October 05, 2016 | | Comments 0
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Ah, the fresh (de)scent of hell…

Two relatively disparate topics of conversation this week; one that I suppose could be characterized as good news, the other not so much…

First, the good news: The Joint Commission is continuing in its review and revision of the various and sundry accreditation programs and has earmarked a number of EC performance elements for the scrap heap, one of which is kind of interesting (and none of which is what I had really hoped for—the management plans, like the monster in some horror flicks, just keep coming back for more). So the requirements that are either redundant or will be left up to the decision of each organization are as follows:

 

  • The requirement to monitor and report all incidents in which medical equipment is suspected in or attributed to the death, serious injury, or serious illness of any individual. Reason: All required by the Safe Medical Devices Act of 1990.
  • The requirement to have procedures that address how to obtain emergency repair services. Reason: Issue should be left to organization discretion.
  • The requirement to provide emergency access to all locked and occupied spaces. Reason: Should be left to organization discretion.
  • Requirement for staff and LIPs to describe or demonstrate methods for eliminating and minimizing physical risks in the environment of care. Reason: Left to organization discretion.
  • Requirement for staff and LIPs to describe or demonstrate how to report EC risks. Reason: Left to organization discretion.
  • Requirement for semiannual environmental tours in patient care areas. Reason: Left to organization discretion.
  • Requirement for annual environmental tours in non-patient care areas. Reason: Organization discretion.
  • Requirement to use environmental tours to identify environmental deficiencies, et al. Reason: (all together now!) Organization discretion.
  • Requirement for representatives from clinical, administrative, and support services to participate in the analysis of EC data. Reason: You guessed it!
  • Requirement to evaluate changes to determine if they resolved environmental safety issues. Reason: not quite what you might be thinking—It’s because this element is implicit in the requirement for your organization to take action on the identified opportunities to resolve environmental safety issues. But wait: How are we going to identify opportunities if we are wicked discreet about the environmental tours? Hmmm…

So we lose 10 performance elements that will now become “ghost” standards (don’t get any ectoplasm on you…icky!) Clearly the expectation that these elements are going to be present somehow and/or somewhere in your EC program is not going away and, to be honest, I’m not convinced (at least at the moment) that you’ll be able to risk assess your way out of a lot of this stuff. I’m most disappointed (after the management plans—I really, really, really don’t have a whole lot of use for them—they bring no intrinsic value to the process and are naught but an exercise in paperwork) in the removal of the specific requirements for staff to be able to describe or demonstrate methods for eliminating risks and to be able to report EC risks. I suppose you could decide that folks don’t have to know that stuff, but I have spent a lot of time and energy beating the drum for the “spread” of safety to point of care/point of service folks. Safety does not live on a committee; it does not live on a periodic survey process. Safety lives everywhere in your “house” every moment of every day. Somehow removal of those two EP’s makes me a little verklempt…

But not as verklempt as some of the folks in Chicago might be of late. Quick background: Periodically, CMS is charged with notifying Congress as to how the various and sundry accreditation organizations are faring when it comes to surveying to the Conditions of Participation, which is pretty much the fundamental task of the deemed status process. At any rate, the information that CMS shared with those pesky Congresspersons can be found here. Of particular interest to this conversation is the information beginning at the bottom of p. 38 of the document, where you will find a table that outlines the disparity rate between Condition-level findings identified by the accrediting organizations (referred to as AOs in the report) and those found by CMS during validation surveys. While (and I don’t think it’s much of a surprise) CMS does ferret out things that were missed during the regular accreditation survey, of the “big three” accreditors of hospitals (AOA/HFAP, DNV, TJC), only TJC did not improve its disparity score in FY 2014 (as the only accrediting agency for psychiatric and critical access hospitals, it didn’t do real well there, either—see pp. 39-40).

But where things get kind of ugly for us is the table (lucky #13) on p. 44, which lists the types of findings missed most frequently in hospitals by the accreditation organizations as compared to CMS. And the most frequently missed Condition of Participation? Why, it’s our old friend, the Physical Environment! The environment fares somewhat better in psychiatric hospitals (which, to be honest, surprises me a little, but it may be a question of a small sample size; unless, of course, your sample size is HUGE!) and about the same in critical access hospitals. At this point, I think I’ve probably yapped enough for one week, but I would encourage you to check out the analysis of the physical environment findings starting on p. 49. It doesn’t paint a particularly bright picture, particularly if there were any of you folks anticipating a return to the clinical side of things during surveys. All signs point to even more scrutiny (happy, happy, joy, joy!) of the physical environment…imagine that.

Batten down the hatches, mateys—we’re in for quite a blow!

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Filed Under: CMSEnvironment of careThe Joint Commission

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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 stevemacsafetyspace@gmail.com.

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