August 01, 2016 | | Comments 0
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Maybe these maps and legends have been misunderstood…

I don’t know about you folks, but The Joint Commission’s discontinuation of the PFI process has left me in a rather unsettled state. Heretofore, I think many of us (and I will include myself among that number) relied on TJC to provide some level of illumination into the inner workings of compliance as a function of what CMS is requiring. As I think I noted earlier, I was fully cognizant that CMS has been no particular fan of the PFI process as a means of ensuring compliance with the Life Safety Code®, but (presumably) there was always a tacit understanding—falling somewhat short of acceptance—that the PFI process wasn’t causing enough of a ripple in the fabric of compliance to warrant any direct intervention.

And now we find ourselves officially in August and still awaiting the arrival of the latest modular addition to The Joint Commission’s Physical Environment Portal (PEP), which was “scheduled” for a July release (at least that’s been the info posted on the portal site). At this point, I’m starting to think that the life safety modules may be on hold until the updated Life Safety chapter is unveiled later this year (presumably sometime ’twixt now and November). But the greater concern I have (and hopefully this is just a hyperbolic response to the deluge of changes) is whether the information contained in the PEP (and, to some degree, the physical environment FAQs) is as valuable (Useful? Reliable?) when it comes to keeping in line with CMS’ expectations. I think to one extent or another, we all relied on TJC as an arbiter/translator of how the physical environment Conditions of Participation could be interpreted/implemented from a practical/operational standpoint, but now I can’t help but wonder if that status has been torn asunder along with the PFI process. I’m probably over-thinking this, but I don’t have a feeling of comfort with the current state of things. I guess we shall see what we shall see—I, as always, remain optimistic, but, for whatever reason, it seems to be more of a struggle at the moment. But enough of that, for the moment…

As I was checking to see if there was an update to be found, I stumbled upon a missive in TJC’s leadership blog that I do not recall having seen before. So let me take you back about 10 months to those halcyon days of the early chortlings of the portal… (insert going back in time sound effects here).

In looking at this particular missive (penned by one G. Mills, Director, Department of Engineering—you can find the whole magillah here), there is some ground covered that is among my most favoritest of topics: the universality of the responsibilities when it comes to the management of the physical environment (and for those you who are keeping count, I have no idea how many times I’ve discussed this particular topic, but I’m going to guess it’s well into double digits. And that’s not even counting the number of times I’ve had variations of this conversation with clients…). In the blog, Mr. Mills notes that “…the patient care environment is not owned by one group in the healthcare setting.” I couldn’t agree more and yet I still (still, still, still!) encounter organizations that have not fully embraced that concept—which results in very little surprise on my part that eight of the 10 most frequently cited standards are in the physical environment. Mr. Mills goes on to say, “(W)e cannot look to one group to keep the area clean, another to keep the area warm/cool and then another group to treat patients independently.” But organizations continue to do just that, get bounced around during surveys, and still (still, still, still!) fail to grasp the team concept of managing the environment.

Now it’s certainly not every organization that has these issues, but until every organization gets “down” with this as a way of conducting the business of healthcare, the EC/LS findings will continue to pile up. The silos of clinical and non-clinical functions in healthcare organizations are no longer a tenable model—I’ve said it before and I will (no doubt) say it again—every individual working at every level in every healthcare organization is a caregiver. I’ll give you the direct/indirect split, but taking care of the patient in the bed is the role and responsibility of everyone. It is past time for a new paradigm—let’s make it happen—even without updates to the PEP!

Regardless of what happens in regards to the TJC/CMS dynamic, I think that healthcare as an industry needs to embrace this model for management of the physical environment. I know on an individual basis, everyone is wicked busy, but the success or failure of the management of the physical environment is a function of how ingrained the “see something, say something” philosophy is at point of care/point of service. You and I both know that I could say that I will speak of this no more, but you and I also know that the chances of my avoiding this topic are somewhere between slim and none…

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Filed Under: CMSEnvironment of careLife Safety CodeThe 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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