February 23, 2015 | | Comments 0
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By George, I think you should get it!

I suspect that the conversations regarding the number of EC and LS findings are likely to continue for the foreseeable future, for all the reasons we’ve discussed in the past and probably some that haven’t occurred to me yet, but surely will. At any rate, I want to encourage you to grab a copy of the February 2015 issue of Joint Commission Perspectives and turn directly to p. 10, on which begins a discussion of the use of dashboards as a means of keeping EC/LS compliance on the front burner. The article (part of George Mills’ ongoing series of Clarifications and Expectations) shows some dashboard examples, as well as providing links to some tools on the Joint Commission Resources website (including a blank form suitable for use in your very own organization). Heck, it even outlines a six-step process for setting up your own dashboard if the one from JCR doesn’t quite fit the bill. All in all (as much because it pretty much reiterates what I’ve been preaching almost since the beginning of time, but I digress), a most worthy addition to the safety canon and a resource that you would be well-advised to consult as you start to formulate your calendar year 2015/fiscal year 2016 activities.

All that said, I would encourage you, particularly as any number of you are embroiled in your annual evaluation process, to look over the information and make a (very, very) good faith effort to adopt at least the dashboard concept, if not an outright adaptation of the formats included in the article. One of the truisms of the compliance game is that anything that shows up in Perspectives is potentially surveyable/enforceable as a standards-based requirement, so there is a pretty fair likelihood that the surveyors are going to start looking for something along these lines when they next stop by your place for a visit. But please don’t look at this as one more thing to do; if you set this up and operationalize this properly, you will gain a great deal of information on where your organization stands on the compliance continuum, plus you will have data that you can use to clarify findings that may come up (okay, probably will come up) during survey. As always, it goes back to the management of imperfections in the environment—you know they’re there, I know they’re there, TJC knows they’re there. Our best “safety net” is to be able to demonstrate an ongoing process for managing those imperfections. Identify those pesky vulnerabilities and you are on your way!

One bit of caveat emptor, p. 13 includes a sample “In-Depth Data Analysis Worksheet,” which in this case is being used to collect data on the Daily Verification of Appropriate Air Pressures for In-Use Rooms. And you might well note that there is no specific requirement for the daily verification of appropriate air pressures for in-use (or indeed any other) rooms. For some strange reason, this one is giving me a bit of the willies as I can certainly see an instance in which a surveyor might interpret this to mean that there is such a requirement. It may be much ado about nothing (and I, for one, hope that is indeed the case), but probably something worth keeping an eye on.

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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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