Joint Commission: Insight into the Top Cited Elements of Performance and SAFER Scoring Bryan Connors, MS, CIH, HEM Practice Director, Healthcare Environmental Health & Engineering, Inc.
Agenda Drivers behind the change to the SAFER methodology SAFER methodology pros and cons Mapping the top 10 citations on the SAFER matrix Strategies and best practices for addressing the top citations Insights into a survey and post survey follow-up under the SAFER methodology
Source of Data 5 Joint Commission surveys reports reviewed since Jan. 1 42 EC and LS mock surveys since Jan. 1 Northeast Community hospitals and large medical centers
Drivers Behind the Changes TJC is accountable to CMS CMS and TJC used different approaches to scoring deficiencies Now closer aligned CMS increased pressure for 100% compliance CMS finds the discrepancy rate unacceptable See It, Cite It Plan for Improvement (PFIs) ended
SAFER Methodology
What s Changed? New approach to scoring findings Requirements for Improvement scored based on: Immediate Threat to Life Likelihood to harm patients, staff, visitors (H,M,L) Scope / prevalence Evidence of Compliance Survey 60 days* to address findings Additional steps to resolve high risk, pattern and widespread findings *30-45 days revisit for conditional findings
Pros & Cons See it, Cite it results in an increase in the number of citations Maybe incorrectly viewed by leadership as lower performance No longer know where findings will fall in the scoring matrix based on EP standard alone More realistic picture of risk from vulnerabilities
Top 10 Citations Under the SAFER Methodology
Likelihood to Harm Patient, Staff or Visitor SAFER Matrix Immediate Threat to Life Low Moderate High Moderate Harm Limited Frequency Low Harm Limited Frequency High Harm Any Frequency Moderate Harm Pattern or Widespread Low Harm Pattern or Widespread Limited Pattern Widespread Scope or Prevalence
Likelihood to Harm Patient, Staff or Visitor 1. Ligature Risks within Behavioral health 100% of mock, 100% of actual surveys cited Low Moderate High EC 02.06.01 EP 1 ~40% EC 02.06.01 EP 1 ~60% Limited Pattern Widespread Scope or Prevalence
Likelihood to Harm Patient, Staff or Visitor 2. Pressure Dependent Spaces 100% of mock, 80% of actual surveys cited Low Moderate High EC 02.05.01 EP 15 ~20% EC 02.05.01 EP 15 ~80% EC 02.05.01 EP 16 ~100% Limited Pattern Widespread Scope or Prevalence
Likelihood to Harm Patient, Staff or Visitor 3. Firestopping & Material on Sprinkler Piping 100% of mock, 100% of actual surveys cited Low Moderate High LS 02.01.35 EP 4; LS 02.01.30 EP8-EP12; LS 02.01.10 EP3-5 ~15% LS 02.01.35 EP 4; LS 02.01.30 EP8-EP12; LS 02.01.10 EP3-5 ~40% LS 02.01.35 EP 4; LS 02.01.30 EP8-EP12; LS 02.01.10 EP3-5 ~35% Limited Pattern Widespread Scope or Prevalence
Likelihood to Harm Patient, Staff or Visitor 4. Door Compliance 90% of mock, 80% of actual surveys cited Low Moderate High LS 02.01.35 EP 4; LS 02.01.30 EP8-EP12; LS 02.01.10 EP3-5 ~40% LS 02.01.35 EP 4; LS 02.01.30 EP8-EP12; LS 02.01.10 EP3-5 ~60% Limited Pattern Widespread Scope or Prevalence
Likelihood to Harm Patient, Staff or Visitor 5. Inspection, Testing & Maintenance 65% of mock, 60% of actual surveys cited Low Moderate High EC 02.03.05 EP 1-27 (Fire), EC 02.05.07 EP1-10 (EP) ~20% missed test generator related EC 02.03.05 EP 1-27 (Fire), EC 02.05.07 EP1-10 (EP) ~80% Limited Pattern Widespread Scope or Prevalence
Low Moderate High Likelihood to Harm Patient, Staff or Visitor 6. Compressed Gas Cylinders 40% of mock, 60% of actual surveys cited EC 02.02.01 EP 9 ~60% EC 02.02.01 EP 9 ~40% Limited Pattern Widespread Scope or Prevalence
Likelihood to Harm Patient, Staff or Visitor 7. Fire Drills 30% of mock, 60% of actual surveys cited Low Moderate High EC 03.03.03 EP 3 ~10% EC 03.03.03 EP 3 ~90% Limited Pattern Widespread Scope or Prevalence
Likelihood to Harm Patient, Staff or Visitor 8. Fire Alarm Panel 25% of mock, 40% of actual surveys cited Low Moderate High EC 02.05.01 EP 8 100% Limited Pattern Widespread Scope or Prevalence
Likelihood to Harm Patient, Staff or Visitor 9. Labeling and Signage S 90% of mock, 60% of actual surveys cited Low Moderate High EC 02.05.01 EP 8 source valve & breakers not labeled ~70% EC 02.05.01 EP 8 ~ 30% Limited Pattern Widespread Scope or Prevalence
Likelihood to Harm Patient, Staff or Visitor 10. Eyewashes 30% of mock, 60% of actual surveys cited Low Moderate High EC 02.02.01 EP 5 ~30% EC 02.02.01 EP 5 70% Limited Pattern Widespread Scope or Prevalence
Strategies and Best Practices: Avoiding the Top Citations
Prioritize Biggest Risks Stay out of the red zone Address ligature and pressurization risks Most common red zone findings Conduct mock surveys Prioritize high/moderate Assure your consultant is using a risk ranking similar to TJC (and knows what they are doing)
Ligature Risks Intense focus in 2017 from TJC / CMS Onsite survey TJC surveyors will document all observations of ligature or self-harm risks in the environment and will: Determine if the facility has previously identified these risks Evaluate existing plans the facility has for removing these risks Evaluate the organization s environmental risk assessment process Ligature findings will also be cited at the appropriate Condition of Participation (CoP) 482.41 and, if in the highest risk areas, will be cited at the Condition level and noted as high risk on the SAFER Matrix.
Pressurization Inventory ALL pressure dependent spaces Know the code! Create deficiency list and action plan Routine monitoring program Staff education Not all fixes are mechanical fixes
Firestopping and Material in Sprinkler Pipes Focus on building separations if you know you have issues Above fire doors on rated walls Assume you may take a hit Fix everything that you can onsite Stay out of the red/amber zone to limit ESC follow-up
Tips from TJC Surveys 1 st place inspected is main fire panel 2 nd place is behavior health for ligature risks 3 rd OR and critical area pressure If Life Safety arrives on the 2 nd day of survey, use that day to your advantage
Tips from TJC Surveys Some surveyors are measuring to 0.01 /H 2 O column for areas required by FGI guidelines Fix as much as you can during survey Pressure Ligature (hopefully fixed before survey)
Single Tool for Surveyors and Customers
Additional Anecdotes from Actual Surveys
General Impression from Surveys Intense pressure from CMS; discrepancy rate Take advantage of Special Issue Resolution sessions Be polite and professional, but do no be afraid to present additional data on why you comply There is no excuse and little surveyor forgiveness for documentation not being in order
General Impression from Surveys Power taps are being cited more this year Hazard communication labeling on belly and other tanks in mechanical spaces Eyewash near outside emergency generators (maintenance v. maintenance free batteries) Monthly inspection of illuminated exit signage Other IC physical environment plans are coming up on survey (USP, water management plans)
Post Survey Process: Conditional Findings, Medicare Resurveys, and Evidence of Standard s Compliance
Tips from TJC Surveys All findings must be fixed within 60 days What extension is needed? A Survey-related Plan for Improvement (SPFI) must be created within 45 days of the survey Time limited waivers are reviewed by CMS central office If the waiver request is denied, the 60 day deadline still stands
ESCs are Linked to SAFER Matrix
Evidence of Standards Compliance Who who is responsible, by title, for the corrective action and ongoing compliance What concisely describe the actions completed to correct each finding Make sure you describe all findings When - dates each action was completed to correct each finding Should match up with the what How - describe how compliance will be sustained with this EP
Evidence of Standards Compliance Two additional actions required for any High severity and Moderate pattern/widespread scoring 1. Leadership involvement: describe how leadership involvement is helping to sustain compliance with this EP in the future 2. Preventative analysis: what analysis was completed to ensure the noncompliant issue was corrected AND that any underlying reasons for the failure were also addressed? High severity and Moderate pattern/widespread will be subject to further review during future triennial surveys
CMS Deficiency Resurvey 30-45 day resurvey All conditional findings will be reviewed during the CMS deficiency resurvey Have ESC binder, pictures and documentation in order, detailed and comprehensive Helps expedite the resurvey EH&E participated in 3 CMS deficiency resurveys in 2017 (average duration <2 hours) Typically will visit ligature and pressurization corrections at a minimum
Questions? Bryan Connors, MS, CIH, HEM Practice Director, Healthcare Environmental Health & Engineering, Inc. 800-825-5343 bconnors@eheinc.com