December 2017 PHC Newsletter

by dawnconrey
Patton Healthcare Consultants

Accreditation – Compliance – Patient Safety

December 2017

Inside This Issue

December 2017 PHC Newsletter


Survey Report Enhancements:

This month Perspectives discusses some significant changes that will be occurring in survey reports for 2018. We have seen mock ups of some of the reported changes and it looks like an improvement in ease of use. One of the planned changes we are particularly fond of is the ability to download a copy of the report findings into Excel. Each observation for each element of performance will appear in a unique row. That is the same format we use for our Patton HC mock survey consultation reports and it allows the user to assign corrective actions, assign responsible parties and completion dates, and sort and close out completed tasks. Stay tuned, but this looks like an improvement in the ability to manage the accreditation process.

2018 Prepublication Standards – Download Now!

There is also an article on the changes that will be occurring in the EC and LS chapters for 2018. There is a link to the prepublication standards and this will lead you to an 87-page document, which details everything that is new, everything that has moved, and everything that has changed or been revised. For purposes of your preparation, those items that have moved, but the requirement is identical to the prior requirement, there is little need for discussion. The revisions or changes, for the most part reflect changing references to different versions of the NFPA manuals. You may need to verify that you have these new NFPA editions. Some revisions are more substantive, such as the change to EC.02.03.03, EP 3, which previously stated at least 50% of quarterly fire drills are unannounced, and in 2018 it just says quarterly fire drills are unannounced. Similarly, EC.02.05.09, EP 1 has a significant change. The old EP required the hospital to inspect, test and maintain critical components of piped medical gas and vacuum systems. In 2018, this EP adds to the requirement by including waste anesthetic gas disposal and support gas systems on the “inventory.” Then it goes into addition detail about all the items which must be on the inventory. Lastly the EP now also establishes a certification requirement for the individual performing the inspection per the American Society of Sanitary Engineers, or ASSE. Standard EC.02.05.09, EP 5 that previously discussed piped medical gas systems has moved to EP 11 and it has changed substantially. They have added considerable detail to the labeling requirements for medical gas pipes and shut off valves. EC.02.06.05, is the standard that discusses a preconstruction risk assessment to include implementing actions needed to minimize risk during demolition, construction, and renovation. Now in 2018 EP 3 was modified to add “or general maintenance” to the list of work to evaluate how to minimize risk during that work.

The really important list of changes however is all of those that are new for 2018. You don’t want to get surprised on survey if you are due in 2018 and even if you are not due, you don’t want to have too short a track record in compliance with these new requirements. We did note at the beginning of 2017 that many organizations were caught off guard by changes TJC made to these chapters in late 2016. There are two ways you can organize this analysis. The first and perhaps easiest way is to simply print the entire 87-page document and share it with your facilities leadership, asking them to provide feedback on all the new requirements and to make sure they are all up and running in the next few weeks. However, we can attest that sorting through the new, the revised, and the moved is indeed a tedious assignment. A second and perhaps easier way is to use the E-Edition for 2018, which is available on your extranet and set your filter to just those items that are “new.” Now you can print that limited portion of each chapter identifying just the new requirements. In the print dialogue box, it is also easy to save this to a PDF file that you can email and search.

We wanted to point out one of the new requirements in EC.02.03.01, EP 12 because it requires clinicians to implement certain practices relative to fire safety in the operating room. The new EP establishes requirements for safe use of flammable germicides or antiseptics in the OR. The Joint Commission language brings in content from the CMS Interpretive Guidelines, Tag A-0951 (last updated in Nov 2015) in their entirety. In addition, we noted an additional requirement that flammable “solution soaked materials must be removed from the operating room prior to draping and the use of surgical devices.” If you had not already included this fire safety time out like process in your operating rooms, you will want to do so as soon as possible.

Scoring Begins Again for Hand Hygiene Lapses:

The December Perspectives also discussed that failed hand hygiene observations will again be scored in 2018. Several years ago, TJC had modified its process for evaluating the National Patient Safety Goal for hand hygiene, instead looking at goal setting, establishment of a process and making improvements. Well; scoring of the NPSG will still focus on these issues, but now IC.02.01.01, EP 2 is where they will instruct surveyors to score any failures they see in proper hand hygiene.

 Looking for Hospitals to Meet CMS Definition of a Hospital:

Perspectives also announced the immediate implementation of a new requirement as a result of the CMS SC memo we discussed in the October Patton HC newsletter relative to the definition of a hospital. The CMS memo was both detailed and confusing in terms of how they would assess the veracity of being a hospital, but one decision that came out of it is that Joint Commission will not conduct an accreditation survey at a hospital if there are less than 2 inpatients present. This has no impact on the vast majority of our readers, but some smaller surgical specialty hospitals should take note. The announcement indicates this requirement is only being applied to hospitals, not to critical access hospitals.

New Decision Rule for PDA – Be Aware:

There is also an article on the 2018 Decision Rules for Hospitals. We have previously discussed this portion of the accreditation manual as one of the least read sections of the entire manual, but very important to the overall outcome of your survey process. There is one important addition to the decision rules for 2018 with the addition of what they call DA06. This is denial of accreditation and it will be the survey outcome when an organization has been placed in preliminary denial of accreditation status on two sequential surveys.

EC News:

The lead article in this month’s EC News is on managing sprinkler systems, EC.02.01.35. We see sprinkler issues being scored frequently in hospitals and Joint Commission indicates this standard was scored in 14% of surveys in the first half of 2017. The first compliance problem is EP 4, a failure to keep the sprinkler pipe free from any attachments, draping of cables, tubes or other pipes. The expectation is that nothing is suspended or attached to the sprinkler pipe. Unfortunately, these pipes are above the ceiling and somewhat invisible to detection. When either staff or vendors are in the hospital working above your ceiling, you want to conduct an above the ceiling inspection at the completion to verify that they have not laid something on or tied off something to your sprinkler pipe. In addition, you should have an above the ceiling inspection process to detect if anyone made this error in years past, so that it can be corrected by eliminating the attachment. The second problem with this standard is EP 5 that requires undamaged, clean sprinkler heads. These get contaminated over time with grease, dust, hair and sometimes paint and must be either cleaned professionally or replaced. Fortunately, these are easily visible and dirty or damaged heads should be looked for during rounds. The next issue is the classic 18-inch rule, EP 6. This is an issue that everyone seems to be aware of, but problems continue to occur with compliance. Here they provide a helpful explanation of the so-called “library” rule that allows storage above 18 inches around the perimeter of the room with certain qualifications, of course. The last significant compliance issue is a new EP 7 that was added to the 2017 standards requiring at least 6 spare sprinkler heads with associated wrenches to be on hand and stored at less than 100 degrees F. Many organizations missed this new requirement early in 2017, but most have now caught up. The issue about being stored below 100 degrees F is explained in the article stating that the O rings in the head can degrade is stored above 100 degrees. You do want to look at where these are being stored since some shop areas may be un-air-conditioned.

Changes for the Behavioral Health Organizations:

EC News also has an article on some additions to EC.02.03.05 for behavioral healthcare programs that brings in many of the difficult requirements hospitals continue to struggle with. This includes the testing of fire alarm equipment, inspection of fire extinguishers, annual maintenance to portable fire extinguishers, and a continuing problem EP for documenting the name, date, inventory of devices, required frequency, results and NFPA references for each of the required fire safety tests in their documentation books. At the end of the article there is a useful checklist for self-assessing compliance with this standard that is potentially useful to both behavioral health organizations and hospitals.

Another Vincristine Alert:

Last month Joint Commission issued one of their Quick Safety newsletters, issue 37 on eliminating vincristine administration errors. Vincristine is a chemotherapy agent that is administered intravenously, but is fatal if administered intrathecally. Unfortunately, it is sometimes part of a treatment regimen, a portion of which should be administered intrathecally, however the vincristine must never be given intrathecally. Joint Commission had issued a Sentinel Event Alert on this same subject in 2005, and the Quick Safety newsletter identifies Joint Commission, the Institute for Safe Medication Practices, the Oncology Nursing Society, the World Health Organization and the National Comprehensive Cancer Network all of whom are consistent in recommending this drug be dispensed in a minibag, not a syringe. This recommended practice illustrates a concept we have discussed previously in our Patton HC newsletter, namely, error elimination rather than error reduction. Error elimination means engineering out the chance of error, not just applying warning labels to reduce the chance of error. This Quick Safety newsletter references an international survey which identified that 31% of reporting hospitals are still dispensing vincristine in a syringe instead of in a minibag. Our suggestion is to verify with your pharmacy that your hospital has indeed engineered out the potential for error made by the newest nurse, medical resident or pharmacist and always dispenses this product in a minibag.

Suicide Risk Algorithm:

Last month we discussed the latest requirements for hospitals providing care to patients who may be at risk for suicide. These requirements were extremely detailed and can be difficult to remember and analyze. Flow charts are sometimes helpful so we have developed a one page diagram that depicts the decision process and interventions we believe are required to help implement the requirements in behavioral health, emergency and medical unit settings. The flow chart can be found on the last page for your use.

CMS Update:

There were no CMS Survey and Certification memos focused on the hospital industry this past month.

Are you ready for 2018?

In our earlier discussion about the new EC and LS requirements we mentioned filtering to identify what’s “new” in your E-Edition search. We also suggest doing this as a final check that you have prepared for all the prepublication standards published this year, which take effect in January, as well as the new EM requirements, which actually took effect in November. When you go into E-Edition now you will see a November database and a January database. If you first click on the November database, and set your filter to “new,” you will see the new EM elements of performance which took effect in November to coincide with the CMS changes for emergency management. This will identify 16 new elements of performance across 6 standards. Since many of the new requirements identify new content that must be added to your emergency operations plan, you want to make sure that each is addressed as required in your 2018 update if not already modified.

Then return to the E-Edition and change the database to the January 2018 standards edition. This will identify changes in the EC, LD, LS, MM, MS, PI, PC and RC chapters. Again, we would encourage readers to print these out to verify they have been addressed. The EC and LS changes mandated by CMS were addressed earlier in this newsletter. The LD, MS, PC and PI changes are the ones associated with the new pain management standards. The medication management changes were in MM and EC and one minor change in RC just affecting critical access hospitals. You can also use the following checklist to verify you have addressed each of the new requirements announced earlier this year.

Medication Relation Standards:


EP 14: Have we developed a policy to provide emergency backup for essential medication dispensing equipment?

EP 15: Have we developed a policy to provide emergency backup for essential refrigeration for medications?


EP 1: Have we developed a policy on signed and held orders that addresses the clearly defined circumstances when a signed and held order should be released for use?


EP 16: Have we developed a policy for automated dispensing cabinets that describes the types of medication over rides that will be reviewed for appropriateness?

Pain Management Standards:


EP 1: Have we identified our pain management leader or leadership team?

EP 2: Do we provide nonpharmacologic pain treatment modalities?

EP 3: Did we provide our staff and LIPs with educational resources and programs to improve pain assessment, management and safe use of opioids?

EP 4: Have we informed staff and LIP’s of available consultation services for complex pain management needs?

EP 5: Have we identified opioid treatment programs that can be used for patient referrals?

EP6: If your state has an opioid prescription drug monitoring program have we facilitated easy access for our physicians and pharmacists?

EP 7: Has leadership provided clinical staff with the equipment needed to monitor patients who are at risk for adverse outcomes from opioid treatment?


EP 18: Has the medical staff established protocols and quality metrics for pain assessment and management and has a process been established to provide data to the medical staff for analysis?


EP 1: Do we have defined criteria to screen, assess and reassess pain that is consistent with the patient’s age, condition and ability to understand? (Note: This is a simplification of the prior requirement to conduct a comprehensive assessment)

EP 2: Do we screen patients for pain during ED visits and admission?

EP 3: Do we either treat pain or refer patients for treatment?

EP 4: Do we develop an evidence based pain treatment plan appropriate to the patient’s condition, past history and pain management goals?

EP 5: Do we involve patients in the treatment planning process, developing realistic expectations, objectives of treatment and providing education?

EP 6: Are we monitoring those at highest risk for adverse outcomes related to opioid treatment?

EP 7: Are we reassessing and responding to pain by evaluating and documenting response and interventions, including progress toward achieving goals, side effects of treatment and risk factors for adverse events?

EP 8: Are we educating patients and families on discharge plans relative to the pain plan of care, side effects, ADL in the home that might increase or decrease pain and the safe use, storage and disposal of opioids?


EP 56: Have we set up a data collection process on pain assessment, management, interventions and effectiveness?


EP 18: Is our PI team analyzing collected data on pain assessment, management and able to identify areas in need of change?

EP 19: Are we monitoring the safe use of opioids by tracking adverse events such as respiratory depression, naloxone use, as well as dose and duration of opioid prescriptions?

Consultant Corner

We hope everyone had a wonderful Thanksgiving!

Don’t forget to check out our new Blog.  Enter your email address to receive notifications of new posts by email to stay up-to-date.

We are still scheduling all 2018 surveys, so please contact us soon to reserve your time.  Your compliance is our importance!

We wish all of you a happy, healthy, safe holiday season and a very successful 2018!


Thank you,

Jennifer Cowel, RN MHSA

Kurt Patton, MS RPh

John Rosing, MHA

Mary Cesare-Murphy, PhD