May 2018 PHC Newsletter

by dawnconrey
Patton Healthcare Consultants

Accreditation – Compliance – Patient Safety

May 2018

Inside This Issue

  • Perspectives
    • Staying Safe – New SEA on Workplace Violence
    • E-Edition Update – Finding what Changed
    • Welcome Changes for Telehealth Applicability Grid
    • Sterile IV Compounding Compliance Details
  • EC News
    • Scorecard and Strategy for Creating and Managing the Physical Environment Steering Committee
    • Managing Utility Risks Related to General Anesthesia
    • Sample Design and Construction Partner Checklist
  • CMS Update
  • AHRQ Action Planning Toolkit
    • 3 Useful Resources for Culture of Safety Survey

May 2018 PHC Newsletter


The lead article in Perspectives this month is a reprint of the Sentinel Event Alert issued April 17, 2018 on workplace violence. We would encourage readers to read either the SE Alert itself or the Perspectives article electronically as they both include many useful links to additional resources. Going directly to the link while reading makes it more likely that you will obtain the information rather than hoping you remember to go to it later. This SE Alert is an important subject concerning physical and verbal violence against healthcare workers. Unfortunately, this alert points out how often violence is being reported against healthcare workers. They quote OSHA stating “approximately 75% of the nearly 25,000 workplace violence assaults reported annually occurred in healthcare and social service settings.” In addition, the Joint Commission references its own sentinel event database which shows 68 incidents of homicide, rape, or assault of hospital staff members over an 8-year period. We also have to remember that the voluntary reporting to the sentinel event database only represents the tip of the iceberg, so this is clearly an issue of concern for hospitals.

Another factor leading to under reporting of workplace violence is healthcare workers believing patients are not responsible for their actions. Here, TJC references two publications from Emergency Medicine and the Online Journal of Nursing that indicate nursing staff only report incidents 30% of the time, and emergency room physicians only 26%. Even worse than the hospital setting, 61% of home care workers report episodes of workplace violence each year.

TJC reminds readers of their regulatory responsibility to report all workplace injuries to the OSHA Injury Tracking Program and provides a link to do so. Getting the information into a national database will make analysis more meaningful and potentially effective. TJC also reminds readers that employers are subject to the “general duty clause” to provide a workplace that is “free from recognized hazards that are causing or are likely to cause death or serious harm.”

Like all of the Sentinel Event Alert Newsletters, TJC suggests multiple recommendations but you are not required to implement all of them. However, the standards and survey process do expect that you will evaluate each to determine if you need to modify current practices, already have an alternative or don’t have a need to implement the suggestion. We suggest a formal gap analysis with conclusions and action items. One really simple suggestion they include in the first formal recommendation is to encourage reporting and discussion about any type of workplace aggression, including verbal abuse, during huddles. More and more organizations are using the daily huddle to help improve patient safety, and this may be a good opportunity to help improve employee safety in what has already become a familiar and non-threatening setting.  There are 7 formal recommendations, each with multiple factors to consider. It is in these recommendations where many of the links to external resources reside.



The links to resources include the Crisis Prevention Institutes published “ten tips for de-escalation.” If you have conducted CPI training staff may already be familiar with these, but often such training is not across all disciplines and all units so distributing these tips may be helpful. There is also a link to a Workplace Violence Program Checklist published by the CDC that appears to be particularly helpful. If you form a team to help analyze your risks and develop action items, this tool identifies many important issues for analysis. It is also published in an easy to use column format allowing for the identification of action items for follow-up.

The SE Alert also includes a list of standards that are potentially applicable to this situation, however a long list of standards is of limited use because most readers would have to look each one up and formulate their own opinion on how it might be cited against their organization. Fortunately, TJC also included a link to a November 2017 Topic Library posting where their experts have already responded to the question: “Does the Joint Commission have standards that specifically relate to workplace violence?” In a very general sense, the answer is an emphatic, “they sure do have standards on workplace violence.” While these might not be routinely scored against your organization, if you have a sentinel event or incidents related to workplace violence these are sure to be explored and potentially scored.

A starting point for your standards analysis might be your safety and security plan and standards EC.01.01.01, EC.04.01.01, EC.04.01.03, and EC.04.01.05. These require organizations to have processes for managing, evaluating, analyzing and improving the safety and security of the environment. If you have had such a sentinel event or incidents, then these existing processes must be judged to have failed in some way. They also discuss EC.02.01.01, EP 1, which requires you to conduct risk assessments including those for workplace violence. As we have stated previously in this newsletter and our presentations, a documented risk assessment can be your best friend on survey. A failure to have conducted the risk assessment means you never thought about or analyzed the risk. EC.04.02.02, .03 and .05 then discuss the requirement to report these risk assessments to your multi-disciplinary EOC committee. (see the discussion in the EC News section of this newsletter relative to one organization’s process). PC.01.02.13 includes a requirement to assess those receiving treatment for emotional or behavioral disorders for “maladaptive or other behaviors that create a risk to patients or others.” In the BHC manual there is also CTS.02.01.01 which requires screening and identification of risk for harm to self or others. The leadership chapter includes a requirement in LD.03.01.01 to create and maintain a culture of safety and quality throughout the hospital, one aspect of which is the code of conduct for staff interactions since some abuse can be staff-on-staff.

In conclusion, this is an important topic and we encourage our readers to obtain and study the links and establish a formal discussion, gap analysis and action plan. The issue is by itself very important and in addition there are many survey risks if you don’t give it due consideration.

 E-Edition Update –  Finding what Changed:

Perspectives also includes a notice about another update to the standards database on E-Edition that will take place later this month. Right now, you have the January 1, January 13 and March 11 updates available to access. The next update will include a modified introduction in the leadership chapter, new requirements for obstetric care in the PC chapter, new EPs in the EC chapter relative to fluoroscopy services, and the consolidated requirements after EP deletions related to Phase IV of their Project Refresh. The deletion of the two home care requirements for environmental monitoring of hazardous compounding areas we discussed last month will be reflected in this update also. As we described in our December 2017 newsletter, when a new version of the E-Edition becomes available this is an excellent opportunity to verify that you have the new requirements. This can be done by setting your filters to “new” and then displaying the PC, EC, RC, IM chapters which will bring forth only the new requirements. Remember this will not display the changes mentioned above until the May edition is posted. Any earlier versions of the E-edition will display those requirements that were new at that time.

Welcome Changes for Telehealth Applicability Grid:

There is one last standards change that we welcome for the ambulatory manuals applicability grid for telehealth providers. We have a small number of readers and clients from that industry and TJC is removing the applicability for many requirements that organizations, surveyors and consultants sometimes looked at and wondered “how do I implement that,” or “how do I evaluate that” issue in a telehealth setting. This includes issues such as hand hygiene where no patients are directly served, participation in the communities’ emergency response planning when no clinicians work at the telehealth office, and collection of incident data relative to adverse effects of anesthesia when the telehealth offices clinicians are not the providers of such services. If you are a telehealth provider accredited using the Ambulatory care manual, be sure to study the deletions on page 16 of Perspectives.

The article is silent on hospitals that may be providing telehealth services, but hopefully the surveyors will use their good judgment and not explore these same issues in the hospital’s telehealth program.

Sterile IV Compounding Compliance Details:

This issue of Perspectives has the latest column TJC calls Consistent Interpretation. This month there is discussion about an issue of increasing importance, sterile IV compounding. The first part discusses a surveyor observation under standard EC.02.04.01 EP 4, where the hospital failed to have the testing requirements and frequencies for IV admixture hood also known as the primary engineering control (PEC) available. Joint Commission points out that the alternative equipment maintenance (AEM) option is not an available option for the compounding hoods. TJC states here that hood maintenance and recertification must be every 6 months as required by USP Chapter 797. TJC also mentions that if it is the ante or buffer room that failed to be recertified, then the issue should be scored under EC.02.06.01, EP 1. Most importantly however is that if the hoods genuinely failed to be recertified as required, then the surveyor is instructed to call central office. Whenever the surveyor says, “I have to call back to Chicago” it is not a good sign. We have not seen it happen yet in this situation, but this call could be to discuss whether to levy an immediate threat to life decision.

The second issue discussed is a surveyor observation that the incubator used by the pharmacy staff for their media fill testing was not calibrated for temperature and not being monitored for temperature. TJC points out that the incubator should be calibrated only if the IFU states it should. We assume the manufacturer has tested and validated the effective temperature, absent the IFU saying something different. Additionally, TJC states that there should be a method to validate temperature if there is no process to do so.

Probably the most important message from this article is to re-emphasize that sterile compounding has become increasingly important in the survey process. The second important message is that the facilities team or biomed should be involved in providing oversight of these processes with complex medical equipment. Additionally, we would suggest involvement of the hospital quality and infection prevention teams should any defects be identified either in equipment functioning, environmental sampling, or employee competency. Lastly, should any of these defects be found, there should be a good paper trail documenting rapid corrective action and analysis for any potential impact on patient care.


Scorecard and Strategy for Creating and Managing the Physical Environment Steering Committee:

The lead article in this month’s edition discusses one large health systems approach to creating and managing their Physical Environment Steering Committee. They provided a list of members and described their overall strategy to use scorecards to help them “identify issues, trends and opportunities for improvement.” They included one such scorecard in the article that enabled them to better understand employee training on de-escalation techniques and outcomes. Given the previously described new Sentinel Event Alert, this seems particularly timely and worth taking a look at. We would suggest the article be shared with your EOC committee and aspects of their program be “borrowed” as needed.

Managing Utility Risks Related to General Anesthesia:

EC News also has a useful article on managing utility risks that specifically focuses on EC.02.05.01, EP 27 that became effective just this past March 11th. This new EP is applicable in areas designated for administration of general anesthesia and specifically inhaled anesthetics, medical gases, or involve vacuums. The article describes effective implementation strategies for this new requirement and it certainly should be shared with your facilities team, along with feedback about the status at your hospital.


Sample Design and Construction Partner Checklist:

There is also an EC Toolbox article about a Design and Construction Partner Checklist. We were somewhat underwhelmed by the attached checklist. It asks meaningful questions, but the yes/no format for documenting responses seems too superficial to be helpful. We would suggest as an alternative using the old adage, “Trust but Verify” meaning a thorough examination of references, other hospital’s recommendations for the vendor and its staff leaders and technical demonstration of expertise in working in the hospital environment during an interview will provide a more careful screening.

CMS Update:

There were no new QSO, or Quality, Safety and Oversight, group memos issued to the hospital industry this month.

FDA Alert:

New Alert on Multi-Patient Endoscope Connectors:

On April 18th the FDA issued a MedWatch notice advising users about 24-hour, multi-patient endoscope connectors and the risk of cross contamination. These devices connect a water source to the endoscope channels. The FDA points out that some of these devices do not include a back-flow preventer and there is the risk of patient cross contamination. The FDA specifically references the ERBEFLO port connector. FDA advises using a single patient use connector, or providing high level disinfection of the connector using the manufacturers IFU for such HLD.

AHRQ Action Planning Toolkit:

3 Useful Resources for Culture of Safety Survey:

We have seen recent emphasis by TJC on discussion and analysis of hospitals culture of safety survey. Too often results come in, leaders are disappointed with the feedback, other priorities intervene and over time the survey is repeated with similar results. AHRQ has three useful resources to help you interpret and manage your results. The first if the AHRQ tabulation of results from users of their tool published just in March of 2018. This can be obtained from:

This report identifies 3 areas of strength for participating hospitals. These are: teamwork within units (82% agreement), management support for patient safety (80% agreement), and organizational learning (72% agreement). AHRQ also identifies 3 weaknesses identified at participating hospitals. These are 47% agreement on a non-punitive environment for error reporting, a 48% agreement with no fumbles during handoffs, and 53% agreement on the adequacy of staffing. So, if you have looked at your results on these issues and been disappointed, it is still possible you are at or above national norms being reported for these measures. More importantly this report identifies benchmark data for all of the questions posed on the survey and compares results based on hospital size and geographic location. Even if you don’t use their precise tool, there may be elements you can crosswalk to your questionnaire for comparison purposes.

The second useful improvement tool is the AHRQ publication of resources for action aligned with the scoring categories from the survey tool. This can be accessed from:

AHRQ has identified potentially useful tools, reports and examples of improvement for each of the domains of questions posed on the survey.

The third and potentially most useful improvement tool is the AHRQ Action Planning Tool. This document helps hospitals to design a goal directed improvement plan based on the results reported at your organization. This can be downloaded from:

This is the issue many organizations struggle with the most. Now that we know where we are weak, what can we do about it and how do we start. Making better use of these tools and eventually being able to demonstrate improvement will put your hospital in a much better position to talk-the-talk and walk-the-walk during survey.

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Thank you,

Jennifer Cowel, RN MHSA

Kurt Patton, MS RPh

John Rosing, MHA

Mary Cesare-Murphy, PhD