July PHC Newsletter

by dawnconrey
Patton Healthcare Consultants

Accreditation – Compliance – Patient Safety

July 2020

Inside This Issue

  • Perspectives:
    • Surveys Resuming – More Details
    • Remote Surveys
    • New Laboratory Standards
    • Fire Drills
    • Promoting Psychological Well-Being
    • TJC Pandemic Q+A Webinars
    • Authorizing Less Potent Analgesics
    • Do You Have a Policy?

    EC News:

    • Medical Gas Flow
    • Emergency Room Design and COVID-19
    • Fire Sprinklers in Elevator Machine Rooms


    • Public Health Emergency Being Extended?

July 2020 PHC Newsletter


Surveys Resuming – More Details:

This month’s issue of Perspectives shares additional details about the resumption of accreditation surveys. TJC will be reaching out to organizations due for survey to verify the following information:

  • The organization has ceased emergency operations;
  • The organization has ceased using federal waivers;
  • The organization has closed its surge capacities or sites;
  • No staff have tested positive for 14 days;
  • Does the organization still have any visitor restrictions in place?
  • Does the organization have any sites of care in a different state than the main site?

Physical distancing including limiting the number of participants at group sessions, minimizing the number of staff traveling throughout the hospital with the surveyor, and surveyors will travel independently to remote sites of care;TJC also identified additional safety measures that will be taking place during the onsite survey. These measures include:

  • Surveyors will wear masks and other hospital required PPE and request that this PPE be provided by the hospital;
  • Organizations are also asked to maximize the use of technology including screen sharing or projection of medical records during tracers to allow social distancing and the use of audio/video conference calls for some attendees at group sessions.

We also learned at the June consultant’s forum meeting with TJC that they are closely monitoring the number of cases and the trend in new cases in communities with organizations due for survey. As you might expect, TJC has developed a rather complex formula for analyzing cases per thousand residents within the last two weeks, the growth rates in new cases over the past two weeks, and the percentage of positive tests relative to all tests within the state. Since this involves searching multiple databases, it is not an easy task to duplicate the same type of analysis TJC is conducting.

On June 22nd, TJC posted a revised position statement and FAQs on the resumption of surveys and they provided a link to the data they are using to help decide whether or not to conduct surveys in a particular community. This link is really great as it integrates the disparate databases for census, new cases, and trend in cases into one site. It also helps to inform you how well your community may or may not be doing as compared to elsewhere in the state or nation. At this time, the link is in their June 22 posting (Position Statement) and the entire posting should be read, but the link is duplicated here:


Remote Surveys:

TJC mentioned at the consultant’s forum that they have done a few initial (new organization) surveys using remote survey technology, however, this has not been officially approved yet by CMS for resurveys. Joint Commission International is already conducting remote surveys for organizations and they provided a teleconference in June describing how this process works. They are using Zoom technology which allows visual and audio communication and the setup is really quite easy for conference room discussions which may include system tracers in-whole or in-part.

Medical record tracers are also feasible as Zoom allows screen sharing. As long as the hospital’s computer being used for accessing the medical record has internet access, you can communicate verbally through Zoom and display the record. This allows the surveyor to request staff to display items that should be present in the medical record and the remote surveyor can see the results on their computer. They have even developed a way to do an environmental tour, using a workstation on wheels, or trolley with an iPad, computer, or USB connected high quality webcam. The key requirement to make this technology work effectively is WIFI throughout the organization.

We at PHC are now also using this same technology to help keep organizations ready for survey by conducting accreditation readiness surveys remotely. We have a corporate Zoom account, but we also can utilize the hospitals preferred platform such as Microsoft Teams to conduct the remote review. This seems to be quite popular now to help keep organizations ready for when accrediting bodies return to a normal survey schedule. Let us know if you are interested in a remote consult visit, we would be glad to help describe the process and its requirements

New Laboratory Standards:

The July issue of Perspectives announced some new laboratory standards that take effect January 2021. These new standards address embryology, molecular testing, and pathology requirements. The standards are not published in Perspectives, but they provide a link to the standards prepublication section of the Joint Commission website. These standards can be accessed at:


Since the application process will probe to determine if you offer these services, it is important that if you do, that you have a chance to download the new requirements and prepare to avoid surprises. We recommend you share this link with your laboratory director for their evaluation of applicability in your organization.

Fire Drills:

There is an excellent article in Perspectives reviewing the requirements of EC.02.03.03 relative to fire drills. This is a complex subject because in addition to the Joint Commission standards, you have to implement these drills in accordance with NFPA’s detailed requirements, only some of which are duplicated in the standards. The article makes clear certain mysteries such as the ability to silence audible alarms during nighttime drills. For example, this is only applicable between 9:00 PM and 6:00 AM. In addition, while the audible alarm can be silenced, the visual strobes and automatic door closers cannot be disconnected or turned off.

Another frequently cited issue, that is made clear in this article, is that quarterly drills must be more than 1 hour apart. Thus, subsequent drills must be scheduled at least 61 minutes apart from the previous quarter’s drill. They also provide valuable guidance in critiquing the drills to include the response of staff, and the proper functioning of automatic door closers and unlocking mechanisms. While not mentioned in the article, these critiques should be used to help evaluate the effectiveness of the fire response plan. Too many organizations conclude their plan works perfectly and nothing needs to change, while the individual critiques may not support that conclusion. Be sure to share this article with your facilities leadership.

Perspectives also references a very timely Quick Safety Publication, Issue 54 from June on promoting psychological well-being of staff during a crisis. This publication provides advice for staff to support themselves as well as advice for management and leaders to support their staff. Given what has happened so far in 2020, these tips seem to be useful and perhaps good content for surveyors to discuss when talking with leaders during one or more system tracers. We would suggest reviewing the Quick Safety to determine if anything similar was already done and, if not, implementing some of these measures as the healthcare system continues to deal with the pandemic. You can download the Quick Safety using this link: Promoting Psychological Well-Being: https://www.jointcommission.org/resources/news-and-multimedia/newsletters/newsletters/quick-safety/quick-safety-issue-54/

TJC Pandemic Q+A Webinars: 

The Joint Commission did another of their pandemic Q+A webinars with senior leaders responding to questions sent in by healthcare organizations. It was very informative and if you missed it, they have distributed a link to the slides:


Some of the questions dealt with resumption of surveys and the material we discussed earlier about case rates is used to determine if it is safe and appropriate to go to a particular organization or city. In addition, TJC indicated that the organization should have been able to terminate their use of alternate sites of care and have ended their local emergency in order for a survey to be conducted. There were also many questions relative to infection control and TJC provided links in their slides to CDC guidance on these issues.

Some of the questions submitted and their responses seemed to us as if they might be appropriate subjects for questions during future surveys. For example, one questioner asked if the organization should keep track of dates when the EOP was operational and as you might imagine the response was a definitive yes. Another question came in about fit testing for N95 masks as many organizations had to switch models to obtain sufficient supplies. TJC indicated that while fit testing might not have been repeated, at a minimum staff should have been educated and surveyors might ask what training might have been provided to staff so that they could tell if their new model mask was properly fitted. In addition, we have seen guidance from OSHA on this issue recommending staying within a product line or brand that uses the same mold to manufacture the new model, making a correct fit more likely.

Authorizing Less Potent Analgesics:

We have discussed previously in this newsletter how quickly and quietly important standards FAQs can change or disappear without notice. Some of these sudden changes have important implications for accredited organizations. We noted one change this month in the FAQ on authorizing less potent analgesics to patients when multiple therapeutic options are prescribed. For example, with a pain rating of nine (9), administering a prescribed non-narcotic based upon patient request instead of the narcotic prescribed for severe pain. Previously, the FAQ had indicated that organizations could do this if there was a policy authorizing the nurse to accommodate such patient preference. Now, there are eight (8) steps detailed in the FAQ. The most important of which is a new Step 1 that states, “The medication order is written in a manner that supports deferring to patient preference.” Thus, it is no longer sufficient to just authorize the practice in policy.

Do take a look at this June 25, 2020 change in the Medication Management and Provision of Care sections of the posted FAQ, but also take a look at existing practices at your organization. We frequently see this type of interchange or substitution taking place, although there is neither a policy authorizing it, nor does the medication order permit the use of patient preference considerations to administer a less potent analgesic. Also, bear in mind that neither the old FAQ nor the new one authorizes the administration of a more potent analgesic than prescribed for that level of pain.

Do You Have a Policy?

Surveyors often ask to see policies to better understand exactly how something should work at your organization. Many years ago, TJC added that “D” for documentation icon (Ⓓ) to the standards manuals for the specific elements of performance that require policies. To further add clarity, the element of performance often starts with the phrase: “the organization has a written policy that…” Sometimes the policies are the subject of discussion during a system tracer and in particular during the medication management system tracer. In many organizations however, the response is often that “we don’t have a written policy that describes that process.”

Did you know that you can print a list of these Ⓓ elements of performance from your E-Edition and use that list to validate you actually have all the required policies? You can do this by setting a filter. In this case, the filter icon in E-Edition looks like a small yellow funnel and you want to select the filter that says, “requires written policy.” If for example you print your list of Ⓓ elements from the medication management chapter it will identify 23 EPs, 19 of which are policy requirements and 5 are documentation of effort requirements. While this does not mandate 19 unique policy documents, you want to make sure that each of these 19 issues are addressed somewhere.

Several similar policy issues can be addressed in a larger policy, but still do verify that the content of your policy actually addresses what TJC has asked for. We suggest highlighting that content so that you know exactly where that requirement is stated. In addition, be sure to read carefully as sometimes TJC uses a “compound” sentence to ask for two unique items. For example, MM.01.01.03, EP1 requires organizations to have written list of (1) high alert and (2) hazardous medications. Every organization always has a list of high alert medications, but many are missing the required hazardous drug list.

Sometimes the element of performance is unclear to the reader and a surprising number of organizations just move on, assuming it is unimportant because it is not clear. For example, MM.03.01.01, EP 4 requires each organization to have a written policy addressing the “control of medication, between receipt by an individual and administration of the medication, including safe storage, handling, wasting, security, disposition and return to storage.” Too many readers look at that long sentence and just say, we get it from the automated dispensing cabinet and we give it.

Unfortunately, hospital processes are much more complex and people sometimes need to hold onto a medication until the patient is available to take it. So, this EP is asking you to design a process describing how you will safely and securely manage that medication until it is administered; and if it is not administered, how can it be returned to stock or how will it be wasted. In simpler terms, can I carry it in my lab coat pocket and if I wear my lab coat out of the organization can I return it to stock? Your expectations on how this should be managed should be written out so staff don’t have to make up their own policy.

You can perform this same filtering technique with every chapter in the standards manual and your chapter leaders can verify (or not) that they have all the policy requirements met.


Medical Gas Flow:

The lead article in this month’s EC News suggests taking a look at the rated flow of your medical gas systems to determine the total capacity. This issue drew attention during the pandemic surge as more than a usual number of patients were on ventilators or high flow oxygen.

The authors advise that exceeding design by 50% or more can lead to a drop in either pressure or ice buildup on the oxygen vaporizer. The authors also suggest calculating exactly how many patients can be served by the existing systems and suggest some alternative solutions. As case rates rise again in many parts of the nation, you may want to analyze this situation in your organization. They do provide a link to an Excel tool to calculate gas consumption issued by the American Society of Respiratory Care.

Fire Sprinklers in Elevator Machine Rooms:

There is a very informative and detailed article on fire sprinklers in elevator machine rooms. This article also points out the very complex interaction of different NFPA requirements that are tied to the CMS decision to use NFPA 101, 2012. The crux of the issue is, should there be fire sprinklers inside the elevator machine room since water might short an electrical safety circuit or somehow affect the elevator brake mechanism, either of which sound very undesirable. In this case NFPA 101, 2012 cross references NFPA 13, 2010 which does not provide an exemption for the elevator machine room, whereas the 2013 edition of NFPA 13 does.

Fortunately, the authors suggest a work around to install a more sensitive heat detector for elevator recall that will trigger before the higher temperature sprinkler heat detector. The good news is that at the conclusion of the article, TJC indicated that its life safety code surveyors will work with organizations to provide educational guidance on this complex subject. In the interim we suggest you share this article with your Facilities leadership to initiate analysis.

Emergency Room Design and COVID-19:

There is also an article on how emergency room design might be affected by communicable diseases such as COVID-19. This article will be of particular interest to those of you who have an emergency room design or renovation project in the planning phase. There are multiple suggestions for air handling and infection prevention and incorporation of telemedicine capacity into the design.


Public Health Emergency Being Extended?

At the time we are writing this newsletter there are no new QSO memos for the hospital industry. However, HHS has indicated through their spokesperson that HHS Secretary Azar will extend the public health emergency that was due to expire in late July by another 90 days.

Consultant Corner

Dear Readers,

We are pleased to report that the remote surveys we have conducted thus far have been successful!!  As previously mentioned, we have the capabilities to perform these remote visits through our corporate Zoom account or your organization’s Microsoft Teams account.

The future of surveying is followed by a question mark, as more and more states are reporting new surges of COVID cases.   In efforts to keep the people at your organization and our consultants safe, many have turned to remote visits.  Contact us to inquire about scheduling.

As a reminder, we do not publish in August, as many are enjoying the last month of summer before the school year begins.   We wish everyone well health and strength as we continue to go through this together!

See you all in September!

Jennifer Cowel, RN MHSA

Kurt Patton, MS RPh

John Rosing, MHA

Mary Cesare-Murphy, PhD