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• PR: Consistent Interpretation (PDF/QV) [REF: AOM, EC] Perspectives March 2016, Vol 36, #4, Pg 5 JCp1603_B2
EC.02.06.01 requires organizations to establish and maintain a safe, functional environment. It was the most frequently cited standard for hospitals in 2015. Apparently some of the common reasons it is being cited relate to the following:
Re: Under-sink storage – under sink storage is not prohibited by TJC standards, but if used, the organization should have addressed it under defined storage requirements and risk assessment where appropriate.
- Re: Ligature points – Hanging hazards in patient rooms can be cited under this standard. If the organization has no mitigation efforts in place and/or has not done a risk assessment, there may also be cites under EC.02.01.01, Eps 1 and 3 respectively
- Re: Empty and full oxygen tanks stored together – Note that an opened tank is considered ‘empty” and there must be a physical separation between empty/used and full/unused tanks.
- Re: Fire Extinguisher Unavailability – If a fire extinguisher is within a locked enclosure and no keys are readily available it can be cited as a safety (vs fire) hazard under LS.02.01.35.
Other citations related to emergency pull cords and decontamination rooms were also addressed. In addition, it should be noted that surveyor guidance for the first two issues indicated, ‘If no risk assessment process is in use…‘ the organization was to be cited under EC.02.01.01, EP1.
Tip 1: Pay particular attention to the 4 issues referenced above (and those from earlier installments of this series) during environmental safety rounds and/or practice tracers.
Tip 2: Perform and document a risk assessment on any apparent or potential environmental risks that are not slated for elimination in the near future with the use of the TJC 7-Step Risk Assessment Tool. This will help demonstrate that a risk assessment processes is in use.
See also: Clarifications and Expectations: 7 Easy Steps to Risk Assessment: How you can do it and why you need to x EC News February 2013, Vol 16, #3, Pg 6
See also: TJC Physical Environment Portal – Built Environment – EC.02.06.01.
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3 responses to “RTN1603_B2_Consistent Interp: EC.02.06.01”
Ligature points- As a Life Safety Consultant, I often see hospitals that have not performed a risk assessment regarding ligature points as well as other issues in which a patient could harm themselves. When new patients are admitted this is a critical time as staff do not know the patient yet, it is important for the facility during environmental rounds to walk the route the patient will walk, consider what rooms and items they may have access to. Risk Assessments must be documented and to develop mitigation activities in writing, follow through with those mitigation activities.
Empty and full oxygen tanks stored together –I recently surveyed a hospital that had a great process for the Oxygen tanks. The facility had recognized their vulnerability regarding storage of e-cylinders during their environment of care rounds. Their solution to their hospital wide problem was the purchase of 3 labeled, holding racks for every nursing unit, a Red Rack for Empty, a yellow rack for partial and a green rack for fulls, this process has helped the facility stay in compliance.
I think this is a good article to highlight. As the medical director of a state facility, shortages of resources are always discussed although it is a good reminder for the facility to look at the risk with plan for mitigation even if the needed fixes may not occur as quickly as we would like.
To fully understand the breadth of the EC 02.06.01 standard, state psychiatric hospital staff must focus on four words within the standard/element of performance. The key terms include “establish and maintain”.
This means that, if it is needed it should have been implemented and if it was implemented the hospital must keep it working appropriately.
The need or lack of need is most likely documented within the agency wide environmental risk assessment.
If the hospital has never conducted a Risk Assessment, then there is no basis to argue. (The hospital does not know and did not take action to find out about the risk)
If the hospital has conducted a risk assessment then there can be conversations about how the assessment was conducted, how priorities were established for risk reduction and whether this particular item/area was assessed.
The difference lies in the quality of the risk assessment as opposed to the lack of an attempt to identify risk.
Most surveyors will consult with an organization that is working diligently to identify and reduce risk, unless the omission is so serious that it indicates a question of competency in conducting the risk assessment or neglect of a serious patient safety issue.
The second key term is “safe and functional”. This can be where subjective interpretations can pop up and is also where surveyors must use their experience and judgement to make a solid finding.
Generally, surveyors will probe the issue with staff, logically leading the conversation until it is clear to all involved that a situation is deemed “unsafe” or not consistently functioning in the manner it was intended.
If the hospital does not agree with the opinion of the surveyor, the surveyor may seek incident data or other documentation to support the rationale for a finding.
The examples provided in the article can provide a good learning experience for hospital staff:
-Under the sink storage is not prohibited by TJC, but if the items stored under the sink are paper products and the pipes leak…
-If there is a clear ligature point in the environment that is in an area where only certain patients with movement privileges can occupy and multiple staff accompany these patients, the agency may assess this risk as “lower priority”, to be addressed at a later time.
However, the same ligature point in a bedroom or bathroom may be assessed as a “High risk”, to be remedied immediately because it is located in an area where a patient can be alone. Both risks have been assessed but time frames for corrective action may differ.
-Oxygen is compressed into tanks and pressurized. If not handled properly by staff injury can occur. Therefore all Oxygen tanks need to be stored securely (wherever they are located) to ensure that they do not fall.(This is especially true of the larger tanks) The hospital separates empty tanks from full tanks to ensure that staff don’t mistakenly try to use an empty tank in an emergency. These actions are good examples of risk reduction activities.
The bottom line for all state psychiatric hospitals is to conduct a thorough and credible risk assessment of the environment and begin to take action on reducing the risks identified.