May 31, 2016 | | Comments 0
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Before you a-Q’s me, take a look for yourself…

As we await new content on the PEP (aka the newly-popular Joint Commission offering, the Physical Environment Portal), I want to draw your attention to an interesting development on another part of the Joint Commission’s website: the ever-popular (such popularity and minimal polarity…) Frequently Asked Questions page (now re-imagined as Standards Interpretations—really, check it out). And let me tell you, there is a ton of newly configured information to be found. If I were really attentive to such things (I usually am, but in this case I wasn’t expecting such a sweeping re-imagination of this part of the TJC website), I would be able to tell you how much more information there is to be had, but I think I can safely say that, at least in terms of the numbers of entries, the amount has easily doubled in relation to the “old” FAQ page. Some of the material appears to be derived from information that had been previously shared through George Mills’ Clarifications and Expectations column in Joint Commission Perspectives; other bits and pieces seem to be derived from information shared on the PEP. There also seems to be some stuff that hinges on the practical application of the now-expiring CMS categorical waivers (which I guess means there will be some updating of content in the not-too-distant future) and some other stuff that appears to have been developed specifically for this new page. (Dare we call it the Standards Interpretation Portal? We’ll be able to engage in regular SIP-ing!)

At any rate, I’m going to be poring over these entries with great interest and I would recommend that you keep a close eye on the SIP as well. Remember, the interpretations published on the SIP (I really do like that!) are “enforceable” as standards, and there’s no reason to think that TJC surveyors aren’t going to be checking out these materials as well. One interesting note: I don’t recall seeing any official announcement regarding the re-birthing of the FAQs (I won’t claim that I track every utterance from the folks in Chicago), so I may be pre-empting the grand unveiling (if you have a standards question, don’t forget to SIP!).

One item that really caught my fancy (and this was in response to a client question) was the entry regarding oxygen storage, which I know has plagued a number of organizations, particularly as a function of the segregation requirements. My thoughts on this have been that the simplest means of separation is to focus on full and not-full as the segregation metric; most folks do not have sufficient space to be able to reasonably pull off the full/in use/empty trifecta and NFPA 99 really only requires that the full cylinders be separated from everything else. So, if you use the full/not full designations, it’s not only a simpler decision-making process in the moment, it appears to be in keeping with the information shared on the SIP.

I’ll let you be the judge of what’s going to work in your organization, but I do believe that the fewer complications in the mix, the greater the likelihood of compliance.

I recommend you starting SIP-ing right away and maintain your compliance hydration throughout the hot summer months!


Entry Information

Filed Under: Environment of careThe Joint Commission


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

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