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The mystery of the disappearing EP and other tales

I have no way to be certain of the numbers, but I do know of at least one organization that fell victim in 2017 to an Element of Performance (EP) that has since gone “missing.” Once upon a time, EC.02.05.03 (having a reliable emergency electrical source) had an EP (#10, to be precise) that, among other things, required hospital emergency power systems (EPS) to have a remote manual stop station (with an identifying label, natch!) to prevent inadvertent or unintentional operation. (I’m not really sure how a big ol’ stop button that’s labeled would prevent somebody from inadvertently operating the emergency power system; it would surely help if the inadvertent operation happened, but prevention…)

So, to follow this back to the applicable NFPA citation NFPA 110-2010, we find “(a)ll installations shall have a remote manual stop station of a type to prevent inadvertent or unintended operation located outside the room housing the prime mover, where so installed, or elsewhere on the premises where the prime mover is located outside the building.” The Explanatory Material goes on to indicate that “(f)or systems located outdoors, the manual shutdown should be located external to the weatherproof enclosure and appropriately identified.” So, that all seems pretty straightforward, don’t you think.

Well, recently (last week) I was working with a hospital that had not bumped into EC.02.05.03, EP 10 and, since I had not yet committed the standard and EP numbers to memory (every time things get changed, I swear to myself that I will not memorize the numbers, but somehow it always ends up happening…), we went to look at the online portal to the standards. And we looked, and looked, and looked some more, and could not find the EP for the remote manual stop. I just figured that I had sufficiently misremembered where this EP, so my plan was to look at survey reports that I know included RFIs for not having the remote manual stops and go from there. So, I looked it up in the survey report, checked the online portal and, guess what? No more EP 10 (in the interest of the complete picture, this EP also requires emergency lighting within 10 seconds at emergency generator locations and a remote annunciator (powered by storage battery) located outside the emergency power system location). Now, from a strict compliance standpoint, as the 2010 edition of NFPA 110 is the applicable code edition based on adoption of the 2012 Life Safety Code® (and I did check the 2013 and 2016 editions, each of which contain the same requirements), I can only guess that the requirements contained in EP 10 are still actionable if your (or anybody else’s) AHJ sees fit to cite a deficiency in this regard, so it’s probably worth keeping a half an eye out for further developments if you have not yet gotten around to installing the lighting, remote stop, and annunciators for your emergency power system equipment locations.

Also, just to alert you to (yet) another offering from ECRI, this past week saw the unveiling of the Top 10 Patient Safety Concerns (download the white paper here). There are a few items on the list that should be of interest to you folks (in bold):

  1. Diagnostic errors
  2. Opioid safety across the continuum of care
  3. Care coordination within a setting
  4. Workarounds
  5. Incorporating health IT into patient safety programs
  6. Management of behavioral health needs in acute care settings
  7. All-hazards emergency preparedness
  8. Device cleaning, disinfection, and sterilization
  9. Patient engagement and health literacy
  10. Leadership engagement in patient safety

I haven’t delved too much into the latest emergency preparedness stuff (ECRI’s take, as well as the Johns Hopkins report), but I’ve queued that up on my reading list for this week, just as soon as I dig out from our most recent wintry spectacular—currently raging outside my window, so I’m going to send this on its way before the power gets too dodgy…

Cylindrical musings and nudging as a compliance strategy

Howdy, folks. After surviving the battering of this past weekend’s tumultuous weather in the Northeast (I got to experience it twice—once in Indiana and again back home), I’m going to be (relatively) brief for this week’s missive.

First up, hopefully most of you are familiar with the TED Talks concept (all the info you need about that you can find here) and NPR has a weekly program that kind of crystallizes some of the TED offerings in their TED Radio Hour. This past weekend (no TV, so we had to huddle around the radio, just like in olden times), the program revolved around the use of gentle pushes or nudges to change behaviors (you can hear that broadcast here). As safety professionals, I think we are all acquainted with the various attempts to get folks to do our bidding when it comes to safe practice (that sounds a little authoritarian, but it’s kinda what we’re up against) and I thought the entire program really gave me some food for thought in how we might come at compliance from a slightly different perspective. I thought some of the ideas were fascinating and definitely worth sharing, so if you have a spare 55 minutes or so (the webpage above does break it out into the individual sections of the broadcast—I think it’s all good, but whatever description seems most interesting to you would be a good starting point), you might give it a whirl…

I also want to bring you some hopeful news on the cylinder storage segregation front; when this whole focus started, quite a few folks were cited for storing non-full (empty or partial) cylinders in the same location as full cylinders. I don’t know when The Joint Commission posted the updated FAQ on cylinder storage, but, and I quote, “Full and partially full cylinders are permitted to be stored together, unless the organization’s policy requires further segregation.” I know this whole thing was the bane of a lot of folks’ existence, particularly after we had to work so diligently to get folks to secure the cylinders properly, only to have this little paradigm shift towards the edge of darkness. I believe that this will make things somewhat simpler in the execution (make sure your policy reflects the allowance for full and partials to be stored together—they’ll be looking to review that policy).

As a final, non-safety note, I just flew cross-country and was able to watch Gary Oldman’s performance as Winston Churchill in Darkest Hour. I’ve always been something of a history buff, with World War II as a central theme and must tell you that I thought it was a really great performance and a fine movie (or is it a film?). It really points out the power of consensus and the use of the spoken word to galvanize folks (which kind of ties back to the nudging—though Sir Winston’s nudge packed a lot of wallop). At any rate, I thought it was very well done (no surprise about the Best Actor Oscar) and probably my favorite since Lincoln (the movie, not the car or President…though Lincoln in the Bardo was a very interesting book…).

’Tis the season…for more emergency management goodness!

Recognizing the somewhat hyperbolic nature of this week’s headline (you need only listen to current news/weather feeds to be able to determine that emergencies are not quite as seasonal as perhaps they once were…), I did want to share one more emergency management-related nugget with you (I do try to mix things up, but until I start seeing some “hard” survey results—or some regulatory panjandrum makes some sort of announcement, I’m going to keep seeding this space with various and sundry bits of stuff), this coming to us from the left coast, aka California.

While I have little doubt that you Californians in the audience are familiar with the California Department of Public Health (CDPH—four scary letters, though perhaps not as scary as OSHPD for the facilities folks in Cali) requirements for workplace emergency plans (which is highlighted in this month’s CDPH Occupational Health Watch), I think that there might well be some useful information for folks in other parts of the country (I have found, over some few years of experience, that regulatory tsunamis can start in California and find their way to all manner of locales). To be honest (and why else would we be here?), the plan elements required (or at least the ones the surveyors want to see) by the usual regulatorily-inclined suspects, are frequently not quite as useful from an operational preparedness/mitigation/response/recovery standpoint (they provide a useful structure for the aforementioned quartet, but when it comes down to doing the do, again, sometimes not so much).

At any rate, the Cal/OSHA Emergency Action Plan requirements, provide (at least in my mind—feel free to disagree) a good basic sense of the pieces to have in place that are not necessarily as patient-focused. When the fecal matters starts impacting the rapidly rotation turbine blades, it’s important to have a structure in place that addresses the employee aspect, particularly for those of you with offsite non-clinical operations (billing, finance, HR, etc.: a lot of folks don’t have enough space at the main campus for all the moving pieces that constitute a healthcare organization). So, here’s the California stuff (and please feel free to share any good stuff your state might have on the books—this is all about getting prepared and staying prepared—every little bit helps):

(b) Elements. The following elements, at a minimum, shall be included in the plan:

(1) Procedures for emergency evacuation, including type of evacuation and exit route assignments;

(2) Procedures to be followed by employees who remain to operate critical plant operations before they evacuate;

(3) Procedures to account for all employees after emergency evacuation has been completed;

(4) Procedures to be followed by employees performing rescue or medical duties;

(5) The preferred means of reporting fires and other emergencies; and

(6) Names or regular job titles of persons or departments who can be contacted for further information or explanation of duties under the plan.

(c) Alarm System.

(1) The employer shall establish an employee alarm system which complies with Article 165 (link to that info here).

(2) If the employee alarm system is used for alerting fire brigade members, or for other purposes, a distinctive signal for each purpose shall be used.

(d) Evacuation. The employer shall establish in the emergency action plan the types of evacuation to be used in emergency circumstances.

(e) Training.

(1) Before implementing the emergency action plan, the employer shall designate and train a sufficient number of persons to assist in the safe and orderly emergency evacuation of employees.

(2) The employer shall advise each employee of his/her responsibility under the plan at the following times:

(A) Initially when the plan is developed,

(B) Whenever the employee’s responsibilities or designated actions under the plan change, and

(C) Whenever the plan is changed.

(3) The employer shall review with each employee upon initial assignment those parts of the plan which the employee must know to protect the employee in the event of an emergency. The written plan shall be kept at the workplace and made available for employee review. For those employers with 10 or fewer employees the plan may be communicated orally to employees and the employer need not maintain a written plan.


I hope this provides you with some useful (and perhaps even thoughtful) information as we roll through emergency year 2018. I am hoping for a time of minimal impact for communities this year (I think we had just about enough last year), but the oddness of the weather patterns over the past couple of months gives me pause. (I live in the Boston area and Houston and its environs had snow before we did!)

Emergency Management Monkeyshines: All Things Must Pass…

Sometimes like a kidney stone, but nonetheless…

Before we dive into this week’s “content,” I have a thought for you to ponder as to the nature of basing future survey results on the results of surveys past (rather Dickensian, the results of surveys past): Recognizing that authorities having jurisdiction (AHJ) always reserve the right to disagree with any decision you’ve ever made or, indeed, anything they (or any other AHJ) have told you in the past, how long are existing waivers and/or equivalencies good for? Hopefully this ponderable will not visit itself upon you or your organization, but one must be prepared for any (and every) eventuality. Which neatly brings us to:

In digging around past emails and such, I noticed that I had not visited the Department of Health and Human Services Healthcare Emergency Preparedness Gateway in rather a while and what to my wondering eyes should appear but some updated info and a link to CMS that I think you’ll find useful. So, the current headlines/topics:

  • Considerations for the Use of Temporary Care Locations for Managing Seasonal Patient Surge
  • Pediatric Issues in Disasters Webinar
  • 2017 Hurricane Response – Resources for Children with Special Health Care Needs
  • Supporting Non-resident/Foreign Citizen Patients
  • A new issue of The Exchange newsletter
  • A link to the CMS Emergency Preparedness Final Rule surveyor training (you can find the information available to providers here). Unfortunately, the post-test is not available to providers, but sometimes it’s like that.

It is my intent over the next little while to check out the education package, so I will let you know if I have any grave reservations about the content, etc., or if I think you need to earmark it for priority viewing.

So, kind of brief this week, but I’m sure there’ll be more to discuss in the not too distant future. And so, with the end of wintah on the horizon, I wish you a moderately temperate week!

There’s no such thing as someone else’s code: Infection control and the environment (again…)

Periodically, I field questions from folks that require a little bit (well, perhaps sometimes more than a little) of conjecture. Recently, I received a question regarding the requirements in ASHRAE 170-2008 regarding appropriate pressure relationships in emergency department and radiology waiting rooms (ASHRAE 170-2008 says those areas would be under negative pressure, with the caveat that the requirement applies only to “waiting rooms programmed to hold patients awaiting chest x-rays for diagnosis of respiratory disease”).

Right now, that particular question is kind of the elephant in the room from a regulatory perspective; there is every indication that The Joint Commission/CMS are working their way through ASHRAE 170-2008 and have yet to make landfall on this particular requirement—as far as I know—feel free to disabuse me of that notion. The intent of the requirement (as I interpret it) is to have some fundamental protections in place to ensure that an isolated respiratory contagion does not have the capacity of becoming a legitimate outbreak because of inadequate ventilation. Now, you could certainly use the annual infection control program risk assessment to identify whether your waiting rooms are “programmed to hold patients awaiting chest x-rays for diagnosis of respiratory disease” based on the respiratory disease data from the local community (and you might be able to obtain data from a larger geographic area, which one might consider a “buffer zone”).

Best case scenario results in you being able to take this completely off the table from a risk standpoint, next best would be that you introduce protocols for respiratory patients that remove them from the general waiting rooms (depending on the potential numbers, you may not have the space for it), worst case being that you have to modify the current environment to provide appropriate levels of protection. The notation for this requirement does provide some relief for folks with a recirculating air system in these areas, which allows for HEPA filters to be used instead of exhausting the air from these spaces to the outdoors, providing the return air passes through the HEPA filters before it introduced into any other spaces.

Knowing what I do about some of the ventilation challenges folks have, I suspect that it may make more sense to pursue the HEPA filtration setup than it would be to try to bring each of the spaces under negative pressure, but (going out on a limb here) that might be a question best answered by a group of knowledgeable folks (including an individual of the mechanical engineering persuasion) as a function of the (wait for it…) risk assessment process.

Ultimately, it comes down to what the Authority Having Jurisdiction chooses to enforce; that said, it might be worth having someone work through your state channels or by putting the question to the Standards Interpretation Group at Joint Commission (I suspect that their response would not be not particularly instructive beyond the usual “do a risk assessment” strategy, but there is a new person running the Engineering group at TJC, so perhaps something a little more helpful might be forthcoming). At any rate, as noted above, I’ve not heard of this being cited, but I also know that if there’s an outbreak tied to inadequate ventilation somewhere, this could become a hot topic pretty quickly (probably not as hot as ligature risks at the moment, but you never know…).

When the tough get going: Emergency Management and other considerations

First off (and apologies for the short lead time on this), but next week (February 13), CDC is hosting a webinar on the importance of assessing for environmental exposures during emergencies (and in general). While this is likely to be some useful information as a going concern, you can also earn CEUs for tuning in. A summary of the program as well as registration information, etc., can be found here. Overall, I think hospitals had a pretty good track record of emergency response in 2017, but somehow these things never seem to get easier over time…

Another issue that I see starting to gain a little traction in the survey world is dealing with concerns relating to medical gas and vacuum systems; for the most part (I’m sure there are some exceptions, but I can’t say that I’ve run into them), folks in hospitals tend to rely on contracted vendors to do the formal inspection, testing, and maintenance of medical gas and vacuum systems, which tends to keep an in-depth knowledge of the dirty details at (more or less) arm’s length. A couple of weeks ago, I received some information from Jason Di Marco of Compliant Healthcare Technologies (many thanks to Jason!) that I thought would be worth sharing with you folks. Of primary interest is a downloadable guide to medical gas systems (available here in exchange for your email address) that really gives a good overview of the nuts and bolts (as it were) of your med gas system. Jason also publishes a blog on the critical aspects of medical gas and vacuum system inspection, testing, maintenance, compliance, etc., where I found a fair amount of useful information. Again, I can see the regulatory compliance laser focus starting to turn in the direction of all the systems covered under NFPA 99 and I can also see some of those prickly surveyor types trying to pick at the knowledge base of the folks managing these processes. So, in the interest of never having too much information, I would suggest getting a little more intimate with your medical gas and vacuum systems.

You don’t have to be a weather(person)man to tell: Kicking off survey year 2018!

Your guess is as good as mine…

Just a couple of brief items (relatively—you know how I do go on, but I will try) of interest. I don’t know that there’s a common theme besides an effort to anticipate in which direction the survey winds might blow in 2018:

  •  Previously in this space, I’ve mentioned the work of Matt Freije and his team at HCInfo as they have done yeoman’s (yeoperson’s?) work in the field of water systems management and the “fight” against In response to last year’s letter of intent by CMS to take a more focused look at how hospitals and nursing homes are providing appropriately safe water systems for their patients, Mr. Freije has developed a checklist to help folks evaluate their current situations and has posted the checklist online for comment, suggestions, etc. I’m having a hard time thinking that this might not become something of a hardship for folks arriving late to the party, so if you’ve not yet embraced poking around this subject (and even if you have), you’d do well to check out the checklist.
  •  A couple of inspection items relative to the ongoing rollout of the various and sundry changes wrought by the adoption of the 2012 Life Safety Code®, some of which have yet to migrate in detail to the accreditation organization publications (at least the ones that I’ve seen), but have popped up during recent CMS surveys:
    • Make sure you fire alarm circuit breakers are clearly marked in red (check out NFPA 72 for the skinny on this).
    • Make sure your ILSM/fire watch policy/process reflects the appropriate AHJs—you need to make sure that you know for sure whether your state department of public health, et al, want to be notified. They do in California, and probably elsewhere.
    • In NFPA 25, chapters 5 and 13 indicate some monthly inspections of gauges, valves for condition, appropriate position (open or closed) and normal pressures—again, they’re not specifically listed in the accreditation manuals yet, but I suspect that they’ll be coming to a survey report near you before too long.
    • A final note for the moment in this category, NFPA 70 (2011 edition) 400.10 indicates that “flexible cords and cables shall be connected to devices and to fittings so that tension is not transmitted to joints of terminals.” Keep an eye on power strips, particularly in your IT and communications closets for those dangling power strips (and some of them aren’t so much dangling as they are pulled across open spaces, etc. I suspect you know what I mean.) I know the folks who manage this stuff think that we are just being pains in the butt, but now you may have a little codified leverage.
  •  In my post a couple of weeks ago, I don’t think I played the personal protective equipment (PPE) card with sufficient gravity; part of folks’ understanding of the hazards of using chemicals is recognizing the importance of actually using appropriate PPE as identified on the product SDS. When you think about it, the emergency eyewash station is not intended to be the first line of defense in the management of exposures to chemical hazards, but rather what happens when there is an emergency exposure. If the use of PPE is hardwired into the process, then the only time they’ll need to use the eyewash equipment is when they do their weekly testing. At that, my friends, is as it should be.


What it is ain’t exactly clear: Hazardous materials management and the SAFER matrix

I was recently asked to ponder the (relative—all things are relative) preponderance of findings under the Hazardous Materials and Wastes Management standard (EC.02.02.01 for those of you keeping track). For me, the most interesting part of the question was the information that (as was apparently revealed at the Joint Commission Executive Briefings sessions last fall) findings under EC.02.02.01 frequently found their way to the part of the SAFER matrix indicating a greater likelihood of causing harm (the metric being low, moderate, and high likelihood of harm) than some of the other RFIs being generated (EC.02.06.01, particularly as a function of survey issues with ligature risks, also generates those upper harm-level likelihood survey results). Once upon a time, eyewash station questions were among the most frequently asked (and responded to in this space), so it’s almost like replaying a classic

Generally speaking, the findings that they’ve earmarked as being more likely to cause harm are the ones relating to eyewash stations (the most common being the surveyors over-interpreting where one “has” to have an eyewash station the remainder pretty much fall under the maintenance of eyewashes—either there’s a missing inspection, access to the eyewash station is obstructed during the survey, or there is clearly something wrong with the eyewash—usually the protective caps are missing or the water flow is rather anemic in its trajectory). All of those scenarios have the “potential” for being serious; if someone needs an eyewash and the thing doesn’t work properly or it’s been contaminated, etc., someone could definitely be harmed. But (and it is an extraordinarily big “but”) it’s only when you have an exposure to a caustic or corrosive chemical, which loops us back to the over-interpretation. OSHA only requires emergency eyewash equipment when there is a risk of occupational exposure to a corrosive chemical (the ANSI standard goes a bit further by indicating eyewash equipment should be available for caustic chemicals as well as corrosives). A lot of the findings I’ve seen have been generated by the clinical surveyors, who are frequently in the company of hospital staff that aren’t really clear on what the requirements are (you could make the case that they should, if only from a Hazard Communications standard standpoint, but we’ll set that aside for the moment), so when the clinical surveyor says “you need an eyewash station here” and writes it up, the safety folks frequently don’t find out until the closeout (and sometimes don’t find out until the survey report is received). The “problem” that can come to the fore is that the clinical folks don’t perceive the eyewash finding as “theirs” because it’s not a clinical finding, so they really don’t get too stressed about it. So, the surveyor may ask to see the SDS for a product in use and if the SDS indicates that the first aid for eye exposure is a 15- or 20-minute flush with water, then they equate that with an eyewash station, which in a number of instances, is not (again, strictly speaking from a regulatory standpoint) “required.” Sometimes you can make a case for a post-survey clarification, but successful clarifications are becoming increasingly rare, so you need to have a process in place to make your case/defense during the survey.

The other “batch” of findings for this standard tend relate to the labeling of secondary containers (usually the containers that are used to transport soiled instruments); again, in terms of actual risk, these conditions are not particularly “scary,” but you can’t completely negate the potential, so (again) the harm level can be up-sold (so to speak).

In terms of survey prep, you have to have a complete working knowledge of what corrosive chemicals are in use in the organization and where those chemicals are being used (I would be inclined to include caustic chemicals as well); the subset of that is to evaluate those products to see if there are safer (i.e., not corrosive or caustic) alternatives to be used. The classic finding revolves around the use of chemical sprays to “soak” instruments awaiting disinfection and sterilization—if you don’t soak them, then the bioburden dries and it’s a pain to be sure it’s all removed, etc.; generally, some sort of enzymatic spray product is used—but not all of them are corrosive and require an eyewash station. Then once you know where you have corrosives/caustics, you need to make sure you have properly accessible eyewash equipment (generally within 10 seconds of unimpeded travel time from the area of exposure risk to the eyewash) and then you need to make sure that staff understand what products they have and why an eyewash is not required (strictly speaking, there really aren’t that many places in a hospital for which an eyewash station would be required) if that is the case—or at least make sure that they will reach out to the safety folks if a question should come up during survey. Every once in a while there’s a truly legit finding (usually because some product found its way someplace where it didn’t belong), but more often than not, it’s not necessary.

You also have to be absolutely relentless when it comes to the labeling of secondary containers; if there’s something of a biohazard nature and you put it in a container, then that container must be properly identified as a biohazard; if you put a chemical in a spray bottle, bucket, or other container, then there needs to be a label (there are exceptions, but for the purposes of this discussion, it is best managed as an absolute). Anything that is not in its original container has to be labeled, regardless of what the container is, the reason for doing it, etc. The hazard nature of the contents must be clear to anyone and everyone that might encounter the container.

At the end of the day (as cliché an expression as that might be), it is the responsibility of each organization to know what’s going on and to make sure that the folks at the point of care/point of service have a clear understanding of what risks they are likely to encounter and how the organization provides for their safety in encountering those risks. We are not in the habit of putting people in harm’s way, but if folks don’t understand the risks and (perhaps most importantly) understand the protective measures in place, the risk of survey finding is really the least of your worries.

It’s knowing (hoping) that this can’t go on forever: A little bit of regulatory mishegas…

It being only the third week of the New Year, it’s a little early for any trends to fully manifest themselves, so a couple of odds and ends to get you caught up on (or, upon which to get you caught up, for any hard-core grammarians in the crowd…).

The latest issue of Health Facilities Management has a couple of articles (and a risk assessment available to ASHE members—gotta love a new risk assessment) that should prove of some value/interest over the next little bit:

  •  ASHE issues update on CMS ligature-risk policy – this is basically a recap of the CMS memo issued in December (details here) but also includes mention of an environmental ligature risk tool (updated to include a worksheet for EDs) that is available to ASHE members. I’m not sure if the “hand in glove” relationship between ASHE and TJC will remain the same with the departure of George Mills, but there is every reason to feel that ASHE’s position as an advocacy group will continue. In that light, probably a good idea to check out the ligature risk tool and adopt any elements that you may not have yet considered. I still feel that you have to rule everything in as a risk until you can start ruling stuff out, but I also think that we should be checking out any and all available resources.
  • An interesting article on airflow in the OR; to be honest, I love this kind of digging around into the corners of what makes the surgical environment such a bear from a compliance standpoint and where regulatory scrutiny might be headed as a function of increasing attention to the infection control impact of the environment. I’m not suggesting you have to mimic the study, but it might help you anticipate some pointed survey questions or requests.
  • Also in the latest issue of HFM, there’s an update on the CMS interpretations relative to rolling latches and related concerns as well as a request for volunteers to assist in gathering information, policies, etc. on how folks are keeping things quiet at night.

Moving on to our friends from Chicago, in the continuing unfolding of information regarding the management of ligature risks, the latest issue of Joint Commission Online includes further guidance relating to “other” (my quotation marks) behavioral health environments such as residential treatment, partial hospitalization, intensive outpatient and outpatient treatment programs. The guidance indicates that these settings are not required to be ligature resistant, but then goes on to indicate that a risk assessment should be conducted in these environments, and then policies and procedures implemented to address how to manage patients in these settings that may experience and increase in symptoms that could result in self-harm or risk of suicide. The piece also indicates that the expert panel met again in December and there will be additional guidance relating to suicide risk assessment and safe monitoring of high-risk patients. And so the conversation continues…

An invitation to the regulatory dance—and the band keeps playing faster…

About a year ago, we chatted a bit about the likely changes to the regulatory landscape under a new administration, most of which (at least those related to the changing of the guard) never really materialized to any great extent. But one thing held true—and continues as we embark upon the good ship 2018—the focus on management of the physical environment is very much at the forefront of preparatory activities.

We also chatted a bit about The Joint Commission’s previous exhortations to healthcare leaders to focus more attention on the management of the physical environment (I was going to provide a link to TJC’s leadership blog regarding our little world, but it appears that the page is not so easily found, though I’m sure it has nothing to do with revisionist history…). But it does appear that there’s no reason to think that the number (and probably types) of survey findings in the environment are going to be anything but steady, though hopefully not a steady increase. Remember, we still have two years in the survey cycle before everyone gets to have undergone their first survey with the loss of the rate-based performance elements.

Which brings us squarely to 2018 and our continuing storm of regulatory challenges; I had made a list of stuff that I believed would play some role of significance in 2017 and (strangely enough) appear to be poised to do the same in the coming year (or two…or three?!?):


  1. Physical environment standards remain among the most frequently cited during TJC surveys (Nine of the 10 most frequently cited standards for the period January through June 2017). Please check out the September 2017 issue of Joint Commission Perspectives for the details! Just so you know (and I do believe that I’ve mentioned this in the past), I “count” IC.02.02.01 as a physical environment standard. Yes, I know it’s under the Infection Control chapter, but disinfection, the management of equipment and supplies? That all happens in the environment!
  2. CMS, in its report card to Congress, identified the physical environment as the largest “gap” of oversight during all accreditation organization surveys
  3. Also in its report card to Congress, CMS singled out TJC as lagging behind its competition when it comes to improving identification of deficiencies relative to the Conditions of Participation. I firmly believe that the report card to Congress was the proverbial “spark” that fanned the flames of regulatory focus in the environment. I don’t know when we can expect an updated edition of the report card (I suspect that it may be a while), but knowing that CMS is “concerned” can only mean continued focus…
  4. CMS adoption of the 2012 Life Safety Code® (effective survey date of November 1, 2016) definitely did create some level of confusion and uncertainty that always accompanies “change.” And 2017 demonstrated very clearly that it’s not just “us” that have to learn the practical application of the new stuff—the surveyors have to catch up as well! I am definitely starting to see the impact of the adoption of the 2012 Health Facilities Code (NFPA 99)—if you don’t have a copy in your library, it might just be time.
  5. TJC is in the process of revising its Environment of Care and Life Safety chapters to more closely reflect CMS requirements. January 2018 continues the rollout of the standards/performance elements updates—and they’re still not done. As we’ve discussed over the last few weeks, there’s still a lot of shifting requirements (some we always knew were in place, others merely rumored).
  6. Recent TJC survey reports indicate an increasing focus (and resulting vulnerabilities) on outpatient locations, particularly those engaging in high-level disinfection and/or surgical procedures. The physical environment in all areas in which patients receive care, treatment, and services are generating up to 60% of the total physical environment findings in recent surveys. That was just as true in 2017 as in 2016—each care location in the organization has to be prepared for multi-day scrutiny.
  7. CMS published its final rule on Emergency Preparedness (including Interpretive Guidelines, effective November 2016, with full implementation of requirements due November 2017). While organizations in compliance with current TJC Emergency Management standards will be in substantial compliance with the new rule, there will be some potential vulnerabilities relative to some of the specific components of the rule. The key sticking points at the moment appear to relate to the Continuity of Operations Plan (COOP) and the processes for delegating authority and leadership succession planning during extended events.
  8. Introduction of TJC’s SAFER matrix, which did indeed result in every deficiency identified during the survey process being included in the final survey report. Formerly, there was a section called Opportunities For Improvement for the single findings that didn’t “roll up” into a Requirement For Improvement. With the SAFER matrix, everything they find goes into the report. And there did seem to be a preponderance of findings “clustered” (make of that descriptor what you will) in the high risk sections of the matrix.
  9. As a final “nail” in the survey process coffin, effective January 2017, TJC will no longer provide for the clarification of findings once the survey has been completed. While this didn’t result in quite the devastation in the process as it might have first appeared (mostly because I think it forced the issue of pushing back during the survey), it also appears that clarification only during survey was not the hard line in the sand it appeared to be when this first “dropped.” That said, there very definitely seems to be a reluctance on the part of the folks at the Standards Interpretation Group (SIG) to “reverse the call on the field” once the survey team has left the building; just as there is a reluctance to vacate physical environment findings once the LS surveyor has hit the bricks. If you feel that a finding is not valid, there is no time like the present when it comes to the pushback.
  10. One unexpected “change” during 2017: The focus on ligature risks in the various environments in which behavioral health patients receive care, treatment, and/or services. We’ve discussed the particulars fairly extensively in this space and while I didn’t see it “coming,” it has certainly leaped to the top of the concern pile. The recent guidance from the regulators has (perhaps) helped to some degree, but this one feels a lot like the focus on the procedural environment over the past couple of years. I don’t think they’re done with this by any stretch…


In my mind, still working from the perspective of CMS calling out the physical environment as an area of concern, the stuff noted above indicates the likely result that the next 12-24 survey months will show a continued focus on the physical environment by the entire survey team (not just the Life Safety surveyor) and a likely continued plateau or increase in findings relating to the physical environment. I still believe that eventually the regulatory focus will drift back more toward patient care-related issues, but right now the focus on the physical environment is generating a ton of findings. And since that appears to be their primary function (generating findings), there’s always lots to find in the environment.

As I like to tell folks (probably ad nauseum, truth be told), there are no perfect buildings/environments, so there’s always stuff to be found—mostly fairly small items on the risk scale, but they are all citable. The fact of the matter is that there will be findings in the physical environment during your next survey, so the focus will shift to include ensuring that the corrective action plans for those findings are not only appropriate, but also can demonstrate consideration of sustained compliance over time. Preparing for the survey of the physical environment must reflect an ongoing process for managing “imperfections”—not just every 36 (or so) months, but every day.