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I saw Mommy kissing the senior engineer…

Late last week, The Joint Commission provided information regarding the mid-term edition of this year’s Survey Activity Guide (SAG—and no, I will not make any gratuitous remarks about that particular acronymic confluence…), which includes “new description for Facility Orientation-Life Safety Surveyor and minor revisions to Environment of Care Session and Life Safety Building Tour for hospitals and critical access hospitals.”

While the minor revisions to the Environment of Care session and Life Safety building tour are indeed just that (with one exception that you already know about—more in a moment), it appears that Santa Mills has left us a nice little package under the Christmas in July tree: a new Life Safety and Environment of Care Document List and Review Tool (just think, kids—now you can survey like a real surveyor!). While I jest a wee bit (jester that I am), I do think that this is a pretty useful thing for the good folks in Chicago to be sharing. I think you’ll find the tool may give you a sense of “what” they’re looking for in terms of documentation; it also contains a nifty little typographical error. Let’s see who has the eagle eyes out there in radioland…

The one change that is a little more than minor (if only for its far-reaching consequences in surveys the past 18 months) is the instruction for surveyors to assess operating rooms for proper pressure relationships. I guess highlighting it in the new SAG means that there were some surveyors who weren’t checking the ORs for proper pressure (or perhaps some hospitals who were surprised that it happened—hey, that’s not in the book!?!). At this point, it seems hard to imagine anyone in the industry that isn’t expecting this, but I suppose stranger things have happened. As I’ve said probably too many times, they are getting a lot of mileage out of this, so best to be on one’s toes in the management of the procedural environment.

Also, one other item: they’ll be requesting a list of all the locations in your organization in which high-level disinfection and sterilization are in use, so you’d best be keeping an eye on OPA usage out in the hinterlands of your organization. You wouldn’t want a pesky surveyor finding one of your clinic sites using OPA without your knowledge (and appropriate environmental management—air pressure, eyewash stations—I think you know the drill on this stuff).

At any rate, this link will take you to the download page, if you’ve not already opened the “present.”

Happy survey prep!

Meet the new Survey Activity Guide, same as the old Survey Activity Guide (with apologies to the ‘Orrible ‘Oo)

Sorry I’m a little tardy on this one. I’ve been juggling a bunch of blog ideas and this one faded to the back of the pack a bit.

Back in January (and it seems so very long ago, perhaps due to the lovely weather we’re experiencing in the Northeast), The Joint Commission released the 2015 Survey Activity Guide, which details the ebb and flow of the survey process. Fortunately, they always identify a means of determining what is new (presumably as a function of 2014 Guides and so on), so I always look for any changes to the EC/EM/LS troika to see if anything funky has come to the fore.

Strangely enough, there are three documents that are indicated as being “new” that I’m pretty sure have been in the mix for at least a little while: your written fire response plan, your Interim Life Safety Measures Policy, and your fire drill evaluations. To fact-check myself, I went back to the 2013 SAG (I was a little lazy and skipped the 2014) and sure enough, all three were identified as “new” to the mix back then (I don’t seem to have a copy of the 2012), so no big surprises on the document front.

Likewise, the EC/EM interview sessions appear to be consistent with survey practice for the last couple of survey cycles. To be honest, I’m not entirely convinced that there’s a lot of exposure for organizations during these sessions, so long as the group is “chatty.” I think a good measure of how well you’re doing is in inverse proportion to the number of questions the surveyor has to ask to keep things moving. Strictly speaking, these sessions are designed to gain information on how organizations manage risk/respond to emergencies and how planning and preparedness activities function as a means of improving the various component programmatic elements. You should be able to discuss how the program has gotten “bettah” (I like to inject a little of the Bostonian vernacular from time to time), with an eye towards the use of data to demonstrate/support the notion that things have improved. I’ve not heard of anyone getting in trouble during these sessions, but I suppose there is always the potential for some misfortune. I think as long as there is recognition that compliance is a journey and not a destination, folks will be comfortable describing that journey (including setbacks) with winning survey results.