Industry Update - October 2018

by Joe Brothman, Director, EHS & EM, UCI Health


Click here to access the full PDF version of this month's update.

Top 5 Joint Commission Findings for Hospitals

The table below identifies the Top 5 Joint Commission requirements identified most frequently as “not compliant” during surveys and reviews from Jan. 1, 2018, through June 30, 2018.

% Cited Standard Hospital Accreditation
86% LS.02.01.35 The hospital provides and maintains systems for extinguishing fires.
73% EC.02.05.01 The hospital manages risks associated with its utility systems.
72% IC.02.02.01 The hospital reduces the risk of infections associated with medical equipment, devices & supplies.
72% LS.02.01.30 The hospital provides & maintains building features to protect individuals from the hazards of fire & smoke.
70% EC.02.06.01 The hospital establishes & maintains a safe, functional environment.

Joint Commission Issues Inpatient Suicide Data

An estimated 49 to 65 hospital inpatient suicides occur each year in the United States, far fewer than the widely cited estimate of 1,500, according to a new study reported in The Joint Commission’s Journal on Quality and Patient Safety. Based on data from 27 states reporting to the National Violent Death Reporting System and hospitals reporting to The Joint Commission’s Sentinel Event Database, the study estimates the annual inpatient suicide rate at 3.2 per 100,000 psychiatric admissions and 0.03 per 100,000 nonpsychiatric admissions. The commission said the findings support recommendations by its expert panel last year that hospital settings associated with psychiatric treatment be made ligature-resistant.

ASHE Career Map Self-Assessment Tool

ASHE's Career Map will help define career paths and enrich members’ professional development. The online self-assessment tool will help identify professional strengths, largest gaps, and learning needs. Upon completion, members receive a customized list of suggested tools and resources to help improve their skillset and expand their professional knowledge base.

Ligature Facility Extension Request (LFER)

Ligature / Self-Harm Risks that result with a Condition Level for Deemed Status organizations will receive a Medicare Deficiency (MedDef) Follow-up Survey. If not cleared at time of MedDef a Secondary MedDef will be scheduled. Items can be either removed (permanent solution), replaced or perform a risk assessment and mitigate threat appropriately and where permitted, only. Non-deemed may result in an Accreditation with Follow-up Survey. The Ligature Facility Extension Request (LFER) is a process the Joint Commission is developing (has developed) to assist organizations through this process of deficiency identification, plan approval and follow-up survey activities.

National Cybersecurity Awareness Month

October is National Cybersecurity Awareness Month, which emphasizes the need to use the internet safely and securely. A flyer released by the National Cyber Security Alliance outlines various themes to be covered throughout the month — week one will focus on online safety at home, week two on careers in cybersecurity, week three on online safety at work, and week four on the public’s role in safeguarding critical infrastructure. For more information about cybersecurity in hospitals, visit CHA’s dedicated web page.

Updated Tool Helps Hospital Pharmacies Comply With Sterile Compounding Regulations

CHA and the California Society of Health-System Pharmacists have finalized a tool to assist pharmacy staff in complying with sterile compounding regulations. Developed by CHA’s Medication Safety Committee, the attached grids interpret U.S. Pharmacopeia (USP) 797 and proposed USP 800 requirements, as well as California Board of Pharmacy sterile compounding regulations. The grids also detail requirements related to temperature and monitoring, frequency of documentation and cleaning, facilities and engineering controls for hazardous and non-hazardous drugs, competency and training, and garbing. More resources can be found in CHA’s Medication Safety Toolkit.

2018 CHA Disaster Planning Conference

Nearly 800 health care professionals, disaster planners, and first responders came together to hear more than 50 speakers share personal experiences and blueprints for improved planning.

CDPH Issues Guidance on Reducing Legionella Risk in Water Systems

CDPH has issued the attached All Facilities Letter 18-39, which addresses Legionella risks in health care facility water systems. Hospitals, critical access hospitals and skilled-nursing facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems, in order to reduce the growth and spread of Legionella and other pathogens in water. CDPH directs facilities to guidance issued by the Centers for Medicare & Medicaid Services, which clarifies expectations and notes that facilities must:

  • Conduct a facility risk assessment to identify where Legionella and other pathogens could grow and spread.
  • Develop and implement a water management program.
  • Specify testing protocols and document testing results.
  • Comply with other federal, state and local requirements.

Prepublication Standards – Standards Revisions for Deeming in Hospitals and Critical Access Hospitals

The Centers for Medicare & Medicaid Services (CMS) requested changes to Joint Commission elements of performance (EPs) to more closely align with language in the Medicare Conditions of Participation (CoPs). These changes resulted from CMS’ review of The Joint Commission’s EP Review Project for the “Leadership” (LD) chapter and as part of the deeming application review for psychiatric hospitals. These EP revisions are applicable to critical access hospitals and hospitals. PC.03.01.01, EP 8 was displayed in a previous prepublication report; it has since been updated as a part of these CMS revisions. The language in these reports is the most current version, and the updated language for this EP is underlined.

New Emergency Management Checklist Aims to Help Organizations Post-Disaster

The Joint Commission has published a new Emergency Management Health Care Environment Checklist to help health care organizations as they navigate the reopening of a facility following a disaster. The checklist — developed by an internal Joint Commission workgroup — stems from a request by the U.S. Department of Health & Human Services’ Office of the Assistant Secretary for Preparedness and Response (ASPR). The checklist aligns with Joint Commission Emergency Management (EM) standards, covers both clinical and environmental issues, and addresses post-disaster elements of critical importance for a health care organization to address before reopening. View the checklist, which is also posted on The Joint Commission’s EM portal.