Regulatory requirements have undergone considerable changes in the past year, adding urgency and pressure for healthcare leaders to upgrade their compliance efforts. The introduction of The Joint Commission’s SAFER™ matrix, exclusion of PFIs, expanded Life Safety Code, and a shrunken timeline for correcting deficiencies all mean one thing: Waiting to address regulatory deficiencies in the months before a survey, as was common in the past, is now a recipe for disaster. Rather, healthcare organizations must pursue 24/7 survey readiness, staying vigilant to prevent, spot and correct problems on a daily basis—long before a surveyor spots them.
It’s easy to feel overwhelmed under the weight of such a lofty goal, but know that it’s well within your reach—no sleepless nights required. In helping healthcare facilities achieve 24/7 survey readiness, we’ve learned it’s helpful to cultivate four simple but crucial practices:
>> Be Your Own Watchdog
Perform a self-assessment now to review potential deficiencies that could fall on the new SAFER evaluation matrix spectrum that is used by The Joint Commission. Then repeat it periodically.
When evaluating the likelihood that a deficiency could cause harm to a patient, staff, or visitor, it’s important to be critical, channeling the most demanding surveyor you can fathom. The SAFER matrix recognizes Low, Moderate, and High ratings. The Low rating only applies to risks where harm would be extremely rare, while those with potential for occasional harm are ranked as Moderate and the High rating is reserved for areas where harm could happen at any time.
In terms of scope, the SAFER matrix recognizes Limited, Pattern, and Widespread deficiencies. Note that the Limited rating is designated for isolated incidents. Even two occurrences of the same deficiency, whether they are rated Low, Moderate or High, can escalate it to a Pattern.
For all deficiencies cited within the matrix, remediation must be completed and Evidence of Standards Compliance (ESC) documentation submitted to The Joint Commission within 60 days. High-risk deficiencies (Limited, Pattern & Widespread) and Moderate-risk deficiencies (Pattern & Widespread) within the matrix do require additional documentation of sustained correction efforts in the ESC, including leadership involvement and preventive analysis. Note that for those deficiencies, future surveyors will have access to those deficiency records for re-evaluation in subsequent surveys.
Be mindful that self-identification of issues no longer secures a greater timeline for correction, nor does it mean those deficiencies won’t be cited in the survey. But it is still a good practice to track self-identified deficiencies in the time between surveys. This will allow you to address large-scale problems, like compliance with new Life Safety Code standards, well in advance of the survey so your facility has adequate time to budget for and implement corrections that might otherwise be impossible to achieve in the 60-day ESC window.
Don’t just pay attention to your own organization, however. Identifying industry survey trends—common deficiencies The Joint Commission is focusing on—is a relatively simple way to avoid the same hits at your facility. If hospitals are getting “dinged” on door latching, air exchange and pressure relationships, it would be wise to look at those same areas in your own facility.
One last note on self-assessments: Ensure you have a basic understanding of The Joint Commission’s annual ORYX performance measure requirements. This is a quality initiative that embeds performance and outcomes into The Joint Commission’s accreditation and certification process. Even if your survey isn’t due for a year or more, you’re still required to report yearly for an evaluation of performance.
To this end, your organization can provide chart abstractions, electronic Clinical Quality Measures (which are also required by CMS), or a combination of both. While collecting and submitting this performance report may not be the explicit duty of hospital executives, they should at least understand the requirements and be confident that the information submitted represents the facility’s compliance with The Joint Commission standards.
>> Stay organized
When a surveyor steps into your facility and sees staff scrambling to find compliance documentation, it raises red flags to that surveyor, increases his/her level of scrutiny, and turns up the stress level for everyone. Clearly, you can’t prove to a surveyor that compliance goals have been achieved if your records aren’t neatly organized.
You can avoid this by enforcing clear policies and procedures that ensure your documentation is easily accessible, up-to-date, and consistent. In our work with healthcare facilities, we’ve systematically collected and organized policies, procedures and documents required for compliant operations, keeping the process as simple as possible.
Whatever method you adopt, creating and enforcing policies that guarantee organized documentation is one of your chief responsibilities as a hospital leader.
>> Communicate the WHAT & WHY clearly
Your staff can’t incorporate compliance standards into daily practices if they don’t understand them clearly.
How will self-identified deficiencies be addressed? When will improvements begin and end, and who’s responsible for what? And why must they do certain things a certain way? Clear communications can be as simple as a visual timeline for testing all fire alarms, or setting a date when all staff will complete a required training.
Staff shouldn’t know just what is required of them, but why. How does the requirement impact safety, patient care, or the work environment? What’s at risk if the requirement isn’t observed? Understanding the why will go a long way to motivate staff to carry out their tasks in a compliant way, and help them articulate a compelling justification to patients when challenged.
>> Don’t go it alone
No one expects you to know all the answers, and no hospital can do it alone. Astute leaders know their limits and don’t waste time trying to reinvent the wheel.
Whether it’s hiring a contractor to inspect and repair fire systems or training new hires about documentation requirements, the most successful hospitals are those that find trusted allies to advance their compliance on a daily basis. In any case, get in front of compliance concerns by developing your own, internal compliance training, or partnering with a reputable expert to do so.
As you strengthen your regulatory compliance efforts, not everything will go according to plan. Setbacks will happen. But your organization can bounce back quickly if good processes are in place.
By breaking compliance into smaller, actionable tasks and finding a trusted advisor to share those responsibilities, you can turn a massive undertaking into a matter of daily routine.
About the Author: Larry LaCombe is the Vice President of Program Management and Facilities Compliance at Medxcel Facilities Management, specializing in facilities management, safety, environment of care, emergency management and compliance. Medxcel Facilities Management provides healthcare service support products and drives in-house capabilities, savings and efficiencies for healthcare organizations that, in turn, improve the overall healing environment for patients and staff. LaCombe leads the development and implementation of compliance programs that ensures 24/7 survey readiness for a national network of hospitals that Medxcel Facilities Management serves.