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Chapter 3
Through my work with hospitals across the country, I hear certain standards that continue to be cited over and over again. In many cases, the hospital has established a policy or procedure that exceeds the intent of the elements of performance (EP). When staff performance does not comply with the organization’s requirements, the surveyor finds the EP noncompliant, which subsequently yields the standard noncompliant. In the surveyor’s written report, these types of findings are typically explained as follows:
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