• EC Tracer Scenario: Environmental factors in preventing patient falls EC News, September 2016, Vol 19, #9, Pg 8 – There should be no disagreement that every hospital needs to be moving along the road to improved quality of care and greater patient safety.  However, sometimes we get lost in the jargon and rhetoric of High Reliability, Zero Harm, Safety Culture, etc.  Our September Article-of-the-Month (AOM) focuses on a practical, seemingly perrennial concern of patient falls.  Patient injuries related to falls are a preventable form of harm that deserve our attention and committment to improve. A number of facilities have relatively recent initiatives to do just that. We encourage you to read this article, utilize the tracer and share your improvement initiatives in this area… particularly if you have taken advantage of the Fals TST.
  
• Click here for our REVIEW(Mbr/Guest); the FULL TJC ARTICLE(Mbr); to share a COMMENT(Mbr/Guest).

**RECOMMENDED READING:

1. PR: Top Standards Compliance …First Half of 2016 (PDF)[REF:EC, IC, LDR, SC]
2. PR: Notifying TJC About Organization Changes (PDF)[REF:GB, LDR, 2016]
   
3. TS: Achieving Zero Harm: Q&A with Ronald Wyatt, MD (PDF)[REF:LDR, MD]
4. EC: Understanding EC Standards Update for 2017 (PDF)[REF: EC, SC]
5. EC: Checklist for compliance with Standard EC.02.03.01 (PDF)[REF: EC, Tool]
6. EC: Environmental factors in preventing patient falls (PDF)[REF: EC, RN, Tracer]

**USEFUL UPDATES, LINKS & DOWNLOADS:

• TJC: Sentinel Event data reveals patient falls with injuries among 3 most frequently reported sentinel events in the first half of this year.
  
• TJC: Targeted Solutions Tool (TST) for Falls
  
• Latest TJC Blogs: Physician Leader Monthly – Leadership Blog
  

**SupporTips

PR: Top Standards Compliance Data for First Half of 2016

     The most frequently cited standards in the first half of 2016 have not changed much from the final 2015 listings. The most significant change is the new entry of IC.02.02.01 (The hospital reduces the risk of infections associated with medical equipment, devices, and supplies.) Although not on the 2015 list for TJC, this standard ranked #11 on the SPHCC listing of most frequently cited standards for Psychiatric Hospitals. It should be noted that it now ranks #2 on the TJC list.
For those organizations with BHC components, the top 5 standards continue (in order) to be CTS.03.01.03, HRM.01.02.01, NPSG.15.01.01, IC.02.04.01 and HRM.01.06.01. There were some minor shifts/additions among the lower 5 resulting in the following order: EC.02.06.01, CTS.04.03.33, CTS.02.01.05, CTS.02.01.11, EC.02.03.05.
Tip1: Hospitals should pay  particular attention to IC.02.02.01 as it enters the Top 10 for the first time since 2014 and was cited in 59% of hospitals.
Tip2: BHC should take the persistence of top 5 citations as stimulus for more rigorous review of compliance in those areas.

• PR: Notifying The Joint Commission About Organization Changes (PDF)[REF:GB, LDR, 2016] Perspectives September 2016, Vol 36, #9, Pg 12 JCp1609_B2

Effective October 1, 2016 organizations should not wait 30 days after the fact to notify TJC of significant changes, but rather do so “when leadership within the organization has approved moving forward with the proposed change and identified a time frame for
implementing that change.”  Significant changes include those related to ownership, location volume of services, adding or discontinuing programs/types of services.
Tip: Make sure Leadership and Governing Body is aware of this change.

*TS: Achieving Zero Harm: The Joint Commission’s First Patient Safety Officer Shares His Insights A Q&A with Ronald Wyatt, MD (PDF)[REF:LDR, MD] The Source, September 2016, Vol 14, #9, Pg 1 JCs1609_B3

Although it is no longer the red hot topic of choice for Leadership Interviews during survey, advocacy for becoming a High Reliability Organization (HRO) is still a priority of TJC.  A such, so is the goal of achieving zero harm.  In this article/interview with Ronald Wyatt, MD, it is first made clear that zero harm is truly achievable, especially if you think in terms of harm that is in fact preventable.  Dr. Wyatt also shares a fair amount of insight on achieving the necessary Safety Culture that makes zero harm possible.
Tip 1: Leaders should read this article to help keep them mindful of moving toward High Reliability and Zero Harm.
Tip 2: Since a physician is the primary voice in this article, it might be particularly suited for sharing with Medical Leaders/Staff

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

* EC: EC Toolbox: Checklist for compliance with Standard EC.02.03.01 (PDF)[REF: EC, Tool] EC News, September 2016, Vol 19, #9, Pg 5 JCe1609_B5

During 2015, his standard was among the ten most frequently cited for both hospitals and BHC programs. That continues to be the case for BHC in the first half of this year as well.  The standard requires that any fire safety equipment and fire safety building features (e.g., fire alarms/notification devices, sprinklers, fire extinguishers, hoses, samplers, smoke detectors, fire doors) present in your facility have to be inspected, tested and maintained according to prescribed time frames.  In addition, the inspections, testings and maintenance must be documented.  Failure to document will result in a finding of non-compliance.  For this reason, TJC has developed and provided in this article (page 7) a Checklist for Compliance with EC.02.03.05.
Tip: Download the checklist and utilize it as part of your annual evaluation of EC management plans.
See also: RTN1402_B7_EC040101 – EC Documentation Checklist

* EC: EC Tracer Scenario: Environmental factors in preventing patient falls (PDF)[REF: AOM, EC, RN, Tracer] EC News, September 2016, Vol 19, #9, Pg 8 JCe1609_B6

In response to continuing concern about patient falls, TJC developed a Targeted Solutions Tool (TST) to help address this issue.  The TST was made available in September of last year (RTN1509_B4). Recently reported Sentinel Event data (see The Source, Sept 2016, page 7) reveals patient falls with Injuries to be among the three most frequently reported sentinel events in the first half of this year.  Perhaps with this in mind this article provides a tracer focusing on environmental factors related to the detection and prevention of patient falls.  It also suggests that in this regard environmental safety rounds should pay particular attention to patient area lighting, walkway clutter, handrail stability, furniture sturdiness, window security, equipment safety and potential fall risks in outside areas accessed by patients.  This month’s tracer scenario focuses on an elderly patient with risk of falling.
Tip: Utilize the 21 questions provided in this scenario to conduct your own fall risk tracer and better assess potential compliance concerns in this area.
See also: Targeted Solutions Tool (TST) for Falls.