December 19, 2014 | | Comments 0
Print This Post
Email This Post

A curiosity from the (left) coast

This is another plucked from the oblivion of the mailbag…

Back towards the end of September, I received an email from an acquaintance out in California who had attended The Joint Commission’s Executive Briefings conference, which included a session on CMS compliance, presented (or so it would seem) jointly by TJC and Joint Commission Resources. In their never-ending pursuit of encouraging customer participation, the audience (or learners as they are identified on the slide sheet) got to submit some questions to the faculty (who shall remain nameless … primarily because I don’t have that information), for which responses were prepared and shared with the group (there were 6 questions asked, based on the document I’ve seen).

At any rate, there are two questions asked for which the responses were somewhat illuminating, albeit in a rather frightening way:

Q. Does temperature and humidity need to be done/recorded daily in procedural areas even if they are closed (i.e., operating room closed on a Sunday or holiday)?

A. Indoor air quality testing that includes directional air flow, humidity, and temperatures should be done daily when in use, however, it is only recommended monthly when the rooms are not in use. So if the rooms are closed they need not be tested unless they are closed for more than one month, but tested when they are put back in use.

The question I have for the studio audience is this (and it’s not like we’ve had this conversation before in various permutations): Where in the regulations does it require daily performance of “indoor air quality testing that includes (which by extension can be interpreted as “not limited to”) directional air flow, humidity and temperatures”? Now it may very well be that this is an extension of the whole magillah regarding the maintenance and testing of critical utility systems components in accordance with manufacturer recommendations (and I don’t have nearly enough knowledge of the OEM guidance on the various and sundry HVAC systems there are out in TV land to be able to speak to that piece of it). Maybe this is destined to show up on TJC’s FAQ page (I see we’re getting a little acronym-heavy here, so I will try to refrain from further acronymization), but this one seems a little beyond the pale. My advice for the moment is that you really ought to look at this as a risk assessment and make the determination of frequencies, etc. for this kind of stuff. Which brings me to the other question of note, but let’s leave that for next time…

Entry Information

Filed Under: CMSThe Joint Commission

Tags:

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.

RSSPost a Comment  |  Trackback URL

*