The October 2016 issue of The Joint Commission Perspectives has a must read for your facilities leadership team in its Clarifications and Expectations column. Here George Mills summarizes all the changes brought about by eliminating the regular PFI, the elimination of clarifications for delayed handling of required documents in the survey process, ILSM documentation, time limited waivers and equivalencies. There are many new acronyms to learn too with TLW, time limited waivers, SPFI, survey related plans for improvement, and SCD for scheduled completion date.
After receiving this document facilities staff should analyze their current status and report back to a hospital wide accreditation team meeting on what the changes mean for your hospital and how you are responding. For example issues, which should be addressed, include:
- Did we have any open items on our existing plan for improvement and what has been done to bring them to a conclusion? While TJC has committed to not having surveyors review these open items, each one is a risk heading into survey if not corrected.
- Has anyone completed the documentation checklist detailing where your essential survey related documents are filed and readily retrievable?
- Do we have evidence of evaluating any and all self-identified life safety code defects for interim life safety code measures?
- If our evaluation leads to the need to implement ILSM, do we have evidence that we did it for the duration of the project as required in the evaluation?
- Do we have any building defects we have been lucky TJC has not identified in the past that pose a risk for us on a future survey and is there a chance an equivalency could be developed?
The Joint Commission’s discussion on ILSM was interesting, indicating they would not use it as a backdoor method to find LS deficiencies, since the ILSM is designed to keep patients safe while that defect exists. The language used by Joint Commission in this section was as follows:
“The survey activity associated with evaluating ILSM policy is to
request a completed project that included implementing the ILSM policy to
review and evaluate its effectiveness ( , EP 1); it is not
intended to search for deficiencies to cite. In a similar manner, if a
surveyor encounters a project with ILSM implementation, the surveyor should
not be citing the project deficiencies as RFIs, as the ILSM is already
providing interim measures to reduce the impact of the deficiencies.
However, if the ILSM policy is not being followed, an RFI will be generated
for not following policy at the specific EP related to noncompliance (for
example, , EPs 2-14).”
The October 2016 issue of EC News has the same article discussed in Perspectives on all the survey changes for 2017 in EC and LS chapters. The last article is particularly interesting in that it discusses performance improvement in the Environment of Care. A perpetual issue we see in writing annual evaluations for the EOC plans is a lack of data to help critique the success of the plan. More often than not a subjective evaluation is concluded that the plan worked as designed and there is no need to change anything in the plan. In this article TJC supplies a great Fire Drill summary report with 31 very specific questions which can be evaluated for proper conduct during a fire drill. Then the aggregate responses can be analyzed to determine where a weak point might reside. For example if staff fail to provide the appropriate response or take the appropriate action, then this can become the focus of next years annual training and added to new employee on-boarding education. Too often we see questions asked, incorrect responses provided, and those conducting the critique do some ad hoc training on the spot thinking it is effective. Having the data to focus future efforts would be much more effective.
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