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New Survey Terminology Cropping up in Joint Commission Visits

Matt Phillion, for HealthLeaders Media, February 25, 2010

The term "observed but corrected on-site" has been cropping up in survey terminology in recent site visits, and has left some in the field confused.

What, exactly, is an "observed but corrected on-site" (OCO) deficiency and how will it impact your survey? The Joint Commission has described that OCO deficiencies have the following characteristics:

  • Correcting these deficiencies does not require organizational planning or forethought
  • They are easily corrected, posing no significant threat to safety
  • For forms, adding missing elements or pieces of information that would not impact the process(es)
  • Policy does not follow practice; policy changed to match practice

If a deficiency is OCO, explains Elizabeth Di Giacomo-Geffers, RN, MPH, CSHA, a healthcare consultant in Trabuco Canyon, CA, and former Joint Commission surveyor, the surveyor will flag this item in the report for review in central office. If accepted, it will not count toward the total of RFIs; however, it stays in the report.

"OCO" examples
What do "observed but corrected on site" items look like? Geffers cites the following as a few specific examples hospitals have encountered:

  • Immediately disposing of a multi-dose vial that was not dated
  • Disposing of an expired quality control test strip immediately
  • Missing dates for logs. If, for example, refrigerator logs are missing a few dates, but temperatures before and after missing dates are within range and no patterns or trends observed.
  • Stretchers or gurneys blocking medical gas shut off valves. Often, these blockages can be easily and immediately moved.
  • The same goes for food carts blocking fire extinguishers. If it's a matter of moving the cart, this is a readily fixable issue.
  • Here's an example many of us have encountered before: exit light partially burned out. This can be readily corrected when observed.

On the flip side, here are some examples that cannot be corrected on site, which The Joint Commission has addressed:

  • While immediately disposing of undated multi-dose vials is correctable, if a pattern/trend is found—e.g., undated vials are found in multiple units—this becomes a pattern or trend.
  • Missing refrigerator logs might be potentially correctable, but if temperatures are found out of range there is no procedure in place to make sure the items stored (food, medications) are useable
  • Because it would require significant consideration before being implemented, one cannot simply add a suicide risk assessment to an assessment form.
  • Failing-to-latch several fire doors (pattern and trend)
  • Any finding related to a decision rule

Matt Phillion, CSHA, is senior managing editor of Briefings on The Joint Commission and senior editorial advisor for the Association for Healthcare Accreditation Professionals (AHAP).

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