Changing Expectations & Surveyor Approaches Marty Piepoli December 10, 2009.

Changing Expectations & Surveyor

Approaches

Marty Piepoli

December 10, 2009

Disclosures

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“Courtemanche & Associates Healthcare Synergists is an Approved Provider of continuing nursing education by the North Carolina Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation.”

Continuing Education Contact Hours will be awarded upon full attendance of the program and receipt of the participant course evaluations.

There are no influencing financial relationships or commercial support relating to this activity.

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Courtemanche & Associates does not discuss any products for use for a purpose other than that for which they were approved by the Food and Drug Association.

Session Objectives


At the conclusion of this session, learner will be able to:

Describe the importance of assessing risk as it relates to Life Safety and Emergency Management preparation.

Identify at least two challenging standards & potential solutions.

Identify the impact of the disparity in findings for the Environment of Care regarding TJC and CMS surveys.

Glossary of Terms


AIA – American Institute of Architects ASHE – American Society for Healthcare

Engineering CMS – Centers for Medicare & Medicaid

Services CoP – Conditions of Participation EC – Environment of Care EM – Emergency Management e-PFI – Electronic Plan for Improvement EPA – Environmental Protection Agency ESC – Evidence of Standards Compliance HAI – Healthcare Acquired Infections HAP – Hospital Accreditation Program

Glossary of Terms


HCO – Healthcare Organization ICC – Incident Command Center ILSM – Interim Life Safety Measures LS – Life Safety LSC – Life Safety Code NFPA – National Fire Protection Agency OSHA – Occupational Safety Health

Administration PARA – Pro-active Risk Assessment SA – State Agency TJC – The Joint Commission

CMS Driving TJC ExpectationsCMS Driving TJC Expectations


CMS Deeming Application


TJC-accredited hospitals = 4,153 82 percent of all hospitals

participating in the Medicare program

The CMS validation program assures accredited hospitals are in compliance with statutory requirements in 42 CFR Part 482

CMS Validation Surveys FY 2007*, 4164 CMS surveys were

performed 55 Look-back surveys were done (1.3%) 4,109 Allegation (complaint) surveys were

completed (98.7%) Look-back surveys demonstrated:

55 of 1,451 (3.8%) hospitals surveyed by TJC in 2007

40% disparity rate between TJC and SA ability to detect CoP deficiencies

29% of the disparities relate to physical environment * CMS 2008 Annual Report to Congress, November 2008



Increase in the disparity rate from 2006 (14.6%)

In 2007, 73% of Physical Environment findings by TJC were not cited at the Condition Level

Lack of detailed emphasis on the conditions of the physical plant/building safety

By the Numbers – CMS Survey Activity

CMS/TJC Disparity

With high disparity seen in the physical environment, TJC changes include: Completion of the Statement of Conditions by

Qualified Personnel

Set Minimum Standards for the Statement of Conditions/Plans for Improvement

Submission of the Statement of Conditions and Plans for Improvement to TJC prior to survey

Incorporating a Life Safety Surveyor into the process


CMS Deeming Application


Open dialogue between TJC & CMS Onsite visits Working through outstanding issues such as

telemedicine, environment of care. Announcement in Federal Register November

27, 2009: approval of a deeming application from TJC for continued recognition as a national accreditation program for hospitals that request participation in the Medicare or Medicaid programs.

Effective July 15, 2010 through July 15, 2014

Top EC/EM/LS Findings 2009Top EC/EM/LS Findings 2009


Challenging Standards % Non-Compliance


Standard 2008 (N=1427)

2009(N=664)

Issue

EC.02.05.07 45% 43% Minimizing effects of fire, heat, smoke

EC.02.03.05 26% 38% Maintaining fire safety equipment

EC.02.06.01 3% 20% Maintaining a safe environment

EC.02.05.09 16% 20% Medical gas & vacuum systems

EC.02.01.01 3% 15% Safety and security risk assessment

LS.02.01.10 45% 43% Minimizing effects of fire, heat, smoke

LS.02.01.20 45% 45% Maintaining egress

LS.02.01.30 45% 35% Maintaining building features from fire & smoke hazards

EC.02.01.01 – Safety & Security Risks


Findings: Identification of risks not evident – proactive risk

assessment, etc. Secure areas accessible

Strategies: EC or Safety Committee to charter and guide annual

(more frequent as needed) risk assessment process; assure results & follow-up activities identified & implemented

Implement secure access to high risk areas – i.e., pharmacy, mother/baby, hazardous storage rooms and assure staff adhere to security measures

Change keypad codes regularly

EC.02.03.05 – Maintaining Fire Equipment & Fire Safety


Findings: Inspecting, testing, etc.:

Fire alarms, sprinklers Fire extinguishers Tamper switches

Strategies: Assure that vendor testing & maintenance

documentation is maintained onsite Testing logs should include all required elements

(i.e., tamper switches) Assure systems are fully functional and tied to

local Fire Department

CMS Update – Dampers

Option for Damper Testing Interval Hospitals permitted to apply the NFPA 6-year

damper testing interval for fire and smoke dampers.

Testing system must conform to the testing requirements under the 2007 edition of NFPA 80 and NFPA 105.

At the time of a CMS onsite life-safety code survey, hospital must notify survey team it has elected to operate under this waiver.

S&C-10-04-LSC 10/30/09


EC.02.05.07 – Inspect & Test Emergency Power Systems


Findings: Testing of battery powered lights, generators,

automatic transfer switches

Strategies: Assure that vendor testing & maintenance

documentation is maintained onsite

Testing logs should include all required elements (i.e., automatic transfer switches)

Once issues are fixed, test the system again

EC.02.05.09 – Inspect, Test & Maintain Medical Gas & Vacuum


Findings: Defined timeframes not met

Shutoff valves not accessible or clearly labeled

Strategies: Have testing and maintenance timeframes

approved by EC or Safety Committee who will require status checks

Assure shut-off valves are on an inventory, labeled and checked periodically

EC.02.06.01 – Safe, Functional Environment


Findings: Furnishings & equipment not safe/in good repair Space inadequate for care

Strategies: Conduct regular EC rounds (particularly

behavioral health and pediatric areas) to identify hazardous (safety and infection control issues) equipment and furniture; then remove/repair

Where space is an identified issue, document Leadership knowledge and understanding and future plans; if a Life Safety issue – place on e-PFI

LS.02.01.10 – Minimize Fire, Smoke, Heat Effects


Findings: Fire/Smoke door integrity Penetrations!!!

Strategies: Use a building maintenance program to check

doors regularly Institute an “above the ceiling” process to

assure penetrations are filled when they happen

“Red line” badges of vendors who work in the ceiling – so they can be easily identified

LS.02.01.20 – Maintaining Egress


Findings: Hallway clutter Stairwell storage Exit signs not visible

Strategies: “Garage” sale days – remove all broken, obsolete

equipment Only what is in immediate use should be in halls Create docking areas for computers on wheels Use several vehicles for rounding – including

Leadership Rounds

LS.02.01.30 – Maintaining Buildings from Fire Hazards


Findings: Issues in boiler rooms, flammable storage areas, labs,

etc. Dampers inaccessible or inoperable Corridor door integrity

Strategies: Assure these areas are secure from public access Clutter patrol! Engage folks from outside the area -

you don’t see the cobwebs in your own home Evaluate dampers – identify those that are

inaccessible or inoperable and fix them or place on the e-PFI

LS Document Review and EC/EM Tracer Document Review occurs the morning

of Day 1 followed by building tour unless LSS arrives later.

Provides additional observations for the surveyor directing the EC/EM tracer.

The EC/EM session combined into one session in 2009.

This session has three parts: EC Discussion EM Discussion EC Tracer


Getting Ready

Know What Surveyors Review

Annual evaluations of the Environment of Care (EC) management plans (EC.04.01.03)

EC multidisciplinary team meeting minutes for the previous 12 months (EC.04.01.03)

Hazard Vulnerability Analysis (EM.01.01.01)

ILSM Policy (LS.01.02.01)


Getting Ready

Know What Surveyors Review

EC-related issues observed in previous survey activities by other survey team members

Note identified risk points as possibilities for tracer observation


What to Expect – Emergency Management Surveyor Discussion Points

Proactive Risk Assessment (HVA)

Emergency Operations Plan

Involvement of various organizational disciplines and the community

Approaches for educating staff

Organizational communication and notification plans


Surveyor Approaches 2009Surveyor Approaches 2009


Emergency Management Tracer

Selection

Consider your top three vulnerabilities on your HVA

Let’s consider recent concerns: Influx of H1N1 Miracle on the Hudson Floods in the Midwest Tornados everywhere!


Who, What and When Some Practical Tips

Print out the standard survey agenda for your organization to see when the EC/EM tracer will be conducted.

Check the backgrounds of your survey team

Does the Life Safety Specialist come on the first day or later during the survey?


Some Results from the Field

Example #1 Conducted by the physician Heavy focus on the specific items on the HVA

Majority of discussion on the top 3 items Preparation to address these items Framework of mitigation, preparedness, response

& recovery How the “Big 6” were addressed

Chose to focus on Utilities Disruption of Water which was identified on proactive risk assessment related to planned well.



Example #2 Life Safety Specialist Arrived on day 3 of the 3.5 day survey.

Conducted review of all of the EC Mgmt Plans and the EOP.

In his review of the EC Management Plans, he tied in the Big 6 as they related to each of the plans.

Very consultative and educational.



Example #3 Life Safety Specialist

Arrived on day 4 of the 5 day survey.

Conducted his review standard by standard from EC and EM.

In his review of EM, focus was on the HVA methodology and sustainability.

Emphasis on Communication, Assets and approach to drill critiques.


Surveyor Findings

No specific scoring of the EM chapter thus far: only 3 direct impact EP’s in the EM chapter.

EM.02.01.01 EP#8 In an actual emergency, the hospital implements its response procedures related to patient care, treatment, and services.

EM.02.02.13/02.02.15 EP#5 that addresses volunteer disaster privileges to LIP and non-LIP volunteers.


EM and Other Tracer Activity

Surge Capacity related to the Infection Control tracer.

Availability of emergency medications in the medication management tracer.

Patient Flow tracer/discussions in the ED related to Surge and same level of care.


Use of Pro-active Risk Use of Pro-active Risk Assessment in the Assessment in the Environment of CareEnvironment of Care


Risk Assessments

Risk Assessment is a method for identification of potential harm to a patient population using quantifiable approaches.

Objectively determining the potential for a negative outcome based on: Severity of outcome Frequency of event Likelihood of detection


Proactive Risk Assessments To correct process issues or barriers

and reduce the potential for experiencing adverse events

To evaluate processes to see how they could fail

To understand the potential impact of such a failure

To identify components of the process that need improvement

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Process Examples

Clinical:

Surgical Procedures

Medication Administration

Central Line Insertion

Environmental and Other Non-Clinical:

Maintenance of building fire prevention features

Maintenance of medical gas systems



Risk Assessment Cycle

Environmental Risks

EC.01.01.01 The hospital works to assess and minimize risks in the environment of care. Can be managed by one or more individuals.

Managing these risks through a systematic, proactive approach to evaluating potential harm and mitigating opportunities for harm is key.

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Environmental Risks

Potential for environmental risks Safety and security for people, equipment, and

other material; The handling of hazardous materials and

waste; Fire; The use of medical equipment; Utility systems.


Environmental Risks

EC.02.06.05 - Experts, i.e., AIA, TJC, ASHE, recommend including at least the following in your pre-construction risk assessment Air quality requirements, Infection control, Utility requirements, Noise, Vibration, Other hazards

Also refer to LS.01.02.01 related to interim life safety measures


Environmental Risks

IC.01.03.01 EP#1Tells us that we should identify

our risks for spread of infection by considering geographic location, community, and population served.

EP#2 And always includes concerns related to the care, treatment, and services it provides for patients and the community.


TJC – What to Expect in the TJC – What to Expect in the FutureFuture


TJC – Evolving to Drive Sustained Improvement


Standards & NPSGs focused on contributing to improved health outcomes. Attributes: Relates to quality & safety Has a positive impact on outcomes Has a ROI for safety & quality Can be measured or surveyed

More in depth analysis of adverse events to identify sustainable improvement initiatives

Improved internal operations - while maintaining integrity of survey process

Resources


2009 Comprehensive Accreditation Manual for Hospitals (CAMH): The Official Handbook. Published by: Joint Commission Resources, Inc., Oak Brook, IL.

TJC Hospital Executive Briefings – September 2009. Presented by: Joint Commission Resources, Inc., Oak Brook, IL.

CMS S&C-10-04-LSC. http://www.cms.hhs.gov/SurveyCertificationGenInfo/downloads/SCLetter10_04.pdf. Published: October 30, 2009. Accessed: December 8, 2009.

Resources


Environment of Care News, February 2009, Volume 12, Number 2. Published by: Joint Commission Resources, Inc., Oak Brook, IL.

Environment of Care News, March 2009, Volume 12, Number 3. Published by: Joint Commission Resources, Inc., Oak Brook, IL.

CMS 2008 Annual Report to Congress, November 2008. http://www.cms.hhs.gov/CFOReport/Downloads/2008_CMS_Financial_Report.pdf. Published: November 2009. Accessed: December 8, 2009.

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Changing Expectations & Surveyor Approaches Marty Piepoli December 10, 2009.

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