EC & LS for Clinical Managers Top Scored & Other Hot Spots

1. EC & LS for Clinical ManagersTop Scored & Other Hot Spots Jennifer Cowel, RN MHSA

2. Speaker • Jennifer Cowel, RN MHSA • TJC Experience: Former TJC Hospital Surveyor and former Director of Service Operations in Accreditation in Central Office • Accreditation and regulatory compliance consultant • Vice President and Principal Patton Healthcare Consulting • 630-664-8401 • JenCowel@PattonHC.com

3. Learning Objectives • Why EC & LS are now top scored • Explain how the length of survey changed for LSC • Discuss three ways EC or LS can lead to an Immediate Threat during survey • Describe a short-cut to an adverse decision in LS or EC • Define the e-BBI, PFIs and ILSM • Describe the top scored EC & LS standards • Explain how clinical staff can help prepare

4. Balance of Power Shift • In 1965 TJC was written into legislation and granted “deemed” status • In 2008 TJC was written out • In 2009 TJC applied for and was awarded deemed status by CMS, awarded for 3 years • TJC cross-walked all CoPs to standards • TJC added new requirements to meet

5. Why CMS Drives the Bus

8. Disparity Rate May Findings • Particularly with • Life Safety Code • An extra LSC day added to each survey starting in 2011! • Leadership (governing body) • Double ding is back!

9. Scoring in 2010 • 4 of the top 5 scored standards were in EC or LS in 2010 • In 2009 EC was the most scored chapter • EC has 42 direct impact EPs • LS has 37 direct impact EPs

10. LS Chapter Cheat Sheet • Based on NFPA 101-2000 LSC • Chapter Outline • Administrative (LS.01.01.01) • Interim Life Safety Measures (LS.01.02.01) • Three types of occupancy • Healthcare (LS.02.xx.xx) • Ambulatory (LS.03.xx.xx) • Residential (LS.04.xx.xx)

11. Definition of Occupancy • CMS Changed the definition in 12/10 • No public notice from TJC about this yet • CMS definition is: • If patients receiving medical treatment or services could potentially be incapable of self-preservation during an emergency, and are provided with sleeping accommodations or treatment and services on a 24-hour basis, the facility must be classified as a Health Care Occupancy.␣ • If patients receiving medical treatment or services could potentially be incapable of self-preservation during an emergency or receive anesthesia services, but are not provided with sleeping accommodations or treatment and services on a 24- hour basis, the component facility must be classified as a Ambulatory Health Care Occupancy.

12. CHANGES TO THE SURVEY IN 2011

13. Increase LSC DaysPerspectives, Nov. 2010 • Beginning in Jan.1, 2011 • Depending on hospital size 1 to 3 days will be added • >750,000 sq feet • > 1.5 mil sq feet • More than one inpt site= add a day • Most likely, if you had a one day LSC last survey, will get a two day LSC next

14. Increase LSC DaysPerspectives, Nov. 2010 • LSC surveyor to conduct the EOC system tracer • More time for LSC review • More time for education

15. Survey Process Preparation • Before your next survey prepare for and/or practice the following: • Day one documents – surveyor planning session • Environment of Care system tracer • Document Review session * • Emergency Management system tracer • LSC building tour *

16. Day 1 Documents Documents needed day 1: • Environment of Care (EOC) meeting minutes past 12 months • Six EOC management plans • Annual evaluations for each plan • Safety Committee minutes • Performance Indicators (EC.04.01.01)

17. Day 1 Documents (cont) • Statement of Condition documents (eSOC) including any Plans for Improvement (PFI) • Map of Organization (need compartment drawings for the tour) • Emergency Operating Plan, annual evaluation and HVA

18. EOC System Tracer • Was conducted by clinical surveyor • Now conducted by LSS surveyor • Focus: discussion oriented • Discussion topic areas: chemical spills, medical waste, infant security, medical equipment, OR fire safety, Utility failures

19. Document Review Session • “C” Element of Performance • Show me the documentation • Generally, they are looking back 12 months, but for EP’s that require less frequent testing/maintenance, they can go back three years or more • If the documentation isn’t found quickly – you are scored

20. Time Frames Defined • Intro to EC Chapter: • Daily, weekly, monthly and quarterly are calendar references • Semi-annual is 6 months from the last occurrence +/- 20 days • Annual is 12 months +/- 30 days

21. Now That You Know… fix it • Options for managing self identified deficiencies in LS.02.xx.xx – LS.04.xx.xx • Correct it immediately • Fix in 45 days in corrective maintenance – document it. • If it takes >45 days, create a Plan for Improvement (PFI) in your e-SOC • Consider equivalency request to TJC

22. What is the SOC? • The Statement of Condition (SOC) is required by TJC, parts done on Joint Commission site, includes: • Basic Building Information – eBBI • Plan for Improvement – PFI • There are other parts!

23. What is the BBI? • The Basic Building Information eBBI: • Done online – part I of SOC • Required for each healthcare and ambulatory facilities on your eAPP • Update is needed when you add new sites to your eAPP • Look at it, part is pre-populated, other parts need your input! • Drives the length of your LSC survey

24. What is the PFI? • The Plan for Improvement: • Done online, part IV of the SOC • Document PFIs on a regular basis when the deficiency cannot be fixed within 45 days • Includes start and end dates • Failure to meet end date plus 6 months leads to adverse decision

25. Short Cut to Trouble • Immediate Threat to Life • Situational Decision Rule

26. Immediate Threat 2 “Situational” Decision Rules 3 Direct Impact Indirect Impact Immediate Threat to Life • It is the Joint Commission equivalent of the “go directly to jail” card! • Joint Commission believes there is substantial noncompliance issues that have caused or could cause harm/death to patients or staff. • ITL called, your accreditation status changes to Preliminary Denial of Accreditation (PDA) overnight!

27. Immediate Threat “Situational” Decision Rules 2 Direct Impact 3 Indirect Impact Immediate Threat to Life • EC & LS examples from Perspectives, conferences, other communications: • One single issue or a combination of observations: • Inoperable fire alarm system • Inoperable or unreliable fire pump • Inoperable Medical Gas System or alarms • Negative pressure rooms not working • Generator tests failed, not fixed

28. Immediate Threat “Situational” Decision Rules 2 Direct Impact 3 Indirect Impact Immediate Threat to Life • EC & LS examples cont: • Utility system: main circuit breaker not tested or maintained • Raw sewage leaking from pipes in basement • No way to transmit fire alarm signal to local fire department • No emergency exit and no ILSM to compensate

29. Immediate Threat 2 “Situational” Decision Rules 3 Direct Impact Indirect Impact Situational Decision Rule for LS • Short cut to AFS or PDA • AFS13 Defined: • The hospital did not complete corrective action identified in your PFI in a timely fashion or failed to implement ILSM In plain English: • Busted plan - Failure to implement corrective action in e-SOC review PFI • Failed ILSM

30. Busted Plan Defined • If you do completed a PFI, you did not request and extension and you are more than 6 months past the due date, and the surveyor has “accepted” your eSOC: this is a “busted plan” • Results in adverse outcome, identified day one of survey!!! • Review your own PFIs regularly!

31. ILSM in Brief(LS.01.02.01) • Interim Life Safety Measures (ILSM): The hospital protects occupants when LSC is not being met & during construction • Applies to LSC deficiencies • Applies to both construction and other non-construction repairs. • Applies to issues identified on your PFI. Ask to see these! • Many ITL could be avoided if ILSM was implemented

32. ILSM in Brief(LS.01.02.01) • Interim Life Safety Measures (ILSM): • Hospital needs an ILSM policy • The policy must have criteria • The criteria are used to assess deficiencies and identify the need for ILSM • Ask for your criteria, ask to see the paper work showing ILSM was evaluated for construction and for PFIs

33. Top Scored EC & LS Standards • Surveyors see these everywhere, low hanging fruit • These are seen by both the LSC surveyor and the clinical surveyors • Prevent them from seeing these at your organization and create an impression on day 1

34. Exits and Cluttered Corridors(LS.02.01.20 -50% in ‘10) Hospital maintains means of egress: Blocked or locked egress doors Corridor clutter, storage in hallways Cart on Wheels can be plugged in but not parked for >30 minutes Crash carts are considered “in use” Isolation carts outside occupied room also considered “in use”

35. Exits and Cluttered Corridors, cont LS code requires 2 exits per story If exit is blocked, you need ILSM and an alternative exit for staff Exit discharges to outside uneven surface or obstructed (EP8) Exit signs – burned out, enough, proper location “No Exit” signs posted

36. Fire Protection Features(LS.02.01.10 - 44% in ‘10) Building & fire protection features minimize the effects of fire, smoke and heat. • Fire and smoke doors labeled, correct type, close, label visible, under cut, door gaps • Penetrations are sealed with correct material – IT cables biggest offender. Consider a “bounty” system!

37. Fire Doors, cont • Inspect and maintain fire doors • Appropriate fire rating on doors and frame • Door positively latches • Door had a closure • No gaps > 1/8 inch, or undercut >3/4 inch • Resulted in ITL if multiple problems

38. Rated Doors (cont.) • Must have legible labels on the door and jambs. Options available: • Scrap off the paint! • Have third party testing agency re- label doors • Implement ILSM, or • Request equivalency from TJC

39. Penetrations – Seal with Fire Stop • If there are cracks or gaps then it is to be removed and repaired using current technologies • TJC does not accept the expanding foam used for insulation in any fire or smoke barrier – not UL rated & toxic

40. Fire Protection Equipment(EC.02.03.05 – 38% in ‘10) Hospital inspects, tests & maintains fire safety equipment. • Has resulted in ITL! • Includes inspection, testing and maintenance of: fire alarms boxes, smoke detectors, sprinklers, portable extinguishers, magnetic release devices, tamper switches & water flow devices. • If outsourced to a vendor keep the report, read the report and act on problems! • Make sure reports are tied to an inventory of devices

41. Fire Extinguisher Dating(EC.02.03.05 EP 15) • Month, day, year and initials of inspector required per NFPA 10-1998 • They will review the tag • If bar coded, they will review documentation • Required monthly

42. LS -Maintain Building Features(LS.02.01.30 – 37% in ‘10) Building features are provided and maintained to protect individuals from fire and smoke • Label all Hazardous Areas (such as boiler rooms, laboratories, O2 tank supply rooms) • Limit access to hazardous areas • Education to staff with access • Smoke dampers • Corridor doors that do not latch properly • Smoke doors with gaps > 1/8 inch, >3/4 inch undercut

43. Provide/Maintain Fire Systems and Equip (LS.02.01.35 EP6) Sprinklers • 18 inch rule • Sprinkler pipes can not support other items like cables or wires • Sprinkler head clean and free of obstruction, collar flush

44. Defibrillators: FAQ (EC.02.04.03) Q. Are defibrillators considered life support equipment? • Yes. examples include: ventilators, heart-lung bypass machines, defibrillators, AED. • Must be on your inventory of medical equipment • Maintenance per manufacturer instructions • You are scored per your policy

45. Emergency Power(EC.02.05.07 – 26%) Inspect, test, and maintain emergency power systems… battery powered lights, generators, automatic transfer switches • Has resulted in ITL decision

46. Emergency Power, cont. • Make sure generator testing done per standard • Retest after a fix to ensure is passes eg the 4 hour generator test • Inspect, test, maintain transfer switches • If testing is outsourced to vendor keep, read and act on reports!! Leaders need to be notified when there are problems.

47. Safe, Functional Environment(EC.02.06.01 – 20%) • Areas scored here: furnishing and equipment are in good repair, the environment meets needs of patient. • Ripped mattresses, cracked ceiling tile, mold, broken wheel chair • In behavioral health units do environmental risk assessment for suicide risks. Either fix or implement other safety interventions such as increase monitoring. Document and keep your risk assessment. ( or scored at EC.01.01.01)

48. Medical Gas(EC.02.05.09 – 20%) • Test & inspect & maintain medical gas and vacuum per policy • Get vendor reports, fix problems noted • Gas shut off valves must be labeled with rooms they shut off. Staff must know who can shut these off and when. • Alarms must be working. Has led to ITL

49. Safety and Security(EC.02.01.01 – 15%) Hospital manages safety and security risks • Complete risk assessments on areas of potential risk • Scored in sensitive areas such as Labor and Delivery, Pediatrics • Trace your own policies, do staff stop you or surveyor when they enter area? • See unsecured O2 scored here JKC

50. Strategies for SuccessPreparing Clinical Areas • Rollout the Clinical Area Checklists • Email them out, assign, implement, collect them back, analyze compliance • Involve/educate clinical & frontline staff • Everyone knows who to call to get fixed • Identify areas to improve, fix it, then reassess • Make LS an every day expectation!