Late last week, The Joint Commission provided information regarding the mid-term edition of this year’s Survey Activity Guide (SAG—and no, I will not make any gratuitous remarks about that particular acronymic confluence…), which includes “new description for Facility Orientation-Life Safety Surveyor and minor revisions to Environment of Care Session and Life Safety Building Tour for hospitals and critical access hospitals.”
While the minor revisions to the Environment of Care session and Life Safety building tour are indeed just that (with one exception that you already know about—more in a moment), it appears that Santa Mills has left us a nice little package under the Christmas in July tree: a new Life Safety and Environment of Care Document List and Review Tool (just think, kids—now you can survey like a real surveyor!). While I jest a wee bit (jester that I am), I do think that this is a pretty useful thing for the good folks in Chicago to be sharing. I think you’ll find the tool may give you a sense of “what” they’re looking for in terms of documentation; it also contains a nifty little typographical error. Let’s see who has the eagle eyes out there in radioland…
The one change that is a little more than minor (if only for its far-reaching consequences in surveys the past 18 months) is the instruction for surveyors to assess operating rooms for proper pressure relationships. I guess highlighting it in the new SAG means that there were some surveyors who weren’t checking the ORs for proper pressure (or perhaps some hospitals who were surprised that it happened—hey, that’s not in the book!?!). At this point, it seems hard to imagine anyone in the industry that isn’t expecting this, but I suppose stranger things have happened. As I’ve said probably too many times, they are getting a lot of mileage out of this, so best to be on one’s toes in the management of the procedural environment.
Also, one other item: they’ll be requesting a list of all the locations in your organization in which high-level disinfection and sterilization are in use, so you’d best be keeping an eye on OPA usage out in the hinterlands of your organization. You wouldn’t want a pesky surveyor finding one of your clinic sites using OPA without your knowledge (and appropriate environmental management—air pressure, eyewash stations—I think you know the drill on this stuff).
At any rate, this link will take you to the download page , if you’ve not already opened the “present.”
Happy survey prep!