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Sounds like you’re going to have to push a little more paper next survey

Hospital Safety Insider, June 14, 2018

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

A few weeks ago, our friends in Chicago upped the ante in releasing the updated documentation list for the Life Safety portion of the survey. (You can find it, and I really, really, really suggest that you do so sooner rather than later, by logging into your Joint Commission portal and the clicking through the following internal links: Survey Process > Survey Activity Guide > Additional Resources.)

And this is definitely a case of the list having shifted towards documentation of activities and conditions for which folks have been struggling to get in line. Now, from anecdotal discussions with folks, there’s not always a ton of time available for document review. So, in a lot of instances, the focus is on inspection, testing and maintenance of fire alarm and suppression systems equipment, emergency and standby power supply systems, medical gas and vacuum systems, with some “drift” into fire drills and other more or less standard areas of concern/coverage, including the management plans (sometimes—and those don’t appear to have earned a mention on the updated list).

However, according to that same updated document list, looks like a lot of focus on inventory lists (operating components of utility systems; high-risk operating components on your inventory, infection control components); “embracing” (you can think of that as reviewing and adopting) manufacturer recommendations for inspection, testing and maintenance of utility systems or outlining the Alternative Equipment Maintenance program being used. And the same types of things for medical equipment—inventory, high risk equipment, consideration of manufacturer recommendations, etc.

It also appears that there will be focus on sterilizer inspection, testing, and maintenance; compliance of your hyperbaric facilities (if you have them) with Chapter 14 of NFPA 99-2012; testing manual transfer switches in your emergency power supply system. Let’s see, what else... Oh yes, for those of you with recently (I’m guessing that pesky July 6, 2016 date is the key point in time) constructed or renovated procedural areas, you need to make sure that you have (and are testing) task lighting in deep sedation and general anesthesia areas (the annual testing requirement is for a 30-minute test).

I’m sure there’s other stuff that will pop to the surface as we move through this next phase of the survey process; I’m curious about how much in-depth looking they’re going to be able to do and still be able to get to the lion’s share of your building (unless they start using unmanned drones…). I’m also curious that they don’t specifically indicate the risk assessment identified in Chapter 4 of NFPA 99-2012 (it has been asked for during CMS surveys), but that may be for the next iteration.

Part of me can’t help but think back to those glory days when we wished for adoption of the 2012 Life Safety Code®; I guess we can take full advantage of the operational flexibilities inherent in suite configuration and a couple more things, but it never really seems to get any easier, does it?

At any rate, please hop on your organization’s TJC portal and give the updated list a look. If you see something that gives you hives, sing out: we’re all here to help!

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