Patton Post – December 2021

2022 ORYX Requirements:

Happy Holidays to our readers. There were no new requirements announced in Perspectives this month, but there was some interesting information. The lead story is about the 2022 ORYX requirements and more specifically how you will get your 2021 and 2022 data to the Joint Commission.

On September 19^th, their vendor for data submission informed TJC they were going out of business as of September 30. TJC states in their article that given the short notice, mitigation plans to provide continuity of service could not be developed. Sometime in the second half of 2022, TJC will complete its own data submission platform. Requirements for accredited organizations to collect ORYX data will not be suspended, but you will not be able to submit that data until the platform is completed.

This situation reminded us of the leadership standard LD.04.03.09, EP 8 that requires the accredited organization to maintain the continuity of care when contracts are terminated. This pause does not affect the certified program data submission requirements that use a different platform, nor does it delay any data submission to CMS.

Cybersecurity:

Perspectives has a reminder article about the Quick Safety #62 they published in October on the subject of cybersecurity. This is an issue that healthcare organizations need to be concerned about and TJC provided recommendations for leadership, staff education and training, emergency management, and IT security resources.

One particularly interesting recommendation was to test staff’s response to cyber challenges by sending them “test challenges” to see if they click the link or more appropriately just delete the message. I am reminded of these phishing scams because while drafting this newsletter I noticed an email popup from an online store I have never purchased from sending me an email stating I have to change my credentials.

In the Quick Safety, TJC also provides multiple links to resources that may help identify mechanisms to strengthen your defenses against cybersecurity threats.
As always, we would suggest sending this publication to your subject matter experts, but more importantly plan a briefing to understand your current state of deterrence and determine if your organization has already implemented these recommendations.

Water Management Requirements:

Last month we discussed new standards changes for 2022 and this month Perspectives includes a schedule identifying when these new requirements were published in E-edition, hard copy manuals, and PDF manuals.

We did note that water management standard EC.02.05.02 is new for 2022 but we did not discuss it last month because it does not show up as being new in the E-edition for 2022. Instead, it appeared as new in the July 2021 update, although the start date for the new standard is not until January 1, 2022.

The new water management standards for 2022 had been published in your April 2021 edition of Perspectives and were also discussed in our April 2021 newsletter.

Water management expectations are already a frequently scored issue on survey and the additional detail in the new standards will likely lead to even more findings. There are two issues that should be double checked now. The first is to ensure that you have identified a person or team that is assigned responsibility for managing your water management program. The second is to verify that you have created the “basic diagram” that maps all water supply sources, treatment systems, processing steps, control measures, and end use points.

Coincidentally, the December issue of EC News has a refresher article on new requirements for 2022. They explain that this “basic diagram” need not be a highly detailed drawing that indicates “every water feature in the organization, or every sink, shower head, and toilet.” It can be a basic diagram that indicates a patient unit with sinks, toilets and showers.

This same EC News article also has some very practical advice about units that are closed, or features such as showers, that may not be used by some patients. Here they recommend that housekeepers run the showers daily if patients are not using them to prevent stagnation of water.

Extranet Access and Security:

The December Perspectives has a reminder article about extranet security and periodically updating who is still authorized to have access to the extranet, and who has left the organization and should now be removed. In addition, TJC advises against having consultants as your primary organization contact for the extranet.

That primary staff role is not the type of consulting that we do at PHC, but we have consulted in smaller organizations that do use a local consultant as their primary contact. These local consultants are sometimes actively working at a larger facility and moonlighting at the smaller organization, or recently retired from a Joint Commission leadership role at a nearby facility and are providing technical expertise to the smaller organization.

As TJC does more and more extranet based communication this can get overwhelming for organizations that don’t have someone dedicated to just this function, with a backup, to seek out extranet based communication. However, their guidance is that this should be a staff role, not a consultant role.

More importantly this same article refreshes the guidance on how staff at your organization can access their own copy of Perspectives from the extranet. The good news is if staff use a facility domain email address the process looks quite easy:

1. Start at the self-registration for guest access page on the jointcommission.org website.
2. Enter the city/state or zip code to find your HCO ID if not already known.
3. Fill in the required fields and security challenge and submit.
4. If you used a facility domain email address you are done. If you used a personal email address the staff person assigned as the primary contact for the facility will receive an email from TJC asking them to grant the access.

Standards Interpretation:

The Consistent Interpretation column is consistently intriguing and at times surprising. This month they focus on two EC standards, one for utility system testing and maintenance EC.02.05.05, and the “catch all” standard EC.02.06.01, where anything the surveyor considers risky in the environment can be scored. When you look at the wide array of surveyor observations including mold, slime, unknown red substance, and odor, our term “catch all” will be clear.

The column also discusses IC.02.02.01 and tries to differentiate when this standard should be scored vs EC.02.06.01. What we noticed among the many examples described in this column were three classic issues that modify existing doctrine we have seen applied for many years.

The first “myth buster” is under IC.02.02.01 and TJC advises its surveyors not to score a failure to clean children’s toys between patient use. Instead TJC states that if the toys are in a supervised area and the organization ensures hand hygiene upon entry, then the toys would not require cleaning after each use. The failure to clean toys between patient use is an issue we have all seen scored for more than 30 years, but it appears that a reinterpretation has been applied. We theorize that similar logic could be applied to the use of commonly used, soft-surface rehab equipment like foam handles on a stair-stepper, but would caution our readers to confirm any expansion beyond toys with the Standards Interpretation Group (SIG).

The second “myth buster” is under the discussion of IC.02.02.01, EP 4 where Joint Commission now states: “TJC does not require a solid bottom shelf on a wire storage rack. However, there must be a process to protect shelf” contents from contaminants, such as a splash from wet mopping. If the organization does not use string mops to clean floors, for example, instead using microfiber mops, this may not be scoreable.” The failure to have a solid bottom shelf on a wire cart is another classic we have seen scored for our entire careers.

The third issue that surprised us was also under the discussion of IC.02.02.01, EP 4, where TJC now states that clean biohazard bins may be stored in the dirty utility room providing they are “stored in a manner that prevents the items from contamination.” This just seems to run contrary to the teaching principle of clean items in the clean utility room, dirty items in the dirty utility room. The biohazard bins are going to become dirty with contaminated instruments or other material, but when they are brought into the patient care area for use, they must be clean.

You might be thinking what, if anything, do we need to do with these new interpretations and do we need to change current practices. If your current practices are working for you and staff are consistently compliant, our suggestion would be to not change anything. Interpretation is subject to change and there is always the potential for some subjectivity to be applied in the scoring process, such as a surveyor thinking your process to keep the biohazard bins clean, while stored in the dirty utility room is insufficient.

If, however you have found difficulties in cleaning toys, ensuring a solid bottom shelf on wire rack storage, or insufficient space in a clean utility room to store clean biohazard bins, then you might want to consider some of these new interpretations. However, if you do want to change current practices, we would suggest formal risk analysis in conjunction with your infection prevention leaders, and maintaining this month’s Consistent Interpretation column as your reference, should you ever be cited.

We also wanted to point out one other tidbit of information from this column and it’s the last item mentioned where TJC states: “Food and dietary/nutritional supplements may not be stored in the same refrigerator as medications.” We have not seen this prohibition articulated so clearly, or scored in the past. It also runs contrary to a practice we commonly see where prescription nutritional formulas and enteral feedings are stored in the medication refrigerator instead of the pantry.

Future Standards:

As we head into 2022, readers should very soon be on the lookout for new emergency management standards, which are pending approval from CMS. These are anticipated to take effect in July 2022, and will be published on the prepublication page of the TJC website.

On the last content page of Perspectives, TJC provides insight into additional future directions as they are currently considering additional standards development for antibiotic stewardship, environment of care, patient rights, quality and safety of electronic medical records, and strategies to reduce healthcare disparities. At present these are only being considered for development, not yet drafted for field review.