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Briefings on Hospital Safety: Making sense of Joint Commission complaints

Hospital Safety Insider, October 20, 2016

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Editor's note: This Q&A was taken from the July 2016 webinar, "Clarifications of the Most Common Joint Commission Safety Findings". Healthcare safety and life safety consultant expert Brad Keyes, CHSP, owner and senior consultant for Keyes Life Safety Compliance, gave his professional insight into how to use Joint Commission findings to improve your facility. To listen to the full program on demand, check out the HCPro Marketplace at http://hcmarketplace.com/2012-life-safety-code.

Q: In regards to ventilation guidelines, does the renovation include renovation of the OR rooms or the ventilation system?
Brad Keyes: My understanding [is] if you are renovating the operating rooms, you have to upgrade the ventilation system as well. Now that may be subject for interpretation. Usually the state agencies on behalf of hospital construction and maybe the local building authorities assist the hospital in making that interpretation. Accreditation organizations typically do not get involved with approving design. So it's kind of left up to what your state and local authorities dictate and they will tell you what you must do. Obviously, if you're upgrading the ventilation system, if you're changing out the air handler but not necessarily the operating rooms, then you still have to meet the new design requirements.


Q: Is there a standard that addresses sharps container heights? OSHA and NIOSH recommend 52 to 56 inches, but what does The Joint Commission recommend?
BK: If they recommend anything, I'm not aware of it. That doesn't mean they haven't. It's not in their standards and so it's not official. I've not seen it in their Frequently Asked Questions. So I wouldn't be surprised that they've probably addressed this on a case-by-case basis. My advice is follow what NIOSH and OSHA requires until such time that the accreditor tells you differently.

Q: What are the impacts of the Statement of Conditions (SOC) process changes effective August 1, affecting Plans for Improvement (PFI) as stated in the July 13 edition of Joint Commission Online?
BK: For those that aren't fully aware of what that question is referring to, CMS insisted that Joint Commission do away with their PFI section. Until August 1, the PFI section of the Statement of Conditions allowed the hospital to identify a life safety deficiency. It [would] go on the survey deficiency report; however, it would not require the hospital to submit a plan of correction. And the hospital [could] decide how long they want to take to decide that deficiency. CMS disagreed with that. CMS has a, let's call it, a policy. I'm not sure it's written but they have a procedure that says "all deficiencies are required." It's not suggested. It's not an option but they're required to be resolved when it's 60 days after the survey.

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