In an effort for The Joint Commission to “get with the current times”, they announced in the June 2016 issue of the EC News, they would be launching “Project REFRESH TM”. As part of their initiative for this project, the Joint Commission will take a look at the different elements of the process for surveying to ensure their procedures are relevant to the hospital. As stated in the September 2016 edition of the EC News, they will use the following guidelines to update their process:

• “Simplify– processes and make them transparent to customers”
• “Relevance-Enhance the significance of the survey process and all supporting accreditation activities”
• “Innovation-Use innovative approaches and technology to enhance customer experience”
• “Transparency-Increase transparency throughout the survey process”

In moving forward with their initiative the Joint Commission has taken a look at their standards and has been able to eliminate many elements of performance which might be redundant or unnecessary to determine a facilities compliance with quality and safety. Approximately 131 elements of performance have been removed from their manual for hospitals. Of the 131 deleted elements of performance, there were 8 from the “Environment of Care” chapter. The following eight EC elements of performance were removed:

• EC 01.01.01 EP 2 “Leaders identify an individual(s) to intervene whenever environmental conditions immediately threaten life or health or threaten to damage equ8ipment or buildings.”

• EC 02.01.03 EP 4 “If the hospital decides that patients may smoke in specific circumstances, it designates smoking areas that are physically separate from care, treatment, and service areas.”

• EC 02.03.01 EP 2 “If patients are permitted to smoke, the hospital takes measures to minimize fire risk.”

• EC 02.04.01 EP 1 “The hospital solicits input from individuals who operate and service equipment when it selects and acquires medical equipment.”

• EC 02.05.07 EP 9 “If a required emergency power system test fails, the hospital implements measures to protect patients, visitors, and staff until necessary repairs or corrections are completed.”

• EC02.05.07 EP 10 “If a required emergency power system test fails, the hospital performs a retest after making the necessary repairs or corrections.”

• EC 04.01.03 EP 3 “Annually, representatives from clinical, administrative, and support services recommend one or more priorities for improving the environment of care.”

• EC 04.01.05 EP 3 “The hospital reports performance improvement results to those responsible for analyzing environment of care issues.”

The Joint Commission’s decision to eliminate the 8 foregoing standards was largely based on their expectation that these concerns would be adequately addressed by the fact that:

1 – Organizations already have an ongoing process in place for managing environmental risks

2 – Organizations routinely plan and implement six required EC management plans

3 – Organizations annually evaluate those six required EC management plans and data related to the organization’s performance.

Tip 1: Ensure your Management Plans are current, reviewed and evaluated on a regularly scheduled time frame annually.

–by Barbara G. Pankoski, CHFM, CHSP-FSM