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Here’s your plan for avoiding the top Joint Commission violations.

Hospital Safety Insider, September 3, 2015

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It sounds somewhat like a broken record. No matter how many times the experts tell us how to avoid getting hammered by The Joint Commission during a hospital survey, the same problems always seem to make the list of top violations.

Published in the April issue of The Joint Commission Perspectives, the 2014 list includes the top 10 standards for which hospitals received Requirements for Improvement citations during the 2014 calendar year. Compiled from 1,278 surveys, the 2014 list was dominated by violations of Environment of Care (EC) and Life Safety (LS) standards. But some safety experts say that's more or less to be expected.

Joint Commission officials gave rare insight into the standards and offered some tips about how hospitals can avoid some of the top citations during an informative session of the annual conference of the American Society of Hospital Engineers (ASHE) in Boston in early July.

Here are some of their recommendations for avoiding some of the top citations:
 

• Grow more eyes. The most seasoned hospital safety coordinators say the key to their success is recognizing that they can't do the job alone; now you've heard it from the surveyors themselves.
• Exercise some common sense. Some of the most common citations are for violations related to fire doors and smoke barriers, ducts, and blocked egress points. These are things that should be easily avoided with a quick tour through the facility. Is there a cart blocking an exit door? Move it. Does a physician have a fish tank in his office with an air tube running into the ceiling tiles to tie into the hospital's air system? It's happened before, and it's a major hazard, as it creates another hole through which smoke can penetrate.
• Collect data. And do something with it. You shouldn't wait until a surveyor finds something wrong to start fixing it. The well-prepared facilities know what their biggest problems are, and they make a plan to fix them. If the surveyors see you being proactive, they are more likely to give you a break, in the form of a categorical waiver.
• Do a risk assessment every year. Ideally, every department should do its own, and use it to make a plan to fix the problems, whether it be the fire doors that won't close right, the copiers in front of the oxygen shutoff valves at the nurses' station, or the fish tank in the physician's office.
• Document and have a paper trail. You may say that you have a plan in place to fix whatever problems your facility has, but that means nothing if the surveyors can't read it. Write it down, and make sure there is a clear paper trail. For your reference, take good notes at all meetings and training sessions; have a written record of all hazard assessments and inspections, and any plans of action that are taken. Better yet, make sure everyone else is doing this as well and keeping the results in binders. If you can't lead the surveyor to the records, you will have problems.
• Make schedules for tests. Mills said that about 21% of facilities get cited for seemingly simple things, such as missed generator tests. These tests, he said, should be scheduled, commonplace events.

This is an excerpt from the monthly hospital safety resource Briefings on Hospital Safety. Subscribers can read the rest of the article here. Non-subscribers can find out more about the journal, its benefits, and how to subscribe by clicking here.
 

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