Three new Joint Commission questions for building tours

Accreditation Insider, August 30, 2016

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During your next Joint Commission survey, be prepared to answer three new questions before even starting your building tour. Jim Kendig, the Joint Commission’s field director for surveyor management and development, told the American Society for Healthcare Engineering (ASHE) that the questions are intended to spur conversations among surveyors and healthcare facility managers about common areas for findings.

The three new questions are:

1.    What type of fire-stopping is used in the facility?
Surveyors will ask this question to find out the brand of firestopping is used and gives them a better idea of what they should expect to see during the tour. It’ll also prelude a conversation on the type of training healthcare personnel have received on firestopping and barrier management.

2.    What is the organization’s policy regarding accessing interstitial spaces and ceiling panel removal?
The goal of this question is twofold. First, it helps surveyors prepare for restriction in high-risk areas. For example, surveyors could learn that ceiling tile removal is prohibited on the floor where organ transplants are done unless there is a high-efficiency particulate arrestance (HEPA) system in place. The surveyors can then arrange for the HEPA systems for that area in a timely manner.
The second thing it does is help surveyors determine how sophisticated a facility’s infection prevention and facility management are. Surveyors would be on the lookout for things such as bone marrow transplants occurring in hospitals without interstitial spaces restrictions. 

3.    Which materials are used (glutaraldehyde, ortho-phthalaldehyde, peracetic acid, etc.) for high-level disinfection or sterilization?
This question is focused on occupational safety and ventilation. Facility personnel should know when asked what chemicals are being used for sterilization and if the environment meets manufacturer recommendations.

“They’re pretty straightforward—there’s no hidden agenda here,” Kendig said. “We’re just trying to get some information before we start the building tour.”

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