Being compliant isn't hard when you have a library card

Briefings on Accreditation and Quality, December 1, 2017

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New EP: Avoid RFIs by keeping documents and service manuals in library

“If it wasn’t documented, it wasn’t done.” It’s a phrase that every accreditation professional should know by heart. It’s a phrase that should be drilled into every doctor, nurse, and caregiver. It’s a phrase in the mind of every surveyor.

The second, lesser-known phrase that everyone should know is: “It doesn’t do me any good if I can’t find it.”
That’s the philosophy behind one of The Joint Commission’s newest Environment of Care elements of performance (EP). Starting on January 1, 2018, healthcare organizations will need to create and maintain an accessible library of service manuals, instructions for use, technical bulletins, and other information manufacturers provide, and keep it as rigorously updated as other required documentation of tests, inspections, and maintenance.

During the annual Executive Briefings session, held just outside Chicago September 29, John D. Maurer, Joint Commission acting director, Department of Engineering, said the requirement for a library of information is one of the most important of the new EPs under EC.01.01.01, and is among the continuing revisions of the Environment of Care and Life Safety standards.

Newest changes effective January 1

The latest revisions, which are still a response to last year’s adoption by CMS of the 2012 NFPA 101 Life Safety Code® and the NFPA 99 Health Care Facilities Code, will go into effect January 1, 2018.

Having a library of technical instructions on-site for workers to reference is part of the NFPA codes, and hospitals will be expected to have them accessible to staff whether they are inspected by Joint Commission surveyors or officials with other authorities having jurisdiction.

“This is code driven,” emphasized Maurer, who has taken over in the interim as The Joint Commission looks for a replacement for its longtime engineering director George Mills, who has gone on to the private sector as a consultant and lobbyist.

Maurer began his presentation by emphasizing the importance of having “go-ready” documentation updated and available when surveyors arrive. In 2016, half of the hospitals undergoing survey requested the opportunity to clarify information when an RFI was imminent, and half of those clarifications involved the EC and LS chapters, Maurer noted.

Of those clarifications, 65% were because the facility could not present documentation on request.

And that was before the spike in the number of RFIs following the recent CMS-required changes to The Joint Commission’s survey process that has created a “see it, cite it” inspection culture.

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