Insights on The Joint Commission and Related Surveys

Editor's Note: Part of ISHE's Credo states that "...quality and excellence are best achieved in an environment of teamwork and cooperation between the professionals entrusted with attaining the overall goals of healthcare organizations...." In that spirit, we asked one of our members for insights regarding various surveys. Included among these are those of The Joint Commission, which accredits and certifies more than 20,000 health care organizations and programs throughout the U.S., with many in Indiana.

Notably, the items mentioned below are referenced in the various official publications, so more information can be found there if you have any questions.

Without being specific to our citations and recommendations, the JC, ISDH, OSHA, and CMS are all aligning on environmental issues that affect patient or staff safety. Infection control is a big concern, so systems and processes that affect infection control, use of hazardous chemicals or biological/hazardous waste are hot topics. This includes, hospital acquired infections and environmental processes that limit the spread of communicable disease...

Emergency preparedness is a big issue, as demonstrated by fire drills and disaster drills; staff will be quizzed about RACE and use of fire extinguishers. Chemical hazards and eye wash stations with automatic tepid water controls were on their lists. Also hallway clutter and "do not exit" signs where needed to prevent egress obstacles and/or confusion with exits. MRI safety zones were an issue. Unobstructed walkways (exterior) from emergency exits were also an item. Wall penetrations were checked.

Psych areas were a focus for our surveyor who had a work background in this area. He was especially focused on anti-ligature safeguards, taking issue with bathroom doors and lavatory fixtures.

ISDH gave some indication of things to come when they took interest in areas that involved chemicals (e.g. a washing machine located in Physical Therapy). They are paying attention to chemical storage areas (e.g. housekeeping closets and storerooms) and looking for eyewash stations within 10 seconds of each location. The JC took it another step and addressed the operations of the eye wash stations. Reading the ANSI standards also give cause to be concerned about temperature of the water, hands free operation, 15 minute or longer operation (if gravity fed), weekly testing, staff training, and annual preventive maintenance records.

The JC surveyor commented that he was more instructional and consultant oriented than CMS inspectors. He said they WILL issue citations and make it painful when organizations fall short of the mark. Probably very important to have OSHA certified folks on the Safety Committee.

Most frustrating about this survey was the fact that JC issued unexpected recommendations that do not have obvious solutions, and trying to achieve solutions in the limited timeframe allowed has proven to be a challenge.

Do you have insights you would like to share with your fellow ISHE members in the interest of improving quality and excellence in healthcare? Let us know at info@isheweb.org.

ISHE Hill-Rom Spring Meeting Registration

Improve your facility management at ISHE's most popular spring event. If you are a healthcare facility engineer, introduce your colleagues to ISHE's top-notch education and idea sharing at this event!

The annual ISHE Spring Meeting is approaching and space is limited. Reserve your spot today to attend the different informational sessions, golf outing, and lodging.

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Lodging for the Event on May 10th
Attending the May 10th Sessions
Attending the May 11th Session

Accommodations and hosting by Hill-Rom @ JAWACDAH Farm, Batesville, IN
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Agenda

"Fundamentals of Health Care Renovation and Construction" - April 19th ISHE Purdue Education Event

New and veteran healthcare facility employees will gain helpful information from ISHE's "Fundamentals of Health Care Renovation and Construction" education program April 19th at Purdue University. RSVP Now

Whether it is a new greenfield hospital project or renovation of an existing building, a construction project involving a health facility requires careful planning and diligent execution. This one-day seminar focuses on several fundamental topics critical to a successful project including:

• Safety and comfort of patients that might be impacted by the project.
• Compliance with codes and standards, including NFPA 101, NFPA 99 and the Guidelines for the Design and Construction of Health Care Facilities. Some of the requirements that are new or that have changed in the 2012 edition of NFA 101 and NFPA 99 will be discussed.
• Environmental infection prevention assessment and mitigation measures.
• Mechanical and electrical systems including medical gas, HVAC and the Essential Electrical System.

Agenda
8:00 - 8:30:
Meet and greet, continental breakfast provided

8:30 - 11:30:
Education program

11:30 - 11:45:
Purdue ASHE Student Chapter presentation

11:45 - 12:00:
ISHE announcements and business

12:00 - 1:00:
Lunch (on your own)

1:00 - 4:30:
Education program

4:30:
Program adjourns

Presented by:
Steve Spaanbroek, MBA, FASHE, CHFM, CHC
Managing Director
MSL Healthcare Consulting, Inc.

Tim Adams, FASHE, CHFM, CHC
Director, Professional Growth
American Society for Healthcare Engineering (ASHE)

Directions
The Krannart Building is located on the southwest corner of W State Street and N Grant Street. Parking is available at the Grant Street parking garage just north of W State Street on N Grant Street. Following is a link to a map of the Purdue Campus: http://www.purdue.edu/campus_map/

Build your hospital's effectiveness by bringing everyone that has a need to better understand health care renovation and construction. RSVP now.

April 19th
Purdue - ISHE Education Event
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May 10-11
Hillrom Spring Meeting