“M
ay I have your attention please? We welcome the representatives from The
Joint Commission to our facility.” This overhead announcement catches some organizations unawares. But it doesn’t have to be that way. “Being ever-ready is essential to a successful survey and
quality patient care,” says Mark Kaldahl, facility support director, Carilion Franklin Memorial Hospital (CFMH), Rocky Mount, Virginia. CFMH is a
37-bed rural health facility with 24,000 emergency room visits each year and robust outpatient service. It’s just one of several hospitals throughout south- west Virginia owned and operated by Carilion Clinic.
When The Joint Commission comes to a health care organization, Life Safety Code®* Surveyors (LSCS) focus on two areas as they perform the environment of
Key 1 – Provide only what’s needed.
Give the surveyor only the documen- tation she or he is seeking. Sometimes, organizations bring stacks of files and records to the documentation review. “Many of the items facilities track and document may not even be the items surveyors need,” Kaldahl says. “The best idea is to provide only those records sur- veyors are specifically seeking.” The “EC Frequency Documentation Checklist” online at http://www.ingentaconnect
.com/content/jcaho/ecn/2014/00000017
/00000002/art00004 and on pages 10–11 of the February 2014 Environ ment of Care News names key items surveyors will want during the document review. “Although other records may
be important, I wouldn’t bring them to the document review unless specifically requested by the surveyor,” Kaldahl says.
the last two annual inspections to ensure that the most recent one was completed within the one-year parameter (that is, one year from the date of the last event, plus or minus 30 days; see “Joint Commission Official Time Defi ” page 10).
Key 3 – Organize!
Organize your documentation so it’s easy for the surveyor to find. “I keep all my documents in a 5-inch binder,” Kaldahl says. Labeled “Environment of Care Documentation Review Binder,” the book’s table of contents lists the items named on the EC Frequency Documentation Checklist. Tabs on the
binder identify each section listed in the table of contents (for example, battery- powered emergency lights—monthly [EC.02.05.07, Element of Performance (EP)1]; fire extinguishers—annually [EC.02.03.05, EP 16]; and so on). For
care (EC) review:
tabs in which there’s only one inspection
Checking for the required EC-related documentation
Completing a life safety survey of the facility†
This article highlights the documen- tation portion of the EC Review and pinpoints nine key elements Kaldahl believes make that part of a survey flow more smoothly.
report (for example, fire extinguisher testing—annually), Kaldahl simply places that inspection report behind the appropriate tab. He separates each quar- terly or semiannual inspection from the others with a colored piece of paper. For monthly inspections, he inserts monthly calendar tabs and places each individual monthly inspection report accordingly.
“Organizing your binder in this way
makes it very easy for a surveyor to look
* Life Safety Code is a registered trademark of the National Fire Protection Association, Quincy, Massachusetts.
† In small and critical access hospitals, LSCS perform the full EC and EM session as well. Or, in a smaller organization, an administrative surveyor may perform these functions.
Key 2 – Bring only one year’s data to the document review.
Surveyors will look back only one year from the date of the survey. Exceptions are activities that are performed only annu- ally; in that case, surveyors will want to see
down through the table of contents and find the documentation she or he is seek- ing,” says Kaldahl. It also allows you to keep better track of activities and ensure that they’re occurring when they should.
(continued on page 10)
36
THIS
MONTHS
12
MONTHS
6
MONTHS
3
MONTHS
1
MONTH
7
Joint Commission Official Time Definitions
Many standards, including those related to equipment maintenance activities, include designations of time. The following are Joint Commission official time definitions.
Triennially/every 36 months/every 3 years =
36 months from the date of the last event plus or minus 45 days
Annually/every 12 months/once a year/every year =
1 year from the date of the last event plus or minus 30 days
Every 6 months =
6 months from the date of the last event plus or minus 20 days
Quarterly/every quarter =
Every 3 months plus or minus 10 days
Monthly/30-day intervals/every month =
12 times a year, once per month
Every week =
once per week
see “Joint Commission Official Time Definitions,” above). Failure to complete an inspection during this allotted time frame may very well result in an RFI.
Key 6 – Follow up on any deficiencies noted during the inspections.
“Not following up is what many facilities are cited for during the docu- ment review,” Kaldahl says. Although the inspections may have been performed
on time, the deficiencies are often not corrected in a timely fashion—or not corrected at all. “Don’t expect individuals doing the inspection to follow up with you to make the corrections. That just isn’t going to happen,” says Kaldahl. It’s up to the designated individual in the organization to read the reports and make sure the issues are corrected promptly.
Once they are corrected, the individual who performed the initial inspection should provide the organization with a follow-up letter/report noting completion of all the corrected deficiencies identified.
Surveyors aren’t surprised when they find deficiencies noted on the inspection reports. However, they also want to find evidence that the deficiencies have been corrected, and a correction sheet goes a long way toward meeting that need.
DAYS
Nine Keys to a Successful Environment of Care Document Review
(continued from page 9)
Key 4 – Provide a summary sheet.
At the front of your documentation review binder, Kaldahl suggests provid- ing a summary sheet showing the dates when the inspections were completed for everything listed in the binder’s table of contents (see “Sample Summary Sheet,” page 11). Surveyors can see at a glance not only the inspection comple- tion dates but also whether the activity was completed within the prescribed time schedule. If the surveyor wants
to refer to a specific inspection report, she or he can find that report under the appropriate tab in the binder.
Key 5 – Make sure all activities are completed on time.
The Joint Commission has outlined some very specific time frames in which activities are to be completed. Say, for instance, that an activity is to be per- formed quarterly (for example, fire department water supply connections). “Quarterly” is defined as every three months plus or minus 10 days from
the date of the last inspection (again,
Key 7 – Make sure there are no holes in the documentation.
To avoid the pitfall of missing docu- mentation, make sure that all activities were completed on schedule and all defi- ciencies have been corrected. If deficien- cies cannot be completed in a reasonable time frame (generally about 45 days), track the progress through the environ- ment of care committee and the process used to manage corrective maintenance. Doing so alerts The Joint Commission of the issue and provides the organization’s time frame for correcting the deficiency.
Key 8 – Keep three years’ worth of data available at all times.
“Although I’ve never seen it written
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anywhere, I’ve always been told it’s best to keep three years of data (inspection reports, generator logs) available for the surveyors in case they ever want to look back over the records since the last sur- vey,” Kaldahl says. This is especially true when inspections are completed only annually—or in the case of fire dampers, only once every six years.
Note that other outside agencies not associated with The Joint Commission may also want to see previous records. These may include the organization’s property insurance carrier, the local fire marshal, or other life safety inspectors. “I keep the longer-term documents in binders labeled ‘Environment of Care Documentation Review Binders, Years 2–3’,” says Kaldahl. “When I add new documents to the current 12-month
Documentation Review Binder, I remove the records older than one year and place them in the Years 2–3 binders.” Records in the Years 2–3 binders that are more than three years old are either archived or shredded. “By following this process,
I always have three years of data available at any given time,” says Kaldahl.
Sample Summary Sheet
This sample summary sheet shows the completion dates of all activities listed in the binder’s table of contents. It allows surveyors to see in a single glance not only the completion dates but also whether the activity was completed within the prescribed time frame. This sample is partially completed. A blank sheet you can adapt to your organization can be found online at https://www.jcrinc.com/assets/1/7/ECN0615
Key 9 – Be sure to have all your environment of care policies and procedures up-to-date and ready for review in case the surveyor requests them.
Often during the document review, a surveyor will ask to see the facility’s policy on a particular environment of
care issue. “Knowing that these questions are likely to occur, I have found it best
to bring my Environment of Care Policy and Procedure Manual with me to the document review,” says Kaldahl. “Just
as I tab my Document Review Binder,
I also tab my policy and procedure man- ual.” Should a surveyor ask to see how Kaldahl’s team has addressed a particular standard or EP, she or he can simply turn to that tab. If all your documents as well as all your policies and procedures are well organized, you can produce what the surveyor is seeking without having to say,
“I’ll have to get back to you on that.” Being surveyed by The Joint Com-
mission can be a positive, successful experience if the organization maintains a constant state of readiness. “I update my Documentation Review Binder monthly,” Kaldahl says. Many of the inspection/preventive maintenance tasks (for example, monthly fire extinguisher, generator testing) are completed by Kaldahl’s in-house maintenance staff.
Once those preventive maintenance work orders are turned in for the month, they go immediately into the Documentation Review Binder, he explains. Outside
vendors that complete routine inspec- tions (such as kitchen vent-a-hood and sprinkler system testing) are added to the binder as soon as they are completed. “Updating the binder on a regular basis ensures that the organization will be
in a constant state of readiness,” says Kaldahl—readiness to provide high- quality patient care in a safe environment and readiness for The Joint Commission to walk through the front door. EC
Contributed by Mark Kaldahl, facility support director, Carilion Franklin Memorial Hospital, Rocky Mount, Virginia.
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