Accreditation

Joint Commission surveyor focus remains on EC, LS, ligature risks

Briefings on Accreditation and Quality, November 1, 2018

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Highlight the ZIP codes where employees live so you can have a handy reference of staff availability in emergencies, keep policies consistent and updated with the most relevant references, and focus suicide prevention efforts on making your physical environment ligature-resistant. 

Those were some of the top takeaways for environment of care and other healthcare and quality professionals attending The Joint Commission’s (TJC) annual Hospital Executive Briefings held September 14 in New York City. The state of healthcare “is not good,” said Ana Pujols McKee, MD, TJC’s chief medical officer, rattling off uncomfortable facts such as the U.S.’s rising maternal mortality rate and that medical errors are the third leading cause of death. She urged attendees to accept nothing less than achieving zero harm in their hospitals and facilities. 

She did say that efforts to reduce redundancy and simplify the survey process have been paying off. In particular she noted the SAFER Matrix had changed how people talked about problems in their facilities—from survey “dings” to safety “risks.”

Attendee Brian Pitt, safety director of SUNY Downstate Medical Center, said his biggest takeaway from the briefings was that there are a lot of opportunities to make changes and improve. That was particularly true for the areas of environment of care and infection control, which never seem to get full administrative support, he noted. Among other things, the briefing taught him the need for consistency regarding which organizations—such as the CDC or the Association for the Advancement of Medical Instrumentation—you reference in your hospital policies. 

“These policies can be used against us if you don’t keep it consistent and follow a consistent national standard,” said Pitt. 

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