Inside This Issue
ORYX Requirement Changes:
The lead article in this month’s edition of Perspectives discusses changes being made to the ORYX requirements. As was done previously, there are different requirements for different types and sizes of hospitals. One important change for 2021 is that the driving factors will be type of hospital, licensed beds, and outpatient visits, not average daily census. There are ten variations on the same theme, but many of our readers will fall into the more than 26 beds and more than 50,000 outpatient visit category. These organizations will need to collect four chart abstracted measures for perinatal care, PC-01,02,05 and 06, plus four electronic quality measures from the 12 that are available. Do take a look and verify the specific requirements for your organization, as 2021 is just around the corner.
Mandatory COVID Reporting:
In September, CMS published an announcement in the Federal Register mandating that laboratories report the results of their COVID testing. TJC has identified laboratory standard LD.04.01.01, EP 2 as the anchor point for potential scoring of this issue. This somewhat generic EP requires a laboratory to provide services in accordance with licensure requirements, laws, rules, and regulations. The new note added to the EP then states: Laboratories that perform tests intended to detect SARS CoV-2 or diagnose a possible case of COVID-19 report all positive and negative results on a daily basis to the appropriate state or local public health authorities.
Sentinel Event Definitions:
Effective July 2021, TJC is revising definitions for rape, assault, and homicide in their sentinel event policy. Current definitions categorize rape, assault, or homicide into two groupings: the first one for patients and a second for staff, LIPs, visitors, and vendors. The revised definitions are categorized into six groups, three for patients and three for staff, LIPs, visitors, and vendors.
Rape is broadened and replaced by the sexual abuse/assault term, then followed by physical assault, and homicide definitions for both patients and staff, LIPs, visitors, and vendors. Similar to the guidance we provided in June when they changed the definition of a fall that qualifies as a sentinel event, the key with these changes made by TJC is to ensure that your hospital policy also changes in concert and on time with the new TJC definitions. There is plenty of time left to make this more recent change before July 2021.
Medical Staff Tracer Tools:
Last month we discussed the new tracer tools TJC has developed to facilitate the bylaws review, credential file review, GME review, and general tracer discussion of medical staff practices. This month’s Perspectives indicates that these tools will be published with the January Survey Activity Guide. There is one important update in this month’s Perspectives article relative to future bylaws review.
TJC believes that they will be able to ask hospitals if there have been any changes to the bylaws since the last survey after this tool is implemented, and if not, they will forgo the next review of bylaws. We find this to be an interesting perception, that future surveyors will skip a medical staff bylaws review because their colleague did a review on the survey three years prior. We more often find surveyors revalidating (or not) that their colleague did as thorough a review as they can do. When you download the new SAG in early 2021 be sure to share these tools with your medical staff office and let them self-assess using these new tools. Encourage the medical staff leadership develop a comfort level in the verbal discussion of practices based on these standardized tracer questions.
Changes to Standards for 2021:
Perspectives also contains a grid identifying when different types of accreditation manuals will be updated with changes taking place in 2021 and November is identified as the month when the last of the updates should have been completed. More importantly they have also included a narrative summary of all the significant changes taking place, which you can use to double check that you have reacted to or prepared for each of the changes. Please note, however, that the document TJC prepared contains all significant accreditation and certification changes so you will want to read carefully and only validate those changes for which you have the applicable program.
This month’s Consistent Interpretation column focuses on MM.03.01.01 which describes the requirements for medication storage. There are two important interpretation highlights that readers should make note of. The first is that TJC does not require a “temperature management process” (log for daily recording) for medications stored in a room when the manufacturers package insert requires storage at room temperature, ambient temperature or a temperature range between 59-86oF.
This is particularly edifying as we have seen this very issue scored many times over the years. Most areas of a hospital have heating and cooling that provide a stable room temperature. Bear in mind, even with this guidance, TJC would likely still be critical of medication storage in an unheated and non-airconditioned warehouse.
The second important highlight discusses vaccine storage and similarly breaks apart another long-standing myth that we have also seen scored in many organizations. There has been a scoring perception that any and all vaccines stored should be stored according to CDC guidance for vaccines. TJC now states that CDC guidance must be adhered to only if they are examining vaccines distributed from the Vaccines for Children’s program, if your state mandates CDC storage criteria, or if the hospitals policy states all vaccines must be stored per CDC guidance.
TJC does indicate that hospital policy and vaccines must be stored in accordance with the individual vaccine manufacturer’s guidance, also known as package-insert or manufacturer’s instructions for use, MIFU.
While we are discussing vaccine storage, we should mention that the annual CDC Vaccine Storage Toolkit published earlier this year (link provided in October Newsletter) was updated in late November 2020 with additional guidance relative to storage of Covid-19 vaccines. The table of contents was not updated to help locate the Covid-19 information, but we found it on pages 50-56 of the revised document. Additional information is likely to be forthcoming from each manufacturer and the national wholesaler involved in distribution plans as well as state public health authorities.
Air Handling Requirements:
This month’s lead article is on Optimizing Indoor Air Quality. Given this year’s extensive and intensive focus on Covid-19, and prior years focus on other airborne infectious diseases including aspergillus mold, this article is a great summary of indoor air handling requirements.
They detail TJC’s requirements relative to EC.02.05.01, EP 15 for critical spaces and EP 16 for noncritical spaces. The authors also discuss air exchanges and filtration requirements or MERV, minimum efficiency reporting values, for filtering room air which has become even more important this past year. The authors also discuss a concept that they consider a best practice that is not apparent from the standards, although it could be implied, and that is the idea of a ventilation management plan. This is not explicitly required in EC.01.01.01, however a utilities management plan is, and ventilation/HVAC is certainly one of the utilities you would discuss in the utilities plan. The ventilation plan is also recommended by a 2016 addendum to ASHRAE 170 2013.
The EC News article along with the ASHRAE FAQs and the OSHA Guidance should be shared with facilities leadership and infection prevention and a gap analysis conducted to determine what existing practices may need to be modified.
EC/LS Top 10:
TJC has not been able to conduct many surveys this year, so we have not seen much in the way of details about scoring patterns for 2020. This month’s EC News contains the first glimpse at EC/LS scoring from just under 300 surveys conducted this year. The article contains a comparison of scoring along the SAFER™ Matrix in 2019 and 2020, however as there is a much smaller number of surveys conducted as yet this year, and the Matrix is subjective, this is not conclusive of anything significant. However, TJC also included the ten most frequently scored EC/LS elements of performance from each of those years and 9 of the top 10 are identical. Listed below are this year’s Top 10 as well as a statement about the types of issues frequently identified and advice for not being identified with these same issues at your hospital.
- 02.01.35, EP 4:
This is the somewhat invisible problem we have talked about many times before in our newsletters. This is the issue with sprinkler pipe “supporting” some other material above the suspended ceiling in the hospital. The term supporting is very loosely interpreted and it can include touching, leaning, resting upon, or actually attached to sprinkler pipe. The key is that nothing can touch the sprinkler pipe and you can only see the problems when you remove a suspended ceiling tile and look at conditions above the ceiling.
There should be two opportunities to catch these defects. The first is upon completion of any above the ceiling work done by staff or contractors. There should be an acceptance inspection at the conclusion of work to verify the maintenance worker did not violate this standard when performing the work. Remember when laying computer cable or HVAC ducts these sprinkler pipes look nice and sturdy anchor points for those who are not familiar with this NFPA prohibition. The second opportunity to find this issue is by establishing a “whole house inspection process above the ceiling.” Admittedly this is a huge task, but you don’t know how big the iceberg is unless you look up above that ceiling to understand the scope of your hospital’s existing defects.
- 02.06.01, EP 1:
The EP requires that interior spaces meet the needs of the patient population and are safe and suitable for the care, treatment, and services provided. This sounds fairly simple and straightforward, but it is not. There are really two failure points with this EP. The first is that ligature hazards identified in the environment and not identified, mitigated, and documented on your environmental risk assessment can be scored under this EP. Second is that any defect in physical environment could potentially be scored deficient here. This could include tripping hazards, peeling paint that cannot be cleaned, torn mattresses, rust on equipment, or anything else that looks risky or unsanitary.
The only way to prevent this very frequently scored issue is to proactively identify and correct these defects before they are identified by TJC. Very often we see these issues noted as “observed and corrected on site.” This means the problematic issue is either taken out of service immediately, or the issue was easily corrected by some other method. If that is the case, you have to ask yourself why these defects can’t be identified internally by staff working in the area, by quality or infection prevention rounds, or during EC rounds.
- 02.02.05, EP 6:
This EP requires the inspection, testing and maintenance of non-high risk utility systems with a 100% completion rate. TJC and CMS in more recent years raised their expectation for the completion rate and that continues to affect some organizations with gaps in their completion either due to workload or missing some aspect of a manufacturer’s guidance on inspection, maintenance, or testing. The scoring pattern on this one may go down in the coming year as the national emergency has allowed certain inspection, maintenance, and testing requirements to be waived.
- 02.01.35, EP 14:
This is the same standard as #1 above, but a different EP. This is the miscellaneous EP, where any fire extinguishing system issue not covered by its own, very specific, EP can be scored. Examples we have seen include sprinkler heads not turned up in an area without a drop ceiling and a heat detector being within two feet of a sprinkler head.
- 02.02.01, EP 5:
The EP requires the organization to manage the risks of hazardous chemicals and the most frequent culprit is the surveyor identifying a chemical, asking staff to pull up the SDS, and then noting that it is a corrosive substance and there is no nearby eye wash station.
This is a good issue to examine during EC rounds, but unfortunately it is too easy for any inpatient or outpatient department, or even a contractor, to purchase some new chemical and begin to use it within the hospital. Hospitals may want to consider some restrictions on user departments or contractors directly purchasing chemicals for cleaning or maintenance of equipment. Another option to consider is a list of approved agents and teaching staff during orientation or annual training that if they see something new, not previously approved they should question its use, or ask to see the SDS. A third option is to have the requesting manager verify the purchasing request that they have personally reviewed the SDS and noted that the agent they are seeking to obtain is not corrosive or listed as a Category 1 eye exposure risk.
- 02.01.10, EP 11:
This EP requires fire rated doors to be self-closing and latching with appropriate gaps between the leaves and undercuts. These fire doors, which may at times be smashed by stretchers or other equipment being moved through the hospital, require annual inspection and maintenance. This is another one where we often see the issue noted on the survey report as “observed and corrected on site.” Again, if it’s that easy to fix, it needs to be identified and corrected before TJC arrives. The only way to do this is a periodic inspection process throughout the organization to proactively identify the defective doors and to correct the defects. In addition, just as organizations have incentivized clinical incident reporting, there may be a way to incentivize the reporting of damaged, non-latching fire doors, or doors with excessive sunlight coming between the leaves or under the door.
- 02.05.01, EP 9:
The EP requires utility system circuits to be labeled for partial or complete emergency shut down. There are two important notes in this EP where TJC identifies the types of issues where this applies. The second note is particularly important in that it requires the fire alarm system circuit to be clearly labeled, the circuit breaker to be marked in red, and access to be restricted to authorized personnel. The absence of a red circuit breaker is an issue we have seen scored frequently against this EP.
- 02.01.30, EP 14:
This is the same standard as #6 above, but a different EP. This EP requires penetrations to be sealed with an appropriate fire rated material. This is a subject we have discussed frequently and this issue has been scored with alarming frequency for many, many years. Identification frequently requires inspection above the ceiling and the defect often jumps out at the surveyor when they observe missing fire stop, different color fire stop materials, dried out and cracked fire stop, or even urethane foam material which is not an approved fire stop.
Again, there are two opportunities to identify these issues, one being immediately after staff or contractors complete work that involves drilling between walls or floors, and the second is through a periodic inspection process to identify fire stop that has dried out and potentially no longer fills the gap it filled when new. In regard to the different color fire stop, if you change brands, do keep the manufacturers specifications so that you can show the surveyor the product was an approved fire stop material. Never mix two different materials to seal the same penetration. In addition, take a look at what contractors plan to use, or provide them your approved product, to prevent this problem from being identified at a later time.
- 02.01.35, EP 5:
This is the same standard as #1 and #4, which means this standard is particularly problem prone. EP 5 requires that sprinklers are not damaged, free from corrosion, paint or any foreign material, and that the escutcheon plate is properly installed. This is something that surveyors do much better than staff, they walk around and periodically look up at the ceiling to note if the sprinkler heads are clean or the escutcheon plates are drooping or missing. Sprinkler heads get dirty, dusty, and sometimes greasy and potentially may not work as expected as a result. Potentially these situations could be identified during EC rounds, or perhaps by staff working in the area, just looking up at the ceiling every few months. If you do try to sensitize staff to this issue, do remind them not to attempt to correct the issue themselves, but rather to report the issue and have a professional service gently clean the sprinkler head so as to not damage or set it off.
- 02.05.09, EP 12:
This EP was not reported last year in the top ten, although it was an issue that was scored quite often. The EP requires proper storage and handling of medical gas cylinders and the one that has proven difficult is proper segregation of full vs empty oxygen cylinders. A second issue which has been frequently scored for many years is failure to properly store a medical gas cylinder in either a rack or on an approved rolling cart. Unsecured medical gas cylinders are unstable and may tip over, raising the fear that they will become a projectile if the head snaps off during a fall. This is a type of issue that can and should be readily identified and managed by clinical staff as they are the ones who are obtaining, using, and storing medical gases used in patient care settings.
These top ten lists are informative and point out the most frequently cited issues. We often call these “low hanging fruit,” or the types of issues surveyors get used to looking for because they are easily scoreable and scored in so many different organizations each year. The early and easy identification of this low hanging fruit during a survey can start things off on a wrong footing, giving the surveyors the impression, you were not prepared, or not maintaining a safe environment. Knowing what troubles many hospitals can help you to prevent making the same mistakes at your organization.
EC News this month contains a summary of material presented by the Joint Commission’s Engineering and Surveyor leadership during ASHE’s virtual conference in October. They highlighted the issue of water management, which is a subject currently in development for new standards anticipated in July 2021, but already covered by guidance from the CDC, ASHRAE, and CMS.
Based on these national references, surveyors are already asking about risk assessments, water management plans, testing protocols, and control measures. The article then provides an early draft copy of more explicit water management standards currently in development. We encourage our readers to take the time now to review the draft standards published in EC News and to plan out their implementation efforts if not already in existence based on earlier CDC, CMS and ASHRAE guidance.
Non-Waivable ITM Requirements:
This same article developed from the TJC presentation at ASHE then identifies what are called non-waivable requirements for inspection, maintenance, and testing (ITM). During the Covid-19 national emergency there have been many blanket waivers including some, but not all ITM activities. This article highlights specific ITM activities for which there was no waiver and surveyors will still expect a complete track record. Specifically, there were no waivers for:
- 02.03.05, EP 6: weekly fire pump testing
- 02.03.05, EP 15: monthly fire extinguisher inspections
- 02.03.05, EP 27: monthly, elevator firefighter emergency recall testing
- 02.05.07, EP 5: monthly generator testing time under load for 30 minutes
- 02.05.07, EP 6: monthly generator testing load of 30%, or manufacturers exhaust gas temperature or testing annually at 50% for 30 minutes followed by 75% for 60 minutes
- 02.05.07, EP 7: automatic transfer switch testing monthly.
Remember if you were not able to complete these ITM activities, there is no opportunity to correct the gaps at this point. You might get an RFI, but an RFI just requires correction going forward which is easily resolvable as compared to a perception that documentation was falsified.
Issues in the Kitchen:
Lastly, this same article based on the ASHE presentation also discusses frequently scored issues in the hospital kitchen. Remember TJC has a new kitchen tracer tool that helps to standardize this portion of the survey. The authors highlight three frequently scored issues in the kitchen. These are:
- Deep fat fryers needing a minimum separation of 16 inches from open flames or a steel or tempered glass baffle plate at least 8 inches high between the fryer and the open flame source.
- A method to return any cooking equipment that is temporarily moved for cleaning back to its correct placement so that the Ansul fire suppression system above is properly centered over the cooking surface. TJC suggest wheel chocks as a best practice if the cooking surface is on wheels.
- The K type portable fire extinguisher must be located within 30 feet of grease producing equipment and the K type fire extinguisher must have signage stating the need to activate the Ansul system before using the K type fire extinguisher.
This entire article should be shared with facilities leadership and a gap analysis performed to determine any changes in practices that might be needed.
Hospitals Without Walls:
On November 25th, CMS issued a press release adding more depth to their “Hospitals Without Walls” program. CMS is going to permit hospitals to provide care for patients with more than 60 different acute medical conditions such as asthma, congestive heart failure, pneumonia, and chronic obstructive pulmonary disease at home using proper monitoring and treatment protocols. Patients must be admitted from either an emergency department or inpatient hospital and an in-person physician evaluation is needed prior to starting care at home.
A registered nurse must evaluate each patient daily, either in person or remotely, and two in person visits must occur daily either by a registered nurse or mobile integrated health paramedics, based on the patients nursing plan and hospital policies. The press release provides additional links to very brief feedback from hospitals that have piloted the program and FAQs with additional information.
Lab Remote Surveys:
There was also one QSO memo released this past month, QSO-21-04, regarding a CMS remote survey process for laboratories. This has minimal importance to Joint Commission accredited hospitals that use TJC or CAP accreditation, but it provides insight into CMS’ thinking about remote surveys. For example, the remote survey process is only available to laboratories that did not have condition level findings, failures on proficiency testing, and no substantiated complaints filed against the laboratory since their last survey.
The Joint Commission Advisory Group was held on Dec 7th. There were a few updates we wanted to share. First, the Joint Commission is still in discussions with CMS on details, but they are scheduling virtual follow-up surveys such as Accreditation with Follow up (AFS) and Medicare Condition Deficiency surveys. In addition, they will start conducting full re-surveys at deemed hospitals and other deemed programs in January utilizing remote technology. They will communicate when they have further details on which re-surveys can be conducted remotely and they will publish more detail on the need for an onsite, abbreviated survey when conditions permit.
In our previous newsletter we reported that the Joint Commission is calling organizations in safer counties to inquire about organizational readiness. We learned that starting soon, Joint Commission will instead post a questionnaire to your secure extranet asking about readiness. Those organizations that are in an open county and self-report that they are ready for survey will receive a call from their account representative. Do keep an eye out for new postings to your extranet.
Finally, as many of you struggle to onboard contracted or other temporary staff during this PHE, Joint Commission did state that the hospital is obliged to provide onboarding education for critical job duties and responsibilities but the onboarding process does not need to duplicate the full onboarding you provide to employed staff. This may provide a bit of relief but it does require you critically identify necessary education and training.
We have made it to the last month of 2020! This has been quite
the year for everyone, but our own healthcare industry was
especially hit hard.
Each and every one of you deserve an extra gift in your stocking this year. Your perseverance to push through, your
dedication to your community, and devotion to patient safety deserves a round of applause – thank you!
Wishing you, your work family, and personal family a very happy,
safe, and healthy Holiday Season! See you all in 2021!
Jennifer Cowel, RN MHSA
Kurt Patton, MS RPh
John Rosing, MHA
Mary Cesare-Murphy, PhD