The Joint Commission announced a Physical Environment Portal, in partnership with the American Society for Healthcare Engineering (ASHE), which focuses on 25 Life and Safety and Environment of Care elements from 8 standards identified as the most cited for violations over the last four years.
This simple infographic identifies the standards being featured: Utility Systems, Means of Egress, Built Environment, Fire Protection, General Requirements, LS Protection, Automated Suppression System, and Haz Mat/Waste Management. Each standard is being highlighted in 2-month modules: The first month features information for facilities managers; the second month focuses on strategies for leadership and clinical impact. The current modules may be found on the Portal’s Announcement Page.
For example, violations associated with LS.02.01.20 – The Hospital Maintains the Integrity of the Means of Egress, the Portal offers examples of improved compliance – both for facilities managers and leadership. For example, two Elements of Performance are identified as problem areas: Corridor Clutter was found to have a non-compliant rate of 22.41% and Doors unlocked in the direction of egress was found to have a non-compliant rate of 16.84%. A flow chart provides examples of improved compliance: looking at issue identification, risks associated with non-compliance, the potential impact of the risk and mitigation strategies. Notice that for each of these EPs there is a cross walk to the CMS Conditions of Participation.
Navigate to the ASHE website’s Focus on Compliance for additional resources on each standard. For example, for violations of LS.02.01.20 – The Hospital Maintains the Integrity of the Means of Egress, three specific areas are identified: Obstructions of the Means of Egress, Inappropriate Locking Mechanisms, and Improper Use or Designation of Suites. Also, remember to visit NAHAM.org and explore the resources in the Joint Commission Survey Toolkit.