The Joint Commission and Centers for Medicaid and Medicare services (CMS) have identified several areas where site surveyors are focusing their efforts. It is these suggested areas that the committee will initially prioritize and address. Currently, the three areas of focus are Verbal Order Authentication Process/Signing and Dating, Procedural Verification Process, and Professional Behavior Management.
1. Verbal order authentication process/Signing and Dating: Understanding that many hospitals are in the process of creating an electronic health record, the order authentication process is increasingly more challenging. The current requirement is that these orders are authenticated within 24-48 hours after they are issued.
2. Procedural verification process: Encourage physicians’ full attention and commitment to the process, as well as other guidelines such as the marking of the surgical site by the physician.
3. Professional behavior management
4. Care providers practicing outside the scope of their licensure
5. Falsification of the medical record
6. Preprinted order set management process
7. Conscious sedation privileging
8. Unapproved abbreviations
9. Physician Hand-Off Communications