TJC Expands Required Documents List

In the September 2013 update to the 2013 Survey Activity Guide, The Joint Commission (TJC) added the following environment of care documents to its list of documents required at the beginning of a hospital survey. 

28. Written fire response plan
29. Interim Life Safety Measure policy
30. Fire drill evaluations

TJC Notification Requirements for CMS Categorical Waivers

The Joint Commission (TJC) recently clarified its notification requirements if an organization decides to take advantage of any CMS categorical waivers.  If a categorical waiver relates to a Life Safety Code requirement, TJC has requested that the organization identify that decision in the Additional Comments field of the eBBI section of the eSOC at TJC’s eConnect website for that organization.  On the other hand, if a categorical waiver relates to another chapter requirement, such as the motor-driven fire pump testing requirement within EC chapter Standard EC.02.03.05, TJC asks that the organization document its decision in the Safety Committee or EOC Committee meeting minutes.  This is a change from information previously disseminated by ASHE shortly after the waivers were released by CMS.

The organization should also notify the TJC surveyors at the beginning of the survey of any waivers that the organization has elected to use.

TJC Emphasizes Pressure Relationships for Infection Prevention

By David Stymiest, PE, CHFM, CHSP, FASHE

In his October 25th ASHE-sponsored webinar, TJC Director of Engineering George Mills emphasized the importance of maintaining proper pressure relationships for infection prevention where rooms are required to be positive or negative with respect to adjacent rooms or spaces.  Mr. Mills reiterated previous statements regarding how TJC surveyors will test for required pressure relationships – surveyors will use the tissue test very early to assess the adequacy of pressure relationships at the doorways of rooms subject to those requirements.  The tissue test is often performed by holding a thin tissue at the bottom door gap of a closed door.  The tissue will typically bend or flutter in the direction of air flow, which will be from a more positive to a less positive (or from a less negative to a more negative) space.  As a rule of thumb, the “more clean” areas need to be positive pressure with respect to the “less clean” areas.  If the tissue flutters from the “more clean” areas to the “less clean” areas – no problem. If the tissue flutters in the opposite direction however – big problem.  This is likely to result in a Requirement for Improvement (RFI) against Standard EC.02.05.01, Element of Performance (EP) #6, which states the requirements for areas designed to control airborne contaminants along with the concomitant need for appropriate pressure relationships, air-exchange rates, and filtration efficiencies. 

Joint Commission discusses Fire Safety Equipment Inventories at ASHE Conference

 By David Stymiest, PE CHFM CHSP FASHE

The Joint Commission (TJC) Engineering Director George Mills addressed the issue of fire safety equipment inventories at his 2013 ASHE Annual Conference plenary in July.

Mr. Mills stated that with respect to Standard EC.02.03.05, Elements of Performance (EPs) # 1 through # 20 inclusive, every device required to be tested must be documented in an inventory. He further stated that TJC surveyors will expect the facility to be able to identify specific variances in devices tested from year to year, and that simply having the total quantity of devices without more specific definition will not be adequate. Finally, Mr. Mills stated that lack of a written, electronic, or other form of inventory addressing the devices covered by any of the 20 EPs could result in a finding against that EP. Needless to say, Organizations who have yet not finalized their EC.02.03.05 inventories can be subject to numerous RFIs during survey.

TJC Addresses CMS Categorical Waivers

 
By David Stymiest, PE CHFM CHSP FASHE

 ASHE recently discussed in its Listserv TJC’s response to the CMS categorical waivers.

According to ASHE, TJC requested that organizations indicate in the eBBI’s Additional Comments field the acceptance of any categorical waivers as well as so noting those decisions in the EOC Committee minutes. TJC Life Safety Code surveyors will field-verify that the CMS conditions are being met for any accepted waiver, similarly to the CMS onsite field-verification approach.

CMS ISSUES MORE CATEGORICAL WAIVERS

By David Stymiest, PE, CHFM, CHSP, FASHE

 

Waivers address selected life safety, medical gas master alarm, emergency power testing, and firesafety equipment testing requirements.

The Centers for Medicare & Medicaid Services (CMS) issued a new Survey & Certification memorandum # S&C: 13-58-LSC to its State Survey Agency Directors on August 30, 2013.  This new S&C memo identifies several areas where several separate requirements more than a decade old are being relaxed for (and only for) those facilities that take the necessary steps to elect to use the waivers.

TJC Provides Tips for Meeting Problematic Life Safety Compliance Requirements 

By David Stymiest, PE, CHFM, CHSP, FASHE

TJC Director of Engineering George Mills provides tips for meeting problematic life safety compliance issues in the July 2013 of The Joint Commission’s EC News.  This valuable multi-page article addresses the following elements of performance (EPs) and related types of survey requirements for improvement:

ASHRAE Publishes Improved HVAC Design Manual for Hospitals & Clinics 

By Ron Holdaway, PE, CEM, LEED AP

ASHRAE recently published the 2nd edition of the HVAC Design Manual for Hospitals and Clinics.  ASHRAE states that this book, a complete rewrite of the 1st edition, focuses specifically on HVAC system design for health care facilities, omitting general system descriptions that are readily available in other ASHRAE publications.

TJC Strengthens Leadership Accountability for Emergency Management

By David Stymiest, PE, CHFM, CHSP, FASHE

In the July 2014 issue of Joint Commission Perspectives, TJC officially issued new and revised leadership requirements intended to provide “a clearer description of leadership-level oversight of emergency management.”  The new and revised elements of performance are all effective January 1, 2014. 

TJC Issues 2014 National Patient Safety Goal on Clinical Alarm System Safety

By David Stymiest, PE, CHFM, CHSP, FASHE

In its Joint Commission Online article dated June 26, 2013 (available at http://www.jointcommission.org/assets/1/23/jconline_June_26_13.pdf) The Joint Commission announced a new 2014 National Patient Safety Goal NPSG.06.01.01 on clinical alarm safety for both hospitals and critical access hospitals.  The July 2013 issue of Joint Commission Perspectives discusses the new NPSG in detail.

Compliance News: TJC Revisits EC Plans

 
By David Stymiest, PE, CHFM, CHSP, FASHE

A recent article placed in both the EC News and TJC Perspectives clarified TJC requirements for management plans.  Written for the June 2013 issues by TJC Department of Engineering Director George Mills for the Clarifications and Expectations segment of both publications, the article clarified some issues that have been resulting in TJC requirements for improvement (RFIs) during survey.

Compliance News: Reducing Emergency Power Vulnerabilities

 By David Stymiest, PE, CHFM, CHSP, FASHE

Healthcare facility emergency power systems are held to a very high standard.  They are expected to deliver power to what they must, when they must, for as long as they must.  A review of some medical journals will find references to clinical expectations for “uninterrupted power supply” and similar phrases.  In fact uninterrupted power is not guaranteed despite the misconceptions of some clinical personnel.  Hospital power systems are not as robust as large data center power systems, and even data center power systems sometimes fail.  But healthcare facilities can take steps to reduce the probability of emergency power failures. 

Firstly it is helpful to understand the differences between reliability, availability and dependability.  Reliability can be considered the probability that a system operates and gives the same result on successive trials.  Availability on the other hand can be considered the probability that a system will function at any instant required, including the next instant, and for as long as required from that point.  And finally dependability can be considered as the metric that measures availability, reliability & maintenance support.

Compliance News: CMS Issues Categorical Waiver 

 By David Stymiest, PE, CHFM, CHSP, FASHE

The Centers for Medicare & Medicaid Services (CMS) issued a categorical Life Safety Code waiver permitting new and existing ventilation systems supplying hospital and critical access hospital (CAH) anesthetizing locations to operate with a relative humidity (RH) of ≥20%, instead of ≥35%. CMS is also recommending that RH not exceed 60% in these locations.

CMS issued the new Survey & Certification memorandum # S&C: 13-25-LSC & ASC on April 19, 2013.  In its S&C memo, CMS referenced the recent code changes that adopted the lower requirements.  Many hospitals are expected to welcome this change, and it was supported by ASHE.

Organizations will not need to apply for this waiver or wait until they are cited by CMS or by state validation surveyors representing CMS.  However if organizations choose to take advantage of this waiver, they are required to document their decision to do so (such as within Safety Committee meeting minutes) before they start using it.  Organizations are also required to advise every Life Safety Code survey team at the beginning of any survey of their prior decision to use the CMS waiver.  CMS stated that lack of documentation of the prior decision to use the waiver may result in citations that would otherwise have been unnecessary.

The CMS waiver does not overrule more stringent state or local laws or regulations nor does it apply if the reduction of the relative humidity would negatively affect ventilation system performance.

According to CMS, organizations must still monitor relative humidity levels in anesthetizing locations and must take action when needed to ensure that RH levels remain at or above 20%.  Specifically, the CMS S&C memo stated “Facilities must monitor RH levels in anesthetizing locations and be able to provide evidence that the RH levels are maintained at or above 20%. When outdoor humidity and internal moisture are not sufficient to achieve the minimum humidity level, then humidification must be provided by means of the hospital’s or CAH’s ventilation systems. In addition, facilities must provide evidence that timely corrective actions are performed successfully in instances when internal monitoring determines RH levels are below the permitted range.”

The categorical waiver contains 17 pages of details including updated State Operations Manual Appendices A, I, L and W.  All organizations should obtain a copy of the letter and review it closely. 

The URL for the CMS Survey and Certification Memo is:
http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-13-25.pdf

CMS Issues Categorical Waiver to Lower OR Humidity Requirement

Please see below and refer to the URL to obtain your own copy of the just-issued CMS categorical waiver regarding Operating Room minimum allowable relative humidity (RH).

CMS is lowering the humidity requirement for operating rooms from at least 35 percent to at least 20 percent.  In its S&C letter, CMS referenced the recent code changes that adopted the lower requirements.

You will not need to apply for this waiver or wait until you are cited, however if you choose to take advantage of this waiver (and I expect many hospitals will) you must document your decision to do so (such as within your Safety Committee meeting minutes) before you start using it.  You must also advise every Life Safety Code survey team at the beginning of any survey that you have made the prior decision to use the CMS waiver.  CMS stated that lack of documentation of your prior decision to use the waiver may result in your being cited against the 35 percent requirement.

The CMS waiver does not overrule more stringent state or local laws or regulations.

The CMS waiver does not apply if the reduction of the relative humidity would negatively affect ventilation system performance.

According to CMS, you must still monitor relative humidity levels in anesthetizing locations and must take action when needed to ensure that RH levels remain at or above 20 percent.

The URL for the CMS Survey and Certification Memo is:

http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-13-25.pdf

I suggest that you read the entire CMS S&C memo and share it with your staff.

Compliance News: The Power of Tracers

Compliance News:  The Power of Tracers 

by David Stymiest, PE, CHFM, CHSP, FASHE 

The Joint Commission (TJC) discussed the use of a sample hazardous material and waste management environment of care (EOC) tracer in its March 2013 issue of EC News.  The article provided specific examples for conducting the tracer to explore issues related to orientation and training, physical environment, and quality improvement priority focus areas.   

EC News articles also discussed the use of non-patient tracers in June 2011 (sterilizer maintenance) September 2012 (fire safety) and November 2012 (utilities systems).  An earlier Joint Commission International publication also discussed the uses and benefits of a similar tracer methodology approach called System Tracers.  In the writer’s opinion, tracers of this nature have been proven to be extremely powerful in assessing not only compliance with individual TJC Standards and Elements of Performance but also in determining where opportunities for improving the EOC management processes exist within an organization.  As TJC also stated in its November 2012 issue, “Performing mock tracers can help your organization evaluate the effectiveness of its policies, engage staff in looking for opportunities to improve processes, and identify compliance issues that need attention.”

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Compliance News: Risk Icons Considered as TJC FSA Replaces PPR

Compliance News:  Risk Icons Considered as TJC FSA Replaces PPR

by David Stymiest, PE, CHFM, CHSP, FASHE

Users of The Joint Commission’s (TJC’s) 2012 "Update 2" and 2013 accreditation manuals found a new RISK ICON "R" in selected elements of performance. According to TJC in its September 26, 2012 Joint Commission Online edition, This new icon is related to TJC’s "Replacement of the Periodic Performance Review (PPR) with the Focused Standards Assessment (FSA)" and the "new risk icons denote elements of performance (EPs) assessed through the FSA process, applicable to all except the long term care program." A more comprehensive discussion occurred in TJC’s October 2012 Perspectives.

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Compliance News: EOC Risk Assessments

Compliance News:  EOC Risk Assessments

by David Stymiest, PE, CHFM, CHSP, FASHE 

  

In its March 2013 issues of both Perspectives and EC News The Joint Commission (TJC) continued to promote the use of risk assessments to evaluate whether to accept, mitigate or avoid environmental risks when there not definitive right or wrong answers. The articles by Joint Commission engineering director George Mills reiterated previous TJC guidance on 7-step risk assessments.
  
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Generator Risk Assessments

An ASHE member recently posted on the ASHE Listserv asking if anyone knew of a generator risk assessment.

We responded to the Listerv:   

1. "Log into ASHE's website and go to  
 http://www.ashe.org/resources/management_monographs/mg2009stymiest.html  

2. "Managing Hospital Emergency Power Systems - Testing, Operation, Maintenance and Power Failure Planning".  

3.  A PDF of this document is available for free to all ASHE members.  It can be downloaded from that URL.  

Please feel free to contact me if you have any questions.

After The Storm - Expanding the Concept of Emergency Power Reliability

After The Storm - Expanding the Concept of Emergency Power Reliability

by David Stymiest, PE, CHFM, CHSP, FASHE

As mission-critical equipment, hospital emergency power systems are expected to provide power consistently to what they must, when they must and for as long as they must. This is a tall order, and the impact of an emergency power system failure when normal utility power also has failed is potentially severe for patient care. 

The failure of some facility emergency power systems during and after last fall’s superstorm Sandy already has spawned investigations, which ultimately will result in lessons learned and more knowledge upon which health facilities professionals can base best practices to reduce vulnerabilities.

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