Accreditation

Partial Compliance Delay for Electronic Statement of Conditions (eSOC)

Accreditation Monthly, October 19, 2006

On September 26, 2006, the Joint Commission announced a revised implementation schedule for the requirements of the new Electronic Statement of Conditions (eSOC). http://www.jointcommission.org/Standards/esoc.htm 
I've asked Steve MacArthur, a consultant with The Greeley Company and our resident environment of care expert to assist me in analyzing these new requirements in this month's e-zine.

The announcement extended the compliance date for certain components of the eSOC until July 1, 2007. This extension has been implemented to allow sufficient time for the Joint Commission to address two concerns that have been raised by industry leaders regarding the uploading of current (and future) Statement of Conditions information managed at each hospital, as well as providing appropriate and secure access to those individuals charged with managing this process. At present, anyone in your organization that is listed on your extranet contact list is given access to all of your organization's information; there is currently no means of granting limited access to your organization's JCAHO extranet site, in this instance, limiting access solely to the eSOC.

In response to these concerns, the announcement indicates that the JCAHO is developing an interface that will facilitate the conversion of Statement of Conditions information from current formats to the extranet version and to create an appropriate solution to the security concern, most likely a format similar to those employed in the Accreditation Manager Plus program, thus facilitating better access control.

What does this mean for your Environment of Care program?

Well, as noted above, this extension only applies to certain specific requirements of the eSOC roll-out. There are still a number of requirements that will become effective January 1, 2007 with which your organization must be in compliance or risk negative impact on your accreditation status, specifically for noncompliance with APR 19 (Organization meets all requirements for timely submission of data and information to JCAHO). Thus, there are two sets of information that must be available in the electronic format by January 1, 2007:

  1. Creation of an electronic Basic Building Information (eBBI) - the BBI (also known as Part 2 of the Statement of Conditions) requires the identification of each building in your organization occupied by patients/residents/clients (basically any building in which care is provided) and summary of the building's component physical and life safety characteristics / systems (# of stories, occupancy classification, sprinkler systems, etc). Be aware that the eBBI contains more questions than the old paper-based version (for example, the eBBI asks facilities to briefly synopsize previous Medicare, state, and local inspections).

  2. All new Life Safety Code deficiencies identified within the Statement of Conditions must be managed using the electronic version of the Part 4 Plan For Improvement (ePFI), again, beginning no later than January 1, 2007.  Basically, this means that any Life Safety Code deficiencies identified after December 31, 2006 must find their way to the eSOC.

Regardless of the complexity of your physical plant, our recommendation would be to begin the process identified in #1, as soon as possible (if your facilities folks have already completed this task - that's a bonus). December 31 will be here before you know it - if the Basic Building Information is not up and current on the eSOC, then the APR 19 clock starts ticking, and a potential negative finding is only 31 days away.

As to #2, your organization may need to develop a policy to make clear the expectations as a function of "timely submission" and ensure that any appropriate Life Safety Code deficiencies migrate to the ePFI as soon as possible upon identification. Clearly the intent is for your organization's management of the eSOC to be a regular and ongoing function, not one that relies simply on retrospective review.

So, you may ask, what about the extension? The extension applies only to currently identified Life Safety Code deficiencies being managed through the PFI process and scheduled to be completed after December 31, 2006. This probably represents a fairly finite number of entries - those of you whose organizations manage your Statement of Conditions manually (on paper as opposed to computer-based) I would encourage you to get what information you can to the eSOC. Those of you with computer or web-based management programs for the SOC are probably going to need time allotted by the extension to migrate data via the yet-to-be-developed interface. That being said, if your organization's current slate of deficiencies that are scheduled to be completed after December 31 is fairly limited, it's certainly worth considering moving forward prior to implementation of the interface.

My consultative philosophy in general is that tasks like this usually look a whole lot better in the rear view mirror than in the windshield. Extension or no extension, the sooner your organization embarks on this never-ending journey, the more experience you'll have as the process moves forward.

Speaking on behalf of my colleagues at The Greeley Company, any of us would be happy to assist you in fine-tuning your response to these changes and updates including helping to craft policies and effective processes designed specifically to fit your organization.  It may also be time to schedule an Unannounced Compliance Test-Run visit by one of our Greeley Company mock survey teams.  For more information please call our Practice Manager, Sandi Reen at 888-749-3054, ext. 3263, e-mail sreen@greeley.com, or visit us on the Web at www.greeley.com. Our initial telephone consultation is completely free and without obligation.

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