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Oh, what fun -- the most frequently stubbed toes during TJC surveys in 2017!

Hospital Safety Insider, March 29, 2018

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Editor's note: This was originally published on Steve MacArthur's blog, Mac's Safety Space.

As luck would have it, the latest (April 2018) edition of Perspectives landed on the door step the other day (it’s really tough to pull off the home delivery option now that it is an all-electronic publication) and included therein is not a ton of EC/LS/EM content unless you count (which, of course, we do) the listings of the most frequently cited standards during the 2017 survey season. And, to the continued surprise of absolutely no one that is paying attention, conditions and practices related to the physical environment occupy all 10 of the top spots (I remain firm in my “counting” IC.02.02.01 as a physical environment standard — it’s the intersection of IC and the environment and always will be IMHO).

While there are certainly no surprises as to how this list sorts itself out (though I am a little curious/concerned about the rise of fire alarm and suppression system inspection, testing & maintenance documentation rising to the top spot — makes me wonder what little code-geeky infraction brought on by the adoption of the updated Life Safety Code® and other applicable NFPA standards has been the culprit — maybe some of it is related to annual door inspection activities cited before CMS extended the initial compliance due date), it clearly signals that the surveying of the physical environment is going to be a significant focus for the survey process until such time as it starts to decline in “fruit-bearing.”

I do wish that there was a way to figure out for sure which of the findings are coming via the LS survey or during those pesky patient tracer activities (documentation is almost certainly the LS surveyor and I’d wager that a lot of the safe, functional environment findings are coming from tracers), but I guess that’s a data set just beyond our grasp.

For those of you interested in how things “fell,” let’s do the numbers (cue: Stormy Weather):
 

•     #1 with an 86% finding rate – documentation of fire alarm and suppression systems
•     #2 with a 73% finding rate – managing utility systems risks
•     #3 with a 72% finding rate – maintenance of smoke and other lesser barrier elements
•     #4 with a 72% finding rate – risk of infections associated with equipment and supplies
•     #5 with a 70% finding rate – safe, functional environment
•     #6 with a 66% finding rate – maintenance of fire and other greater barrier elements
•     #7 with a 63% finding rate – hazardous materials risk stuff
•     #8 with a 62% finding rate – integrity of egress
•     #9 with a 62% finding rate – inspection, testing & maintenance of utility systems equipment
•     #10 with a 59% finding rate – inspection, testing & maintenance of medical gas & vacuum systems equipment

Again, I can’t imagine that you folks are at all surprised by this, so I guess my question for you all would be this: Does this make you think about changing your organization’s preparation activities or are you comfortable with giving up a few “small” findings and avoiding anything that would get you into big trouble? I don’t know that I’ve heard of any recent surveys in which there were zero findings in the environment (if so, congratulations! And perhaps most importantly: What’s your secret?), so it does look like this is going to be the list for the next little while.

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