September 06, 2016 | | Comments 0
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And to the surprise of absolutely no one…

Last week, the good folks at The Joint Commission announced the list of the five most challenging standards for hospitals surveyed during the first six months of 2016 (for those of you remaining reluctant to subscribe to the email updates, you can find the details for all accreditation programs here. For the purpose of this discussion, the focus will be on the hospital accreditation program—but if you want to talk detail specific to your organization—and you are not a hospital, just drop a line).

While there has been some jockeying for position (the once insurmountable Integrity of Egress is starting to fade a wee bit—kind of like an aging heavyweight champion), I think we can place this little grouping squarely in the realm of the management of the physical environment:

 

  • 02.06.01—safe environment
  • 02.02.01—reducing the risk of infections associate with medical equipment, devices and supplies
  • 02.05.01—utility systems risks
  • 02.01.20—integrity of egress
  • 02.01.35—provision and maintenance of fire extinguishing systems

I suspect that these will be a topic of conversation at the various and sundry TJC Executive Briefings sessions to be held over the next couple of weeks or so, though it is interesting to note that about while project REFRESH (the survey process’s new makeover) has (more or less) star billing (we covered this a little bit back in May) , they are devoting the afternoon to the physical environment, both as a straight ahead session helmed by George Mills, but also as a function of the management of infection control risks, with a crossover that includes Mr. Mills. I shan’t be a fly on the wall for these sessions (sometimes it’s better to keep one’s head down in the witless protection program), but I know some folks who know some folks, so I’m sure I’ll get at least a little bit of the skinny…

I don’t think we need to discuss the details of the top five; we’ve been rassling with them for a couple of years now and PEP or no PEP (more on the Physical Environment Portal in a moment), I don’t believe that there’s much in the way or surprises lurking within these most challenging of quintuplets (if you have a pleasant or unpleasant surprise to share, please feel free to do so). And therein, I think, lies a bit of a conundrum/enigma/riddle. As near as I can tell, TJC and ASHE have devoted a fair amount of resources to populating the PEP with stuff. LS.02.01.35 has not had its day in the port-ular sunshine yet,  but it’s next on the list for publication…perhaps even this month; not sure about IC.02.02.01, though I believe that there is enough crossover into the physical environment world, that I think it might be even be the most valuable portal upon which they might chortle. And it does not appear to have had a substantial impact on how often these standards are being cited (I still long for the days of the list of the 20 most frequently cited standards—I suspect that that list is well-populated with EC/LS/IC/maybe EM findings). As I look at a lot of the content, I am not entirely certain that there’s a lot of information contained therein that was not very close to common knowledge—meaning, I don’t know that additional education is going to improve thing. Folks know what they’re not supposed to do. And with the elimination of “C” performance elements and the Plans for Improvement process, how difficult is it going to be to find a single

  • penetration
  • door that doesn’t latch
  • sprinkler head with dust or paint on it
  • fire extinguisher that is not quite mounted or inspected correctly
  • soiled utility room that is not demonstrably negative
  • day in which temperature or humidity was out of range
  • day of refrigerator temperature out of range with no documented action
  • missing crash cart check
  • infusion pump with an expired inspection sticker
  • lead apron in your offsite imaging center that dodged its annual fluoroscopy
  • missed eyewash station check
  • mis- or unlabeled spray bottle
  • open junction box

 

I think you understand what we’re looking at here.

At any rate, I look at this and I think about this (probably more than is of benefit, but what can one do…), even if you have the most robust ownership and accountability at point of care/point of service, I don’t see how it is possible to have a reasonably thorough survey (and I do recognize that there is still some fair variability in the survey “experience”) and not get tapped for a lot of this stuff. This may be the new survey reality. And while I don’t disagree that the management of the physical environment is deserving of focus during the survey process, I think it’s going to generate a lot of angst in the world of the folks charged with managing the many imperfections endemic to spaces occupied by people. I guess we can hope that at some point, the performance elements can be rewritten to push towards a systematic management of the physical environment as a performance improvement approach. The framework is certainly there, but doesn’t necessarily tie across as a function of the survey process (at least no demonstrably so). I guess the best thing for us to do is to focus very closely on the types of deficiencies/imperfections noted above and start to manage them as data, but only to the extent that the data can teach us something we don’t know. I’ve run into a lot of organizations that are rounding, rounding, rounding and collecting scads of information about stuff that is broken, needs correction, etc., but they never seem to get ahead. Often, this is a function of DRIP (Data Rich, Information Poor) at this point, I firmly believe that if we do not focus on making improvements that are aimed at preventing/mitigating these conditions (again, check out that list above—I don’t think there’s anything that should come as a surprise), the process is doomed to failure.

As I tell folks all the time, it is the easiest thing in the world to fix something (and we still need to keep the faith with that strategy), but it is the hardest thing in the world to keep it fixed. But that latter “thing” is exactly where the treasure is buried in this whole big mess. There is never going to be a time when we can round and not find anything—what we want to find is something new, something different. If we are rounding, rounding, rounding and finding the same thing time after time after time, then we are not improving anything. We’re just validating that we’re doing exactly the opposite. And that doesn’t seem like a very useful thing at all…

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Filed Under: CMSHospital safetyThe 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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