August 30, 2016 | | Comments 2
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If accredited you wish to be, you must answer these questions three!

And other tales: If you thought the dervishes were whirling last week…you ain’t seen nothing!

Hortal hears a chortle from the portal: The much-anticipated (you tell me how hyperbolic that characterization might be…) return of updated content for the Joint Commission (oops, THE Joint Commission)’s Physical Environment Portal (PEP) has finally reached these shores. O frabjous day! Callooh! Callay! He chortled in his joy (from Jabberwocky by Lewis Carroll; see, chortling has been around for a while…).

The new content breaks down into three sections: one for facilities and safety folks, one for leadership, and one for clinical folks, lending further emphasis to the ongoing melding  of the management of the physical environment into a tripod-like structure (tripods having more stability and strength than a one- or two-legged structure—think about that one for a moment). At any rate, interestingly enough, the suggested solutions for both the clinical and leadership “legs” of the tripod are aimed at “supporting” the facilities “leg” through endorsement of the key process(es) as well as keeping smoke doors closed, not compromising closing devices (how may doors can a doorstop stop if a doorstop could stop doors?), and participation during construction activities. So, if you visit the noted URLs, you will find a whole bunch of stuff, some of it downloadable, to share with the other “legs” in your organization. It seems pretty evident to me, that at least part of the intent of the information shared, particularly the stuff earmarked for leadership and clinical folks, is to ratchet up the “investment” of those two groups in the management of the physical environment. On the face of it, nobody in healthcare has “time” to shoulder this burden on their own, hence the practical application of the tripod (sort of: that may be a bit of a reach on my part, but there’s some truth lurking around somewhere—and we will ferret it out).

Also breaking recently was the information (funneled from our fine friends at ASHE) that TJC is going to be including a set of three questions in the pre-building tour portion of the survey process (I think this is in addition to other questions that might be asked, including whether you have any identified Life Safety Code® (LSC) deficiencies). The intent, as described by Jim Kendig, TJC’s field director for surveyor management and development (I worked with Jim, like, a million years ago. Hi, Jim!), is to gather some pertinent/useful information before setting out to tour your facility.

Question 1: What type of firestopping is used in the facility?

Question 2: What is your organization’s policy regarding accessing interstitial spaces and ceiling panel removal?

Question 3: Which materials are used for high-level disinfection or sterilization?

On the face of it, I’m thinking the response to Question 1 might very well be the most challenging as I can’t recall too many facilities that have just one manufacturer’s product protecting their rated barriers. My consultative advice is you would be well-served to have some sort of document that identifies the various products in use, where they “live” in your organization, perhaps even color pictures of the products in situ so the surveyors will know what they are looking for (and please don’t try to pass off that yellow expanding foam stuff as an appropriate product—no point in getting into a urination competition with a surveyor over that). As to the other questions, as near as I can tell they’re pretty straightforward; the surveyor is going to have plan for extra time if a containment has to be erected/constructed for every ceiling tile removal or perhaps they will identify specific locations for inspections and just run through those one after the other. As to high-level disinfection and sterilization, lots of environmental and infection control opportunities for bungles there (BTW, it’s probably a very good idea to have a very good idea where those processes are occurring; it can be more widespread than you would prefer).

As a final thought for this week, I would encourage you to participate in ASHE’s survey of the potential impact of CMS’s requirement for all hospital outpatient surgery departments to be classified as Ambulatory Surgical occupancies under chapters 20 and 21 of the 2012 LSC. There is a fair amount of potential that this requirement is going to have an impact on facilities in which dental or oral surgery is being performed, plastic surgery, endoscopy, laser surgeries, etc. To help with the assessment of the impact of this change, ASHE is asking folks to complete a survey for each of the facilities you oversee that will be affected; you can find the survey here. https://app.smartsheet.com/b/form?EQBCT=c66f01e829184b648b4b0db3fd2cc552

I think it’s probably well worth your time to at least see what they’re asking about; I’m beginning to think that we are going to look back on 2016 as a really ugly year (compliance, popular culture, you name it!). Where’s that fast-forward button…or do we talk to Mr. Peabody and Sherman about that Wayback Machine…

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Filed Under: CMSHospital safetyLife Safety CodeThe Joint Commission

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Steve MacArthur About the Author: Steve MacArthur is a safety consultant based in Bridgewater, 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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  1. Steve,

    A question that is haunting me in regards to Urgent care centers that are not receiving centers during a mass casualty event. My counterpart in Emergency Preparedness is telling patient care services that there is a TJC requirement for the urgent care centers to be prepared to handle a patient load of 20% more than what they would normally see. I disagree with this statement that there is no TJC requirement for urgent care centers to ramp up to this. What are your thoughts. Thanks, Matthew

  2. Hi Matthew,

    There is nothing in the Joint Commission standards that indicates a specific target percentage for increased volume at an urgent care center (I suppose you could make the case that it would be useful to know how much you could flex up at such a location, based on the average daily census for the center, but that would be as much for planning purposes as anything else). And, if the urgent care center is not a designated in the community plan as a receiving center during an MCI, then I don’t see where any compliance leverage could be applied beyond the impact on your internal response plan. That said, it is no uncommon for such myths to become perpetuated over time, based on (usually) surveyor interpretation. Again, I think it would be useful from a planning perspective to have a sense of how much you could flex up, but there is no Joint Commission-required portion of your normal capacity that needs to be attained/assured, etc.

    Hope this helps; please let me know if you need more info or if somebody comes up with some information as to the genesis of this “requirement”.

    Have a great week – Steve Mac.

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