation Standards) that affect a management plan
- Making sure to distribute management plans to every accredited site, and conversely making sure that accredited sites have management plans reflecting the activities occurring in those locations
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