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Executive Briefings: Joint Commission Surveyor Focus Remains on EC, LSC, Ligature Risks

Highlight the zip codes where employees live so you can have a handy reference of where staff is available in emergencies, keep policies consistent and updated with the most relevant references, and focus suicide prevention efforts on making your physical environment ligature-resistant.

Those were some of the top takeaways for environment of care and other healthcare and quality professionals attending The Joint Commission’s (TJC) annual Hospital Executive Briefings held September 14 in New York City. The state of healthcare “is not good,” said Ana Pujols McKee, MD, TJC’s chief medical officer, rattling off uncomfortable facts such as the U.S.’s rising maternal mortality rate and that medical errors are the third leading cause of death. She urged attendees to accept nothing less than achieving zero harm in their hospitals and facilities.

Attendee Brian Pitt, safety director of SUNY Downstate Medical Center said his biggest takeaway from the briefings was that there are a lot of opportunities to make changes and improve. That was particularly true for the areas of environment of care and infection control, which never seem to get full administrative support, he noted. Among other things, the briefing taught him the need for consistency in what organizations — such as the CDC or the Association for the Advancement of Medical Instrumentation — you reference in your hospital policies.

“These policies can be used against us if you don’t keep it consistent and follow a consistent national standard,” said Pitt.

Here are some brief highlights from the day’s topics:

1. Suicide Prevention and Ligature Risk

Emily Wells, CSW, MSW, TJC’s project director, surveyor management and development, said that the accreditor has realized that no environment can be “ligature free,” so it’s changed the terminology to “ligature resistant.” That said, you still need to do risk assessments and have protocols to keep patient safe including removing as many ligature risks from a patient room as reasonably possible.  Facilities should pay extra attention to standard EC.02.06.01 EP 1 which was the most cited standard related to Immediate Threat. The standard requires hospitals to maintain a safe environment and EP 1 RFI include self harm risks like door hinges, beds, and drop ceilings.

Kathryn Petrovic, MSN, RN-BC, TJC field director of surveyor management and development, stressed was the need to test ligature resistant products to ensure they’re properly installed. Buying special anti-pinch point doorknobs doesn’t matter if they’re put in the wrong way, seize up and create a ligature risk, she says.  Surveyors test to see if your products work, not that you have them. And improperly installed equipment can result in a patient hurting themselves on something you thought was safe.

2. Emergency Management

Jim Kendig, MS, CHSP, CHCM, CHEM, LHRM, field director of surveyor management and development, recommends facilities run zip code tests to determine where most of their employees live. Most staff won’t come to work in during an emergency if their homes and family are in the affected area. Doing a zip code test can tell you ahead of time if you’ll need to call in help from other facilities.

Kendig also said security staff should work with local law enforcement on what to do in the event a hospital becomes a crime scene. There have been cases where a crime was committed in a hospital and police prevented hospital staff from re-entering the facility or move between rooms. That’s a possibility that needs to be dealt with before it happens, he said.

3. Physical Environment 

Kenneth A. Monroe, PE, CHC, PMP, TJC director of engineering, started off the physical environment and environment of care section with a look at Legionella. There have been multiple cases of the bacteria in hospitals, he said, and facilities need to be vigilant to protect their patients.

He also noted that 98% of all surveyed hospitals had at least one finding in the EC chapter, with ligature risks as the leading driver of Immediate Threat findings. However, the most common EP finding in the red category was EC.02.02.01 EP 5 — hazardous material handling and storage.

Ninety-seven percent-of hospitals had a finding in the Life Safety chapter, with LS.02.01.35 (sprinklers) being the most cited. Facilities don’t clean their sprinklers, test them, or put things that block the spray. Easy ways to get a finding. That said, only about 12% of LS findings were in the moderate or high risk range, with LS.01.02.01 EP 1 (No ILSM policy) being the most common high risk finding.

New CMS guidance on ligature risk says Joint Commission recommendations set the bar

Expect CMS surveyors to be referring to recommendations set out by The Joint Commission last fall when looking for ligature risk and other environmental hazards in the push to make hospitals and psychiatric units safer for patients at-risk of self-harm.

For now, assess your hospital’s environmental compliance against those Joint Commission recommendations, regardless of what organization you might use for accreditation, and be prepared to provide one-to-one observation of at-risk patients if you cannot provide a ligature-resistant environment, says one safety consultant.

In a new memo to its state survey agencies, CMS said it would use those Joint Commission recommendations — drawn from a task force convened by the accreditor that included several CMS experts in suicide prevention — as the federal agency goes forward with clarifying and updating interpretive guidelines for its surveyors.

The memo QSO: 18-21-All Hospitals, “CMS clarification of Psychiatric Environmental Risks,” from the Quality, Safety & Oversight Group (QSO), formerly known as the Survey and Certification Group, is dated July 20, although it was not posted online until Aug. 1.

CMS says Joint Commission panel good enough

In earlier communications, CMS had indicated it would convene its own group of experts to update its guidance to increase focus on ligature as well as other physical risks covered under the Condition of Participation (CoP) for patient rights to care in a safe setting.

However, since participating in the The Joint Commission panel, CMS officials now think its own panel would be redundant. “CMS felt that to repeat the work of TJC Suicide Panel (in which CMS participated) would not provide any substantive additional gains and would not be a productive use of the time and expertise of the participants,” according to the newest memo.

CMS is still working to revise the interpretive guidelines for its surveyors but referred regional offices for now to expectations set out in its Dec. 8 memo on clarifying ligature risk, S&C 18-06-Hospitals (ECL 1/1/18). That memo carried extensive guidance, including an initial update to parts of the interpretive guidelines found in Medicare’s State Operations Manual, Appendix A (SOMA).

Expect more changes in the future, though. In the most recent memo, CMS said it would continue to work on updates to Appendix A as well as Appendix AA, guidelines for surveyors at Psychiatric Hospitals, “which will incorporate the standards that were recommended via the collaborative work of the The Joint Commission Suicide Panel Special Report: Suicide Prevention in Health Care Settings.” The memo provided an online link to the November The Joint Commission recommendations.

Written by A.J. Plunkett

CMS’ severe sepsis bundle ISN’T a Joint Commission requirement

The April 17 issue of Annals of Internal Medicine (AIM) incorrectly stated The Joint Commission was considering creating a requirement for hospitals to implement CMS’ Severe Sepsis and Septic Shock Early Management Bundle (SEP-1) to receive accreditation. This information is incorrect and AIM has published a correction.

The Joint Commission: Comments open on proposed suicide risk NPSG through May 7

Wishing you could weigh in on The Joint Commission’s expectations about suicide risk? You have your chance. Through May 7, The Joint Commission is accepting comment on proposed revisions to National Patient Safety Goal 15 on reducing the risk of patient self-harm.

The Joint Commission published the revisions on its Standards Field Reviews web page on March 26. The revisions, which will require hospitals to be more proactive in removing risks from the physical environment, include proposed changes to both the general Hospital and the Behavioral Health Care accreditations programs.

Under the Hospital Accreditation program, a revised Element of Performance (EP) 1 applies only to hospitals, whereas the rest of the now seven EPs — up from just three — will apply only to those patients in psychiatric hospitals or being treated for behavioral health problems in general hospitals, according to the field review information.

The other EPs for both programs outline expectations of conducting suicide assessment of patients, documenting a patient’s risk and the plan to deal with that patient’s suicidal ideation, the need for written policies and procedures and quality monitoring of the programs, among other things.

You can comment on the proposed revisions online or by mail. To read the full set of revisions, and for links and instructions on how to comment, go to the Field Reviews page, https://www.jointcommission.org/standards_information/field_reviews.aspx. — A.J. Plunkett (aplunkett@h3.group)

Joint Commission releases 2017 sentinel event stats

Unintended retention of a foreign body, patient falls, and wrong-site surgery top The Joint Commission’s full list of reported sentinel events for 2017.

Every year, The Joint Commission complies a list of all the sentinel events that hospitals reported to them. Since the list only comes from self-reported data, it tends to underrepresent the real frequency of these problems. However, it’s useful in identifying trends, causes, and outcomes of adverse events. The top 10 sentinel events in 2017 were:

  1. Unintended retention of a foreign body
  2. Falls
  3. Wrong patient, wrong site, wrong procedure
  4. Suicide
  5. Delays in treatment
  6. Other unanticipated events
  7. Criminal events
  8. Medication errors
  9. Operative/postoperative complication
  10. Self-inflicted injury

The only new addition to the list since 2016 is “self-inflicted injuries,” which replaced “perinatal death/injury.” While a few hopped up or down one on the list, for the most part, there wasn’t much change.

Joint Commission changes for March 2018

Deleted: RI.01.01.01, EP 8

Effective immediately, The Joint Commission (TJC) has deleted element of performance (EP) 8 from Rights and Responsibilities of the Individual (RI) standard 01.01.01. While it’ll take some time to come out of the manual, surveyors can no longer survey for it. The EP said that a hospital must respect the patient’s right to pain management. The accreditor said that after reviewing its comprehensive pain assessment and management requirements, the EP was found to be irrelevant.

Revised: EC.02.03.05, EP 25

The point of this revision is to provide extra clarity on non-rated doors. TJC made the revision to make the Environment of Care (EC) chapter align with the Life Safety Code (LSC). This revision applies to ambulatory care, behavioral healthcare, critical access hospitals, home care, and hospitals. You can read the program-specific EPs here.

Revised: EC.02.05.01, EP 27

The purpose of this revision is to address environmental features of areas administering inhaled anesthetics. TJC made the revision to make the EC chapter align with the LSC. This revision applies to ambulatory care, critical access hospitals, hospitals, and office-based surgery practices. You can read the program-specific EPs here.

Joint Commission plans to make new suicide prevention standards

This December, The Joint Commission (TJC) convened the fourth meeting of a suicide prevention expert panel. The accreditor announced in the March edition of Perspectives that the recommendations they came up with went beyond what’s in the standards. So they intend to convert some of them into new Elements of Performance in National Patient Safety Goal 15.01.01. When they are finished updating the NPSG, it will be sent out for national field review, just like it normally would.

The first and second panels were published in November and centered on inpatient psychiatric units, general acute inpatient settings, and emergency departments. The third panel discussed other behavioral healthcare settings and had its recommendations published in January.

Joint Commission updates LS, EC chapters

Three revisions to The Joint Commission’s Life Safety and Environment of Care chapters will go into effect on March 11. The respective changes add more clarity to requirements regarding non-rated doors, environmental features of anesthetics areas, corridor door latch. However, not all changes apply to all the same programs, so you should check to see which ones impact you. The changes are intended to improve alignment with CMS regulations. You can find the prepublication standards below:

•    Ambulatory Health Care
•    Behavioral Health Care
•    Critical Access Hospital
•    Hospital
•    Nursing Care Center
•    Office-Based Surgery
•    Home Care

Joint Commission to roll out new maternal care and infectious disease requirements

On July 1, 2018, The Joint Commission will implement three new elements of performance (EP.) The EPs are intended to reduce the risk of diseases like HIV and syphilis being passed from mother to child during birth. The accreditor made the announcement in the latest R3 Report, with the aim of protecting both the mother and child from harm.

“The requirements will help improve maternal and neonatal health in Joint Commission accredited hospitals and critical access hospitals across the country,” Kathy Clark, MSN, RN, Joint Commission associate project director specialist, Division of Health Care Quality Evaluation, said in a press release. “If left undiagnosed or untreated, infectious diseases can be extremely dangerous and even life-threatening, so it is critical that testing and treatment for both the woman and baby is completed according to clinical practice guidelines.”

The EPs require providers to test pregnant women for certain diseases that could be transmitted to the child during birth: HIV, hepatitis B, group B streptococcus and syphilis. The results are then documented in the patient’s medical record for providers to act upon.

CMS and Joint Commission change hospital eligibility requirements

Both organizations have changed their expectations on the defintion of a hospital. CMS’s new S&C Memo 17-44-Hospitals says that surveyors will use average daily census (ADC) and average length of stay (ALOS) data to determine if the hospital is primarily engaged in providing services to inpatients, and “a hospital must have inpatients at the time of survey in order for surveyors to directly observe the actual provision of care and services to patients, and the effects of that care” to determine if the facility is meeting the Conditions of Participation (CoP) in Medicare.

In addition, both CMS and The Joint Commission say that hospitals will need at least two active inpatients on site for an accreditation survey to be done. This change is effective immediately.