• PR: Upcoming Changes to the Decision Report[®] [REF: JCSC, LDR, 2014] Perspectives July 2014, Vol 34, #7, Pg 8 JCp1407_B2

Effective July 1, 2014, TJC survey reports will be a modified layout that includes a new section. The real news is that this section will be used for documenting a “new category” of findings that TJC calls Opportunities for Improvement (OFI). An OFI is a finding based on a single observation of noncompliance with a Category C element of performance. In the past, these findings may have been informally discussed by surveyors, but were not captured in the report.  The good news is that an OFI will not require a formal ESC or MOS. On the other hand, a hospital will not be able to remove an OFI via the clarification process. So, what is the point?  Organizations are being encouraged to use these findings as additional stimulus for “self-evaluation and process improvement”.
Tip: Depending on the number of cited OFIs and to keep from being overwhelmed with additional post-survey work, organizations may want to consider an aggregate evaluation of OFIs and a focused implementation of improvement actions for selected, highest priority opportunities.  See the comments section of this article for additional explication of this strategy.