October 12, 2011 | | Comments 0
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Mac’s Brief on the September TJC Executive Briefings, Part 2

As promised, I continue going the standards The Joint Commission (TJC) unveiled as the top 10 most frequently cited standards for the first six months of survey year 2011 at the annual Executive Briefings meeting. Five (count ‘em) of those standards were in the environment of care (EC)/life safety (LS) world. Here are the last three:

TJC cited 47% of hospitals for LS.02.01.30 (whew, finally under 50%). This is where things went slightly awry for yours truly as it was apparently indicated that the findings (generally under EP #2, which refers to the fire protection features of hazardous areas) have to do with signage. At EB, an example was given of proper labeling of a vent stack from sterile processing that might have hazardous materials (isn’t that why we have EC.02.02.01?) Also mentioned was the concept of the risk assessment (did you really think that was ever going to go away?) to determine what soiled utility rooms should be locked or otherwise secured. Again, my thought was that this was covered under EC.02.02.01 or maybe EC.02.01.01, but in the Life Safety chapter? I didn’t see that one coming!

When it comes to standard EC.02.03.05 (of which 42% of hospitals were cited), I think the safety community has to come together and convince our maintenance and testing vendors that we are sick and tired of having our heads handed to us because they “buried” some deficiency on page 17 of a report only to have the surveyor find the stinking thing and say, “So, what about this?” We need to have a list of deficiencies identified during any maintenance and testing activity provided to us, before the vendors leave the building. We can no longer afford to wait a month or six weeks to get the report of findings; the clock starts ticking the moment these concerns are identified and we need to be jumping on them quickly and assertively, which may entail including the implementation of some sort of interim measure to ensure that we are not placing folks at risk. I absolutely understand that doing so is, in many ways, nothing but a pain in the tuchus; but until such time, as we are proactively managing this stuff, this is going to continue to be among the most frequently cited standards. I say we end it here—who’s with me? FREEDOM! Sorry, got a bit carried away there. Must be ‘cause I’m wearing my (metaphorical) kilt . . .

Finally, LS.02.01.35 (of which 36% of hospitals cited): This standard relates to all things sprinklers—the 18- inch rule, stuff hanging on sprinkler piping, cabling tied to sprinkler supports, all that stuff. Again, this is very much a numbers game. What’s the likelihood that somewhere, above some ceiling, the cable monkeys have run some conduit or other detritus over a sprinkler line or tied it to a support? Very bloody likely, I’d say, very bloody likely.

Getting back to this infection control thingy (as promised in my last post), it was announced that the life safety surveyors are receiving education relative to basic IC issues, including scope cleaning and the separation of clean and dirty scopes. The announcement brought up a thought—for those of you with not-so-generously-proportioned scope cleaning areas, particularly when the soiled and clean processes are separated only by distance and not by a physical barrier, you might want to consider a risk assessment to determine whether your processes are pristine. I know you are doing the best you can, but sometimes you have to take those types of decisions out, dust ‘em off, and look at them again to make sure they are still viable. It may be your only defense during a survey, and I say you can’t have too many of them, only not enough.

Entry Information

Filed Under: Emergency managementEnvironment of careLife Safety Code

Steve MacArthur About the Author: Steve MacArthur is a safety consultant with The Greeley Company in Danvers, Mass. He brings more than 30 years of healthcare management and consulting experience to his work with hospitals, physician offices, and ambulatory care facilities across the country. He is the author of HCPro's Hospital Safety Director's Handbook and is contributing editor for Briefings on Hospital Safety. Contact Steve at stevemacsafetyspace@gmail.com.

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