Ground Control to Major Compliance: EOC, baby!
As September brings around the unwinding of summah, it also brings around The Joint Commission’s annual state of compliance sessions in locations across the country, better known as Executive Briefings. And, one of the cornerstone communications resulting from the Briefings is the current state of compliance as a function of which standards have proved to be most problematic from an individual findings standpoint.
Yet again (with one exception, more on that in a moment), EOC/Life Safety standards stand astride the Top 10 list like some mythical colossus (the Colossus of Chicago?), spreading fear in the hearts of all that behold its countenance (OK, maybe not so much fear as a nasty case of reflux…).
You can find the Top 5 most frequently cited standards across the various accreditation programs; you’ll have to check out the September issue of Perspectives for the bigger compliance picture, which I would encourage you to do.
At any rate, what this tells us is that (for the most part) the singular compliance items that are most likely to occur (for example, we’ve already discussed the loaded sprinkler head hiding somewhere in your facility—way back in April) are still the ones they are most likely to find. According to the data, of the 688 hospitals surveyed in the first six months of 2019, 91% of the hospitals surveyed (626 hospitals) were cited for issues with sprinkler/extinguishment equipment—and that, my friends, is a lot of sprinkler loading. I won’t bore you with the details (I think everyone recognizes where the likely imperfections “live” in any organization), but (at least to me) it still looks like the survey process works best as a means of generating findings, no matter how inconsequential they might be in relation to the general safety of any organization. I have no doubt that somewhere in the mix of the Top 10 list, there are safety issues of significance (that goes back to the “no perfect buildings” concept), particularly in older facilities in which mechanical systems, etc. are reaching the end of their service life—I always admired Disney for establishing a replacement schedule that resulted in implementation before they had to. It’s like buying a new car and having the old one still on the road: Are you going to replace the engine, knowing that the floor is going to rust through (and yes, I know that some of you would, but I mean in general)? But if the car dies on the way to the dealer to pick up the new one, you’re not going to do anything but tow it to the junkyard. But we can’t do that with hospitals and it’s usually such a battle to get funding/approval for funding/etc. that you can get “stuck” piecing something together in order to keep caring for your patients. It sure as heck is not an ideal situation, but it can (and does) happen. Maintaining the care environment is a thankless, unforgiving, and relentless pursuit—therein is a lot of satisfaction, but also lots of antacid…
One interesting shift (and I think we’ve been wondering when it would happen) is the appearance of a second infection control (IC) standard, which deals with implementation of an organization’s IC plan. I personally have always counted the IC findings relating to the storage, disinfection, etc. of equipment as being an EOC standard in all but name, but I think we may (finally) be seeing the shift to how appropriately organizations are managing infection risks. According to Perspectives, 64% of the hospitals surveyed in the first six months of 2019 were cited for issues relating to implementation, but not sure how the details are skewing. Certainly, to at least some degree, implementation is “walking the talk,” so it may relate to the effectiveness of rounding, etc. Or, it may relate to practice observed at point-of-care/point-of-service. I think we can agree that nosocomial infections are something to avoid and perhaps this is where that focus begins—but it all happens (or doesn’t) in the environment, so don’t think for an instant that findings in the environment/Life Safety will go gentle into that good night. I think we’re here for the long haul…
About the Author: Steve MacArthur is a safety consultant with The Greeley Company in Danvers, Mass. He brings more than 30 years of healthcare management and consulting experience to his work with hospitals, physician offices, and ambulatory care facilities across the country. He is also a contributing editor for Healthcare Safety Leader. Contact Steve at stevemacsafetyspace@gmail.com.