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Just when you thought it couldn’t possibly get any stranger…

But first (as promised), a word about fire drills (there will be more, maybe next week, depends on what comes flying over the transom…): About a month ago, I mentioned the possibility of a shift in fire drill frequencies for business occupancies from annual to quarterly. This was based on actual experiences during a state/CMS survey in the Southeast. At the time, it seemed a bit incongruous, but the lead Life Safety surveyor was very pointed in indicating that this was the “real deal.” Well, as it should turn out, it appears that somewhere between that pointed closing, and the receipt of the survey report and follow-up, there may have been a little excess stretching of the interpretive dance that we’ve all come to know (and not love). As of the moment, business occupancy fire drills will continue to be on the annual calendar and not the quarterly one. So, three cheers for that!

But the oddest headline of the past couple of weeks revolves around CMS and their “sense” that our friends in Chicago are being, for lack of a better term, overly transparent during the survey process, particularly during exit conferences at the end of each survey day. The thought given voice is The Joint Commission (TJC) is “(p)roviding too much detail or having extensive discussions before or during a facility inspection survey can potentially compromise the integrity of the survey process. Based on the level of detail shared, a facility could correct potential deficiencies mid-course, which would skew the findings and final outcome of the investigation,” (you can read the source article here). Exactly how this determination was made is not crystal clear to me, but it did occur during the process through which TJC’s deemed status was renewed—but only for two years.

For those of you who have participated in surveys over the year, I think we are in agreement that excessive clarity was not one of the hallmarks of the survey process, though it shivers my timbers to think of how they could become even less so. I have noticed a marked decrease in useful information, per issue, in Perspectives over the past few years, so maybe that’s one of the forums that will be less instructive as we enter the post-COVID era of accreditation surveys. We know that much of what goes down during a survey is the result of interpretation of regulations that are as broadly-scoped as they could possibly be (or are they?), so it would seem that we are looking at an even more opaque survey process—holy moley!

Until next time, be well and stay safe. We need each other—and perhaps never more than now!

Yes, I know I said fire drills, but…

Please feel free to accuse me of “dogging it,” but since I am on vacation this week and you all probably need something of a vacation from me, here’s just a quick blast relating to our latest conversation thread.

Hopefully, you noted the recent headlines indicating The Joint Commission’s (TJC) continued status as an accreditation organization with deemed status; you probably also noted that CMS continues to tighten the leash (if you will), approving their accreditation status for only two years. The CMS indicated, among other things that they “…are concerned about TJC’s review of medical records and surveying off-site locations, in particular for the Physical Environment Condition of Participation (CoP).” Talk about waving a red flag in front of a bovine nose or two!

I think we can intuit that the folks from CMS (not unlike, say, The Man from Glad, or UNCLE) were reasonably pointed in their discussions with TJC prior to making the announcement and, in the face of what might reasonably be interpreted as an existential threat, we can expect lots of attention paid to the outpatient setting(s) in general, and a keen focus on all things relating to the care environment. Certainly, the level of angst generated by this “omen” will hinge closely on how widespread your organization is and (potentially) how well your corporate structure compartmentalizes offsite locations. If you’re not sure, one thing you might consider doing is hopping over to TJC’s website for searching accredited organizations and see how your place “shakes out.” Nominally, each of the care locations they think you have should be represented, and it’s always fun to see if what’s there matches up with what you think you have. I can tell you with absolute certainty that there have been some surprises in the past and I have no reason to think the future holds anything different.

So, that’s our missive for this week  and we’ll cover fire drills next time—I wicked promise! Unless something else happens…

Take care and stay safe!

Stuck on the same refrain: Outpatient! Outpatient! Outpatient!

I’m hoping to break the spell in kind of a reverse Beetlejuice invocation…

As we try to obtain some level of clarity relative to the Joint Commission survey process moving forward, there is some indication (and a fair amount of it as far as I’m concerned) that they will be focusing even more closely (thoroughly, exhaustively, etc.) on documentation, which means the survey devil will be, as it always has been, in the details. And one of the truisms of spending more time with the documents is the element of interpretation that surveyors will be bringing to the table and what they will consider evidence of compliance. At the moment, it’s not clear who will be engaging in the document review for the outpatient settings if they are not defined as a healthcare or ambulatory healthcare occupancy, but there is most definitely a movement afoot to include LS/EOC documentation for all care locations. Now, the applicability of the document review is going to be based on what systems, protections, etc., are present at each of the care locations, but the clear expectation is that any system that is present will be maintained in accordance with the applicable code and/or regulation. For example, if you have an outpatient care location that has a fire department connection, then you need to make sure that you have the appropriate documentation of that inspection activity. Likewise, if you have sprinklers, then you better make sure that the sprinkler list is up to date and all pertinent information is available for inspection.

It seems that every week I’m thinking that I can set this aside and each week something else pops up that I feel is worth sharing (have you done an eyewash assessment yet for your outpatient care locations?) and I suspect that we’ve not reached the end of this conversation. That said, I think there is going to be increased focus on generating more findings and you could say that outpatient locations represent a whole mess of opportunities for doing just that. We know they’re coming, we just need to get ahead of the curve. Hope these are helping you strategize.

Be well and stay safe until next time…

Probably not the final word on outpatient clinic settings

Sometimes I have a difficult time finding a unifying “thread” for the weekly chronicle and other times the way forward is fairly clear. This week may be more towards the former, but I think I can tie things together with a little bit of judicious “bridging.”

First we’ll start with what can only be described as “old news,” though the topic (CMS continues to make frowny faces towards the various accrediting organizations, coupled with the odd glare or two) is as old as the hills. At any rate, if one were an accreditation organization (AO), one might look at the ongoing skirmishes ’twixt the Federales and their deemed status minions as an existential threat (the exact degree of the threat is tough to figure out: Can CMS “fire” all the AOs and still be able to ride herd on healthcare? I’m not so sure). It can’t be pleasant to be berated on a regular basis, reminded of one’s failings, etc., so the natural tendency would be to try to get out from underneath. And the one sure way of making that happen is to work towards generating lots and lots (and lots!) of findings, and if you can tie those findings to various levels of criticality, then you can demonstrate your value to the process. Certainly, the various AOs have generated a lot of findings within the hospital settings over the last few years and (at least for our friends at TJC) there’s been some branching out into the “field.”

One of the trends I’ve noticed as this “shift” has been occurring is a fair number of findings relating to eyewash stations  in all sorts of areas and I think a recently updated (June 26, 2020) TJC FAQ for hospital and hospital clinic settings may be instructive as a function of setting the stage (or the table—you pick) for increased focus on those instances in which surveyors feel you need an eyewash station and perhaps you do not have a risk assessment prepared that would indicate otherwise. As we have discussed in the past (you can find pretty much all of those mentions here), eyewash stations (or the lack thereof, of the care and feeding of) tend to generate findings, but (as long as you do the math) you only have to have them under certain very specific circumstances—circumstances with which surveyors are sometimes only passingly familiar.

That said, one other trendy thing I’ve noticed is that glutaraldehyde is starting to creep back into the healthcare safety landscape, which poses its own fair share of complexities when it comes to managing risks (some useful thoughts on that subject on Tim Richards’ blog). And sometimes, just sometimes, when one is discussing the far reaches of an organization, the creeping of something like glutaraldehyde can be much less noticeable than if it were under the white hot lights of the main campus (or the mothership, if you prefer). Sooooo, particularly for those of you with lots of offsite locations (or even only a few), keep an eye out for those funky things that “show up” at generally less than useful times. You might find out it’s the difference between survey success and having to write plans of correction for weeks on end…

Hope you are all staying safe and staying positive. It’s looking like the first wave of COVID-19 is not quite done with us (and I don’t think we can have a second wave until the first one is done), but I know you folks are keeping a lid on things: Keep up the good work!

They’re baaaack: TJC returns to the fray!

Last week, our friends in Chicago announced that they will be resuming the survey grind in June (in all candor, I too will be heading out on the highways and byways of the consulting world, though I can’t help but think how “neatly” June sets up, June 1 being a Monday and all—I know nature likes symmetry, etc., but this seems almost too convenient. But I digress).

While it is not yet completely clear how things will be different, it does sound like there will be a fair amount of analysis and communications with facilities being surveyed to ensure that the survey process goes as smoothly as possible from an operational perspective. To that end, if you happen to be at a facility “in the queue” for survey, the account executive coordinating the process will be reaching out to your organization to determine the impact the pandemic has had on your operations and what things look like in their “current state.”

It is also clear that social distancing will be in full force for the next little while (again, I’ll have a chance to weigh on some of those particulars as I recommence client visits), including limiting the number of individuals “present” in group sessions (audio and/or video conferencing will take on much wider application—I know some of your EOC/EM committees have a lot of moving parts); minimizing participants in tracer activities; appropriate use of PPE (as provided for each organization’s requirements—TJC expects you to provide whatever is appropriate); driving in separate cars for off-site location and/or home visits, etc.

The announcement also indicated that the focus of the process will be a thorough assessment, but not a retroactive review of compliance (I am curious as to how that will manifest itself, particularly in terms of inspection, testing and maintenance activities, and other elements of compliance in place prior to the onset of the pandemic). The announcement also indicates that implementation of your emergency operations plan will not be the focus of the survey so much as the development of an understanding of how your organization has adapted to the pandemic and look at current practices to evaluate the extent to which safe care, and a safe working environment are being provided.

 

Time I had some time alone: How negative do we need to be?

Just a quick couple of items this week. Don’t want to take you too far away from your primary focus!

First up, I’ve been working with some folks for whom there’s been something of a disconnect relative to the general concept of a room being under negative pressure versus an Airborne Infectious Isolation (AII) room. While all AII rooms are negative, all rooms under negative pressure (and there is a certain inescapable logic to this) are not AII rooms. It would seem that there are clinical folks that use the terms interchangeably (albeit in good faith) and sometimes, for example, when reporting isolation capacities to authorities, that interchangeability could put people at risk. Fortunately, the current state of affairs with COVID-19 does not require the use of AII rooms for holding patients, but it’s probably a good time to make sure that everyone is on the same page relative to your organization’s “true” isolation capabilities. It’s probably also a good time to keep a close eye on performance of these spaces—current events really highlight the need to be sure of which way the wind is blowing in your critical spaces.

For further reading, you might find the following information useful:

  • This Compliant Healthcare Technologies blog post covers some of the particulars relating to negative pressure considerations; might be familiar territory, but a refresher never hurts.
  • This Stericycle article covers some of the particulars relating to the management of waste during the current conditions; a lot of useful information from my perspective and perhaps yours, too.

As a final note, I suspect there’s been a fair amount of discussion in the background as to how the current state of emergency is going to impact the survey process once it re-emerges from the swamp. Right now, it’s not clear if any of the existing waiver processes is going to result in any flexibility relative to the various and sundry compliance activities that might be delayed, particularly those activities for which you’ve contracted with external vendors (fire alarm and sprinkler system inspection, testing and maintenance being a good example). At this point, it’s anyone’s guess, but past survey experiences in the aftermath of emergencies would seem to indicate that surveyors will feel bad about citing you for missing a timeframe (and will absolutely understand how it happened, etc.), but will still write the finding. I’ve been keeping a close eye on all the issuances from CMS, TJC, etc., and I haven’t seen anything relating specifically to all the stuff we worry about.

That said, my best advice at the moment is to document any compliance challenges manifesting themselves during this implementation of your emergency response plan and have a risk assessment for the impact on the life safety of building occupants in your back pocket, with perhaps some implementation of education initiatives, etc., to ensure nobody is put at an additional risk. Certainly, there are internal processes that could still be administered, but probably there are some that are not—might not be a bad idea to take a few moments to figure out what compliance (and any gaps) might look like if this goes to the end of April, or May, or even June. I’m hoping that you got all your quarterly stuff done early this quarter (don’t forget to check fire drills—some folks will wait until the end of the quarter—don’t want to miss anything), so it will be a question of keeping an eye on the longer-term future.

Stay safe and keep in touch as you can!

What a short, strange trip it’s been…

I think we can safely say that 2020 has manifested itself in a lot of (vaguely unpleasant) ways, but this one has the potential for really shifting the compliance landscape for the next little while.

You probably have already heard this through various sources, but our friends in Chicago are suspending all regular Joint Commission survey activity, effective this past Monday, March 16 until further notice, with no anticipated restart date. I suppose those of you for whom a survey visit was imminent, this gives you a little bit of breathing room (and given the tenor of the times, even a little bit feels pretty darn good), but it also requires you to sustain your compliance and oversight efforts just that much longer (I have always maintained that accreditation surveys look best in the rear view mirror), which could prove challenging.

That said, I have absolute confidence in you folks to keep your organizations sharp and on point (sorry for the mixed metaphor there). We can only prepare one day at a time, and so, can only sustain progress one day at a time. I think we can predict that infection control and prevention will experience focus like never before (but hey, we knew this was coming), so make sure all your infection control-related risk assessments are up-to-date and minty fresh (actually, reviewing all your risk assessments is probably a good way to spend this “grace” period).

There’s a lot going on, but if the past two months+ are any indicator, 2020 has more surprises in store (hopefully not…), you don’t want a bad survey to be one of them.

On your marks, get set, sweat!

But hopefully not a Billy Idol kind of sweat…

Our friends in Chicago are once again tweaking the survey process, with the result being less time for surveyors to wait for organizations to muster their troops at the outset and pretty much no time at all before they are out and about doing tracers. Basically, what used to be the surveyor planning session in the morning of the first survey day is now being flipped and combined with the special issue resolution session at the end of the day. For organizations to adapt their process to the changes, folks should be prepared to do the following:

  • Prompt alert of/to the leadership team of any on-site survey to facilitate their availability for a prompt opening conference (I can’t think of too many folks who are not already doing this)
  • Prepare all required documentation and deliver those documents to the survey team immediately after the team is escorted to their “base” (the list of required documents is available in the Survey Activity Guide, although it begs the question as to whether this includes the life safety documentation…)
  • Gather the scribes together so they are ready to hit the pavement as soon as the (ever-so-brief) opening conference is completed

Somehow I think this may all tie across with the folks from CMS accompanying the Joint Commission folks as part of the validation process—anyone who has dealt with a state and/or CMS survey will tell you, there’s not a lot of time (or indeed, inclination) for pleasantries. The job of being prickly requires a lot of inflexibility, which does seem to be the hallmark of the current survey process.

These changes to the survey process are effective March 2020.

I sit at my table and wage war on myself—and earn an OSHA citation!

While I have a sneaking suspicion that this Top 10 list doesn’t change a whole lot from year to year (other than position in the hierarchy), I thought it would be of interest to trot out which occupational safety considerations are manifesting themselves across industries. I can certainly see where any of these might crop up in healthcare.

And so, to the list:

10: Personal Protective and Lifesaving Equipment – Eye and Face Protection

9: Machine Guarding

8: Fall Protection – Training Requirements

7: Powered Industrial Trucks

6: Ladders

5: Respiratory Protection

4: Lockout/Tagout

3: Scaffolding

2: Hazard Communication

1: Fall Protection

Again, no big surprises, but I guess it does point out some areas for future consideration, mostly as a function of initial and ongoing safety education. These are the types of things, especially when dealing with contractors, that can result in a very uncomfortable situation if something goes sideways on your campus—even if it’s not your staff. Once the Big O gets through the door, it’s tough to contain their interest in all things safety.

Closing out this week, one of the questions that seems to be coming up with greater frequency during Joint Commission surveys relates to how your organization determines that the individual(s) tasked with doing your rated door inspections are knowledgeable/competent (we know from our intense scrutiny of NFPA 80 that these folks do not need to be certified; it is a handy way to demonstrate that an individual is knowledgeable, but you can certainly evaluate/validate competency in other ways). And pondering that equation made me a little more interested in the following news story than might normally have been the case (there isn’t a time when I wouldn’t have been interested, but this was an especially telling confluence). It seems that an individual has been accused of defrauding some VA hospitals by billing them for work that had not been performed; a little more detail can be found here. I know a lot of folks have struggled over the years with vendors who prefer to “come and go as they please,” which typically results in less control over the process, including timely notifications of discrepancies. I’m curious as to how this ends up when it makes its way through the courts, but I can see a time when those pesky surveyors might start to ask about how one knows that the service for which they have documentation actually occurred. Hopefully this case is all a big misunderstanding and there were no real gaps in oversight…

What we all want: If everything is priority one, then everything is priority none

As our friends from Chicago appear to be embarking in earnest on their charge to be as unpredictable as possible (I know of one instance in which a triennial survey “landed” about 10 months early—if that doesn’t merit a “yow,” I’m not sure what does…), the general concept of constant readiness would seem to be in flux (I think we all “knew” that the true survey window was considerably more limited than what it could be).

To that point, lately I’ve been working with folks who are well and truly within a survey window (lots of folks poking around in healthcare organizations these days…) and I’ve been noticing a tendency for folks requesting things to use “tomorrow” (or something similarly unrealistic) when identifying a requested completion date. And then raising a fuss when things are not repaired/replaced/refurbished almost instantly, which puts the folks who actually have to get the work done in a rather precarious position, depending on how quickly/dramatically the fussiness gets escalated. I think we can agree that expectations like instantaneous gratification do not lend themselves to thoughtful assessment of risk, or even (truth be told) basic triaging of tasks. I know that in crisis mode things can become a little unhinged, but the way the survey process is starting to turn, if we don’t find a way to really hardwire that classic finder/fixer dynamic as a way of like, the potential for chaos as a way of life is fairly strong.

So, the question I have for you out there in the studio audience is this: Does anybody have any unique methodologies they’d be inclined to share? I will freely admit to being at something of a disadvantage in that it has been a very, very long time (other than some interim gigs) since I’ve had day-to-day operational responsibilities in a hospital so there are probably technology solutions, etc., that could be leveraged in pursuit of focused order. But I also know that there is still a fair amount of what I like to call the “corridor work order request,” which, in my younger years, was probably not that big a deal, but now, as I approach my dotage, I find that I am not able to instantly recall quite as much “stuff” (I’m still pretty good, but the seams are much more apparent now).

I’m sure you are all following (with perhaps varying degrees of trepidation) the events unfolding in China relative to the Wuhan coronavirus; if you’re not making a regular stop at the CDC website for updates, etc., I would highly suggest it be a touch point at least every day or so. It’s starting to manifest itself a  bit stateside and I suppose, given the omnipresence of travel these days, it’s only a matter of time before it starts showing up in less-populated regions of the country. You can find as much information as is available here. Hopefully, this one subsides quickly, but preparedness, it seems, is everything these days.