November 16, 2020 | | Comments 2
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We know it will never be easy, but will it ever get easier?

It’s always interesting (and perhaps a bit thrilling) when an announcement comes flying over the transom from our friends in Chicago unveiling “modifications” to the Environment of Care (EC) survey process for healthcare occupancies (e.g., ASCs, hospitals, critical access hospitals), but this ended up being a little less breaking news and a little more of a good news/less-good news situation.

For quite some time now, I have mulled over the general thought that the EC interview session portion of the accreditation survey process really doesn’t yield a lot of findings. My sense of the session is that it’s more of an evaluation of group participation than anything else and it appears that others in a position to do something about it are in agreement, at least as a function of identifying survey vulnerabilities.

At any rate, The Joint Commission recently announced that the EC interview session is going away (good news) to provide more time for surveying in the field, including even more focus on EC stuff for the clinical surveyors during tracers (less-good news). I am certainly not worried about folks getting into “big” trouble during this extra hour of time, but it is another hour of wandering around that is likely to generate at least a few more “dings” in the physical environment.

As the Chicagoans continue to battle the forces of CMS in their pursuit of deemed status and reported shortfalls in the surveying of the physical environment, there is a certain inevitability at play here, so I guess we’ll have to wait and see. My immediate prediction is that there will be an increase in EC/Life Safety findings over the next little while (and perhaps a little while after that…).

Now, if they would only remove the requirements to maintain the safety, security, HazMat, fire, medical equipment, and utility systems management plans—I don’t think they generate very many findings and they really don’t serve any real operational purpose for healthcare organizations. Fire response plans and emergency response plans make sense to me, but the rest of it should be captured through the annual evaluation process. Is it really that big a “step” to go from evaluating effectiveness of the EC plans to evaluating the effectiveness of the EC programs in whole? Somehow I don’t think so…

Hope you are all well and staying safe!

Entry Information

Filed Under: Environment of careThe 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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  1. Mac, do you work with DNV at all? They commonly write up EC findings that were previously uncited by TJC including fire safety, gas storage,tracability, etc. In addition, they look very closely at the 7 sister plans including the expectation of performance goals, regular reports to the quality management committee, and improvement plans. How do you propose evaluating a program if there are not goals set forth (part of the plans).
    Do I think this can be improved? Yes, I am a Director of Quality afterall. But i do disagree with you that these plans should be eliminated. They provide valuable information to the Quality department, Executives and other leaders in the organization. They are used to help focus prioritize activities. The facilities department may find them unnecessary, but the rest of the hospital does not.

  2. Hi Pam,

    I do a fair amount of work with clients that are accredited by DNV; but, as with the accreditation demographic, most of the folks I work with are accredited by TJC.

    I am not suggesting that the programmatic elements & functions of the management of the physical environmen are not necessary, but I do think that the elements that you are looking for do not (and probably are better off) rely on the existence of a “plan”. The management of the physical environment is absolutely a PI endeavor and should be fully engaged with any organization’s QAPI process (as required by CMS). If you wanted to have a PI plan for the Physical Environment Management Program, I’m totally on board. But this notion that it hinges on these individual plans that end up parroting the standards-based requirements just doesn’t work for me. The evaluation process is of critical importance, but I have yet to run into a “plan” that enhances that undertaking to any extent whatsoever. But it’s only been 30 years of looking at them, so perhaps that will be my “treat” in 2020.

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