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Inadvertent inundations: Oh, what fun! 2017 most frequently stubbed toes during survey!

As luck would have it, the latest (April 2018) edition of Perspectives landed on the door step the other day (it’s really tough to pull off the home delivery option now that it is an all-electronic publication) and included therein is not a ton of EC/LS/EM content unless you count (which, of course, we do) the listings of the most frequently cited standards during the 2017 survey season. And, to the continued surprise of absolutely no one that is paying attention, conditions and practices related to the physical environment occupy all 10 of the top spots (I remain firm in my “counting” IC.02.02.01 as a physical environment standard—it’s the intersection of IC and the environment and always will be IMHO).

While there are certainly no surprises as to how this list sorts itself out (though I am a little curious/concerned about the rise of fire alarm and suppression system inspection, testing & maintenance documentation rising to the top spot—makes me wonder what little code-geeky infraction brought on by the adoption of the updated Life Safety Code® and other applicable NFPA standards has been the culprit—maybe some of it is related to annual door inspection activities cited before CMS extended the initial compliance due date), it clearly signals that the surveying of the physical environment is going to be a significant focus for the survey process until such time as it starts to decline in “fruit-bearing.” I do wish that there was a way to figure out for sure which of the findings are coming via the LS survey or during those pesky patient tracer activities (documentation is almost certainly the LS surveyor and I’d wager that a lot of the safe, functional environment findings are coming from tracers), but I guess that’s a data set just beyond our grasp. For those of you interested in how things “fell,” let’s do the numbers (cue: Stormy Weather):

  • #1 with an 86% finding rate – documentation of fire alarm and suppression systems
  • #2 with a 73% finding rate – managing utility systems risks
  • #3 with a 72% finding rate – maintenance of smoke and other lesser barrier elements
  • #4 with a 72% finding rate – risk of infections associated with equipment and supplies
  • #5 with a 70% finding rate – safe, functional environment
  • #6 with a 66% finding rate – maintenance of fire and other greater barrier elements
  • #7 with a 63% finding rate – hazardous materials risk stuff
  • #8 with a 62% finding rate – integrity of egress
  • #9 with a 62% finding rate – inspection, testing & maintenance of utility systems equipment
  • #10 with a 59% finding rate – inspection, testing & maintenance of medical gas & vacuum systems equipment

Again, I can’t imagine that you folks are at all surprised by this, so I guess my question for you all would be this: Does this make you think about changing your organization’s preparation activities or are you comfortable with giving up a few “small” findings and avoiding anything that would get you into big trouble? I don’t know that I’ve heard of any recent surveys in which there were zero findings in the environment (if so, congratulations! And perhaps most importantly: What’s your secret?), so it does look like this is going to be the list for the next little while.

What is it they say about the best-laid plans? A chortle-free, portal-free zone!

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.

Welcome Spring!

Don’t be a Haz-been (or perhaps Haz-not would be more appropriate…)

I would like to take this opportunity to draw your attention to the two most recent issues of Perspectives, for a couple of reasons. First, as the articles (part 1 and part 2) deal with EC.02.02.01, which is on the top 10 list for most-cited standards during 2015, and Joint Commission interpretation relative to the wonderful world of hazardous materials (and it is, indeed, a wonderful world). Second, these articles introduce a new “voice” into the mix, Kathy Tolomeo, CHEM, CHSP, who is one of the engineers at The Joint Commission’s Standards Interpretation Group and is one of the folks in Chicago who reviews clarifications, ESC submittals, perhaps (presumably) PFIs, etc. In that context, I think it’s important to have a sense of how individual reviewers “see” the regulatory compliance landscape, and these articles provide some sense (I will stop short of saying insight) of compliance strategies.

As a starting point, those are good reasons to check out the articles. But I also found these articles particularly helpful in that compliance strategies are discussed in some detail (I mean the articles are only a couple of pages long, so there are limits to how much detail), including an example (in the December Perspectives) of a hazardous materials inventory form, which I think paints a very nice (and perhaps most importantly, clear) picture of what you need to have in place (I’ve encountered a lot of folks struggling with what is expected for the HazMat inventory). There are discussions of eyewash stations and lead PPE, ventilation, and risk assessments (imagine that!) in the December Perspectives; the January issue covers hazardous gases and vapors, permits, licenses, manifests, and other documentation, labeling, monitoring for radiation exposure, proper routine storage, and prompt disposal of trash.

I guess you could say it’s a bit of hodgepodge in terms of ground covered, but that is the wonderful world of hazardous materials and waste. Check out these articles and maybe, just maybe, you can keep yourself off this year’s (or next year’s, depending on when you’re going to be surveyed) Top 10 list.

Same as it ever was… same as it ever was… same as it ever was…

As the back-to-school sales reach their penultimate conclusion, I look back on the year so far and am amazed at how quickly we’ve blown through fully two-thirds of 2015—yow! For a while it seemed like winter was never going to release us from its icy grasp and now we’re looking forward to its return, so I guess we have naught to do but look forward towards the onslaught of 2016. I hope, for all our sakes, it is a kinder and gentler new year.

But before the past little while takes on the rosy hue of nostalgia (as it almost always does), our friends in Chicago have provided an excellent opportunity to reflect on the “sins” of the past by revealing the most frequently cited standards during the first six months of 2015. And to almost no one’s surprise, four out of the top five most frequently cited standards (at the moment, the “reveal” is only for the top five—I guess we’ll find out about the rest of the top 10 at some point) are smack dab in the middle of the management of the physical environment, with the top three most frequently cited standards for hospitals being EC.02.06.01 (#1 with 59% of hospitals surveyed being cited), IC.02.02.01 (#2 and 54%) and EC.02.05.01 (#3 and 53%; looks like a real fight for that #2 spot), all of which reflect elements tying together the management of the physical environment with the control and prevention of infection (not everything cited is in the physical environment/infection control bucket, but from what I can gather, rather a fair amount is related to just that).

At this point (and I full recognize that this is a rather reiterative statement), I’m going to crawl out on a limb and say that the single greatest survey vulnerability for any (and every) healthcare organization is the management of the surgical/procedural/support environments. The hegemony of this aspect of the survey (and regulatory compliance) process comes very close to defying understanding. At this point, there’s no real surprise that this is an (if not the, and I would argue “the” is the word) area of intense survey scrutiny, so what’s the deal?!? Forty percent of the hospitals surveyed from January to June appear to have done okay on this, or is that number really a red herring? It would not surprise me that 100% of the hospitals surveyed ran afoul of one of the top three. Anybody out there surveyed so far this year that managed to escape, relatively, scott-free on this?

I’ve certainly done a lot of yammering in this regard over the past few months (years?) and it appears that I am raging against the dying of the light to minimal effect. I have a lot of ideas about this, but I guess I’m putting it out there: has anybody really got this under control? I think we all have a stake in this thing and the sooner we can get our hands on an effective process for managing this, the better. I will admit that it is entirely possible that, particularly given the age of a lot of hospital infrastructure components, this is not going to go away until they stop focusing as much on it. At this point, I haven’t run into too many folks that have been cited under the big three for whom infection rates are anything other than what would normally be expected—though perhaps infection control rates are higher than they “should/can” be—I guess we could be in the midst of a paradigm shift on this. I don’t want to have to wait to find out.

Letting the days go by…

Hair Plugs? Heck, No! Shameless Plugs? That’s another story!

While I would never want to be accused of overusing my little bully pulpit, I did want to bend your ears a bit by way of encouraging you to really consider signing on for next week’s webinar, Surgical Environment Compliance: Meet CMS and Joint Commission Requirements. The program is on Friday, May 8 @ 1 p.m. EDT (you can register here). Plus (and this may really sweeten the pot), I’m not the only speaker, so you won’t have to listen to me yap for the whole program. Sounds like a win to me…

To catch up a bit, I haven’t yet given you a rundown on the most frequently standards during TJC surveys in 2014 as there were some other pretty compelling topics (at least in my mind)—mostly because the year-end tally looked so very much like the mid-term results I figured the sense of urgency might not be quite as acute as it could be. But an interesting thing is happening in 2015 and it keys very much on the top three most-cited standards: EC.02.06.01, EC.02.05.01, and IC.02.02.01, all of which figure in the management of environmental conditions in (you guessed it!) in surgery (and other procedural areas). By the way, as a quick aside, who would ever have guessed that the EC-related standard to go to #1 on the charts wouldn’t have been Integrity of Egress (LS.02.01.20), which sits at a lowly #4. It’s almost like a boy band past its sell-by date, but I digress.

TJC is still looking at the issues related to the surgical/procedural environment and, doggone it, they’re still finding stuff that’s getting folks into trouble (that is, if you think, as I do, that having to endure a second visit from the Joint is rather more troublesome than not). I won’t tell you that I have a magic bullet for this, but my colleague Jorge Sosa and I will be discussing how this issue fits into the grand scheme of things as well as hopefully helping identify the potential pitfalls. And, perhaps most useful of all, you’ll have the opportunity to ask questions that may be the difference between sailing through your next survey or getting hung up because one portal in your OR isn’t pressurized in the right direction (and believe me, it happens way more than you probably think). Lots of stuff to consider and the time and place to consider it.

Be there or be somewhere else that won’t be nearly as entertaining (unless you’re not at work…)

A change will do you good…but what about no change? Exact change?

I’m sure you’ve all had a chance to look over the April 2014 issue of Perspectives, in which EC and LS findings combined to take seven of the top 10 most frequently cited standards during 2013, with issues relating to the integrity of egress taking the top spot.

At this point, I don’t think there are any surprises lurking within those most frequently occurring survey vulnerabilities (if someone out there in the audience has encountered a survey finding that was surprising, I would be most interested in hearing about it). The individual positions in the Top 10 may shift around a bit, but I think that it’s pretty clear that, at the very least, the focus of the TJC survey process has remained fairly constant these past couple of years.

Generally speaking, my sense about the TJC survey cycle is that specific focus items tend to occur in groups of threes (based on the triennial survey cycle, with the assumption being that during each three year period, every hospital would be surveyed—and yes, I do know what happens when you assume…) and I think that 2013 may well represent the end of the first go-round of the intensive life safety survey process (I really believe that 2009-2010 were sort of beta-testing years). So the question I have for you good citizens of the safety world: Has anyone been surveyed yet this year? With follow-up questions of:

  • Did you feel you were better prepared to manage the survey process this time?
  • Was the survey process different this time?
  • More of the same?
  • More difficult?
  • Less difficult?

I’m hoping to get a good sense of whether the tidal wave of EC/LS findings has indeed crested, so anyone interested in sharing would have my gratitude. Please feel free to respond to the group at large by leaving a comment here or if you prefer a little more stealthy approach, please e-mail me at or