The Survey Process in 2011

The Survey Process in 2011

Healthcare Engineering Consultants

Typical Survey Activities in 2011 will Include:

Communication to hospital by JC liaison with tentative agenda, number of surveyors, survey days

Extranet posting (by 7:30 AM local time)

Survey arrival, ID verification

Surveyors include a Physician, Nurse(s), Life Safety Specialist; others may include an administrator and specialty surveyors (lab, behavioral health, home health care, ambulatory, etc.)

Opening Conference (15 minutes)

Organization Orientation (30 to 60 minutes)

Preliminary Planning Session (1 hour)



Survey Activities (continued)

On-Site Survey Activities (including tracers)

Special Issue Resolution (end of day, 30 minutes)

Daily Briefing (end of day, 30 minutes)

Critical Survey Activities for the “Physical Environment” (Life Safety Specialist - minimum of two days, one additional day than in previous surveys, effective 1/1/2011)

- Environment of Care

- Life Safety

- Emergency Management

CEO Exit Briefing (15 minutes)

Organization Exit Conference (30 minutes)



Post-Survey Activities

Summary of Survey Findings Report (laptop computer generated by end of survey)

Official report posted on Connect site after the survey

Central office review performed for situation decision rules, CMS condition-level deficiency and “flagged” issues

Hospital submits ESC for all RFI’s (direct and indirect) and applicable Measures of Success

Clarifications can be submitted to the JC within 10 days of the final report Connect site posting

Quality Report and Accreditation seal received

Reference: 2011 JC Accreditation Process Guide

Revised Accreditation Categories for 2011


Preliminary Accreditation: early survey policy

Accredited: in compliance with all standards

Accreditation with Follow-Up Survey: follow-up survey required within 30 to 180 days (new for 2011)*

Contingent Accreditation: follow-up survey within 30 days (new for 2011)*

Preliminary Denial of Accreditation: immediate threat or failure to resolve requirements

Denial of Accreditation: Organization denied accreditation; appeals exhausted

*Note: Provisional Accreditation category eliminated

The Unannounced Survey Timeline


Unannounced Surveys will Occur:

Between 30 and 36 months from the date of the previous unannounced survey (changed for 2011)

Note: The chance of a survey is not equally distributed from 30 to 36 months from the previous survey

The timing of all surveys after the previous survey may be based on Priority Focus Process (PFP) data and other factors

Surveys will probably occur between the 33 and 36 month anniversary date

Prior to the survey (usually 6 weeks to 3 months), a discussion with the JC liaison to discuss the surveyor team members and agenda will occur

The Unannounced Survey Challenge


Surveys Can Also Occur Due To:

One year follow-up survey for newly accredited organizations that provide high risk or critical services

Sentinel event follow-up

Adverse media coverage of specific issue

Complaint from the public

Any other time that the JC decides it’s appropriate!

Meeting the Scoring Challenges


Understanding Survey Scoring Decisions

Scoring Decisions


Few scoring changes in the in the EC, EM and LS chapters have occurred for 2011

“A” and “C” scores remain

Four levels of scoring risk exist (surveyor discretion):

1. Immediate Threat to Health and Safety: results in

preliminary DOA until follow-up evidence of compliance

2. Situation Decision: results in preliminary DOA or CA

3. Direct Impact Requirements: immediate care

impact; must submit ESC within 45 days

4. Indirect Impact: no immediate risk; ESC

submission within 60 days

Explanation of Scoring Levels


Immediate Threat to Health and Safety

1. Immediate Preliminary Denial of Accreditation

2. Action expected during survey

3. Upon resolution, status changes to Conditional

Accreditation based on follow-up survey

4. Triggered by unaddressed issues with:

- Fire alarm or extinguishing system

- Emergency power supply system

- Medical gas master panel

Note: Refer to EC News, November 2010 edition



“Situational” Decision Rule

1. Immediate Preliminary Denial of Accreditation or Conditional Accreditation issued

2. ESC submission required within 45 days

3. Follow-up survey occurs to validate corrective action

4. Examples include:

- Failure to implement interim life safety

measures

- Failure to meet PFI timelines on SOC



Direct Impact Requirements

1. If non-compliance is likely to have an impact on patient safety or quality of care


3. A single Direct Impact “EP” results in the entire standard being non-compliant


- Failure to perform risk assessments

- Improper disposal of hazardous medications

- Insufficient PM on life support equipment



Indirect Impact Requirements

1. Based on planning and care processes

2. If non-compliance is likely to have an increased risk to patient safety or quality of care



- Incomplete management plan

- Non-compliance to smoking policy

- Insufficient fire drills performed or critiqued

- Insufficient disaster drills

Joint Commission Scoring Decisions


Total Surveyor “Person Days”

*Non-Compliant “Direct Impact”

1-4 7

5-6 8

7-9 9

10-13 11

>13 13

•Meeting or exceeding the “Direct Impact” number results in “outlier” status and SIG review

Note: May be revised or eliminated in 2011



Performance Category

Number

Immediate Threat 0

Situation Decision 0

Direct Impact 41

Indirect Impact 98

“EC” Scoring Categories




Number

Immediate Threat 0


Direct Impact 3

Indirect Impact 111

“EM” Scoring Categories




Number

Immediate Threat 0


Direct Impact 21

Indirect Impact 98

“LS” Scoring Categories for Hospitals




Number

Immediate Threat 0


Direct Impact 65

Indirect Impact 307

“EC”, “EM” and “LS” Scoring Categories

Note: Minimal changes in scoring categories in 2011

Joint Commission Standards Scoring


“A” Scores: High priority, One and Done!

Example: EC.01.01.01, EP 1; Safety officer appointment

You either have the letter or you don’t – Compliant or non-compliant, no partial credit!

Management Plan Scoring Sheet

EC Standard

Element of Performance Scoring Category

Documents Required?

Score Rule

01.01.01 Minimizing Risks in EC 1 Safety leadership appointment A 4 2 Intervention authority A 4 3 Safety management plan A D 4 4 Security management plan A D 4 5 Hazardous materials plan A D 4 6 Fire safety management plan A D 4 7 Medical equipment plan A D 4 8 Utility management plan A D 4

Good News (sort of!) – This is only an “indirect” impact requirement!

Joint Commission Standards Scoring


“C” Scores: Three strikes and you’re out!

Example: EC.02.03.05, EP 15

Portable fire extinguishers

Three missed monthly checks (aggregated) is an Indirect Impact Citation

Fire Risks Scoring Sheet

EC Standard

Element of Performance Scoring Category

Documents Required?

Score Rule

02.03.01 Fire Risk Management 1 Proactive fire protection C 3 2 Reduce fire risk from smoking A 3 4 Unobstructed access to exits A 3 9 Fire response plan A D 4 10 Staff response to fire A D 4 02.03.03 Fire Drills 1 Quarterly fire drills A 4 2 Business occupancy drills A 4 3 50% unannounced drills A 4 4 Staff drill participation C 4 5 Fire drill critique A D 4 02.03.05 Fire Component Tests 1 Supervisory devices A D 4 2 Tamper switches/ water flow A D 4 3 Duct/ heat/ doors/ smoke/ pull C D 4 4 Visual/ audible alarms C D 3 5 Off-site responders A D 4 6 Weekly fire pump test C D 4 7 Water tank level alarms C D 4 8 Water tank cold weather tests C D 4 9 Main drain tests C D 4 10 Fire department connections A D 4 11 Annual fire pump test A D 3 12 5-year standpipe test C D 4 13 Kitchen extinguishing systems A D 4 14 Gaseous extinguishing systems A D 4 15 Monthly extinguisher checks C D 4 16 Annual extinguisher PM C D 4 17 Occupant hose tests C D 4 18 Smoke/ fire damper tests C D 4 19 Air handling shutdown C D 3 20 Vertical/ horizontal fire doors C D 4



Timeframe Test Interval Expectations

Trienniel: 36 months +/- 45 days from the previous test month

Annual: 1 year +/- 30 days from the previous test month

Semiannual: 6 months +/- 20 days from the previous test month

Quarterly: 4 times per year, each quarter

Monthly: within the calendar month



Timeframe Test Interval Expectations

Weekly: Defined as Sunday 12:01 AM through

midnight Saturday

Daily: once per day, beginning at 12:01 AM

Other definitions take priority (example: emergency generator testing)

Note 1: These will be default test interval expectations unless the organization defines other acceptable intervals in a policy that is approved by the safety committee

Note 2: Published in EC News, November 2010 edition

Challenging Physical Environment Standards


What were the most challenging standards for hospitals during 2010?

LS.02.01.20 – 50% (means of egress)

LS.02.01.10 – 44% (fire compartmentation)

EC.02.03.05 – 38% (fire device testing)

LS.02.01.30 – 37% (smoke compartmentation)

Challenging Environment of Care Standards


What were the most challenging standards for “critical access” hospitals during 2010?

EC.02.03.05 – 47% (fire device testing)

LS.02.01.10 – 44% (fire compartmentation)

EC.02.05.07 – 40% (emergency power tests)

LS.02.01.20 – 33% (means of egress)

EC.02.06.01 – 27% (safe, functional environ.)

The Top Sentinel Events for 2010


Description Number

Unintended retention of object 91

Wrong-site surgery 66

Op/post-op complication 54

Delay in treatment 54

Suicide 47

Patient fall 38

Medication error 28

Perinatal death/ loss of function 23

The Top Ten Health Technology Hazards - 2010


Flexible endoscope cross-contamination

Alarm hazards

Surgical fires

CT radiation dose

Retained devices, unretrieved fragments

Needlesticks/ sharps injuries

Computerized equipment problems

Surgical stapler hazards

Ferromagnetic objects in MRI area

Fiber optic light source burns

“EC”-Related Patient Safety Goals


Ambulatory, Behavioral Health and Hospital Facilities

Goal #7: Reduce the risk of healthcare associated infections

Goal #9: Reduce the risk of patient harm resulting from falls

Goal #11: Reduce the risk of surgical fires - Eliminated in 2010 (sort of)

Goal #15: The organization identifies safety risks inherent in its patient population (identify suicide risk – relates to patients being treated for emotional and behavioral disorders) This applies to all areas of the hospital where behavioral patients are treated – don’t forget about the ED and outpatient areas! (refer to Sentinel Event Alert #46)

Note: No new Patient Safety Goals for 2011

Organizational Function Overview


Human Resources (HR)

Staff training, competency and performance

Leadership (LD)

Compliance, resources, patient safety, oversight of

contracts/ services

Performance Improvement (PI)

Data collection, aggregation, analysis , action

Information Management (IM)

Data collection, aggregation, security

Infection Control (IC)

Measurement and reduction of infections

Competition for the Joint Commission


DNV (Det Norske Veritas) Healthcare has received CMS “Deemed Status”

Headquarters; Oslo, Norway; 9,000 employees, 300 offices, in 100 countries

Approximately 150 accredited hospitals

Integrates ISO 9001 standards with CMS Conditions of Participation in annual survey

Averages three surveyors, including Life Safety

Focus on processes to manage patient safety and quality practices

Accredited or Not Accredited outcome

Competition for the Joint Commission


Health Facilities Accreditation Program (HFAP)

Originally intended for Osteopathic Hospitals

First program introduced in 1943; received “Deemed Status” in the 1960’s

Have accredited over 200 hospitals

Requirements closely parallel the CMS “Conditions of Participation”

Accreditation levels include:

- Full Accreditation

- Interim Accreditation

- Denial of Accreditation

The 2011 Survey Process


Questions?

Date post:	27-Jan-2016
Category:	Documents
Upload:	callum
View:	45 times
Download:	0 times