The Surveyor s Perspective. Understanding How The Joint Commission Surveyors Conducts Surveys

Transcription

1 The Surveyor s Perspective Understanding How The Joint Commission Surveyors Conducts Surveys Tim Markijohn MBA\MHA, CHFM, CHE Field Director, Life Safety

2 Learning Objectives At the conclusion of this presentation, participants will be able to: Describe how Life Safety Code surveyors prepare for surveys Explain step-by-step how Life Safety Code surveyors conduct surveys Implement a plan to be prepared for and participate in surveys Initiate measures for a successful Life Safety Code survey

3 Mission: To continuously improve health care By evaluating health care organizations - meaningful assessment To provide safe and effective care Inspiring them to excel

4 Life Safety Code Surveyor Goals To provide a Meaningful Assessment To identified Unknown Risk Inspire customers to improve through education and providing solution

5 Life Safety Code Surveyors (LSCS) Jim Kendig, MS, CHSP, CHCM, HEM, LHRM Field Director, LSCS Tim Markijohn, MBA\MHA, CHFM, CHE Field Director, LSCS 80+ Full/Part Time/Intermittent (Hiring FT and PT) Many currently work in healthcare facility management Minimum of bachelors degree, most have multiple masters & doctorate level Live across the country, survey the globe High performers, very engaged, top 1%

6 ACO-DSSM-SIG Sorta Like the Government DSSM - Legislative

7 Jim Kendig MS, CHSP, CHCM, HEM, LHRM Field Director, Life Safety Kenneth A. Monroe PE, MBA, CHC, PMP Director, Engineering

8 SIG - Department of Engineering Kenneth A. Monroe, PE, MBA, CHC, PMP Director Andrea Browne Medical Physicist Herman McKenzie Engineer Bill Okleshen Engineer Joe Bellino LSCS\Engineer Kenneth Hebert Engineer V A C A N T Engineer

9 ACO Accreditation and Certification Operations Understanding The Survey Process

10 Survey Types Full U (Full Unannounced\Triennial) Med Def (Medicare Deficiency) SSU/OQPS (Special Survey Unit & Office of Quality and Patient Safety) ICM 2 or 3 (Intracycle Monitoring) Extension Survey (New building/services)

11 Life Safety Code Surveyor Days Hospitals Each Physical Address = Min. 2 LSCS days (new) Gross Building Square Footage 0 1,000,000 2 LSCS Days 1,000,000 1,500,000 3 LSCS Days >1,500,000 LSC FD Review Non Hospital Life Safety Code Surveyor Days Gross Building Square Footage AHC / ASC Med Def SSU / OQPS 1 LSCS Day 1 LSCS Day 1 LSCS Day

12 LSCS Pre Survey Review SOC (BBI Eapp) PFI s not visible to LSCS Previous report and ESC s Public web site Surveyor Resources

13 Survey Agenda: LSCS Arrives with Team Day 1 Day Facility Orientation Day #1 Morning Briefing Opening Conference/Introductions Only Building Tour Cont d ish Document Review Lunch 1230 EC/EM Sessions (Separate) 1045 Pressure Relationships (OR s/spd) Lunch Building Tour (End of day Findings) Enter day #2 Findings into report Interim LSCS Exit/Team Exit

14 Day One morning: Facility Orientation Main Fire Panel - Upon arrival by the surveyor, an escort will be needed to take him/her to the main fire alarm panel to verify that it is functional- check breaker. Tip for success: make sure you know location of electrical panel with the designated breaker for the fire alarm.

15 Day One morning: Facility Orientation Life Safety Plans - The surveyor will then meet with an organization staff member(s) to become oriented to the layout of the building. Areas Sprinklered (if not 100%) Hazardous Storage Rooms Fire Barriers Smoke Barriers Suites (both types), including size Smoke Compartments Chutes/shafts Approved Equivalencies or Waivers

16 Day One morning: Facility Orientation New May 2017 Visit generators Obtain name plate info, look for EPO Visit fire pump room Electric or diesel (Day tank at least 2/3 Full) Spare Sprinkler Heads and Tools 100 F Prior to the start of the building tour the 3 Q s Tip for success: Know the number and types of sprinklers so you can determine the number of spares needed.

17 Day One morning: Document Review Paper or electronic, 90 minutes is the goal! Same checklist the Life Safety Code Surveyors (LSCS)/Hospital use Serves as Hospitals prep tool for survey mock review Checklist has Standard, EP, Time frequency Open book test Tip for success: Organize testing document binder in same order as checklist Close all open issues and place work order right behind report

18 Day One morning: Document Review Policies and procedures for Interim Life Safety Measures (ILSMs) Written fire response plan Operator or Security Evaluations of fire drills conducted for the past 12 months complete fire drill matrix Maintenance records for fire protection & suppression equipment Tip Maintenance records for emergency power systems Maintenance records for piped medical gas and vacuum systems Tip for success: LSCS will use IOU if not readily available

19 Day One morning: Document List & Review Tool

20 Day One morning: Documentation Clarification Any document not available at time of survey cannot be clarified post survey Documents readily available Reduce the volume of post-survey clarifications Less time and resources spent after the survey

21 Day One morning: Fire Drill Matrix

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23 Fire Drills - Tips Tip for success: Reminder one drill per shift per quarter +/- 10 days, follows same quarterly time defined > 1 hour between drills (Best Practice: Vary days) Number one location for fires in healthcare? Kitchen! Place central station and FDC checks on fire drill form save time and money and eliminate missed annual and quarterly requirements.

24 Day One morning: Pressure Relationships OR s - Positive to adjacent SPD - Decontam - Negative to adjacent SPD - Prep/Pack, Sterilizing, Sterile storage Positive to adjacent AIIR s Negative to corridor,.01 W.C. Soiled Utility Negative to Corridor Tip for success: When you announce TJC in house someone please check the critical pressure relationships

25 Day One afternoon: The Building Tour Roof labeled Stairs lab exhaust Fire barriers, Rad, MRI Lab, Pharm, Kitchen

26 Day One afternoon: The Building Tour FD s (Label, Gap, Close, Latch, Plates) SD s (Close, Gaps) Corridor doors, latching hardware, no more 5lb exception Above Ceiling (Sprinkler pipes, Barriers, J-Boxes, Med Pipe) Entire building for EC, Hospital and Ambulatory for LS Tip for success: Above ceiling permit system in place?

27 ILSM changes on the report What the LSCS sees What you see on the report if corrected on site while surveyor is still present

28 ILSM changes on the report What the LSCS sees What you see on the report

29 Life Safety Code Surveyors Average RFI s per Survey 2018 YTD N = 632 N = 1448 N = 1448 N = 1457 N = SAFER C Category See it / Cite it OFI s

30 Follow Up Surveys Hospital Program (exc. Psych) 2018 YTD N = N = N = % 48.97% 31.5%

31 Standard 2018 YTD LS % 86% 51% 46% EC % 73% 57% 58% EC % 70% 68% 62% IC % 72% 60% 59% LS % 66% 48% 45% LS % 72% 50% 50% LS % 62% 49% 51% EC % 62% 18% 12% EC % 63% 47% 39% IC % 54% 32% 27%

32 Most Frequently Scored Standards 2018 YTD

33 New 5000A Fuses!

34 Found your missing ladder!

35 #1 LS Sprinkler piping supports nothing else.

36 #2 EC Critical Pressure Relationships

37 #3 EC not considered art

38 #4 IC

39 #5 LS Barrier Penetrations

40 #6 LS Door latching

41 #7 LS Corridor Clutter

42 #8 EC Dishwasher Logs

43 #9 EC Eye Wash

44 #10 IC

45 How Many EPs were touched for 2018 Chapter NEW MOVED REVISED REVISED & MOVED DELETED Environment of Care Life Safety TOTALS TOTAL EP's Touched 283

46 10 requirements surveyors want you to know about Triennial 4 hours generator run applies to all HAP/AHC (EC /9&10) Written surgical fire risk assessment and plan (EC /11) Exit sign testing with batteries (EC /1) Elevator fire fighter operations monthly test (EC /27) LIM s (EC /7)

47 10 requirements surveyors want you to know about Fire response plan, LIP, copy at operator or security (EC /9) Stairwell signage (floor information) tactile (LS /10) Kitchen Hood Extinguishing (FA/Energy/Fans) (EC /13) Succession plan and delegation of authority (EM /12) Generator EPO remote/not on exterior enclosures (EC /11) Corridor/Suite Perimeter Doors (LS /13)

48 Dr. Chassin Letter to Organizations Survey Focus Areas Sterile Medication Compounding Suicide Prevention High Level Disinfection Hemodialysis

49 Tools & Resources

50 TJC main web page News and Alerts

51 Free CMS Surveyor Training

52 Free CMS Surveyor Training

53 Free CMS Surveyor Training

54 Free CMS Surveyor Training Website can be used by anyone No logins or passwords Test and evaluations are not available. Only to State/Feds Website does not track completions As CMS releases new or updated surveyor training, website updated Website will be changing in 2019 to upgrade platform, info will come out once completed.

55 Questions? Jim Kendig, MS, CHSP, CHCM, HEM, LHRM Field Director (630) Tim Markijohn, MBA\MHA, CHFM, CHE Field Director (630)

56 The Joint Commission Disclaimer These slides are current as of 06/20/2018. The Joint Commission and the original presenters reserve the right to change the content of the information, as appropriate. These will only be available until 06/20/2019. At that point The Joint Commission reserves the right to review and retire content that is not current, has been made redundant, or has technical issues. These slides are only meant to be cue points, which were expounded upon verbally by the original presenter and are not meant to be comprehensive statements of standards interpretation or represent all the content of the presentation. Thus, care should be exercised in interpreting Joint Commission requirements based solely on the content of these slides. These slides are copyrighted and may not be further used, shared or distributed without permission of the original presenter and The Joint Commission.