Patton Post – December 2023

Happy Holidays to all our readers! Thanksgiving is over, except perhaps for some leftovers lost in the back of the refrigerator, and there are likely many more festivities and family gatherings to participate in between now and January 2nd. There are also many patients who are still in need of your services this month, but in January there will feel a sense of newness and anticipation for the coming year and wonder about what regulators and accreditors will send your way.

Sentinel Event Involving Suicide:

This month’s Perspectives discusses changes that TJC has made to their definition of a sentinel event involving suicide. We noted that TJC assigned an effective date to this change of January 1, 2024. TJC usually provides at least 6 months’ notice of changes to requirements, consistent with the accreditation contract between your organization and Joint Commission, but we have to assume TJC considers this a patient safety issue requiring a more expedited timeline.

It is also possible that TJC would consider this a policy issue, not a standards issue, however it becomes a standards issue in LD.03.04.09, EP 4, which requires your sentinel event policy to be consistent with their policy. Currently they define a suicide sentinel event as a suicide occurring in a 24-hour staffed setting or within 72 hours of discharge from that setting, or within 72 hours of discharge from the emergency department.

The new definition expands that discharge responsibility to within 7 days of discharge from a 24-hour setting or the ED. In addition, the new definition now specifically includes while in, and within 7 days of discharge from day treatment, partial hospitalization, intensive outpatient, residential, group home, and transitional supportive living. As 2024 is just around the corner, readers, and in particular those due for a survey in the first quarter of 2024, will want to revise their own sentinel event policies and definitions to remain consistent with the changed requirements.

We took a quick look at the E-dition for January and noted that the SE chapter does already include these new requirements. As you begin your policy analysis and revisions you may want to review all the definitions to ensure your policy changes have captured other changes TJC has made the past few years.

Searching our own newsletter, we identified multiple terminology and definition changes including:

• Nov 2019:  invasive procedure, hemolytic transfusion reaction, and fire definitions
• June 2020:  falls definition
• Dec 2020:  rape, assault, homicide categorization
• Oct 2022:  sexual assault/abuse definition

The reporting of sentinel events remains voluntary; however, you can’t be compliant with the requirements if you define sentinel events differently than TJC does. So do take a look at your policy to make edits so that it is consistent with the current definitions described in the SE chapter. While your definition can be more expansive than Joint Commission, it cannot be more limited than TJC.

Summary of Changes- Revisions and Removals:

While we are discussing changes, the December issue of Perspectives has an annual summary of publication dates for new content and a brief discussion of what has changed in the manuals. The first page of the article has a grid with publication schedules for each accreditation program in the E-dition, the second 2023 update, the 2024 comprehensive manuals, the abridged minibooks, and their PDF versions. With the exception of stroke and orthopedic certification, the E-dition appears to be the most up to date reference, so we would suggest using that source during your verification or readiness analysis.

The narrative summary of changes discusses all accreditation programs, so if you manage multiple tailored programs, you have one-stop shopping. If you have only one accreditation program, you will just want to read carefully to separate out only the changes applicable to your organization. This summary does provide a nice reminder of what is changing and an opportunity to verify readiness. You can also apply a filter in the E-dition of your manual to identify only those standards which are new for 2024, which will provide you a tool to focus your verification of readiness.

Critical Areas and Ventilation Systems:

This month’s Consistent Interpretation column discusses EC.02.05.01, EP 15 which is a very heavy hitter with 36% of hospitals being scored noncompliant. The EP requires critical areas designed to control airborne contaminants including biologic agents, gases, fumes, and dust to maintain the appropriate air pressure relationship, air exchange rates, filtration efficiency, temperature, and humidity. In theory this sounds easy, and if you design and construct an area to fulfill these requirements, the room should work as designed, but there is a lot that can go wrong over time.

The most common issues we see on consults and in accreditation reports are temperature, humidity, and air pressure problems. Temperature and humidity problems are often human caused, where for personal comfort someone has substantially lowered the thermostat, and due to the inverse relationship between temperature and relative humidity, the humidity reading goes too high, exceeding the maximum allowable humidity of 60%.

The temperature may be lowered below the ASHRAE allowable limit of 68 degrees for documented reasons on a specific case but must return to allowable limits after the case is concluded. Temperature and humidity problems can sometimes be due to extreme weather, such as winter weather, when the continual use of heat takes the natural humidity below 30%. Just about everyone remembers that CMS permitted healthcare organizations to allow humidity levels between 20-30%, but too few remember that this needed to be done after a formal, documented risk assessment was completed that verified the equipment and supplies in the area could operate safely at this lower range.

The third very frequent problem is air pressure not being consistent with the design requirements. For example, an operating room, sterile, nonhazardous compounding area, or central sterile processing area, which should all be under positive pressure, and on the day of survey they find it not to be positive. Similarly, hazardous compounding and central processing decontamination should be under negative pressure.

These pressures can go out of alignment for many reasons including, a fan break, a loose fan belt, leaving a door open in the critical space, or by creating a wind tunnel by leaving exterior doors open in adjacent spaces. The key to managing this issue is to give staff a tool such as a sensor and alarm to verify pressure is within limits and to use the tool effectively. Sometimes staff shut off the alarm because it is ringing, but they don’t get the cause for the alarm corrected in a timely fashion and continue to use the space.

Do take a look at the surveyor observations of noncompliance discussed in this months’ column. They identify many similar and diverse reasons why this is such a difficult standard to maintain in compliance.

Quick Safety on Pressure Injuries:

In October, Joint Commission published Quick Safety #70 on Early Identification and Evaluation of Severe Pressure Injuries. A link to the Quick Safety is provided in the Perspectives article. In this brief article TJC discusses risk factors, warning signs and symptoms, and provides four safety actions to consider. While the content does not necessarily sound like anything we have never heard hospital staff discuss, there may be one or more content points that are not as well known in your organization, so do take a look.

There are many springboards for discussion of pressure injuries during a survey, from individual patient tracers to PI/data discussions, unit-based PI projects or other. We would suggest sharing the Quick Safety with those who may be involved in leading your organizations efforts at preventing pressure injuries and the staff to determine if there is content you want to incorporate.

In addition, it is always a good idea for staff to be able to be able to discuss TJC safety initiatives if asked by a surveyor, allowing staff to speak to how the recommendations are utilized.

Simplification of MS.06.01.05, EP 6:

The December Perspectives also discusses the removal of a note that is currently a part of MS.06.01.05, EP 6. The EP has always been clear and simple; however, the current note adds complexity, ambiguity, and workload because it seems to expand the requirement substantially beyond what the EP says.

Well, the good news is TJC now agrees, and they are deleting the entire note. The EP requires: “An applicant submits a statement that no health problems exist that could affect their ability to perform the privileges requested.” If you have been exceeding that simple requirement and want to dial the workload back a notch, you can now that the ambiguity of the note has been removed.