OR Manager - January 2018 - 8

Regulations
Continued from page 7
ter or sustain over time. There are practices
some people would sooner not
do if left to their own devices, he says.
They might not agree with the rule, or
maybe it is just too difficult to enforce,
such as banning surgeons from wearing
skull caps. Or the staff may receive ineffective
education and competence validation
on how to carry out the process.
Achieving highly reliable and, thus,
compliant processes hinges on designing
processes using sound performance
improvement principles, educating staff
effectively and validating their competency,
and regularly measuring that staff
continue to sustain this performance
over time.
Regarding the FAQs, Rosing notes
that there are some 300 FAQs listed by
chapter, and " this is where you'll often
find the 'devil in the details.' "
Sometimes people don't find the
FAQs helpful and are left just as confused
as when they started. For example,
in a situation where there may not
be a clear-cut, evidence-based guideline
on which to base an FAQ answer, the
Joint Commission will suggest that OR
managers do a risk assessment and
make their own decisions.
This may be seen as " punting " on
the Joint Commission's part, he says,
but surveyors will likely side with the
organization's thoughtful conclusion because
they will see that the OR manager
has thought it through, looked at
all available research, and made a determination
based on the analysis.
Rosing gives the example of cardboard
boxes. The Joint Commission is
concerned about corrugated cardboard
shipping boxes because they can harbor
insects and other contaminants.
However, it is likely impractical to prohibit
all cardboard shipping containers
from entering and moving through the
hospital. That would require unpacking
all supplies in the loading dock area, repackaging
the supplies in totes or carts,
8
OR Manager | January 2018
and transporting them to where they are
ultimately stored on a shelf or placed
into use.
In the risk assessment, the OR manager
can make decisions along a continuum
saying:
* the loading dock is the dirtiest site
* the OR, central sterile storage, and
procedure rooms are the cleanest
sites
* let's make sure there are no cardboard
boxes entering or remaining in
the cleanest areas, but allow cardboard
boxes in certain other areas
where the risk of harm to a patient
is low
* thus, it is okay to ship a cardboard
box of copy machine paper to the
OR manager's office.
Then, if a surveyor finds a cardboard
box in the OR manager's office and
wants to cite it, the OR manager can
give the surveyor the risk assessment
and decision that was made about cardboard
boxes. " Because you have performed
a credible risk assessment, usually
the surveyor will back away from the
finding at this point, " he says.
In addition to elements of performance/standards,
situational rules in
the manual, and FAQs, surveyors can
score changes to standards or new requirements
published in the Joint Commission's
monthly magazine Perspectives.
" Occasionally, these changes are
scorable immediately, " notes Rosing.
For example, in 2016 there were 87
reported suicides in hospitals. CMS and
the Joint Commission launched a campaign
March 1 called " Zero Suicide. "
The expectations are really catching
people off guard because they want
a behavioral health unit, for instance,
to be ligature resistant, which means
there are no catch points in any room in
the department where someone could
Top 10 scored standards for hospitals
The top 10 most frequently scored standards for the first half of 2017 for hospitals
were released in the September 2017 issue of the Joint Commission Perspectives.
They are:
➤ LS.02.01.35: The hospital provides and maintains systems for extinguishing
fires (86% noncompliance).
➤ LS.02.01.30: The hospital provides and maintains building features to protect
individuals from the hazards of fire and smoke (74% noncompliance).
➤ EC.02.05.01: The hospital manages risks associated with its utility systems
(73% noncompliance).
➤ C.02.02.01: The hospital reduces the risk of infections associated with medical
equipment, devices, and supplies (70% noncompliance).
➤ EC.02.06.01: The hospital establishes and maintains a safe, functional
environment (68% noncompliance).
➤ LS.02.01.10: Building and fire protection features are designed and maintained
to minimize the effects of fire, smoke, and heat (66% noncompliance).
➤ EC.02.02.01: The hospital manages risks related to hazardous materials and
waste (62% noncompliance).
➤ LS.02.01.20: The hospital maintains the integrity of the means of egress
(60% noncompliance).
➤ EC.02.05.05: The hospital inspects, tests, and maintains utility systems
(60% noncompliance).
➤ RC.01.01.01: The hospital maintains complete and accurate medical records
for each individual patient (57% noncompliance).
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