The Joint Commission - Light PP Presentation - …

1 Copyright, The Joint Commission2016 Challenging Standards & Updates George Mills, DirectorEngineering DepartmentThe Joint Commission Copyright, The Joint CommissionEquipment Management Medical Equipment: , Systems: , TO HOSPITAL & CAHPROGRAMSE ngineering Department 2016-3 Copyright, The Joint hospital manages risks associated with its utility EP 1 The hospital designs and installs utility systems that meet patient care and operational needs. (See also , EP 1)Engineering Department 2016-4 Copyright, The Joint EP 2 The hospital maintains a written inventory of all operating components of utility systems or maintains a written inventory of selected operating components of utility systems based on risks for infection, occupant needs, and systems critical to patient care (including all life-support systems).

2 The hospital evaluates new types of utility components before initial use to determine whether they should be included in the inventory. For hospitals that use Joint Commission accreditation for deemed status purposes:The hospital maintains a written inventory of all operating components of utility systems. (See also , EPs 1, 3-5)Engineering Department 2016-5 Copyright, The Joint CommissionUtility Systems & Operating Components Utility Systems are those systems that support the use and function of the physical environment, such as the heating system the cooling system water distribution systemEngineering Department 2016-6 Copyright, The Joint CommissionUtility Systems & Operating Components Utility Systems are those systems that support the use and function of the physical environment.

3 Such as the heating system the cooling system water distribution system Components on the inventory would include the equipment that is performance-related and delivers a measurable outcome. For example, the heating system may have the following components: boiler, DA tank (de-aeration tank), feed water pumps, distribution (including circulation pumps, piping, and condensate return). Support parts to the components, such as belts, filters and steam traps, might not need to be individually listed, although they would likely be part of a preventive maintenance program.

4 Support parts of components such as pumps and motors might also be considered sub-components and may or may not be reflected on the inventory, depending on the maintenance strategies used. Engineering Department 2016-7 Copyright, The Joint EP 3 The hospital identifies high-risk operating components of utility systems on the inventory for which there is a risk of serious injury or death to a patient or staff member should the component : High-risk utility system components include life-support equipment. Copyright, The Joint CommissionProject RefreshEngineering Department 2016-9 Copyright, The Joint CommissionOutcomes of REFRESHP rojectsReal-time information gathering between surveyors and Standards Interpretation Group during surveyEnhanced mobile technologyFewer standardsRevised criticality modelsEasier & less complex decision processStreamlined post-survey processHigher consistency in interpretation of standards Copyright, The Joint CommissionSurvey Analysis for Evaluating Risk (SAFER)

5 MatrixEngineering Department 2016-11 Copyright, The Joint CommissionCurrent State There are multiple different taggings that The Joint Commission uses for our Elements of Performance (EPs). For example, we tag EPs as Direct versus Indirect , A category vs. C category, Measure of Success (MOS) required or not, Risk Icon or not, etc. These multiple taggings were identified by different groups of staff, at different points in time, and are used for different reasons (ESC timeframe, decision rules, ICM, etc.). While the taggingsattempt to prioritize those EPs that are most critical, they often result in one size fits all follow-up as the follow-up is determined by the EP itself rather than the context of the actual finding written under Department 2016-12 Copyright, The Joint CommissionFuture Vision Develop one single, comprehensive methodof categorizing the risk associated with standards Copyright, The Joint CommissionEngineering Department 2016-14 Copyright.

6 The Joint CommissionLikelihood to Harm a PatientScopeA new SAFER concept Copyright, The Joint CommissionA New SAFER MatrixEngineering Department 2016-16 Copyright, The Joint CommissionPhase 1 Pilot Programs Hospital, Home Care, Ambulatory, Nursing Care Centers 20 Surveys Each surveyor to only place his/her findings Placement of findings done outside of survey Placement of findings not shared with organization Copyright, The Joint CommissionA New SAFER Department 2016-18 Copyright, The Joint CommissionBenefits of SAFER Matrix Focus on patient safety/risk to patients Critical thinking Takes each finding to the next level the so-what?

7 As to why the finding is important Helps surveyors think through each finding to cite at appropriate level of scope and severityEngineering Department 2016-19 Copyright, The Joint CommissionBenefits of SAFER Matrix (cont.) Visual representation of survey Indicates severity of findings to organizations for prioritization More clearly identifies the highest risks Aggregate data for standards refinement, improving consistency, etc. Copyright, The Joint CommissionPost-Survey Follow-upEngineering Department 2016-21 Copyright, The Joint CommissionCurrent State After the final report posts to the organization s extranet site, the org has either 45 (Direct Impact) or 60 (Indirect Impact) days to submit their Evidence of Standards Compliance (ESC).

8 Voice of customer has expressed dissatisfaction with the multiple ESC timeframes, as well as with the Measure of Success (MOS) Department 2016-22 Copyright, The Joint CommissionFuture Vision Recognize that the potential for an EP to be related to a risk/safety issue depends on the context of the situation during a given survey, and not just on the EP itself. Opportunity to use new SAFER Matrix to direct more customizedand prioritizedfollow-up based on each finding, and better utilize our systems and structures that support Department 2016-23 Copyright, The Joint CommissionPlacementof RFI on SAFER Matrix and Follow-Up ActivityLOW/ LIMITEDMODERATE/ LIMITEDLOW / PATTERNLOW / WIDESPREADMODERATE/PATTERNMODERATE/ WIDESPREADHIGH/LIMITEDHIGH/PATTERNHIGH/W IDESPREADE videnceof Standards Compliance(ESC) 60 Evidenceof Standards Compliance (ESC)

9 60 -Plus -Additional fields for sustainment planPull into surveyor technologyfor potential review during subsequent surveysPrioritized Follow-up ActionEngineering Department 2016-24 Copyright, The Joint CommissionBeginning June 6th, 2016 Starting with Psychiatric Deemed Hospital Surveys only: The SAFER matrix will be generated and embedded within the survey process and the final report Matrix data will be shared with the customer Updated post-survey processEngineering Department 2016-25 Copyright, The Joint CommissionCustomer Impacts.

10 No more Direct and Indirect EP designations No more A or C categories No more OFIs 60 days due date for allESC Visual grids will be included within the report Copyright, The Joint CommissionReducing Post-Survey ClarificationsEngineering Department 2016-27 Copyright, The Joint CommissionWhat is Clarification? After a survey event, organizations have the opportunity to submit clarifying ESC if theybelieve that their organization was in compliance with a particular standard at the time of Survey . ACC-60 Engineering Department 2016-28 Copyright, The Joint CommissionAnalyze: Hospital Clarifications 50% of Hospitals (HAP) request Clarifications Dominate clarification themes: Lack of Documentation (65%) Incorrect Findings Survey Process Issues 51% of HAP Clarifications are in the EC & LS ChaptersEngineering Department 2016-29 Copyright, The Joint CommissionAnalyze.