January 22, 2015 | | Comments 0
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When will the madness stop?

I don’t know how many of you folks subscribe to The Joint Commission’s (TJC) e-notification products, but an interesting bit of news/info came across the airwaves that relates very clearly to some of the conversations we’ve been having (to one degree or the other) over the last, oh let’s say decade or so. Mark Pelletier, the COO of TJC, has taken on the task of “calling out” those healthcare organizations accredited by the Joint to clean up their acts as it relates to the preponderance of EC/LS findings during triennial and associated survey activities. If you’ve not yet seen it, it might be useful for you to be conversant in some of the details.

Now I think that we can absolutely pinpoint when this shift first manifested itself: way back in 2007 when the initial wave of Life Safety surveyors were introduced to the TJC survey process. Since then, there has been a steady increase in EC/LS findings, particularly as the remainder of the survey teams have also been tasked with observing conditions in the physical environment, which brings me back to the age-old dynamic of “Are they looking for it because that’s what they’re finding or are they finding it because that’s what they’re looking for?”

Having pondered this for quite some time, I believe that I fall squarely in the latter camp. One thing I’ve learned over the last 10+ years of working with hospitals is that there are no perfect buildings—and I really don’t think you need any more evidence than the number of findings generated in the survey of the physical environment to be convinced of that. Does this means that we are putting patients/staff/visitors at risk because of the poor conditions in our facilities? I don’t feel that the evidence supports such a draconian interpretation. Is there an opportunity for the management of the physical environment to better resourced, utilize technology better, etc.? I don’t think there’s anyone out there who would disagree that there have always been, and always will be, opportunities to make improvements in the physical environment.

TJC has not yet revealed the final results of most frequently cited standards during 2014 (I have no reason to think that the January to June 2014 results aren’t a good indicator of what we can expect), though I get the sense from Mr. Pelletier’s blog posting that findings relative to the integrity of egress may finally be taking a back seat to findings relating to the management of the surgical procedure environment (temperature/humidity/air pressure relationships). But that said, from the survey results that I’ve seen and the facilities with whom I’ve done on-site work, it is debatable (at least in my mind) that the findings are representative of a significant systems issue. My experiences indicate that the findings are generally related to what I would euphemistically refer to as transient conditions. Sometimes there are legitimate problems that need to be addressed; I recall one decontamination room that had never had an exhaust installed, but that is indeed an exception. But a majority of the time, we are talking about the sundry imperfections that can be encountered in any facility inspection. At this point, you should have a pretty good idea of how long you’d have to tour your building to find a condition that is not quite as it should be. Do you think if you toured for two or three days in a concerted fashion that you wouldn’t be able to find anything at all? Buildings are never more perfect than the moment before you put people in them—and apparently that perfection has somehow become the expectation. Jeez!

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Filed Under: Environment of careLife Safety CodeThe 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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