TJC STANDARDS UPDATE FOR 2025

Every year in recent memory The Joint Commission (TJC) has made a point of revising, editing, and/or updating its hospital standards.   Some years’ changes and revisions are quite modest, while in other years they are quite profound and extensive.  This is true for what we have come to know as their Physical Environment Standards, which include the Environment of Care (EC), Life Safety (LS) and Emergency Management (EM ) standards.

Going back over 50 years we can see anything from minor tweaks in the wording of a specific standard to a complete overhaul of the content, numbering, scoring system, and even the addition and deletion, or relocation of entire sections of the standards. In all cases it has always been extremely significant from the accredited organization's perspective to know what these changes are going to be, as early as possible, to enable organizations to prepare their staff, systems, policies, and documentation programs to be as consistent as possible, as early as possible, to help ensure the highest level of compliance and best survey outcome possible.

Over at least the past 20 years, TJC has had a history of pre-publishing these standards in early fall and doing presentations giving specific change information to local and national organization meetings (such as ASHE) for their meetings and conferences. This year, unfortunately, things are different.

This year, unlike prior years, TJC has indicated that it will not be making the new standards available until December 2024.  This has been conveyed through information provided on their website and confirmed through various conversations with TJC and Joint Commission Resources (JCR) staff.

In previous years, and even this year, TJC has advertised the importance of getting accredited organizations pre-publication copies of the following years’ standards so they can adequately prepare for upcoming surveys.  Ironically, this year their stated intent is to get these standards to facilities a month or less before implementation.  The implications of the late availability of these standards are likely to have a significant impact on accredited organizations, particularly ones that will be scheduled for survey in the 1st half of 2025.

In response to what we see as the potential need for additional support for our clients in 2025 we intend to:

-          Notify our subscribers as soon as the 2025 standards related to the Physical Environment have been made available by TJC

-          Provide our subscribers with an impact summary of key changes to the Physical Environment Standards once TJC has made them available

-          Sending timely notifications to our subscribers regarding the impact that significant changes in standards and the standards process will have on upcoming surveys.

-          Periodically add specific Monographs to our library on particularly difficult and complex issues including things like Performance Measurement and Monitoring, ILSM Program Management, Pre-Construction Risk Assessment, Conducting Annual Evaluations, Risk Assessment Process, etc.

-          Conduct a mid-year webinar on the status of the impact of 2025 Physical Environment changes.

·       If you are currently a subscriber to EC Online through Safety Management Services Inc., you will receive an annual renewal invoice when your subscription is due and pay by check or EFT,  or you may email gw@compquail.com and request a link be sent to you from which you can register and pay for your upcoming subscription by credit card.

·        If you are not currently a subscriber to EC Online you may sign up by contacting George Williams at Compliance CMS.  Simply, click on http://econlinecms.com/ the site where you will be able to get a full program description, register for and pay for a 1 year subscription for 2025, and identify the names and email addresses for up to 5 total users per facility.

·        Organizations who are uncertain if they wish to subscribe may receive a 2- week free trial by requesting it from gw@compquail.com .

TJC EXITING UPDATE

Adequate exiting has been a fundamental principle in fire protection and life safety since the first fire codes and likely long before that.  In modern times we have always maintained that an exit has three primary parts, the exit access, the exit, and the exit discharge.  Regardless of the occupancy classification, building construction type, fire protection features, etc, these three elements were critical components to consider when designing, constructing, and maintaining a building for the appropriate level of fire and Life Safety.

Exit capability within healthcare occupancies is as important as in any other type of occupancy, and in some cases perhaps even more so.  To that end The Joint Commission and Medicare/Medicaid have historically mandated compliance with National Fire Protection Association’s  “Life Safety Code 101”.   Currently, both of these agencies require compliance with the 2012 edition of NFPA 101 as they have for the roughly past 6 years or more.  Prior to this both agencies referenced various editions of NFPA 101 Life Safety Code going back as far as the 1967 edition.

Within each edition of the Life Safety Code, there has always been a section on exits, and within each one of those sections it identified the same essential components (exit access, exit, and exit discharge).

Just recently, The Joint Commission published an online article addressing the fact that aisle widths in hospital suites, and critical access hospital suites must be maintained at a 36” minimum.  Specifically, they said “Now in effect, Joint Commission Life Safety Code surveyors will cite noncompliance in suites that have less than 36 inches of clearance from side to side to facilitate egress.  This requirement follows the National Fire Protection Association’s (NFPA) Life Safety Code (NFPA 1-1-2012). Section 7.3.4.1(2), in the core chapter on egress, which sets the minimum width of any means of egress at 36 inches in all facilities classified as health care occupancy.  This requirement applies to Joint Commission accredited hospitals and critical access hospitals that use the suite provisions of the code and, depending on their occupancy classification, may apply to behavioral healthcare and human services organizations, facility-based hospice facilities, and nursing care centers.

The finding will be scored at Life Safety (LS) Standard LS.02.01.20, element of performance (EP) 42, which requires organizations to maintain the integrity of the means of egress in accordance with the Life Safety Code.”

The real question that arises is “Why is The Joint Commission highlighting the issue now, when it has been in the code for decades”?  It would seem clear that they are putting us on alert that this is an area that will likely receive heightened attention in future surveys.  We are therefore alerting clients that in the future surveyors will be looking not only as they have in the past at actual exit corridors, but also aisles in suites.  Theoretically, in any suite where there is not a 36” wide, clear, and unobstructed aisle, you could be subject to a finding.   Certainly, the surveyors will focus their attention on ICU’s, Operating Rooms, Nurseries and other common types of patient sleeping suites, but keep in mind the standards also apply to many other types of suites such as Radiology, Dialysis, Receiving Rooms, Large Pharmacies, Laboratories, or any other area where a suite configuration of rooms is used.

Keep in mind, this is not a new standard but rather a re-statement by The Joint Commission of their intent to re-focus surveyor’s attention toward this type of condition.

Getting Ready For Survey Questions to Ask Staff

Getting Ready For Survey Questions To ask Staff

One common aspect of every Joint Commission survey is the propensity for the surveyors to ask questions of staff members related to The Physical Environment.  Generally speaking surveyors will ask general questions of hospital leaders during interviews, and more specific questions of managers and unit/department staff.

To best prepare staff for these questions and help ensure a good survey outcome, it is generally considered good practice to rehearse questions on key topics with staff across the organization.  Most commonly TJC surveyors will ask questions of Nurses, Environmental Service Workers, Dietary Staff, Respiratory Therapists, Security Officers, Laboratory Staff, and many others.

The range of areas the draw question from include all aspects of the Physical environment, including but not necessarily limited to:

• Safety

• Security

• Hazardous Materials and Wastes

• Fire Safety

• Medical Equipment

• Utilities Systems

• Emergency Management

• Pre-Construction Risk Assessment

It can be common practice for a surveyor to single out one employee and ask a series of progressively more difficult questions.  It can be equally as common for a surveyor to gather a group of employees, either all from one department or representing various departments and asking their questions of the group and allowing them to answer as a team.

Whatever their approach, the goal is to determine if organizationally, staff have been provided with the information they need to work safely and protect patients and if they have sufficiently absorbed this information.

When preparing for a survey, we suggest the following as some of the possible and more relevant questions that surveyors commonly address during this questioning.

Safety:

1. If you sustain an injury, what is the process for reporting it?

2. Where and how do you dispose of sharps?

3. Where in the building are you allowed to smoke?  (nowhere)

4. What ligature risks do you have on the behavioral unit, ED, etc?

Security:

1. What is the code for an infant abduction alarm?

2. What is your personal responsibility when you hear the infant abduction alarm?

3. How and where does the infant abduction system work?

4. How do you get security support when you have a combative patient or visitor?

Hazardous Materials:

1. How do you obtain a Safety Data Sheet?

2. How many compressed gas cylinders may you have in a smoke zone?

3. How must compressed gas cylinders be separated?

Fire Safety:

1. Where is the nearest fire alarm?

2. Where are the nearest smoke doors?

3. How and where do you relocate patients in a fire if needed?

4. Who can authorize shutting off the oxygen valve?

5. Who can order building evacuation?

Medical Equipment:

1. How do you know equipment has been tested and is safe for use?

2. What type of outlet should defibrillators be plugged into.?

3. How do you identify broken medical equipment and who gets notified?

Utility Systems:

1. Which electrical outlets work during a power failure?

2. Which lights work during a power failure?

3. What type of extension cords are allowed in the patient vicinity?

Emergency Management:

1. How will you know if the disaster plan has been initiated?

2. What is the code for a Mass Casualty?

3. What is the code for a Tornado?

4. What do you do if the hospital goes on lockdown?

These are just some of the common questions a surveyor might ask during a survey.  Drilling staff on these questions regularly on these and other questions will help insure survey readiness.  Keeping statistical information on the percentage of right and wrong answers as well as which units scored well or poorly, will enable you to show the surveyors that you train your staff, test your staff, and have them properly prepared at all times regarding the Physical Environment. 

The COMPQUAIL compliance software solution will help you prepare for all questions a surveyor might ask during a survey. COMPQUAIL has added a new customized task feature that will help a facility customize and drill staff members and insure survey readiness. SCHEDULE YOUR DEMO TODAY!

Lack Of Follow-up Can Be Costly At Survey Time

Virtually every standard or element of performance The Joint Commission (TJC) publishes is capable of being evaluated and scored from a compliance standpoint. This creates opportunities for improvement through corrective actions or program changes.  Most of the activities we do in the Physical Environment are designed for the purpose of identifying problems.  Whether we are testing systems and equipment, conducting Environment of Care meetings, doing Risk Assessments, Environmental Tours, or evaluating Fire Drills, everything is designed to allow us the opportunity to capture data that will help us identify where our problems are and what opportunities we have to improve those parts of our programs and organization.  With almost every task we do, we are testing either our staff knowledge, our staff performance, or the performance of the equipment and systems they use.  As we document these knowledge and performance outcomes, we are automatically collecting data on the extent and quality of staff knowledge, staff performance, or equipment/system performance.  Failure to use the information we have gathered from these tests and activities as well as failure to make corrections and improvements to our programs as a result of the information we have gathered may be one of our greatest organizational failures and may cause substantial damage during an Accreditation survey.

At almost every TJC survey, somewhere during their process of reviewing documentation, the surveyor will identify numerous if not dozens of occasions where these records of the organization, or those provided by their vendors, clearly indicate that there was a problem, shortcoming, or failure.  In way too many cases, the organization is unable to provide the surveyor clear evidence to demonstrate that corrective actions have been taken.

Once we have captured this information, TJC expects that in every case, we evaluate the seriousness of the issue, establish a plan of correction for the item, and monitor it through completion.

Information regarding deficiencies in the Physical Environment can come from a great many sources including activities and reports from things like vendor inspections, preventive maintenance programs, emergency drills, environmental tours, risk assessments and many other areas.

Perhaps the simplest, clearest, and most user friendly way to track this data is to have one deficiency tracking report for all identified deficiencies in an excel type format which can be sorted by deficiency type, department, source report, length of correction, etc.

The COMPQUAIL Compliance Software provides the solution to all of these tasks actions, issues, reports and more . Request a demonstration today!

LIGATURE ISSUES FOR PATIENTS AT RISK

If there is a hot button (other than Corona Virus) in healthcare regulatory compliance these days, it would have to be the issue of increased patient suicide.  Roughly half of the facilities being surveyed at this time will receive one or more findings related to suicide and specifically ligature issues.  Oftentimes this finding in and of itself is leads to conditional accreditation and/or a follow-up visit.  Surveyors are being very specific about what they won’t accept and quite non-specific about what they will accept.  Quite literally they are often taking the position “we will know it when we see it” as far as non-compliance in behavioral health is concerned.

There was a time in healthcare when the concern for suicide and suicide attempts was mostly limited to patients in Psychiatric Hospitals or Psychiatric Units in Acute Care Hospitals.   Throughout the 1970’s and going forward there were about 1500 Psychiatric Hospitals and about 6,500 Acute Care (Medical/Surgical) Hospitals throughout the United States, a number which has steadily declined over the past 40 plus years.  Within those organizations we generally accepted that we had high rates of suicide attempts and suicides in Psychiatric facilities and relatively low rates in Acute Care Hospitals, except on defined, locked Psychiatric unites which could logically experience the same mortality and morbidity rates as the standalone Psychiatric Hospitals did.

More recently, perhaps in the last 10 to 15 years, regulators and healthcare organizations have become aware of an alarming incidence of suicides in all types of facilities, including Psychiatric Hospitals, Behavioral Units in Acute Care Hospitals,  and patient care units in Acute Care Hospitals, including Emergency Rooms, Medical/Surgical Units, Oncology Units, and many others.  In retrospect, none of this seems terribly surprising as healthcare moved away, through the insistence of Medicare/Medicaid (CMS), The Joint Commission (TJC) and others, from the frequent use of seclusion rooms, hard restraints, soft restraints, and chemical restraints, all of which were perceived by regulators as too restrictive an environment for most situations and all of which were being used largely for the purpose of preventing patients from attempting to cause  self-harm.

What appears to have changed the most in the past 10 to 15 years is the regulators focus on other than behavioral units and specifically the Emergency Department, ICU and other Medical/Surgical Units.  The Joint Commission for example, has published multiple sentinel event alerts and nearly a dozen FAQ’s regarding suicide and ligature issues.  Many of these address issues away from the behavioral units.

Perhaps the most difficult part of this issue is the general lack of clear and specific regulations in the industry related to facilities design, equipment, and practices related to the potentially suicidal patient.  For those who are unfamiliar with the Behavioral Health setting, it is important to know that there are virtually no “Standards” identifying the design/build aspects of features or products that would present a danger to patients.  The standards nearly always lead you in the direction of  “do a risk assessment”, when approaching a decision about whether a medical bed could be put in a behavioral room or whether you can use an architectural lay-in ceiling, or need a hard ceiling in a specific situation or type of room.  The two primary documents that are widely published and used, as well as referred to in The Joint Commission standards are the Facility Design Guidelines and the OMH guidelines.  

When assessing risk for suicide and determining measures that should be taken, be it on a behavioral unit or not, it is important to consider:

-        Inherent patient risks based on both the patients emotional state and the facility design

-          Presence of and adherence to organizational policies and procedures

-          Staff training and knowledge

-          Adequacy of staffing

-          Patient supervision

-          Facility and equipment design and condition

-          Monitoring and surveillance of facility and equipment condition

As it stands today, the facilities that seem to fare the best during survey outcome are the ones that have done frequent and comprehensive documented risk assessments and have incorporated FDC and OMH guidelines into the design and equipment selection for their facilities.

The COMPQUAIL Compliance Solution provides a preliminary risk assessment form which is not all inclusive and should be modified and added to by facilities in order to make it fully relevant to their facility and their facilities needs.

Electrical Panel Inspections During Survey

For more than four decades the Joint Commission has been looking at electrical panels during their accreditation surveys.  Very early on, emphasis was simply placed on whether or not access to electrical panels was clear and unobstructed. Surveyors typically expressed an expectation that there be at least 3 feet of clearance around an electrical panel door.   More attention was typically paid to panels located in egress corridors with lesser attention given to panels located inside rooms and closets.

Over time surveyors progressed to looking to see if cabinets were locked where appropriate (ie., Pediatric units, Psychiatric units, Geriatrics, etc.), and had proper labeling regarding arc flash and missing panel covers.  In recent surveys we have seen surveyors looking for not only these items but appropriateness of circuit labeling for identification of things like circuit number, spares, and future use, as well as fire alarm breaker demarcation EC.02.05.01 EP 8

As we move down the road, we can expect to find surveyors looking at breaker panels and probably finding new things to look at.  One of the obscure possibilities for the future is the requirement that all breakers in a box be the same brand. Whether it is Siemens or Square “D” or any one of the many others, the breakers should be of the same brand to help assure compatibility.

While it is true that The Joint Commission does not have any specific standard requiring testing or inspection of electrical panels at any prescribed frequency, it would nevertheless be highly advisable for facilities to establish such a program, much like they do for medical gas systems. 

Facilities are encouraged to start with a written policy that identifies the inspection frequency (suggested annual) as well as identifying the qualifications of those individuals conducting the inspection (this can be done with hospital staff or contractors, but in either case should be done by individuals with appropriate levels of knowledge and experience). Once a clear policy is established, the organization should develop a set of clear procedures and forms which address:

• Completion of a comprehensive inventory of panels

• Criteria for inspecting the panels

• A form for documenting the inspection and deficiencies found

• A form for documenting repair/follow-up on identified deficiencies

• A process for notification of staff if deficiencies remain after inspection

• A connection to the ILSM program if deficiencies remain

Implementation of such a program and processes will improve the level of safety within the organization while improving the programs appearance to the surveyors during the Accreditation Survey.