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)
The Survey Process in 2011
Healthcare Engineering Consultants
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)
The Survey Process in 2011
Healthcare Engineering Consultants
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
Healthcare Engineering Consultants
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
Healthcare Engineering Consultants
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
Healthcare Engineering Consultants
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
Healthcare Engineering Consultants
Understanding Survey Scoring Decisions
Scoring Decisions
Healthcare Engineering Consultants
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
Healthcare Engineering Consultants
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
Explanation of Scoring Levels
Healthcare Engineering Consultants
“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
Explanation of Scoring Levels
Healthcare Engineering Consultants
Direct Impact Requirements
1. If non-compliance is likely to have an impact on patient safety or quality of care
2. ESC submission required within 45 days
3. A single Direct Impact “EP” results in the entire standard being non-compliant
4. Examples include:
- Failure to perform risk assessments
- Improper disposal of hazardous medications
- Insufficient PM on life support equipment
Explanation of Scoring Levels
Healthcare Engineering Consultants
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
3. ESC submission required within 60 days
4. Examples include:
- Incomplete management plan
- Non-compliance to smoking policy
- Insufficient fire drills performed or critiqued
- Insufficient disaster drills
Joint Commission Scoring Decisions
Healthcare Engineering Consultants
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
Joint Commission Scoring Decisions
Healthcare Engineering Consultants
Performance Category
Number
Immediate Threat 0
Situation Decision 0
Direct Impact 41
Indirect Impact 98
“EC” Scoring Categories
Joint Commission Scoring Decisions
Healthcare Engineering Consultants
Performance Category
Number
Immediate Threat 0
Situation Decision 0
Direct Impact 3
Indirect Impact 111
“EM” Scoring Categories
Joint Commission Scoring Decisions
Healthcare Engineering Consultants
Performance Category
Number
Immediate Threat 0
Situation Decision 2
Direct Impact 21
Indirect Impact 98
“LS” Scoring Categories for Hospitals
Joint Commission Scoring Decisions
Healthcare Engineering Consultants
Performance Category
Number
Immediate Threat 0
Situation Decision 2
Direct Impact 65
Indirect Impact 307
“EC”, “EM” and “LS” Scoring Categories
Note: Minimal changes in scoring categories in 2011
Joint Commission Standards Scoring
Healthcare Engineering Consultants
“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
Healthcare Engineering Consultants
“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
Joint Commission Scoring Decisions
Healthcare Engineering Consultants
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
Joint Commission Scoring Decisions
Healthcare Engineering Consultants
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
Healthcare Engineering Consultants
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
Healthcare Engineering Consultants
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
Healthcare Engineering Consultants
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
Healthcare Engineering Consultants
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
Healthcare Engineering Consultants
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
Healthcare Engineering Consultants
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
Healthcare Engineering Consultants
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
Healthcare Engineering Consultants
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