October 24, 2018 | | Comments 0
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I may not be perfect, but I’m perfect for you: CMS rates the accreditation organizations!

Another mixed bag of stuff for you this week, leading off with a quick spin through CMS’ report card to Congress.

While the numbers have shifted around a little, infection control is making a move on the outside, but the physical environment is still the big point of focus, though you can see where the two are starting to cross over at a greater frequency. I think issues relating to ligature risks are going to be a very sharp focus, particularly with CMS surveys. Although it is interesting to note that (at least at the moment) when ligature risks come up in the CMS survey process, those risks have been cited under the Patient Rights Condition of Participation (each patient has a right to receive care in a safe setting), so we may see Patient Rights at the top of the heap next year. One way you can avoid that little dance of ignominy is to make sure that you have completed a comprehensive ligature risk assessment in those areas in which you are managing behavioral health patients, including mitigation strategies for items that cannot be immediately corrected and solid anticipated completion dates. They are taking ligature risks very seriously because of the potential for harm to patients and you don’t want to have a whole lot of open-ended plans of correction. It almost comes down to a sense that everything that exists is a potential risk to be managed and while I am hopeful that cooler heads will prevail, right now this is a very, very hot topic.

One other thing to note with the report card is a section that deals with an analysis of survey disparity relating to Life Safety Code® compliance and health and safety considerations. I’ve looked at the contents of this section, including their conclusions and recommendations, and I have a hard time thinking that this is ever going to go away as a survey focus. While I tend not to rely on absolutes when it comes to periods of time, I can say quite confidently that there will always be stuff to find during a survey. You can look today and find stuff, you can look tomorrow and find different stuff, you can look the day after and—you guessed it! Stuff happens; people do stuff we don’t want them to, including unauthorized field modifications. The list is literally and figuratively endless. I know they have to find something, but as a collective, I think most hospitals are very well maintained and managed as a function of the physical environment. But if the big “C” knocks on the door (and I guess we have to include the minions as well), there’s going to be a list of stuff. Our job is to keep that list to a minimum. Good luck with that!

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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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