Frequently Scored, Higher Risk, Frequent Pattern, Red and Orange

by Expert Advice

Frequently Scored, Higher Risk, Frequent Pattern, Red and Orange

by Expert Advice

by Expert Advice

Many organizations share their survey reports with us. As a result, we maintain a database of redacted or de-identified findings. We share that data with our consultants providing examples of what TJC is currently scoring. And, the SAFER Matrix risk levels. Two standards jump out at us.

SAFER Matrix Risk Levels

The two standards are EC.02.06.01, EP 1 (ligature risks) and, to no one’s surprise, IC.02.02.01, EP 2, (HLD and sterilization). The number of organizations that have not eliminated the ligature hazards in the behavioral health environment is surprising. But, the number that have not documented the ligature risk on a risk assessment with mitigation strategy is even more surprising.

Several factors seem to be at play here. Some organizations don’t recognize the potential hazard. Other don’t know how to do a behavioral health risk assessment with a mitigation strategy. And, others appear to hope the Joint Commission does not notice the hazard.

Given the frequency that TJC scores these issues, hoping they do not notice seems like a lost cause. Self-identifying the potential hazards can be overcome by reading the FGI Design Guide for the Built Environment. Or, by using a checklist like the one developed by the VA to search for known ligature hazards.

The third potential reason is not knowing how to do a risk assessment with mitigation strategy. And further, to have access to the survey when you need it. When we prepare mock surveys, we ask about the risk assessment. We find that the clinical staff doesn’t have a copy of the document, have never seen it and don’t know what it says. Sometimes it is with facilities, sometimes with the safety officer, but often not on the unit.

In addition, when we obtain the document, many times it is missing information. For example, there is no actual mitigation strategy or details on how to keep patients safe before eliminating the hazard. Remember, documenting a renovation will take place in 2020 is not a mitigation strategy. Instead, it’s a long-term plan.

What Are You Going To Do Today?

Mitigation strategies should identify what you are going to do today. Let’s take hazards in the behavioral health hallway such as a suspended ceiling. The Joint Commission will permit mitigation through constant observation and removal of items that might allow a patient to climb or access the ceiling panels. Hazards in the behavioral health bedrooms and bathrooms are more difficult. Because, TJC expects you to eliminate those known hazards. That can be expensive and time consuming. But, it’s much easier to fix before Joint Commission conducts its survey and you have a 60-day or less deadline to correct the issues.

Sterilization And High-Level Disinfection

IC.02.02.01, EP 2 is a large potpourri of issues related to sterilization or high-level disinfection. Those issues include:

  • Many examples of dry and contaminated equipment
  • Not following MIFU
  • Not testing washers for effectiveness
  • Expired test strips
  • Not properly using test strips
  • Mixing chemicals without measuring
  • Cross contamination of clean and dirty processes
  • Equipment maintenance not performed on schedule

There are also a few examples of improper use of enzymatic cleaners. Of course, you can eliminate that issue with TJC’s new kinder/gentler approach of just keep it wet with a towel.

In fact, these issues are much more difficult to correct. It’s because they are reflective of the actions from staff members throughout the organization. The only long term and effective corrective action is a repetitive competency assessment and repetitive oversight of process with accountability. The missing component in many organizations is oversight.

We have written before about having an HLD Sterilization czar. A content expert that is overseeing the process across many departments. But such content experts often lack management authority to impact individual departments.

But, here is a step that may help reinforce correct practices. Have the content expert report to the C-Suite leaders. Then let those executives lead the corrective action in the departments that they head.

Do you need assistance interpreting and implementing these or other Joint Commission guidelines? Patton Healthcare Consulting provides Joint Commission Compliance Assistance and a full range of pre-survey and post survey services to healthcare organizations. Contact our office at 888-742-4621, via email or through our website contact page to schedule a discussion of your needs and learn more about our compliance and readiness expertise.


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