Monday, December 7, 2015

Check out The Joint Commission's Physical Environment Portal

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 and explore the resources in the Joint Commission Survey Toolkit. 

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