Guest Blogger JCR/EC News: Addressing Challenging Standards (excerpt from May 2012 Issue)

The Joint Commission Resources publication Environment of Care News offers tips and reminders in an article addressing challenging standards effecting Office-Based Surgery providers.   Please note the article does not provide an in-depth analysis of all standards but is meant to provide an at-a-glance review.

OFFICE-BASED SURGERY
Standard EC.02.04.03
(OBS noncompliance: 12%)
Just like laboratories, OBS organizations must inspect, test, and maintain medical equipment according to Standard EC.02.04.03.  An important compliance issue for OBS organizations in this standard relates to performance testing and sterilizer maintenance.
 
REMINDER—Manufacturers’ recommendations
“To fully comply with this standard, an OBS clinic should understand and follow manufacturers’ recommendations for performance testing and maintenance whenever possible” says Virginia McCollum, associate director, Standards Interpretation Group, The Joint Commission, and a specialist in the OBS standards.
 
“Different sterilizer manufacturers may have different requirements, so it is essential to understand and follow the specific recommendations for particular machines. If you apply one manufacturer’s recommendations to another type of sterilizer, you could inadvertently damage the sterilizer or render it unsafe for use.”
 
TIP—Plan for failed sterilizers
If a sterilizer fails a performance test, an OBS organization should have a plan in place that governs how and when the machine is removed from service, how it will be fixed, what initial tests will occur before it is placed back into service, and who will perform those tests. Individuals charged with performance testing should be familiar with this response plan and how and when to implement it.
 
Standard EC.02.03.05
(OBS noncompliance: 11%)
This standard requires an OBS organization to maintain fire safety equipment and building features in order to preserve life safety in the event of fire. Note: Typically an OBS center is a business occupancy, and so it must comply with the fire safety standards found in the EC chapter of the Comprehensive Accreditation Manual for Office-Based Surgery Practices. Such an organization is not required to comply with the LS standards.
 
REMINDER—Fire safety equipment and features
Standard EC.02.03.05 discusses several types of fire safety equipment and features that could be present in an office-based surgery clinic, including but not limited to automatic sprinkler systems, valve tamper switches, water flow devices, and heat detectors.
 
An OBS organization is not required to have these types of equipment in its facility, but if it does, it must comply with the maintenance, testing, and inspection requirements discussed in Standard EC.02.03.05. “If an organization has some of this equipment but does not inspect, test, and maintain it appropriately, the organization could receive an RFI during survey,” says McCollum.
 
TIP—Fire extinguisher testing
An OBS organization must inspect its fire extinguishers every month, and this inspection must be documented and dated.  To make sure this takes place within the standard’s required time frame, an OBS organization may want to assign an individual to the task and designate a general time frame in which the inspection should occur, such as within the first or second week of the month. Leadership should verify that these inspections are occurring regularly and appropriately.
 
In addition to monthly fire extinguisher inspections, an OBS organization must undergo a more comprehensive inspection of the fire extinguishers—typically completed by an outside firm—each year.

Here is the link to The Joint Commission Resources web site http://www.jcrinc.com/Environment-of-Care-News/.  Subscribers may access the May 2012 issue here, and non-subscribers may also sign up for a subscription at this same link.

Comments