February 01, 2012 | | Comments 4
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And I’ll return to claim your hand – as the King of California

I generally don’t single out any of the myriad potential demographics of this portion of the blogosphere, but the Joint Commission’s January 2012 Perspectives, has singled out of you good folks keeping the safety faith out in California, based on some state-level legislation promulgated back in 2010.

The focus of the legislation is those folks engaged in CT scanning activities, which I’m going to guess includes just about everyone (the standard applies to ambulatory, critical access, and hospital accreditation). I don’t see this as a particular nuisance for folks. I believe that everyone with a compliant radiation control program is on top of this, but if you’re not—even if outside of California—this new element of performance (EP) might be worthy of consideration moving forward.

EP #17 (an “A” EP) under EC.02.04.03 requires at least an annual measurement of the actual radiation dose produced by each CT imaging system, and further requires that the radiation dose displayed on the system is within 20% of the actual amount of radiation dose measured. Naturally, the dates of these verifications would be documented (and, by extension, made available during survey.)

(We’ll be chatting more about what documents and documentation could be considered “reviewable” during survey—it’s a long list.

Now, a 20% margin is a pretty wide range, I would say. In fact, if there’s anyone out there in Cali who’d care to weigh in, would you mind speaking to how you’re managing this process and what your experiences have been? I’m going to guess the 20% tag is fairly attainable on a regular basis, but maybe not. It’s not really something that I’ve focused on in the past. It does seem that legislation on the coasts tends to ripple across the compliance landscape, so maybe a future concern is best dealt with now.

At any rate, if you have stories to share, by all means, please include us.

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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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  1. Being the 1st survey of the year for TJC team may have its advantages, but I’m not quite sure what those advantages are. Our survey was conducted last week and an indirect finding under LS.02.01.30 EP 11 due to our 8500 sq.ft. ICU not having latches installed on the sliding glass patient cubicles when built TWELVE years ago, and not being marked on our Life Safety Plans as a unit. After three dozen plus inspections by TJC, AHCA, AHJs, and innurance carriers, this was hard to swallow to say the least.

  2. Mac,
    I just reviewed ECNews January 2012 Volume 15 Issue 1 and cannot find reference to: EP #17 (an “A” EP) under EC.02.04.03 requires at least an annual measurement of the actual radiation dose produced by each CT imaging system… Nor is it listed in the TJC Accreditation Manual 2012. Can you please verify the location of this subject?

  3. Steve MacArthur

    Hi Bryan,

    The reference to this requirement is in the January 2012 edition of Perspectives, which, as an accredited organization, your organization should be receiving from TJC. Probably worth checking with your organization’s survey coordinator to see if there’s a spare copy kicking around somewhere.
    Best – Steve Mac.

  4. Steve MacArthur

    Hi Robert,

    I’m sorry to hear about the finding – and I very much understand your frustration. That said, this is really the type of thing that lots of folks are experiencing during surveys. The fact of the matter is that every surveyor/consultant/pain in the butt has their own list of things to look at. Some love to look for penetrations, some like to close every freaking rated door in the place to make sure it latches. You just happened to get a surveyor who likes to push on the designation of suites. Unfortunately, I don’t know that you’d be able to clarify the finding based on pre-2000 LSC construction, but it might be worth chatting with your architects to see what can be done. One possibility would be to submit an equivalency foran oversized suite (that one would probably be tough as 8500 square feet is a sizable amount beyond what is allowed for a sleeping suite. Alternatively, maybe there’s a way to re-configure the space to get the square footage down to a reasonable target. There is also an exception for existing corridor doors that provides consideration for non-latching situations (I don’t have my copy of NFPA 101 with me, but there is a note under LS.02.01.30 EP #11 which provides for the use of a device that keeps the door closed when a force of 5 foot-pounds are applied to the edge of the door), which may be something to consider that is probably well short of having to install latching hardware on all those doors. Clearly, the area in question was designed to some version of some code – probably worth checking the original drawings of the project to see if there’s any illumination as to what code reference(s) were in play at the time of construction. Regardless of what you end up having to do to resolve the condition, it is certainly appropriate to manage the condition through the PFI process, with applicable ILSM’s, etc.

    Hope this helps – Steve Mac.

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