Month: March 2017

by dawnconrey dawnconrey No Comments

TJC Survey Findings Seen in 2017

Continued Focus on Air Pressure
EC.02.05.01, EP 15 was a heavy hitter last year, and it only appears to be more difficult in 2017. This EP gets scored non-compliant for defects in air pressure relationships or temperature and humidity deviations in critical environments.
Read more

by dawnconrey dawnconrey No Comments

TJC Survey Findings Seen in 2017

Installing Manual Stop Station on Generator

Another new requirement established as a result of adopting the 2012 LSC is in EC.02.05.03, EP 10. This requires installing a manual stop station on the emergency generator to prevent unintentional operation. There was not much time to install this device after publication of the new requirement and prior to the beginning of 2017, but it’s a new “gotcha” in that it has been missed by many organizations.
Read more

by dawnconrey dawnconrey No Comments

Q&A: Texting Orders

Question:  As you know, TJC has been off/on/off about texting. Can you help clarify this issue for us?  We have a team focused on this.  What  can and cannot be sent/communicated via text?  Can we discuss patient care or transmit orders?

Read more

by dawnconrey dawnconrey No Comments

Survey Findings Seen in 2017

Longer Reports, More LS/EC Findings, Scoring on the SAFER™ Matrix

Thus far, we are not seeing any surprises come out of the SAFER™ Matrix. Surveyors seem to be judicious in deciding when to place issues in the red zone, with relatively few that we are seeing at this time. However, we do see a very liberal sprinkling of findings in the dark orange/mustard color area, which just like the red zone, requires management intervention in the ESC, and a discussion of preventative analysis.

Read more

by dawnconrey dawnconrey No Comments

Sentinel Event Alert #57

Recommendations Regarding Role of Leadership in Safety Culture

On March 1 Joint Commission issued Sentinel Event Alert #57 entitled, “The Essential Role of Leadership in Developing a Safety Culture.” This alert notes on page one that leadership’s failure to create an effective safety culture is a contributing factor to many sentinel events reported to the Joint Commission. It is important to note this is not merely the conclusion of the Joint Commission; this is the conclusion of your peers who have actually experienced these sentinel events.
Read more