September 04, 2014 | | Comments 1
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This one belongs on your shelf…big time!

In the nearly six months I’ve been back in the consulting world, one trend during Joint Commission surveys stands out as the most likely to result in survey heartache (and heartburn). And that trend, my friends, has everything to do with the management of environmental conditions in surgical (and other environments). Clearly, the folks at TJC have struck a motherlode of potential findings—and I have no reason to think that these strikes will be abating any time soon. My advice to you is to start cracking the books—one tome in particular (okay, not so much a tome because it’s really not quite long enough, but if we were to somehow measure its impact…).

For those of you who have not yet procured a copy of the American Society of Heating, Refrigeration and Air-Conditioning Engineers ASHRAE-170 Standard for Ventilation of Health Care Facilities, I cannot encourage you too much to bite the bullet and get yourself a copy of this august standard. I can almost guarantee that doing so will decrease the likelihood of survey ugliness, perhaps even for the foreseeable future.

Now, this volume—a mere 14 pages in length—contains a lovely table (pages 9-12, for those of you keeping score at home) that identifies all the areas in a hospital (hey, maybe even your hospital…imagine that!) in which there are specific design parameters for temperature, humidity, air flow, air exchange rates, pressurization. Pretty much everything that is causing so much pain during TJC surveys of late (I’ve seen a significant increase in the number of Condition-level TJC survey results, which is almost exclusively the result of managing these conditions).

Once you have this volume in your hot little hands, turn to page 9 and start looking at all the places where you can expect scrutiny (word to those facing survey in the near future, there is an indication that the focus is expanding to include any areas in which invasive procedures are performed. Can you say interventional radiology and IVF? I knew you could.). My recommendation is to start working through the list (and, rest assured, it’s a pretty lengthy list) and identify where you are compliance-wise relative to the design parameters listed. And if you should find that you have some compliance vulnerabilities in these areas, please, please, please reach out to your infection control practitioner to start working on a risk assessment/response protocol to manage the risks associated with those non-compliant conditions. It may be the only thing standing between you and an awful journey into the darkness of a condition-level finding—a journey none of us would want to make.

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Filed Under: Environment of careEnvironmental protectionThe 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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  1. Spot on, as usual, Mac! I would add that we are also seeing a number of hits within Sterile Processing related to wrong airflow direction, from dirty to clean. Those pass-through windows often complicate the air balancing required to correct this. Pass-throughs should be closeable… and kept closed.

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