A mixed bag of stuff this week (dig, if you will, a picture: sleigh full of regulatory madness), including the Perspectives coverage of the Emergency Management standards. But first, a little musing to usher in the change of the seasons.
The nature of my work/vocation requires me to travel a fair amount—and I am not whining about that—it’s my choice to continue to do so, and I understand that if the travel gods are displeased, there is no point in kvetching, but I digress. One of my favorite travel pastimes is watching fellow travelers as they navigate the various and sundry obstacles that one might encounter as they complete the check-in/TSA gauntlet, etc., after which, they generally “crash” in the gate areas or airline clubs. One of the most fascinating/disturbing trends (and I suspect you’ve probably witnessed this yourselves—perhaps even in your own homes) is groups of people (even families!) staring at their devices…and saying not a word to each other. I can’t help but think that if we can’t (or I guess more appropriately, don’t) converse in our private lives, it’s going to have a not-so-good impact on discourse in the workplace. We are better when we are talking—and even technological isolation is still isolation-y.
Hopping down from the ol’ soapbox, just a quick couple of words on the Emergency Management stuff in Perspectives. Interestingly enough (almost to the point of being strangely enough), it appears that folks responding to emergencies have found that the EM standards facilitate effective response—go figure! While I am certainly glad to hear that, I’m not necessarily surprised, mind you. After all, the basic tenets of small “e” emergency management are what inform the big “E” Joint Commission chapter, so if there’s stuff that doesn’t lend itself to response, recovery, etc., I would hope that it would have been expunged by now. Another area of emphasis in the article is the importance of collaboration with the community and other health providers when you are dealing with a significant emergency (as an aside, the CMS final rule also highlights the importance of that collaboration), which (once again) makes a great deal of sense from a practical standpoint. The article closes out with some links to useful information; I’d encourage you to check them out once the stockings are hung by the chimney with care:
- Joint Commission Emergency Management Resources: I’d bookmark this page as it does appear that content is being updated on a fairly regular basis
- Joint Commission Journal on Quality and Patient Safety: Some of the concepts will, no doubt, be very familiar: safety huddles, serious safety event classification to identify and track undesirable events—good (best) practices to observe.
Finally, to close out this epistle, I would encourage you to climb into the wayback machine and revisit those halcyon days of Sentinel Event Alert #37 and the management of emergency power systems, etc. My gut tells me that e-power is going to continue (if not increase) to be a focal point for pretty much any and all regulatory systems and the advice provided in SEA #37 relative to evaluating your e-power capabilities, assessing the reliability of normal power, etc., can only become more timely as our reliance on technology grows at an almost exponential rate. We certainly don’t want to get caught unawares on the e-power front and I’d be willing to bet that there have been some changes in the technology infrastructure in your place that might be significant enough for some analysis. At any rate, some more links to peruse once you’ve laid out the cookie and milk for that right jolly old elf:
Beyond that, I hope that we all get a chance to turn off the technology for a bit over the next couple of weeks (and I mean that in the best possible way—I am no Luddite!) and allow some real-time reflection with our family, friends and, indeed, the world at large.
Here’s hoping that 2017 rings in the return of civil discourse!
As the ol’ Physical Environment Portal remains barren of new goodies (maybe we will awake the morning of December 25 and find crisply wrapped interpretations under the tree—oh, what joy for every girl and boy!), we will turn yet again to the annals of Perspectives to mayhap glean some clarity from that august source of information. I suspect that as the December issue is chock-a-block full of life safety and emergency management goodness, we’ll be chatting about the contents for a couple of sessions. First, the big news (or what I think/suspect is the news that is likely to have the most far-reaching implications for survey year 2017): a survey process change relative to the evaluation of Interim Life Safety Measures. Actually, I should note that, as the changes were effective November 17, 2016, those of you experiencing surveys ‘twixt then and the end of the year will also be subject to this slight alteration.
So, effective 11/17/16 (the 46th anniversary of the recording of Elton John’s landmark live album 11/17/70—coincidence? Probably…), the evaluation of your ILSM process (inclusive of the policy, any risk assessments, etc.) will be expanded to include discussion of how, and to what extent, ILSMs will be implemented when there are LS deficiencies identified during your survey that (presumably) cannot be immediately corrected, based on your ILSM policy. Sounds pretty straightforward, but it does make me wonder how the LS surveyor is going to have enough time to review your documentation, thoroughly survey your facility, and then sit down to review any LS findings and discuss how your ILSM policy/process comes into play. I have to tell you, when I first read this, my thought immediately went to “one more day of LS surveying to endure for any reasonably-sized hospital” and, taking into consideration all the other changes going on, while I hope I am incorrect, it does make me wonder, wonder, wonder. Also, the ILSM(s) to be implemented until the deficiency is resolved will be noted in the final survey report, so it probably behooves you to have a process in place to be able to FIFI (find it, fix it) every LS deficiency as it is encountered—and since everything counts with the abolition of the “C” performance elements, you know what you probably need to do.
At any rate, with the announcement that we can expect full coverage of the ILSM standard, there was also a note that an additional performance element has been added to provide for any additional ILSMs you might want to use that are not specifically addressed in the other performance elements for this standard. I’m not exactly sure how this would play out from a practical standpoint; maybe you could specifically include in your policy a provision for checking exit routes in construction only when the space is occupied, etc. As near as I can remember, the only instance I can think of somebody being cited for having an ILSM in their policy that did not precisely reflect the performance elements in the standard was back when the EP regarding the prohibition of smoking was discontinued from the standard; there were a few persnickety surveyors who cited folks for not having removed that from their policy (persnickety is as persnickety does), but that’s all I can think of.
Next week, we’ll chat a bit about some of the pending changes to the Life Safety chapter wrought by the adoption of the 2012 Life Safety Code®. In a word, riveting!
Much as 2016 has laid waste to the pantheon of pop culture, so has it decimated the status quo in the realm of facilities and safety management. While this year has brought “pleasures” expected (adoption of the 2012 edition of the Life Safety Code®) and unexpected (the demise of the Plan for Improvement process), it appears that the wheels (gears?) that drive this regulatory machine are not yet done churning out new stuff for us to ponder.
As you’ve probably heard by now, last week CMS finally dropped the mike on the federal requirements relating to emergency management and the healthcare world. (Press release can be found here; link to the final rule–the hospital requirements start on p. 584 of this oh so fabulous 651-page document. Monsieur Needle, please meet Monsieur Haystack…zut alors!)
Let’s do a quick run-through of the four primary components:
- You have to have an emergency preparedness plan that must be reviewed and updated at least annually.
- The plan must be based on, and include, a documented facility-based and community-based risk assessment, utilizing an all-hazards approach.
- The plan must include strategies for addressing emergency events identified by the risk assessment, utilizing an all-hazards approach.
- The plan must address patient population, including, but not limited to, persons at-risk; the type of services the hospital has ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.
- The plan must include a process for cooperation with the various AHJs’ efforts to maintain an integrated response during a disaster or emergency situation, including documentation of the hospital’s efforts to contact such officials, and when applicable, its participation in collaborative and cooperative planning efforts.
- Develop emergency preparedness policies and procedures that must be reviewed and updated at least annually. The policies and procedures must address the following:
- The provision of subsistence needs for staff and patients, whether they evacuate or shelter in place, include, but are not limited to the following:
- Food, water, medical, and pharmaceutical supplies.
- Alternate sources of energy to maintain the following:
- Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions.
- Emergency lighting.
- Fire detection, extinguishing, and alarm systems.
- Sewage and waste disposal.
- A system to track the location of on-duty staff and sheltered patients in the hospital’s care during an emergency. If on-duty staff and sheltered patients are relocated during the emergency, the hospital must document the specific name and location of the receiving facility or other location.
- Safe evacuation from the hospital, which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s); and primary and alternate means of communication with external sources of assistance.
- A means to shelter in place for patients, staff, and volunteers who remain in the facility.
- A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains the availability of records.
- The use of volunteers in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated healthcare professionals to address surge needs during an emergency.
- The development of arrangements with other hospitals and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to hospital patients.
- The role of the hospital under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials.
- Develop and maintain an emergency preparedness communication plan that must be reviewed and updated at least annually, which includes names and contact information for the following:
- Entities providing services under arrangement
- Patients’ physicians
- Other hospitals and CAHs
- The communications plan must also include contact information for the following:
- Federal, state, tribal, regional, and local emergency preparedness staff
- Other sources of assistance
- The communications plan must identify primary and alternate means for communicating with the following:
- Hospital’s staff
- Federal, state, tribal, regional, and local emergency management agencies
- The communications plan must provide a method for sharing information and medical documentation for patients under the hospital’s care, as necessary, with other healthcare providers to maintain the continuity of care.
- The communications plan must provide a means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii).
- The communications plan must provide a means of providing information about the general condition and location of patients under the facility’s care as permitted under 45 CFR 164.510(b)(4).
- The communications plan must provide a means of providing information about the hospital’s occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee.
- Develop and maintain an emergency preparedness training and testing program that is reviewed and updated at least annually.
- The training program must provide for:
- Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role
- Emergency preparedness training at least annually
- Maintenance of documentation of the training
- Demonstration of staff knowledge of emergency procedures
- The testing program must provide for:
- Participation in a full-scale exercise that is community-based or when a community-based exercise is not accessible, an individual, facility-based. If the hospital experiences an actual natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in a community-based or individual, facility-based full-scale exercise for one year following the onset of the actual event.
- Conduction of an additional exercise that may include, but is not limited to the following:
- A second full-scale exercise that is community-based or individual, facility-based
- A tabletop exercise that includes a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan
- Analysis of the hospital’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the hospital’s emergency plan, as needed.
- The training program must provide for:
- The provision of subsistence needs for staff and patients, whether they evacuate or shelter in place, include, but are not limited to the following:
To be honest, at first blush, I don’t see anything of particularly dire consequence (feel free to disagree; I’m always up for some civil—or uncivil—discourse) unless you’ve done a less-than-complete job of documenting your communications with the various and sundry AHJs (“The plan must include a process for cooperation with the various AHJs’ efforts to maintain an integrated response during a disaster or emergency situation, including documentation of the hospital’s efforts to contact such officials, and when applicable, its participation in collaborative and cooperative planning efforts.”). In fact, it will be interesting to see if TJC backs off of their caveat that tabletops don’t count towards the annual exercise requirement though, as you can see, the tabletop must include some very specific elements.
There is some additional language relating to provisions for stand-by and emergency power that includes providing for generator locations when you build new or renovate (who wants an emergency generator that could end up under water?); maintaining fuel sources during an emergency; testing components in accordance with requirements, etc., but, again, I’m not seeing a lot of indigestion-inciting language. I suppose it is possible that, at the end of all this (I mean, what’s left to tweak), there will be enough certainty in the regulatory fabric to promote a consistent application of the standards, etc. during surveys. Wouldn’t that be nice…
Periodically, the whole concept of adopting plain language codes for emergency response plan activities/activations percolates to the top of somebody’s to-do list (I’d much rather embrace the concept of the to-don’t list, but that’s a discussion for another day). There was a little bit of that (more by inference than anything else) in the CMS follow-up report to the hospital response to Superstorm Sandy. Jeez Louise, that seems like eons ago…
This discussion always seems to engender a lot of back and forth, mostly regarding the balancing act of providing enough information to direct an appropriate response and not providing enough information to cause a panic. I recognize both sides of the argument, but I must say that I haven’t seen a lot of data to support a wholesale change, particularly as it would require a fair amount of education (and yes, I know that just because something requires education, etc., is not enough to forego adopting a new strategy, etc.). But I will also say that, depending on your organizational palette when it comes to emergency notification, all the different codes relative to workplace violence, active shooter, emergency assistance calls, etc., may well benefit from a more succinct announcement.
Recently, the Texas Hospital Association has weighed in with a recommendation to its members to adopt plain language codes, including a sample policy, an implementation timeline, and some examples (you can find that information here). It appears that there’s a move away from the (fairly standard, though not quite universal) Code Red designation for a fire alarm activation to the plainer language (though somehow not quite as sexy) “fire alarm activation.” It does appear that medical emergencies will remain as the (again, fairly standard, not quite universal) Code Blue (I guess that one’s gotten enough play on medically-oriented TV programs to have become part of the vernacular—where are the TV shows about safety in hospitals?!?), but there are some other terms that are worth of consideration. I don’t know that there’s necessarily a groundswell of support, but sometimes Texas can be something of a bellwether, so it may be a good opportunity to look at the possibilities, particularly if you haven’t in a while.
That said, I have two (relatively moderate) concerns. One being we are still waiting on the unveiling of the CMS final rule on all things emergency management; I had thought perhaps that pursuit had become somewhat dormant, but with the adoption of the 2012 edition of NFPA 99 excluding the chapter on emergency management, I think we have to believe that something regulatory this way comes. At any rate, will CMS push for some standardized notification language, particularly as a function of a focus on interoperable communications capabilities? I think that card has been dealt, I guess we’ll have to see how it gets played.
The other concern is the overarching concept of interoperable communication capabilities; I, for one, do not recommend you go about changing anything in terms of notification until you have some talk-time with the local emergency response authorities. They may or may not feel like they have a stake in this discussion, but you want to be absolutely certain that any modifications you might be entertaining will not somehow fly in the face of established protocols, language, etc. Isolationism, particularly when it comes to emergency management, is not likely to be a winning strategy as it usually requires the cooperation of disparate resources. So don’t forget to keep the community folks in the loop—you never know when they might come in handy!
Well, I don’t know that I’m disappointed, per se, but I was expecting The Joint Commission to add something new to its physical environment portal, but that appears not to be the case. I guess this calls for an extended drum roll…
But that’s not to say that our friends in Chicago have not been busy—anything but. In fact, it’s been quite a preponderance of stuff this past few days, starting with the 2015 Top 5 most-cited standards. Anyone who bet the under on findings in the physical environment came up a bit short, but surely that can’t be very much of a surprise. We’ve covered the particulars pretty much ad nauseum, but if there’s anybody out there in the studio audience that has any specific questions regarding our top 5, I would be happy to do so again.
So we have the following:
EC.02.06.01—Maintaining a safe environment
IC.02.02.01—Reducing infection risk associated with equipment, devices. and supplies
EC.02.05.01—Managing utility system risks
LS.02.01.20—Maintaining egress integrity
LS.02.01.30—Building features provided and maintained to protect from fire and smoke hazards
I suppose a wee bit of shifting in terms of the order of things, but I can’t say that there are any “shockahs” (after all, I am from Bawston) in the mix. Again, if someone has something specific they’d like me to discuss, I would be more than happy to do exactly that. Check out the online stuff; alternatively, you can also refer to the April edition of Perspectives.
But wait, there’s more…
We also have some new/updated resources for Life Safety Code® compliance, including guidance on how the facility tour is going to be administered, a comprehensive list of documents that would be included in the survey process, information regarding PFI change and equivalency requests, and a bunch of other stuff. You can find all this information online. Something tells me that, at some point, you may be able to link to all this stuff from the Portal (if that is not already the case, that’s what I would do).
And, to finish off a big week of new information, there is a new posting to help the Emergency Management cause. Namely, some resources having to do with the management of active shooter incidents, etc., featuring the joint resource for healthcare providers issued by the Departments of Homeland Security and Health and Human Services to assist with situational awareness and preparedness in the aftermath of the terrorist attacks in Brussels. The focus/intent being to use recent events as an opportunity to reinforce the importance of vigilance and security in our organizations. It is certainly an area for some concern (and, as always, an area of opportunity) and I think that it is very likely that this will continue to be a big piece of the survey puzzle when it comes to emergency management. The risks associated with acts of violence appear to be relatively unabated in society at large and it comes back to the healthcare safety and security professionals to ensure that our organizations are appropriately managing those risks to the extent possible and working towards an emergency response capability that keeps folks safe.
That’s the wrap-up for this week; not sure if any fireside chats are looming close on the horizon, but rest assured, we will keep you apprised of any and all portal-related activity.
Flexible Spending Account, Federal Student Aid, Food Services of America, Focused Standards Assessment.
So, I am forced to pick one. While I’m sure the lot of them is most estimable in many ways, I suppose the choice is clear: the freaking Focused Standards Assessment (kind of makes it an FFSA, or a double-F S A…what the…).
Just to refresh things a bit, the FSA is a requirement of the accreditation process in which a healthcare organization (I’m thinking that if you weren’t in healthcare, you probably would be choosing one of the other FSAs) reviews its compliance with a selected batch of Joint Commission accreditation requirements. The selections include elements from the National Patient Safety Goals, some direct and indirect impact standards and performance elements, high-risk areas, as well as the RFIs from your last survey—and I know you’ve continued to “work” those Measures of Success from your last survey. Ostensibly, this is very much an “open book” test, if you will—a test you get to grade for yourself and one for which there is no requirement to share the results with the teacher (in this case, The Joint Commission—I really don’t understand why folks submit their results to TJC, but some do—I guess some things are just beyond my ken…).
The overarching intent is to establish a process that enhances an organization’s continuous survey readiness activities (of course, as I see various and sundry survey results, I can’t help but think that the effectiveness of this process would be tough to quantify). I guess it’s somewhat less invasive than the DNV annual consultative visits, though you could certainly bring in consultants to fulfill the role of surveyor for this process if some fresh eyes are what your organization needs to keep things moving on the accreditation front.
I will freely admit to getting hung up a bit on the efficacy of this as a process; much like the required management plans (an exercise in compliance), this process doesn’t necessarily bring a lot of value to the table. Unless you actually conduct a thorough evaluation of the organization’s compliance with the 45 Environment of Care performance elements, 13 Emergency Management performance elements, 23 Life Safety performance elements (15 for healthcare occupancies, eight for ambulatory healthcare occupancies)—and who really has the time for all that—then does the process have any value beyond MBW (more busy work)? I throw the question out to you folks—the process is required by TJC, so I don’t want anyone to get in trouble for sharing—but if anyone has made good use of this process, I would be very interested in hearing all about it.
This is my last piece on the FSA process for the moment, unless folks are clamoring for something in particular. I had intended to list the EPs individually, but I think my best advice is for you to check them out for yourself. That said, I have a quick and dirty checklist of the required elements (minus the EP numbers, but those are kind of etched into my brain at this point). If you want a copy, just email me at email@example.com.
In the interest of time and space (it’s about time, it’s about space, it’s about two men in the strangest place…), I’m going to chunk the EM and LS risk areas that are now specifically included in the Focused Standards Assessment (FSA) process (previously, the risk areas were only in the EC chapter). Next week, I want to take one more chunk of your time to discuss now the FSA process (particularly as a function of what EPs the folks in Chicago have identified as being of critical importance/status). But for the moment, here are the add-ons for 2016:
- participation of organizational leadership, including medical staff, in emergency planning activities (you need to have a clear documentation trail)
- your HVA; (interesting that they’ve decided to include this one—they must have found enough folks that have let the HVA process languish)
- your documented EM inventory (I think it’s important to have a very clear definition of what this means for your organization)
- participation of leadership, including medical staff, in development of the emergency operations plan (again, documentation trail is important)
- the written EOP itself (not sure about this addition—on the face of it, it doesn’t necessarily make a lot of sense from a practical standpoint)
- the annual review of the HVA (my advice is to package an analysis of the HVA with the review of the EOP and inventory)
- annual review of the objectives and scope of the EOP
- annual review of the inventory
- reviewing activations of the EOP to ensure you have enough activations of the right type (important to define an influx exercise, as well as, a scenario for an event without community support)
- identification of deficiencies and opportunities during those activations—this means don’t try to “sell” a surveyor an exercise in which nothing went awry—if the exercise is correctly administered, there will always, always, always be deficiencies and/or opportunities. If you don’t come up with any improvements, the you have, for all intents and purposes, wasted your time… (Perhaps a little harsh, but I think you hear what I’m saying)
- Maintenance of documentation of any inspections and approvals made by state or local fire control agencies (I think you could make a case for having this information attached to the presentation of waivers, particularly if you have specific approvals from state or local AHJs that could be represented as waivers)
- Door locking arrangements (be on the lookout for thumb latches and deadbolts on egress doors—there is much frowning when these arrangements are encountered during survey)
- Protection of hazardous areas (I think this extends beyond making sure that the hazardous areas you’ve identified are properly maintained into the realm of patient spaces that are converted to combustible storage. I think at this point, we’ve all see some evidence of this. Be on the lookout!)
- Appropriate protection of your fire alarm control panel (for want of a smoke detector…)
- Appropriate availability of K-type fire extinguishers (this includes appropriate signage—that’s been a fairly frequent flyer in surveys of late)
- Appropriate fire separations between healthcare and ambulatory healthcare occupancies (a simple thing to keep an eye on—or is it? You tell me…)
- Protection of hazardous areas in ambulatory healthcare occupancies (same as above)
- Protection of fire alarm control panels in ambulatory occupancies (same as above)
I would imagine that a fair amount of thought goes into deciding what to include in the FSA (and, in the aggregate, the number of EPs they want assessed in this process has gotten decidedly chunkier—I guess sometimes more is more), so next week we’ll chat a bit about what it all means.
Very much a quick peek this week at more of the latest offerings from our friends in Chicago as they turn to some updated emergency management references. For those of you that have not yet book marked it, first and foremost, you can find the Joint Commission Emergency Management portal here. The portal homepage includes links to information already published, including a Q&A blog from John Maurer’s 2013 presentation at the JCR Annual Ambulatory Care Conference; while the questions primarily relate to ambulatory settings, some of the general concepts certainly carry over. As I look over the materials, I hope that Mr. Maurer finds more opportunities to write (maybe he could fill in for Mr. Mills once in a while); I don’t know about you, but I like to read different “voices” from time to time and I’ve always found Mr. Maurer very informative and useful in helping folks understand what compliance can look like. At any rate, three’s lots of links to lots of stuff—definitely worth checking out (though I will say that perhaps it’s time to remove the 2013 date from the Joint Commission requirements section at the bottom of the home page; I know that 2013 was the last time that the standards were revised, but it makes things look a little dated).
So, on to the new stuff. First up is an update of general references; this includes links to the CDC Hospital Disaster Preparedness Budget Model, which is an Excel-based tool to assist in estimating resource needs across key departments and to help calculate funding reserves that would be needed for response and recovery (I think a lot of folks are good on financing response, but I’m not so sure about recovery—what say you?). Also, there’s a link to ASPR TRACIE (Technical Resources Assistance Center and Information Exchange—which came first, the acronym or the title?), which aims to provide “timely and innovative disaster information, tools and practice guidance for hospitals and community-based providers”; as well as a link to a Religious Literacy Primer for Crises, Disasters, and Public Health Emergencies. Finally for this page, there’s a link to the 5th edition of the Hospital Incident Command System Guidebook, so, basically, the latest and greatest IC stuff. I still think that the toughest thing about IC is getting consistent buy-in from leadership (sometimes it’s hot, sometimes it’s not), but perhaps edition #5 has the key to their hearts.
Lastly, but certainly not leastly, we have some information regarding the management of vulnerable populations, which can be found here.
There is a wide-ranging batch of information here (I would have liked to see a little more for adult behavioral health; they do touch on the pediatric behavioral health population, but maybe that will be in future missives), much of which I think you’ll find pretty helpful, if only to prompt discussion of the various populations served by your organization.
As with any materials published/shared by TJC, there is always the potential that surveyors will start to equate compliance with each organization’s efforts in dealing with this wealth of information. As always, not everything published is going to be as effective everywhere, so it certainly comes down (back?) to the individual organization’s to determine what preparedness looks like for their organization (and it never looks the same across organizations—even organizations that are in the same system). Emergency preparedness is very much a customizable undertaking—one size fits all does not apply very effectively across organizations (in fact, it would be much closer to one size fits none). You know what works best in your house (and, of course, you used the risk assessment process to make that determination, you clever boys and girls!), so don’t be afraid to set something aside because it is not a good “fit” for your organization. You are the best judge of what you need to do, have in place, educate for, etc. Be confident (but not cocky—that never plays well during a survey…).
I couldn’t find any indication that I’d covered this before (mea culpa, mea maxima culpa), so it’s probably past time—but it’s a pretty quick one. One thing to put on the pre-survey to-do list is to inspect the environments in which your emergency generator (or generators, if you are fortunate to have multiples) are located and check to see if you have battery-powered emergency lights in those locations. Now, you can correctly indicate that there is no TJC requirement to have battery-powered emergency lights in emergency generator locations—and you’ll get no disagreement from me. However, as an Authority Having Jurisdiction, The Joint Commission can indeed cite you for not having them, based on the introduction of this requirement (I will use the 2010 edition of NFPA 110 for the source on this; other editions of 110 include this requirement, but for this discussion, we’ll say NFPA 110-2010: 7.3.1).
Also, you probably want to be sure that you have battery-powered emergency lighting in any other spots that might benefit from some illumination if your generator fails and you need to do some work (I’m thinking transfer switch locations would be good). At any rate, I think it makes perfect sense (even if it weren’t required somewhere) to have provisions in place for providing illumination to certain areas if your generator poops out. (I’m almost certainly over-simplifying this, but I think the key piece of this is to look and see what you have and make sure that you can effectively deal with an equipment failure that results in very little in the way of illumination).
One of the most interesting parts of my job is helping folks through the actual Joint Commission survey process. Even as a somewhat distant observer, I can’t help but think that the average survey (in my experience) is about a day longer than it needs to be. Now, I recognize that some of that on-site time is dedicated to entering findings into the computer, so I get that. But there are certain parts of the process, like, oh I don’t know, the EC/EM interview session, that could be significantly reduced, if not dispensed with entirely. Seriously, once you’ve completed the survey of the actual environment, how much more information might you need to determine whether an organization has its act together?
At any rate, I suppose this rant is apropos of not very much, but the thought does occur to me from time to time. So I ask you: is there anybody out there who feels the length of the survey was just right or, heaven forbid, not long enough? As I’ve always maintained, TJC (or, for that matter any regulatory survey type—including consultants) tend to look their best when you see them in the rear view mirror as you drive off into the future. I know the process is intended to be helpful on some level, but somehow, the disruption never seems to result in a payoff worth the experience. But hey, that may just be me…
Any thoughts you’d like to share would be most appreciated.