Inside This Issue
We say “happy” lightly, as we see in the news every day how busy our nation’s hospitals are at this time still dealing with Covid-19 cases. Our hope is that the vaccines getting into staff and patient arms start to take effect and the daily crises you have been dealing with for almost a year will soon start to abate. Our newsletter, as usual, will review all the pertinent content from TJC and CMS, but out of respect for your limited time we wanted to highlight the essential information that needs to be acted upon, rather than the more mundane, informational content.
The most essential action item this month is the article on page 6 of Perspectives. These standards become effective July 1, 2021.
TJC has created a new LS.05.xx.xx and you will want to provide your facilities and outpatient leadership with these standards for self-assessment and identification of likely compliance difficulties ASAP. In the past, there was a perception of complacency in these business occupancies, knowing that TJC did not really focus the same energy in physical environment issues. These standards and the evolving survey process will change that perception and you will want to know about and correct potential problems before being hit with RFIs. We encourage our readers to develop a reporting process to senior leadership about anticipated difficulties now.
The second issue we wanted to highlight is that the delayed public reporting of perinatal care measures is now going to kick in later this month on the TJC website. The planned reporting had been delayed by TJC due to Covid-19, however TJC has identified that most hospitals continued to report data throughout the pandemic, so further delay was not warranted. This is likely to be much easier to deal with than the new life safety code changes but you will want to understand how the data will be publicly displayed and how your data compares. If your data identifies any potential underperformance, you will want to provide a heads up to senior leadership and media staff for potential press inquiries.
Standards Changes – APR, EC, LS:
In more routine matters, TJC has made a change to the Accreditation Participation Requirements chapter, deleting the APR mandating the completion of the Focused Standards Assessment, or FSA. They explain that the requirement to perform the FSA is already detailed in the Accreditation Process, or ACC chapter, of the accreditation manuals. While this is true, having an APR provided TJC with a place to score the deficiency should someone not complete the required FSA. The bottom line on this issue is that the change should have little to no impact on your organization.
Perspectives also has an announcement about new EC and LS standards, effective July 1, 2021 for organizations accredited using the behavioral healthcare manual. These revised standards are posted to the TJC prepublication website and you may access the document here:
Our first advice is to not confuse these changes with the changes we discussed in our opening paragraph relative to business occupancies. These are for either healthcare occupancies or residential board and care occupancies (sleeping facilities such as a residential care facility). To a large extent, these changes add new detail to what were existing requirements.
However, do take a look at EC.02.03.03, EP 1 which has added a new note 4. This note helps identify what is a healthcare occupancy vs a residential board and care occupancy. It states: “Behavioral health care facilities are considered health care occupancy if door locking is utilized to prohibit individuals from leaving the building or spaces in the building.” This may potentially mean that a site you previously thought was a residential board and care occupancy is actually a health care occupancy.
Share these standards changes with your facilities leadership and self-assess any non-hospital, 24-hour locations, accredited under the BHC manual and not already reviewed using the hospital manual. It is likely you will identify some vulnerabilities that are either new or not previously noticed.
EM Changes in Home Care:
Perspectives has an announcement that TJC is changing EM.03.01.03 for home health and hospice organizations to collapse into one uniform expectation for both deemed and non-deemed organizations. They created a new EP 20 for the standard and deleted the existing EP 1. The requirement is still to conduct at least one exercise of your EM plan every year, but the depth of that exercise can differ between years.
As written, they advise a community based, full scale exercise, or a facility based functional exercise in one year and in the second this could again be another community based, full scale exercise or a facility based functional exercise, or alternatively this could just be a mock disaster drill or even a table top or workshop exercise.
Certification Performance Measures:
If you have certifications in either total hip and knee replacement or acute stroke ready certification, then Perspectives has two articles on new performance measures that you should study. The change for the acute stroke ready hospital certification, or ASRH, is that the door-to-transfer measure ASR-OP-2 is being replaced by the STK-OP-1 performance measure. The STK-OP-1 measure uses a stratified data collection approach, using seven different subtypes. This change is effective as of July 1, 2021.
Also effective July 1, 2021, there is a new performance measure for the total hip and knee certification program, THKR-5, which evaluates postoperative functional and health status.
Pediatric Cardiovascular Programs:
Perspectives has a very brief article on a new tracer activity for hospitals with “robust” pediatric cardiovascular programs. You might remember a series of media articles two years ago about patient complications in some of these programs that reportedly went unnoticed or not acted upon. TJC has apparently been test also effective July 1, 2021ing new methods of evaluating these services using a pediatric cardiologist surveyor with cooperation from pediatric professional associations and some volunteer hospitals. The new tracer activity focuses surveyors to evaluate three issues:
- Culture of safety/leadership/transparency
- Data collection/board involvement/reporting
TJC states they will be privately interviewing front line staff, one-on-one, for 10-15 minutes to ascertain information about these three bullet points.
Consistent Interpretation – Thermometers:
This month’s column deals with thermometers and the need to calibrate their accuracy periodically. TJC identifies three different standards and EPs where a failure to calibrate could potentially be scored. These include the medical equipment standard EC.02.04.03, EP 3, the utility systems standard EC.02.05.05, EP 6 and everyone’s favorite catchall standard EC.02.06.01, EP 26.
These standards are scored with some frequency, however multiple different issues can be scored against each of these requirements, thus the total percentage of hospitals scored deficient is likely to be less because many of the deficiencies are unrelated to thermometer issues. Not mentioned in this article is the potential thermometer calibration defects that might be scored in MM for medications or PC for food products.
The take away from this article is that thermometer calibration is an issue that is on their radar screen. In addition, the complexity of this issue is ever increasing as we utilize expensive and complex medical equipment with built-in thermometers, or the hundreds of wireless sensors in use in hospitals today. Prior to this level of equipment complexity, it was relatively easy to just purchase new “throw away” thermometers every two years with a fresh certificate of calibration.
If you are seeking more information about calibration, the 2020 CDC Vaccine Storage Guideline previously discussed in our November and December newsletters has a good description of the process on page 10. More importantly, this is certainly an issue worthy of exploration as surveyors may be more sensitized to looking into calibration due to all the Covid-19 vaccine discussions this past year. Don’t forget calibration is not just important for medications, but also food, blood, tissue, and any mechanical device you have where the manufacturer instruction for use identify a need to recalibrate any built-in temperature sensors.
Spare Circuit Breakers:
The lead article this month, “From the Field Directors” discusses three issues of importance to readers. The first deals with spare circuit breakers in an electrical panel. If genuinely a spare, then the breaker should be in the off position. If the breaker is in the on position, it may not genuinely be a spare, but could be supplying current to some area that you are not aware of. Curiously, TJC says that effective 1/1/21 organizations will receive an RFI for spare breakers being in the on position. However, this announcement may surprise some organizations as more progressive surveyors have already been scoring this issue.
They also discuss the “noncompliant elevator wraps” that many hospital marketing departments have used to cover elevator doors with an advertising message. These wraps were discussed in the June edition of EC News with the guidance that scoring would start for non-UL approved wraps as of January 2021. Then in the July edition, it was mentioned that for the indefinite future surveyors would only advise about the wraps due to Covid-19. Now this article again indicates scoring has begun as of January 2021. These wraps if used should have documentation that they are UL 10B or UL 10C approved.
Fire Drill Matrix:
The third topic discussed in this article is the Joint Commission’s Fire Drill Matrix.
The update is important and adds clarity to an ambiguous issue about fire drills in operating rooms and hyperbaric services. While surveyors have talked about this and scored deficiencies, there has not been a specific element of performance that make this a clear requirement. Now it is clear from the Joint Commission Fire Drill Matrix that they require an annual drill in these unique-service and high-risk areas.
Spare Sprinkler Heads:
EC News has a second article about an important change in the requirements for spare sprinkler heads. LS.02.01.35, EP 7 has required hospitals to keep at least six spare sprinkler heads and the associated wrench in a cabinet that does not exceed 100ºF. This requirement became effective after adoption of the 2012 version of the life safety code and unfortunately it has, and still continues, to surprise many organizations.
Well, it just got a little more difficult in that the change is that hospitals must keep six spare sprinkler heads of each type and temperature rating that are installed in the facility readily available. So, if you have two or more different types of sprinkler heads you will need at least six spares for each type. Thus, if you have four different sprinkler heads you will need 24 spares on hand. Keep an eye out for potential changes to this requirement in the future as we understand the American Society of Healthcare Engineers (ASHE) recommended changes this past October.
Reducing Corridor Clutter:
EC News also has articles about the life safety chapter changes for business occupancies and behavioral health care organizations and the EM change for home care that were duplicated in Perspectives. The closing article is about reducing corridor clutter and is written by accredited, hospital-based life safety specialist at the Bronson Medical Center in Kalamazoo, MI.
They describe their multiyear process to reduce corridor clutter and their constant vigilance to keep the clutter out of their hallways. It is of particular note that they do discuss issues that have arisen since the pandemic—such as isolation cart and staff mask storage. Having just concluded the holiday season, we would say the “proof is in the pudding” so to speak, and they provide a graphical presentation of their trends from early 2019 to August 2020 and the improvement trend is dramatic. Their process included both planning and monitoring teams and if you have a similar team, this article would certainly be worth sharing with your team.
On December 15th TJC issued # 56 of its Quick Safety publications on the dangers of surgical smoke.
The issue is that lasers and various power tools used in the operating rooms can create smoke and that smoke can create hazardous gases and vapors. TJC’s reference warns that this smoke may include “benzene, hydrogen cyanide, formaldehyde, bioaerosols, dead and live cellular material, including blood fragments and viruses.” These can pose problems for the patient during their time in the OR, and also importantly the staff present on a daily basis who may be exposed to this smoke.
The Quick Safety then discusses the regulatory framework surrounding this potential hazard including TJC standards, OSHA, NIOSH, ANSI, AORN, and ECRI guidance. There is an expectation from all of these groups that hospitals should take action to protect both patients and staff from the hazard. This edition of Quick Safety should be shared with your facilities and operating room staff for evaluation of current mitigation activities and their relative effectiveness.
We are with high hopes that 2021 will bring better health and prosperity to the world with kudos going to the exhaustive and incredible efforts of our very own industry. With the most sincerity possible, we say THANK YOU and we wish you a happy NEW year.
Jennifer Cowel, RN MHSA
Kurt Patton, MS RPh
John Rosing, MHA
Mary Cesare-Murphy, PhD