Patton Post – January 2022

Happy New Year to our readers! We hope you were able to enjoy a respite from work and also avoided Covid during the holidays. Throughout last year, and again in November and December, we had reviewed new standards taking effect January 1^st for water management, workplace violence, resuscitation, performance improvement, and accreditation participation requirements. Hopefully our readers are ahead of the curve and have launched these new standards prior to the beginning of the year.

New Standards for July 2022:

We noted in the January Perspectives that it all begins again, with new several new hospital standards scheduled for implementation in July 2022 in the environment of care, emergency management, and patient rights chapters. Joint Commission publishes this new content providing organizations a 6-month lead time to prepare for new requirements.

The changes in EC and RI are relatively modest, however the EM chapter has gone through a much more significant rewrite. There is also a change in the EC chapter for inpatient hospice providers, bringing the limitations on power strips that hospitals have been struggling with to inpatient hospice.
Our advice is to go to the TJC prepublication page now, download the standards changes, and assign them to your chapter leaders or department heads as appropriate for analysis and implementation planning. These will stay posted to the prepublication page until June 30, 2022. Policy development and training is time consuming so the sooner you can start, the better.

In addition, the changes to the EM chapter are substantial and your emergency operations plan (EOP) is going to need revision, as will your staff training about the EOP.

There is also a new R3 report for Emergency Management that may be a useful reference. It is analyzed at the standard level, not the EP level detail, but it does provide insight on the rationale behind each standard, and perhaps more importantly references and links to resources about each of the new requirements.

Patient’s Rights Standards Changes:

These changes are applicable to the hospital, critical access hospital, ambulatory, behavioral, home care, and nursing care center programs. Previously, Joint Commission had a requirement at RI.01.03.01, EP 3 that established a requirement to obtain consent before any images or video were recorded.

That EP has been deleted, but in its place TJC has created a new EP at RI.01.01.01, EP 37 that requires the organization to “consider patients’ privacy and comply with law and regulation when making and using recordings, films or other images of patients.”

In the past there was guidance from TJC, but now you may have to search for national or state laws relative to video, films, and image production and use.

There is also a second change at RI.01.01.01, EP 1 that defers to law and regulation for consent discussion relative to patient care. TJC is adding another bullet point to the EP stating that the consent discussion should be done by “the licensed practitioner permitted to conduct discussion in accordance with law and regulation.”

This remains the understanding most have held in the past, but again, you may want to consult with your attorney to determine if any edits to your consent policy are necessary.

Environment of Care Standards Changes:

These changes are applicable to the hospital, critical access hospital, ambulatory, assisted living, behavioral, home care, nursing care centers, and office-based surgery programs.

The first change is in EC.02.03.03, EP 1 and it adds clarity to the existing requirement. Previously the EP had said you could use alternative methods to notify staff of a fire drill between 9 PM and 6 AM. The revised EP now states you can use a “coded announcement” to notify staff during those same hours and they provide a very specific reference to the NFPA requirement.

Another change is to EP 3 of the same standard and it also adds clarity to an issue we have seen develop into a frequently scored issue without significant warning, then later formal identification in the EC/LS Document Review Tool, and now it will be formally published as a transparent requirement in the EP itself.

Previously the EP required fire drills to be held at “unexpected times and under varying conditions.” However, surveyors were clearly looking for at least one hour separation, not just randomness. The new content is a Note 2 stating: “Fire drills vary by at least one hour for each shift from quarter to quarter, through four consecutive quarters.” This is a welcomed change to make this issue clearer.

There is also a new element of performance #7 at EC.02.03.03 which also adds clarity to fire drill requirements for operating rooms. Surveyors have been asking about OR fire drills for some time and now there will be a specific EP that details the requirement.

The new EP requires hospitals using aerosol germicides, antiseptics, or flammable liquids in conjunction with electrosurgery, cautery or lasers, or other ignition sources to perform an annual fire drill in the anesthetizing location. They also state that this drill can be announced or unannounced, but it should focus on the extinguishment of the patient, drapery, clothing, and equipment.

There are two important notes to this new EP. Note 1 states: “The drill involves applicable staff and LIPs and focuses on prevention as well as extinguishment and evacuation.” Note 2 states that this drill if announced cannot be used to meet one of the unannounced quarterly fire drills required by NFPA. Again, this is a welcomed change to add transparency to an issue that is already being scored.

EP 8 in this same standard is also new and it deals with hyperbaric facilities, requiring at least one fire drill per year. There are specific evaluation points in the new Note 1 that state: “The drill includes recording the time to evacuate all persons from the area, involves applicable staff and LIPs, and focuses on prevention as well as simulated extinguishment and evacuation. Response procedures for fires within and outside the hyperbaric chamber address the role of the inside observer, the chamber operator, medical personnel and other personnel as applicable.” Note 2 then states: “If the hospital conducts the drill unannounced, it may serve as one of the required drills.”

EC.02.03.05 has several changes relative to fire safety devices, the first of which is at EP 1 and it too helps to add clarity. EP 1 already requires a test of supervisory signal devices, and the new EP now explains what these are through the addition of a new note. Note 2 states: “Supervisory signal devices include pressure supervisory indicating devices (including both high and low air pressure switches), water level supervisory indicating devices, room temperature supervisory indicating devices, valve supervisory switches, and other supervisory initiating devices.”

EPs 7 and 8 of EC.02.03.05 relative to water storage tanks for fire systems have both been deleted because these are seen so infrequently today.

EP 11 has been modified to add new detail to the fire pump test. Previously the requirement was to test the fire pump under flow every 12 months. The revised EP now states that you should test the fire pump under flow and also states that the fire pump supervisory signals for pump running, and pump power loss are tested annually.

EP 14 has new details on how to test fire extinguishing systems. The EP now details that “carbon dioxide systems be tested every 12 months, halon systems every 6 months and other special systems per NFPA and the manufacturers recommendations.”

EC.02.04.01 has been updated to bring back a requirement previously seen as EP 8 back in 2016, but was inadvertently dropped, requiring the hospital to monitor and report all incidents in which medical equipment is suspected in or attributed to the death, serious injury, or serious illness of any individual, as required by the Safe Medical Devices Act of 1990.

The last EC change is in EC.02.05.01, EP 27 which discusses requirements for operating room smoke control systems, but not the smoke generated by human tissue in contact with cauterizing equipment. The revised EP provides a reference to the testing requirements of NFPA 92-2012 for newly engineered, designed and installed systems, unless specifically exempted by the authority having jurisdiction.

Additionally, it states that existing systems not meeting the performance requirements of the testing specified in NFPA 101-2012:19.7.7.1 can be continued in operation only with the specific approval of the authority having jurisdiction.

You will want to send all of these EC changes to your facilities leadership for review and analysis as they will likely require policy development and modifications to existing fire safety and equipment safety plans and inspection or testing checklists.

The changes to the 40-page Emergency Management chapter are much more substantial but the bulk of the changes are on pages 23-40 only. We will discuss this chapter in next month’s newsletter. In the meantime, we suggest you do download the chapter and provide it to your Emergency Management leader to start their review.

New Requirements for Inpatient Hospice:

Inpatient hospice facilities have three new requirements. The first of which is EC.02.05.01, EP 23 dealing with power strips or as they are formally known – relocatable power taps (RPTs). Hospitals have been struggling with this requirement for several years as it requires any power strips in the patient care vicinity to be approved by Underwriters Laboratory, specifically either UL 1363A or UL 60601-1.

Power strips outside of the patient care vicinity but still within the room must be UL1363. In non-patient care rooms or areas any power strips must meet other UL standards. Note 2 of this EP helps to define patient care vicinity at 6 feet from the bed or chair or treatment table.

The second inpatient hospice change is in EC.02.05.07, EP 8 and this requires at least an annual test of the fuel quality for the emergency generator. The test required is to ASTM standards (American Society for Testing Materials). We have seen many omissions of this requirement in hospital organizations; the key is to get this on the schedule for the organization every year.

The third inpatient hospice change is a generic, catch-all standard to “keep furnishings and equipment safe and in good repair.” Generic standards such as this are often used to cite dirty, old equipment, devices or furnishings that look to be in disrepair.

Hand Hygiene Scoring:

The Consistent Interpretation column continues to shed new light on the nuances of scoring. This month’s focus in on hand hygiene and as usual there are several revelations.

Under the discussion for IC.01.02.01, EP 3 one surveyor finding mentions that the manufacturer’s instructions for use of their alcohol-based hand rub (ABHR) required the first use of the day to include use of a nail pic. As consultants, this was new information to us as we do not know which brand of ABHR that might be, nor have we seen TJC score this issue.

However, if any of our readers use a brand where the package insert states that staff must use a nail pic, we would like to know what the brand is, so that our readers can find an alternative if they use that same brand. We noted on the right side of the column were SIG weighs in, they state: “Score at IC.02.01.01, EP 2, if nail picks are available, but not used.” Our search for internet details about this turned up empty.

The guidance for IC.02.01.01 is similarly interesting, busting two myths relative to hand hygiene. SIG guidance states that evaluation of hand hygiene for patient care involving C diff patients should depend on hospital policy as there is no clear guidance that alcohol or soap and water is clearly superior.

They also provide guidance that removing jewelry prior to hand hygiene is a CDC level II recommendation and therefore not required by TJC. They also warn that some manufacturer’s instructions for use may have more detailed guidance relative to jewelry.