Recent Articles
EP 5 is a growing influence under EC.1.10
I’ve noticed a general change relative to citations initially falling under EP 4 of EC.1.10 (conducting a risk assessment) and then morphing towards EP 5 (implementing procedures to offset identified risks).
I suspect it’s because EP 5 (as an EP with a C score) is a lot more difficult to clarify than EP 4.
EP 4, as an EP with a B score, is sort of a one and done kind of thing, and it’s very easy for most healthcare organizations to demonstrate that they’ve conducted a risk assessment.
In a way, these two EPs together are very clear from a cause and effect standpoint. For instance, EC.1.20 requires you to have a surveillance tour process, but, in and of itself, it doesn’t really require it to be effective (the requirement is to conduct safety rounds). Now I absolutely recognize that there is an expectation that you would evaluate that process, but it doesn’t necessarily say it in EC.1.20.
When you flip back to EC.1.10, you could skate around EP 4 if you had a process that wasn’t so good. Thus, if EP 4 stood by itself, you could argue your way out of things.
With the shift from EP 4 to EP 5, the benchmark becomes much more difficult to attain because the requirement has gone from a mere “conducts a risk assessment” to the much more challenging “selects and implements procedures and controls to achieve the lowest potential for adverse impact.”
This latter wording leaves the surveyor in the position of determining whether a condition has been managed such as to achieve the lowest potential for adverse impact. That determination effectively makes anything fair game for a citation if the surveyor doesn’t like the looks of it.
EC.1.10 as a haven of surveyor preference
Hi everyone, Steve Mac here. I’m posting as the “blog administrator” today due to some technical glitches.
During a Joint Commission survey that I’m familiar with, there was a finding related to a missing outlet cover in a pediatric waiting area. Access to the outlet was completely blocked by a fairly substantial couch which took two adults to move out of the way.
Surveyors also found a lead apron folded over on itself at an outpatient site, so that was finding two.
They also threw corridor storage into the mix (that was the nurse surveyor’s little crusade), so the three findings together ended up being a requirement for improvement under EC.1.10.
Goes back to the whole general duty clause aspect of EC.1.10–this becomes a haven for surveyor preference and interpretation. Havens to Betsy!
Getting away during an emergency–literally
Many of you probably have already conducted a risk assessment that would take into account any patient inclinations to wander or elope, and hopefully measures are in place to mitigate those inclinations to the degree possible.
That said, in the event of an emergency, it may be necessary to go back to that assessment to ensure that, whatever event is occurring, there’s been no status change in those patients that might increase the risk of them wandering. My gut says that if you have a solid assessment process to start with, then you’re probably most of the way there.
Under EC.4.15, EP 5 requires long-term care organizations (not hospitals) to identify residents who might be susceptible to wandering during emergencies. If this EP affects your facility, I’d focus on the assessment process (maybe do some spot follow-up monitoring to ensure that the process is effective) and go from there.
By the way, we’ll be talking about emergency planning and risk assessments at our Hospital Safety Symposium on May 8-9 out in Las Vegas.
Check extinguisher safety near MRIs during fire drills
Last week, I mentioned the idea that fire extinguishers installed near MRI suites aren’t always MRI-safe.
As a quick follow-up to that discussion: If I happen to see ferrous extinguishers in areas immediately adjacent to an MRI suite, I always ask whether the organization has done fire drills in the area.
During those drills, I’d check to see if members of the response team show up with equipment that would not be safe in MRI rooms.
Train keeps a-rollin’ with EC activities
Well, I guess by now you are well and truly ensconced in the activities of the new year (ah, those holidays are but a distant memory). For many, thoughts are turning to the annual evaluation of the EC program. As you embark on this journey, I’d like to offer you a few words of encouragement and advice.
While the process of reviewing your EC management plans is an important activity, the plans function only as guidance documents for your program–an executive compliance summary of each function’s key components, if you will. Update ‘em if you need to, absolutely, but what I’d ask you to do is to start focusing on what improvement opportunities might be lurking in them thar hills.
Ideally, you want your annual evaluation process to be the engine that drives your improvement activities in the coming year. Pull out those hazard surveillance rounds forms and pull ‘em apart. Are they trying to tell us and show us that we have some processes that could use a little attention?
And for those occurrence reports that trickle through to your desk–I know there aren’t enough to be more than a trickle, right?–is there something there for the improving?
And what about those capital improvement projects that were approved for this fiscal year? If you had to demonstrate that those projects actually brought value to the organization, would you have data to support or refute such a finding?
The evaluation process should be about getting better. No stone should be unturned, no vital sign unassessed, no event unscrutinized. You and I both know that your organization’s care environment is not in perfect shape. You’re doing a good job, sure, but there are always opportunities.
Start digging now and enjoy the fruits of improvement when we speak of this next year (and we surely will).
MRI concerns aren’t new to us
The Joint Commission’s new Sentinel Event Alert about MRI safety isn’t all that new of a concern. Considering the severity of these incidents, I’ve been expecting this as an alert for quite some time.
The amount of MRI procedures has probably prompted the alert. It’s a high-volume, moderate-to-high-risk process to me.
I talk about MRI safety during mock readiness surveys. I sometimes note that the closest fire extinguishers to an MRI area are not MRI-safe items, which is a potential problem to watch for in your own house.
The Joint Commission issues a new alert about MRI safety
Hi folks -
It’s Scott Wallask checking in from HCPro. Just wanted to let those of you know who haven’t already heard that The Joint Commission (formerly JCAHO) released a new Sentinel Event Alert yesterday on MRI safety. This is the first Sentinel Event Alert in almost 18 months.
The alert covers both EC worries and patient safety concerns in MRI suites. As you can imagine, a good deal of the warnings center on the dangers of magnetic objects brought into a MRI room either by staff members or patients (including implanted medical devices).
In brief, The Joint Commission recommends that hospitals:
- Restrict access to MRI suites using a zone concept adopted by the American College of Radiology
- Screen patients twice for metallic objects before they enter an MRI suite
- Ensure MRI techs have compete patient histories (i.e., notice of implanted devices like aneurism clips)
- Require specially trained staff members to accompany others who aren’t familiar with MRI risks into the suites
- Provide safety education to all staff who may enter the MRI environment
- Take precautions to prevent patient burns in MRI scanners
- Only use equipment (e.g., fire extinguishers) in MRI rooms that is approved for such environments
- Plan for handling critically ill patients who require monitoring while in MRI suites
- Provide all MRI patients with ear plugs for hearing protection
- Never attempt to resuscitate patients within an MRI room
And I didn’t know this: Apparently some tattoos contain an iron oxide pigment which could burn a patient in an MRI scanner.
Watch for further details and analysis in upcoming issues of Briefings on Hospital Safety and from Steve Mac on this blog.
Thanks,
Scott Wallask
HICS is a good starting point for useful response plans
When contemplating an incident command structure for your organization that is for the purpose of actually responding to emergencies–as opposed to merely complying with The Joint Commission–I would recommend that you check out the Hospital Incident Command System (HICS) developed in
This was formerly known as HEICS, or Hospital Emergency Incident Command System. The current version is actually the fourth of its kind, but they dropped the “E” this go-around.
HICS has been developed and designed to comply with the National Incident Management System (NIMS). Of course, the recent announcement of the morphing of the National Response Plan into the National Response Framework may have an effect on this whole thing, but it’s much too early to tell for sure.
Regardless, the HICS Web site is a good place to explore the incident command infrastructure.
Web-based communication isn’t a requirement, but at least consider it
There currently exists no requirement by The Joint Commission (formerly JCAHO) or any other regulator of which I am aware for hospitals to use a Web-based program for disaster communication.
To be honest, I don’t think this a likely occurrence for a couple of reasons.
It certainly would be out of character for The Joint Commission to endorse a particular technological innovation, especially one with such wide-ranging cost considerations. Strictly speaking, The Joint Commission is not in the business of telling facilities on what they should be spending their monies.
But notice that I didn’t say The Joint Commission isn’t in the business of telling facilities how to spend their monies, which is a somewhat grayer area.
Standard EC.4.13 requires hospitals to establish emergency communications strategies, a concept that clearly would include consideration of Web-based disaster communications programs.
That said, this can become an “all the eggs in one basket” approach if your response activities rely too much on Web-based communications (stipulating that “too much” is a very subjective measure).
That’s why back-up plans are important to establish and equally important to test.
A wrench in emergency planning for behavioral health facilities
Joint Commission (formerly JCAHO) standard EC.4.12, EP 7, requires hospitals to identify alternative sites for care, treatment, or service that meet the needs of patients during an emergency.
Behavioral health facilities run into a complication in this regard, because their options are likely to be somewhat more limited than those of a “regular” hospital.
I recommend that behavioral health facilities consult with their state departments of public health to help identify those resources for which it would be appropriate and, perhaps most importantly, useful to reach out to as alternate care sites.
Chances are, there are other organizations in your region that are in the same situation. This definitely has a lot of potential for “in helping one, we help all.”
