managing joint commission life safety...
TRANSCRIPT
Making healthcare remarkable
Managing Joint Commission Life Safety Deficiencies
PFI’s No Longer Work
Objectives
Joint Commission Preparation
Your Risk Assessment Process
Mitigating Deficiencies
Interim Life Safety Measures (ILSM)
Time Frames
Responding to Identified Deficiencies
Repairing Identified Deficiencies
Survey-Related Plan for Improvement (SPFI) Waivers
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PFI History
Prior to 2017, TJC would allow a Plan for Improvement (PFI)
If you could show proof of a workorder, you may not be cited.
Many PFIs could be fixed
You could set your timeline for corrective action
There was not a formal risk assessment process
A few months before a survey, rush to fix
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Beginning to 2017
TJC new process: “See it! cite it!”
Workorders will not save you
Cannot create a PFI or timeline to repair
Proactively need to manage and repair deficiencies quicker
A defined process as to how Life Safety deficiencies are identified through inspections
Three months before a survey will not work
Post survey – 60 days to repair or request a waiver
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Leadership Involvement
Is this how you ask for funding?
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Leadership Involvement
There needs to be open communication with your leadership team.
Need to understand that PFI no longer exist and there is only 60 days to make a repair.
This begins with budget preparation (contingency)
It is also important that leadership understand that JC reports will be longer
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Life Safety Deficiencies Policy
Do you have a Risk Assessment Policy?
Define the frequency for conducting a life safety risk assessment
Ensure ILSM is included, if needed
Both construction and routine
Important to define the term “Immediate”
What is your process to manage deficiencies?
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Risk Assessment
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• Conduct Life Safety Assessment• Identify LS Deficiencies• Create Workorder• Repair Within 24-hours• Implement ILSM • Complete Repair within 60-
Days
Risk Assessment Tool
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Risk Assessment Tool
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Risk Assessment Tool
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Risk Assessment Tool - ASHE
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Risk Assessment Tool - ASHE
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Life Safety Drawings
LS.01.01.01 EP 3
The hospital maintains current and accurate drawings denoting features of fire safety and related square footage.
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Life Safety Drawings
LS.01.01.01 EP 3
Fire safety features include the following: - Areas that are fully sprinklered/partially sprinklered
- Locations of all hazardous storage areas
- Locations of all fire-rated barriers
- Locations of all smoke-rated barriers
- Sleeping and non-sleeping suite boundaries, including the size of the identified suites (sq. ft.)
- Locations of designated smoke compartments (sq. ft.)
- Locations of chutes and shafts
- Any approved equivalencies or waivers
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Tracking LS Deficiencies
How are you tracking Life Safety Deficiencies
Workorder System
JC PFI section – JC does not have access.
Excel Spreadsheet
Other Format
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Tracking LS Deficiencies
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Tracking LS Deficiencies - ATG
ILSM Document
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ILSM Document
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Managing the Survey Process
Survey Management – Document Review Organization Have all documentation available at time of survey Walk surveyor through the documentation
Control the review Do not have the surveyor review documentation on their
own Be Confident Repeat surveyor’s question for clarification Answer only what is asked Do Not volunteer information Have support team help with any discrepancies
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Managing the Survey Process
Never volunteer LS deficiencies
Be prepared to address how you will identify and manage LS deficiencies
Ensure that ILSM’s are in place and you can explain, both past and present
Repair as much as possible before the surveyor leaves
If repairs cannot be completed before the surveyor leaves, be able to address the ILSM that will be in place until the repair can be made
Keep your leadership informed of both findings and ILSM’s.
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The Survey is Over
Deficiencies need to be completed within 60 days
If repairs cannot be completed within 60 days, request a SPFI and a time limited waiver request
Found on the JC website
Request needs to be approved by JC and CMS
Repair deficiency within limited waiver time frame
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Gary MilewskiCorporate ComplianceNovant Health(919) 817-6823