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• EC: – Clarifications and Expectations: E-SOC Gets a Facelift[®] [REF: EOC, E&M, JCSC, SFT] EC News October 2013, Vol 16, #10, Pg 1 #JCe1310_B4 This facelift actually went into effect three months ago (7/15/13). Aside from the user friendliness improvements (e.g., direct access to the BBI and PFI from the E-SOC homepage), the take-home point of this article is to pay attention to ILSM Assessments. The new E-Soc requires (i.e., will not let you proceed) you to indicate ‘Yes’ or ‘No’ on performance of an ILSM Assessment every time a new PFI is entered. Be prepared to defend a No during survey. Failure to perform this assessment may result in citation of LS.01.02.01, EP 3. The updated E-SOC also makes it easier for surveyors (and you) to know if the assessment was done and its status. This is now conveniently provided under a tab called ‘PFI View All’ that surveyors will routinely review at the time of survey. |
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One response to “RTN1310_B4_E-SOC/ILSM Assmt”
Although the addition of the ILSM field for each Plan for Improvement (PFI) within the eSOC is a rational move on the part of The Joint Commission, they really should have considered asking users whether any ILSM measures were “implemented” rather than was an ILSM “assessed”. It is the position of this consultant that one should always assess the need for ILSM whenever life Safety is compromised. The determination of whether in fact measures were deemed necessary to implement is truly of more value to surveyors at the time of survey. For example, you may have one or more PFIs that are so minor that, based on your ILSM risk assessment; you choose not to implement any additional measures due to the other safeguard measures that are already in place. This is consistent with TJC’s actual Life Safety standard requiring an ILSM policy (LS.01,02,02 EP3), allowing the organization to make said determination as stated: “The policy includes criteria for evaluating when and to what extent the hospital follows special measures to compensate for increased life safety risk.”
Therefore, it is up to the organization to determine what, if any measures are to be implemented. Either way, you can expect surveyors to validate the actual assessment and implementation process by evaluating the following:
1. The organization’s ILSM policy & procedure.
2. The ILSM assessment for each PFI and determined measures to implement, if any.
3. Evidence of implementation and monitoring of measures implemented.
The format of the assessment one chooses is open to whatever the organization has adopted as long as it is implemented and remains consistent with their own policy. However, it is always critical to assure that when implementing actual “measures” to counterbalance the compromise to Life Safety, that you make a sound and rational determination as to what truly fits the needs for meeting the deficiency. In other words, saying that you choose to take no measures whatsoever for a blocked exit that will exist for a 90-day period of time will surely be challenged by a surveyor. [PEARL] To protect your decision from the subjective perspectives of a surveyor, we always recommend that once the ILSM assessment has been completed, that you submit it through the Environment of Care/Safety Committee for approval. There is safety in numbers and it is far more challenging for a surveyor to dispute your decision when it has been approved by those responsible within your own organization.
To aid those in assessing and documenting your ILSM needs we offer two sample assessment tools – see attached: One is the EZ Format that can be used for single items. The Long Format can be used to assess multiple issues, as many hospitals have on their SOC. Hopefully these tools can help your organization document the assessment process but also keep in mind this very important quotation from the Life Safety Code itself: “The design of every building or structure intended for human occupancy shall be such that reliance for safety to life does not depend solely on any single safeguard.”
George A. Rivas, CHSP-FSM
Senior Vice President
TSIG Consulting