The song remains the same – only the tempo has changed!
As we head toward the promise of a very different 2017 regulatory landscape under a new President, it is very clear that each healthcare organization will continue to experience (endure?!?) an elevated focus on the management of the physical environment. And the clarity is based on a number of factors that have created something of a “perfect storm.”
But first, a little history lesson . . . Way back (or it seems like a really long time ago) in 2015, The Greeley Company covered a couple of issues relating to the management of the physical environment in healthcare. The first being the exhortations of Mark Pelletier, Chief Operating Officer of The Joint Commission (TJC), to the leaders of each healthcare organization to focus more on the management of the environment. (If you care to revisit those halcyon days, you can check out the Greeley Membership January 2015 blog post here.) I’m not sure whether Mr. Pelletier’s utterances were truly taken to heart, but the mid-2015 survey results did not seem to bear out much attention to his recommendation, as 9 of the top 10 most frequently cited standards revolved around the environment of care—with a dollop of infection control/prevention thrown in for good measure (details are provided in the July 2015 Greeley Membership blog post, Physical Environment Continues To Be TJC Survey Hot Button).
Which brings us squarely to the present and our little storm of regulatory challenges:
- EC/LS standards remain among the most frequently cited during TJC surveys (7 of the 10 most frequently cited standards for the period January through June 2016). Please check out the September 2106 issue of The Joint Commission Perspectives for the details!
- CMS, in its report card to Congress, identified the physical environment as the largest “gap” of oversight during all accreditation organization surveys. That’s not just TJC, that’s everyone else as well—DNV, HFAP, CIHQ, etc. (see page 44, Table 13 of the CMS report document).
- Also in its report card to Congress, CMS singled out TJC as lagging behind their competition when it comes to improving their identification of deficiencies relative to the Conditions of Participation (see page 38, Table 7 of the CMS report document which shows that TJC is the only accreditor that did not improve their disparity rate in the most recent period). It appears that the season of beating up on TJC is not over yet . . .
- CMS adoption of the 2012 Life Safety Code (effective survey date of November 1, 2016) will create some level of confusion and uncertainty that always accompanies “change.” Remember, it’s not just “us” that have to learn the practical application of the new stuff—the surveyors have to catch up as well!
- TJC is in the process of revising their Environment of Care and Life Safety chapters to more closely reflect CMS requirements. Effective January 5, 2017, nearly 250 performance elements were revised and nearly 40 performance elements were newly created in the EC/LS chapters. Again, we are on the hook for managing that learning curve!
- Recent TJC survey reports indicate an increasing focus (and resulting vulnerabilities) on outpatient locations, particularly those engaging in high-level disinfection and/or surgical procedures. The physical environment in all areas in which patients receive care, treatment, and services are generating up to 60% of the total physical environment findings in recent surveys.
- CMS published its Final Rule on Emergency Preparedness (effective November 2016, with full implementation of requirements due November 2017). While organizations in compliance with current TJC Emergency Management standards will be in substantial compliance with the new Rule, there will be some potential vulnerabilities relative to some of the specific components of the Rule.
- Introduction of TJC’s SAFER Matrix, which will result in every deficiency identified during the survey process being included in the final survey report. Formerly, there was a section called Opportunities For Improvement for the single findings that didn’t “roll up” into a Requirement For Improvement. With the SAFER Matrix, everything they find goes into the report.
- As a final “nail” in the survey process coffin, effective January 2017, TJC will no longer provide for the clarification of findings once the survey has been completed. This shift is the result of two key programmatic elements:
- The availability of compliance documentation during survey (previously, documentation that was “found” after survey could be submitted for clarification)
- The retiring of the “C” performance element category (previously, an audit of compliance could be submitted to clarify survey findings)
In my mind, particularly as a function of CMS calling out the physical environment as an area of concern, the stuff noted above indicates the likely result that the next 12-24 survey months will show a continued focus on the physical environment by the entire survey team (not just the Life Safety surveyor) and a likely continued plateau or increase in findings relating to the physical environment.
Eventually the regulatory focus will drift back more toward patient care-related issues, but right now the focus on the physical environment is generating a ton of findings. And since that appears to be their primary function (generating findings), there’s always lots to find in the environment.
As I like to tell folks, there are no perfect buildings/environments, so there’s always stuff to be found—mostly fairly small items on the risk scale, but they are all citable. The fact of the matter is that there will be findings in the physical environment during your next survey, so the focus will shift to include ensuring that the corrective action plans for those findings are not only appropriate, but also can demonstrate consideration of sustained compliance over time. Preparing for the survey of the physical environment must reflect an ongoing process for managing “imperfections”—not just every 36 (or so) months, but every day.