August 01, 2013 | | Comments 0
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What time is it? It’s JCST (Joint Commission Standard Time)!

In the June 2013 edition of The Joint Commission’s Perspectives, George Mills covers the thorny topic of the Environment of Care management plans. Within his dissertation, he makes note that he doesn’t recommend inclusion of the Joint Commission standards and Elements of Performance (EP) in the management plans (see p. 6 of the article “Environment of Care Management Plans” for the skinny). The reasons include the caution not to “merely” restate the EPs and standards (I’ve seen management plans that consist of nothing but a reiteration of the standards and performance elements, verbatim, with no supporting description of the organization’s strategies for complying with each of the required elements—not a good thing at all), as well as to avoid the “tedious” task of making sure that minor changes to the standards (which happen periodically, but I don’t know that I’d get to the point where I’d call it tedious to review the standards from year to year) don’t trip you up during a survey. He finishes with the statement that surveyors know the standards and EPs, so they don’t need to be repeated in the management plans.

Now I don’t necessarily disagree with any of those statements, but I don’t know that there isn’t a benefit to indicating the specific performance elements as a function of the management plans, if only to ensure that it is very clear to everyone (internal reviewer, regulatory surveyor, etc.) how your organization manages compliance with each of those elements and standards. My personal experience (and those of folks with whom I have worked with on their management plans) has been that the easier it is for the surveyor to tie a standard or an EP to a specific portion of your management plan, the greater the likelihood that they will “tick” that element off and move on to other things. To be honest, when I’m looking at management plans, I tend to focus as much on what has changed recently as anything—it provides evidence that the folks charged with managing the EC program are making sure that they’re staying on top of changes  to the standards.

As a further enticement to you folks who’ve not yet added Perspectives to your monthly reading list, p. 8 of the June issue also includes a rubric for evaluating the “quality” (my interpretation) of your management plans. It’s an interesting exercise that you might even consider covering as a group exercise with your EC committee. One of the most important aspects of this whole magillah is for your committee to have a comprehensive sense of how risk is managed in the physical environment—from the identification of opportunities through the strategies developed to make good on those opportunities through the monitoring and evaluation of performance relative to those opportunities. While there will always be content experts in the mix, it is of critical importance to a highly performing committee for the committee as a whole to be able to speak to what’s going on. If you can get to that point, you have really got something powerful upon which to sustain your program.

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Filed Under: Environment of careThe Joint Commission

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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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