RSSAll Entries Tagged With: "The Joint Commission"

Update: Defunct Links to/in the FAQ-niverse!

Greetings, fellow travelers!

With special thanks to Claire Rebouche for bringing this to my attention, it appears that the links to the new ligature risk FAQs that appeared in this week’s blog post no longer direct you to the content of the latest information (I swear to you that the links were working Monday), but rather direct you to the FAQ homepage. Now, that wouldn’t be such an awful thing if the latest FAQ (for the record, TJC describes it thusly: “Ligature Risks – Assessing and Mitigating Risk For Suicide and Self-Harm”) were readily discernible, but alas (at least for the moment), this particular FAQ is among the missing.

Rest assured, top people are working on trying to find out what’s going on, and hopefully this is but a temporary circumstance (I figure if we can’t find the information, the surveyors might be having a tough time as well—helps to level the playing field). One other thing to note is that where previously the ligature-related FAQs could be found in the EC section of the FAQ homepage, they’ve all been moved to the NPSG section (and, interestingly enough, increased the number of FAQs dealing with ligatures to just over 20), so you may want to keep an eye on any changes in that section (from a practical standpoint, I understand the shift, but I don’t know that they couldn’t have shown up in both sections as a transition, though perhaps they did—I don’t spend a lot of time monitoring the NPSG section of the FAQ page).

At any rate, what I suspect may be happening is that, in their efforts to “clean up” the FAQ page, it would seem that some of the internal links are no longer working, so I’m hoping that we’re just working through a funky transition period and everything will be up and running soon.

That said, there are a couple of other new items relative to the management of this at-risk patient population that I want to share (while they are still available): this one and this other one, which deal with how the process for managing at-risk patients can result in catastrophic gaps in care. I think they’re pretty straightforward in terms of information, but with everything else going on this week, I would encourage you to check ’em out sooner rather than later.

Déjà vu all over again: A new ligature resistant FAQ!

Using the Hospital FAQ page as the baseline, I reckon we’ve got about a dozen FAQs dealing with ligature resistance with this latest offering. For some reason, the “visual” I get from all of this FAQing is the difference between looking at something from a distance (for example, a celestial body) and seeing that same thing up close and personal. What started out as a sphere of incomprehensibility has become (slowly, ever so slowly, over time) a much more nuanced endeavor—an endeavor that continues to represent survey vulnerabilities for accredited organizations.

One of the interesting things to me is how the narrative has evolved over the last couple of years relative to how hospitals are to deal with all the intricacies of managing ligature risks as a survey vulnerability (which is different than managing the risks to patients, but more on that in a moment). This FAQ reveals some specifics as to what you are required to include in the mitigation strategy for those risks that are not yet removed/resolved/corrected/adjudicated, etc. Now, I don’t know that this is truly ground-breaking stuff, but I think this is cray-cray important because this is what the surveyors are going to be looking for, both in terms of structure, but also as a function of an ongoing process. I’m not going to quote verbatim from the FAQ. I know youse guys are excellent readers and such, so a quick summary:

  • Leaders and staff have to know what risks are currently in the mix and somebody has to be responsible for telling them (and documenting that they were told…)
  • Identification of patients at risk for suicide/self-harm, with appropriate risk-based interventions
  • A process for ongoing assessments and reassessments of organization-defined at-risk behavior
  • Staff education re: management of patient risk and implementation of appropriate interventions
  • Ensuring this whole program/process is integrated into the organization’s quality assurance/performance improvement (QAPI) program (sounds like it might be a good time to include this as a standing agenda item at your QAPI committee meetings)
  • Making sure that any equipment that poses a risk, but is necessary for safe treatment of behavioral health patients (the example given is medical beds with siderails on a geriatric unit), is considered, as a risk, in the patients’ overall suicide/self-harm risk assessments, with appropriate interventions to minimize the identified risks

As I reflect over the seemingly endless amount of survey angst that this topic has wrought over the past couple of years, I keep coming back to the reality that while we can always do better (would we have done as much as quickly without enduring survey bludgeoning?), there is minimal data to support that, while not perfect, hospitals were not doing a good job in managing these at-risk patients. Purely from a risk management perspective, this would be a subject of great interest and concern to any healthcare organization as the burden of managing these patients has shifted over time. I suppose it ultimately gets filed under the “abdication of responsibility” that comes with the disenfranchising of difficult patient demographics and the subsequent “arrival” of those patients in the acute care settings, but it seems to me that (and yes, I recognize that this is part of doing business in healthcare) a little more collaboration during this process (as opposed to pointing fingers and assigning “blame”) might have yielded a better end-product. Hopefully, at some point, we will be given credit for the good work that has been done (and quantified), but I don’t think we are quite there yet.

Don’t Call It A Comeback: The Statement of Conditions breathes again!

Not a whole lot going on in the July 2019 issue of Perspectives, but it appears that a little more consideration will need to be paid to the Statement of Conditions (SOC) and Basic Building Information (BBI) sections of The Joint Commission’s web portal for hospitals and other healthcare organizations. The article in Perspectives indicates that we can expect some changes to the questions asked in the BBI section, though the only specific indication thus far is that the questions relating to square footage of your buildings will be aimed at obtaining greater specificity of information, ostensibly to aid in the planning of survey visits. The impression I always had when it came to the square footage ranges was that they tended to “look” at the upper end of the range information, sometimes “encouraging” additional survey days when they might not necessarily have been warranted. My consultative recommendation to folks was to use the comment section to indicate the precise (or would “exact” be the more appropriate descriptor?) square footage so there would be minimal potential for extra survey days. Should be interesting to see how this all shakes out over the next few months as more “reveals” make themselves known.

In other news, the next edition (2022—can you imagine!?!) of the FGI Guidelines for the Design of Healthcare Facilities is in the development pipeline and the good folks at FGI are looking for comments/suggestions to aid in that development, but the window for doing so is quickly closing. You can check out the skinny here, but please know that the comment, etc., period ends on June 30. So if you have some burning thoughts/suggestions for how we will be managing our future facilities (including renovation activities), now is the time for all good safety professionals to come to the aid of their craft (or something like that…).

To close out this week’s chatter, I would encourage you to (yet again!) check out Tim Richards’ blog regarding medical gas certifications and qualifications. As you’ve no doubt noticed, the ongoing codification of everything has really “leaned” into staff competencies and qualifications, sometimes to the point of really muddying the waters as to what really is required. When it comes to medical gas stuff, I don’t know that you’ll be surprised, but it might be useful information to share with your boss (or your boss’s boss). Check it out here.

Wishing each of you a most festive and safe Independence Day!

One size fits all…or one size fits none

In a world in which the economies of scale don’t always economize, I keep running into situations and/or conditions that result from trying to make something do too much. The classic example (other than those one-size-fits-all bunny suits in ORs across this great land of ours—I always end up looking like late-model Elvis, Vegas edition) is the temperature log that is used for food refrigerators, medication refrigerators, etc. As a general rule of thumb, unless the temperature range for each of the refrigerators being monitored is the same (and never mind trying to mix Fahrenheit and Celsius), then you are just asking for trouble. “Pushing” staff to have to discern between competing “out of range” temperature values requires an almost infinite amount of attention, and while there is, in certain instances, some overlap (food is usually 33-40 degrees F and medication 36-46 degrees F, so 36-40 works for both), it just makes so much more sense to limit confusion to the extent possible. And, to my mind, that means individualized temperature logs. One quick note regarding temperature logs for freezers, if your log doesn’t have a temperature “safe” range clearly indicated, I’ve been seeing a lot of mix-ups regarding those pesky negative numbers. For instance, if you establish a target of -15 degrees or colder, -10 degrees would be considered an -out-of-range value, but in talking with the folks doing the monitoring, they “think” of “10” being less that “15,” kind of missing the whole negative number dynamic. I won’t say that this is happening everywhere, but I have run into it in a couple of instances, so that’s something to keep an eye on.

Turning to the Oddities page, I was cruising through The Joint Commission’s FAQ page (admittedly, looking for blog fodder) and came across something of a puzzle; in the text of the FAQ dealing with the “old” requirement of the building assessment as a function of the Statement of Conditions (the old Part 3, which is no longer available) and has not been since 2007. But if you look at the text of LS.01.01.01, the second performance element indicates that a building assessment is required (at time frames to be determined by each organization) to determine compliance with the Life Safety chapter of the Joint Commission manual. I guess the thing that struck me about this happenstance is that the FAQ would have a good opportunity to indicate that the building assessment has evolved (or mutated—your pick) into its present day purpose  as an exercise in assessing your building for compliance with the LS chapter. Maybe they just haven’t gotten around to updating this FAQ (it is a ways down the FAQ page), and I suppose it is no more than a curiosity.

Making stock, taking stock: Emergency inventory madness!

In trolling The Joint Commission’s FAQ page for interesting tidbits to share, I came across the entry regarding the thought process around the establishment of an emergency inventory. Some interesting takes on certain aspects of the emergency inventory concept—it doesn’t “have” to be centralized, in recognition of “just in time” purchasing and the importance of being able to use stock with a shelf-life (it would not be good to have your EM supplies expire because they were earmarked solely for emergency response).

The FAQ goes on to recommend tracking assets and inventory for a year to ascertain what your organization’s capabilities and needs might be. But I’m trying to figure out how that “recommendation” (recognizing that the FAQs can be invoked at the level of standards-based requirement) dovetails with the “requirement” for an annual “review” (I remain stymied by the use of “review” as opposed to evaluation; it may just be me, but a review doesn’t have the same action level as an evaluation but perhaps they are to be considered synonymous) of the inventory of resources and assets needed during an emergency. My thought would be that you would be looking at how resources and assets are managed on an ongoing basis and that information used to ensure that the organization has what it needs and has the ability to procure additional resources and assets should it experience a prolonged emergency.

I think the key thing to keep in mind (as when one is addressing each of the TJC-anointed critical functions) is to ensure that for each exercise or actual implementation, there is a process in place for evaluating performance in each of those areas. Someone should be looking at:

  • Communications
  • Staff roles and responsibilities
  • Safety/security
  • Utilities
  • Patient care activities
  • The management of resources and assets

And those someones (whoever they may be) need to be particularly forthcoming because (as we have learned over the years) it is not so much about what went right as it is about what opportunities can be identified to make the next time better. Too many times I’ve encountered folks that are reluctant to “air out the dirty laundry.” Identifying potential vulnerabilities is never a bad thing (true, it can make for some difficult discussions), it is the only thing.

He held his head in his hands: Outpatient/Offsite Vulnerabilities

Being something of a quiet week on the compliance front (as we embrace the “dog days” of summer—and spring’s got 10 or so days to go), I wanted to use a recent Joint Commission announcement relative to Environment of Care standards relating to fluoroscopy as they apply to outpatient/office-based surgery practices (which seems rather more logical than not, particularly when one reflects on the Conditions of Participation requirements relating to the management of imaging equipment). You can find the particulars here, but I don’t think that there’s anything that’s going to come as a surprise. To my mind, why would the expectations be any different based on where the equipment “lives”? Just as there must be continuity of care, there must also be continuity of compliance.

Now one could certainly disagree as to how much of a sea change this represents relative to the survey process, but (and I’m going out on a limb here, but it’s a very, very stout one) I think the next significant survey “beachhead” (mixing all sort of metaphors today) is going to be all those pesky little physician practices and clinics and such that dot the landscape and are covered by the “umbrella” of hospital operations (you know, offsite locations that have become “departments of the hospital”). If we accept the premise that the primary goal of the survey process is to generate as many findings as possible (and I accept that premise—the evidence doesn’t really point to much else), then the likelihood of the regulatory folks looking for areas with greater levels of vulnerability seems, again, rather more logical than not.

At any rate, my best advice to those of you with these types of sites is to really kick the tires when you’re rounding. As you are no doubt aware, there can be a lot of resistance when compliance comes to the hinterlands (think about how much angst fire drills can generate!), but the stakes for non-compliance have never been greater and, for the record, one can never be too safe…or too compliant!

Secret Club for Members Only: Some FAQing for your reading pleasure

This week finds us (once again) visiting with our friends from Chicago as they stand astride the accreditation world like some ancient colossus. (I am hopeful that my purple prose will subside at this point, but sometimes the fingers take me in odd directions.)

First up, we have some additional guidance relative to how one might go about managing compressed gas cylinders, particularly those pesky oxygen cylinders that can cause so much grief during survey. So now we have a Joint Commission performance element that establishes the expectation that each organization will have a policy regarding the storage of oxygen and other compressed gas cylinders, said policy is to include the amount of gas at which segregation of full and empty cylinders would take place. You may recall that the initial “take” required full cylinders to be segregated from empty and partially full cylinders, but that “interpretation” of NFPA 99 has shifted a bit to allow for the storage of partially full cylinders in the company of full cylinders.

And now, we have a new FAQ that provides some guidance relative to how one might go about determining the amounts representative of full/partial/empty, depending on whether the cylinder(s) you are using have an integral pressure gauge. The FAQ also introduces the concept of “depleted volume content,” which ( as near as I can tell), is the amount of gas left in the cylinder that requires storage with the empty (as opposed to the full) cylinders. There is also a (maybe) handy table that walks you through the various segregatory considerations—I’ll let you parse those in your spare time.

My takeaway is that you need to make sure that if your current policy (if you don’t have one, it is a standards-based requirement, so best get on it) doesn’t pretty closely mirror how things shake out in this FAQ, you should consider modification of current policy/practice or be prepared to discuss how what you’re doing to be in compliance with the NFPA 99-2012 requirements. The other “thing” I noticed is the discussion of the labeling of empty cylinders as a function of the segregation process—if you have the empties in a separate rack that is labeled as such, then you should be fine. But if you have a single rack with full and empty cylinders cohabitating, then the empty cylinders have to be labeled; unfortunately, this does not appear to allow for the marking of the rack itself (I’ve seen red tape and red paint to identify the empty “slots”), so if that’s your practice you might get some pushback from a literalist surveyor looking for the empty cylinders to be labeled.

Next up, we have some information relative to the management of behavioral health patients, in this case, discussions of the various methodologies for determining the risks of each patient to be managed. I do believe that the regulatory focus on environmental considerations will start to diminish somewhat as we kick into the “next” survey cycle,  but I believe that the focus on the management of at-risk patient populations will continue as a function of: now that we have a “safer” environment, how are we making sure that the patients are being appropriately cared for, which is driven by the assessment process. Assessment stuff can be found here.

As an additional piece of the puzzle (I guess time will tell whether it is more piece than puzzle or the reverse…), TJC has established an information portal to assist organizations in compliance with the July 1, 2019 changes to the National Patient Safety Goal on Suicide Prevention, including links to the issues of Perspectives in which the initial (and ongoing) guidance, etc. can be found. As a one-stop-shop, it looks like a pretty useful thing to have in your back pocket. As I’ve noted any number of times (and I think once or twice in this forum), a lot of the TJC surveyor knowledge comes to them the same way it comes to you, so I think it a positively splendid idea to take a gander at the links contained herein.

Carbon-dating compliance: What happened when…

…and how responsible are you for the sins of the past (turns out, quite a bit).

Kind of a mixed bag of things this week, so please bear with me.

First up, in looking back over the last little while of survey activity, I keep looping back around to one (possibly unanswerable) question: How many of the survey findings being generated are the result of conditions that pre-existed the prior survey? I think we can all agree that there are noncompliant conditions lurking throughout our buildings (including that pesky loaded sprinkler head we talked about a couple of weeks ago), some of which (and perhaps quite a few) are the result of actions or inactions occurring a long time ago (in a galaxy almost too close to home). I’m going to guess there are few of us that have not encountered the angst of having a surveyor pop a ceiling tile or wriggle into some crawl space and find some condition that had previously escaped prying eyes (I suspect that the most common previously undetected finding relates to things attached to sprinkler piping and supports, which supports LS.02.01.35 being the most frequently cited Joint Commission standard). And, as onerous as it may be on the face of it (and every other aspect), we are on the hook for all of it (grandfathering of conditions can help in very limited ways, but there’s really very little in the way of grandfathering noncompliant conditions and practices).

For better or worse (likely more the latter than the former), in these increasingly resource-challenged times, it is almost impossible to ferret out every little imperfection. Particularly in the sense that noncompliance happens in three dimensions—square footage just doesn’t work for this process. So, the questions I ask of you, dear readers, are these:

  • Do you proactively attempt an exhaustive search of your facility from top to bottom (and all the nooks and crannies)?
  • Do you “roll the dice” and correct deficiencies as they appear and if there’s stuff out there, let the surveyors find them?

I’m keen to see how this is going to “split.” I know if we could we would take the higher road of proactivity, but not everyone is in that position.

One other item I’ve been hanging on to for probably longer than I should relates to the management of medical gas and vacuum systems. I would hardly think that this blog is the only resource for information, commentary, etc. (though I do like to think it’s an entertaining and perhaps randomly enlightening one), there is one dedicated to the management of medical gas systems, etc., that I think you’ll find useful (and since it doesn’t publish as often, it’s an easy one to add to your bloggy queue) is sponsored by Compliant Healthcare Technologies (CHT). Recently, Tim Richards at CHT penned a blog post on upcoming changes in NFPA 99 relative to medical gases, etc. As I’ve noted once or twice in the past, I really see NFPA 99 compliance as a likely source of heartburn for facilities and safety folks in the coming survey cycles, so any resource that can increase our operational understanding of what is actually required, etc. gives us a leg up on the survey front. I encourage you to check out the information.

As a final note, it appears that we are gearing up for another wild summer of weather and I wanted to take a moment to send best wishes to those in areas already in the throes of severe weather and those that may find themselves in the same. I do believe that, as an industry, we have done some extraordinary work in the practical preparations to deal with emergencies (I would feel better if appropriate preparedness would “drive” regulatory compliance a little more closely, but perhaps in time) and I trust that we all manage the coming season with minimal impact and disruption.

Like the dust that settles all around me: I got those low-down TJC FAQ blues

I don’t know if there’s anything to be inferred by the fact that the latest updates on the ligature resistance front are “buried” on p. 8 of the May 2019 Perspectives (after an onslaught of what I characterize as Joint Commission advertisements), but it would be nice to think that perhaps folks are going to be allowed to move on at their own “pace” as a function of risk assessments, abatement and mitigation strategies and monitoring for gaps in safety, but I guess we shall see what we shall see.

At any rate, the May Perspectives (on p. 8—imagine that!) provides two topics, one of which, video monitoring we discussed a few weeks back (I guess they like to repurpose content as much as anyone…) and a clarification on the (admittedly somewhat awkwardly worded) requirement that self-closing and self-locking (both, not one or the other) doors are required for the separation of areas required to be ligature resistant and those that are not, with the intent being to eliminate reliance on staff to close and lock those doors to prevent patient harm. The FAQ also prohibits the use of hold-open devices of any kind on these doors, so do keep that in mind. This applies to “staff controlled” areas on a behavioral health unit, like med rooms, utility rooms, consult rooms, etc. This is all based on Recommendation #1 published in the November 2017 Perspectives and the guidance that patient rooms, patient bathrooms, corridors, and common patient areas are to be ligature resistant. If this is news to you (I don’t know that we’ve discussed this particular piece of the puzzle), I can’t say that I am surprised as it really didn’t stand out at the time and really required too much in the way of cogitation to figure out what they were getting at, particularly the descriptor (“Nursing stations with an unobstructed view (so that a patient attempt at self-harm at the nursing station would be easily seen and interrupted) and areas behind self-closing/self-locking doors do not need to be ligature-resistant and will not be cited for ligature risks.”) as it was probably a little too all-inclusive. I think I would have separated them into two bullet points:

  • Nursing stations with an unobstructed view
  • Areas behind self-closing/self-locking doors

But hey, as long as we get there in the end, right? Yeah, sure, fine…

In other news, ASHRAE is in the public comment process relative to proposed changes to ASHRAE 170 Standard for Ventilation of Health Care Facilities (you can see the proposed draft here). Given that NFPA 99 defers to ASHRAE on the ventilation front, I can’t help but think that this is going to continue to be a cornerstone compliance document during survey activities. I don’t know that I noted anything particularly egregious, etc., in the proposed update, but I always try to encourage the folks in the field to review and weigh in when these things are open for comment. Before we got to ligature-resistant considerations, the management of procedural environments as it relates to temperature, humidity, air pressure relationships, etc. was the hot-button topic, so any changes might have a similar impact on the industry. Unfortunately, I just got wind of this last week and the comment period ends May 6, so act fast!

One of your sprinkler heads is loaded: Can you find it before they do?

And now, to the recap of the 10 most frequently cited standards during all of 2018 (in hospitals; other programs are a little more varied), as chosen by somebody other than you (or me): the survey troops at TJC.

The top 10 are as follows:

  • EC 02.01.35—The hospital provides and maintains systems for extinguishing fires (88.9% noncompliance percentage).
  • EC 02.05.01—The hospital manages risks associated with its utility systems (78.7%).
  • EC 02.06.01—The hospital establishes and maintains a safe, functional environment (73.9%).
  • LS 02.01.30—The hospital provides and maintains building features to protect individuals from the hazards of fire and smoke (72.9%).
  • IC 02.02.01—The hospital reduces the risk of infections associated with medical equipment, devices, and supplies (70.9%)
  • LS 02.01.10—Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat (70.7%).
  • LS 02.01.20—The hospital maintains the integrity of the means of egress (67.4%).
  • EC 02.05.05—The hospital inspects, tests, and maintains utility systems (64.7%).
  • EC 02.02.01—The hospital manages risks related to hazardous materials and waste (62.3%).
  • EC 02.05.09—The hospital inspects, tests, and maintains medical gas and vacuum systems (62.1%).

The ongoing hegemony of the top 10’s EOC-centric focus (and I still consider IC.02.02.01 the point upon which infection control and the physical environment intersect—sometimes with spectacular results) leaves little to the imagination (both ours and the surveyors). While you can still get into some significant trouble with certain processes, etc. (more on that next week—I figure if they can have a Top 10 list, then so can I…), the reason that these particular standards continue to jockey for position is because they represent the kinds of conditions (to some degree, I hesitate to call them deficiencies) that you can find literally any (and every) day in your organization. Just think about LS.02.01.35 for a moment: How far would you have to go before you found schmutz on a sprinkler head, something within 18 inches of a sprinkler head, a missing escutcheon (or an escutcheon with a gap), or even something (likely network cabling) lying atop, wire-tied to, somehow “touching” sprinkler piping or supports? I’m going to intuit that you probably won’t have to range too far afield to find something that fits in that category. The only thing I can say is whoever was surveying the “other” 11.1 % of the hospitals in 2018 must not have felt like poking around too much.

At any rate, I don’t know that there is a lot to glean from the 2018 results (same as it ever was…), but if someone out there has a question or concern that they’d like to share, I’m all ears!