TJC Survey Findings Seen in 2017

by dawnconrey

TJC Survey Findings Seen in 2017

by dawnconrey

by dawnconrey

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.

Previously, we have written about and spoken about the need to check air pressures more often than an annual air balance report. We have seen hospitals move up to testing monthly, weekly, daily and even several times a day when they are trying to clear a COP finding or an AFS survey. None of these increases in inspection frequency seem to be working successfully as air balance still gets out of alignment and either the LSC surveyor scores it or one of the clinical surveyors scores it non-compliant. As a result, we are suggesting that if your hospital does not already have an manometer, or a “ball in the wall” to allow staff to always know that the critical air pressure relationship is working, then you want to install something that gives you this constant feedback. Since there is always a chance that someone may fail to notice the ball in the wall is on the incorrect side, we suggest something that will alarm locally so staff can react.

In addition, clinical staff need to be better trained to understand and trouble shoot temporary deviations in air balance. One of the problems that occurs on survey is when your facilities staff accompany the life safety code surveyor and they evaluate air balance. The facilities staff can trouble shoot and find simple temporary issues like an exterior door open causing a hallway draft that is adversely impacting air balance. The LSC surveyor is attuned to looking for this and your facilities staff are attuned to looking for this. However, the clinical staff working here may not be as comfortable in troubleshooting. For example, when one of the clinical surveyors goes to central sterile supply and notices the air balance is off, clinical staff have been known to say, “Oh, I have to call engineering to correct it.” Unfortunately, you just earned an RFI at a COP level and most likely in the red or orange zone of the SAFER™ Matrix. Our suggestion is to have facilities staff train the clinical staff to at least look up and down the hallway, feel the breeze going by and try to fix the issue on the spot.

Subsequent blog postings this month will report on additional findings seen thus far in 2017.  Please stay tuned!

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