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January 2014 Archive for High Reliability Healthcare

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Observations and Lessons Learned on the Journey to High Reliability Health Care.

Ace your hospital survey by focusing on EC and LS

Jan 22, 2014 | Comments (0) | 22767 Views

Mark Pelletier

by Mark Pelletier, R.N., M.S.
Chief Operating Officer, Accreditation and Certification Operations

Among the questions I get asked the most about survey preparation is ‘how can our hospital avoid getting requirements for improvement (RFIs)?’ The answer: take a good look at your environment of care and life safety areas.
Since 2009, the most scored requirements during hospital surveys are those in the Environment of Care (EC) or Life Safety (LS) chapters of the accreditation manual. Most likely, these requirements will continue to be found out of compliance. Why? A lot of reasons: the scope of the environment of care is getting broader; Life Safety Code surveyors are receiving more focused training by national and international experts to ensure that these issues are identified; and, the follow-up surveys conducted by the Centers for Medicare & Medicaid Services also continue to identify noncompliance issues in the environment of care and Life Safety Code® areas.

With some vigilance and appropriate delegation of responsibility from hospital leadership, hospitals can get on top of these compliance issues. Jim Kendig, field director for Surveyor Management and Support, says the compliance issues all stem from a lack of processes, programs or plans to accommodate the EC and LS areas. Kendig offers this advice:

  1. Assign appropriate departmental and individual responsibility for EC and LS areas – and hold them accountable.

  2. Start programs to address permits for above-the-ceiling work and wall penetrations. Examples of program activities include:

  • Affixing orange signs to ladders, indicating the work is permitted and is being done by appropriate personnel.

  • Implementing a bounty program, rewarding employees who find individuals on ladders without signage.

  1. Unblock corridors. A blocked corridor is simply unsafe – whether or not there’s a fire.

  2. Don’t rely on contractors to ensure that the work is done appropriately, carried out safely, and documented accurately; check on it. For example, have the contractor illustrate on the life safety drawings where penetrations were made and ask them to confirm that they were sealed appropriately.

  3. Train appropriate staff and contractors to use fire stop material to seal penetrations.

  4. Separate full and empty high-pressure “e” type cylinders, and place them in approved holders. Remove the plastic shipping mesh from new cylinders.

  5. Educate staff about the written fire response plan, and make sure they know the following:

  • The person responsible for turning off the zone medical gas valve. Is the same person also responsible for turning off the medical gas valves in medical/surgical and the ORs?

  • The role of licensed independent practitioners in the written fire response plan.

  • Why smoke compartmentalization is important to a “defend in place” strategy.

  1. Conduct fire drills and document the drills.

At first glance, these may not seem to be patient safety issues. After all, a blocked corridor isn’t going to kill the patient in room 464, right? Unfortunately, a blocked corridor could impede the rapid response team when responding to a code blue, delaying care. Or, in the event of a fire or smoke event, you will have to spend time clearing the corridor instead of attending to patients. And, is the person standing on the ladder in the ICU authorized to be working in the ceiling space on the electrical wires that lead to your patient’s monitoring equipment? Is that hole in the wall exposing your immunocompromised patient to dust or allergens that could exacerbate their condition? The environment of care is everywhere, and that’s why it’s important to make sure that EC and LS issues are identified and addressed. 
Don’t let a blocked corridor, an absent permit, or a ladder lacking signage set your organization up for an RFI. Free articles to help meet EC and LS requirements:

Articles from 2012 on the following topics can be accessed here:

  • Storage of freestanding medical gas cylinders: compliance and safety tips

  • Piped medical gas: compliance and safety tips

  • Tips for documenting fire response testing

  • Tips for ensuring corridor-related compliance

  • Managing corridor clutter

  • Tips for maintaining fire and smoke barrier integrity


Physicians can have a say in standards development

Jan 15, 2014 | Comments (0) | 7236 Views

By Robert A. Wise, M.D.
Medical Advisor, Division of Healthcare Quality Evaluation
The Joint Commission

Why is this standard phrased the way it is? What does this standard have to do with quality and safety? How was this standard developed?

These are some of the questions about The Joint Commission standards that we get from physicians and other healthcare workers, especially when a new or revised standard affects their work. The standards are based on available scientific evidence with extensive input of experts in the topic area and from the field. New and revised standards undergo an extensive vetting process that can take one year or more to complete. During this time, there are opportunities for physicians and others to voice their opinions about the proposed standards.

In a nutshell, here’s the standards development process:

  • New or revised requirements are identified through the scientific literature or The Joint Commission’s standing committees and advisory groups, accredited organizations, professional associations, consumer groups, and input from physicians, healthcare workers or others.

  • Draft standards are developed using input from external task forces, focus groups, experts and other stakeholders.

  • Technical Advisory Panels (TAP) are assembled when technical or highly controversial issues are involved.

  • The draft standards are reviewed by The Joint Commission’s Professional and Technical Advisory Committees (PTACs), which are composed of outside experts, and the Standards & Survey Procedures (SSP) Committee, a committee of the Board of Commissioners.

  • The draft standards are distributed nationally for review and made available for comment on the Standards Field Review page of The Joint Commission website.

  • If needed, the draft standards are revised and again reviewed by the TAP, other experts and PTACs.

  • The draft standards are approved by the SSP Committee and provided to the Board for a comment period. Once that period of time has passed, the standards are final, unless the Board seeks further discussion.

  • Surveyors are educated about how to assess compliance with the standards.

  • The approved standards are published. Prepublication versions of the standards are posted on the website until they are published in the manuals or E-dition.

  • Once a standard is in effect, ongoing feedback is sought through an online standards question form for the purpose of continuous improvement.


Physicians can influence the development of new or revised standards by participating in the field review or submitting questions via the online standards question form. You can visit the Standards page on the website for more information.

High reliability in healthcare

Jan 02, 2014 | Comments (0) | 15534 Views

Schyve 11 10By Paul M. Schyve, M.D.
Senior Advisor
The Joint Commission

Since publication of “To Err is Human: Building A Safer Health System” by the Institute of Medicine in 1999, we’ve been aware of the estimate that 98,000 patients die in U.S. hospitals annually from preventable healthcare errors. Recently, a report in the Journal of Patient Safety estimated that this number is closer to 440,000 deaths! Perhaps the exact number does not matter. What does matter is that many patients die from preventable errors. While physicians are responsible for some of those errors, our ethical obligation to “first, do no harm” to our patients means we are responsible for reducing harm from all errors – regardless of the source.

We now know that healthcare is often unreliable: routine safety processes – such as hand hygiene, medication administration, patient identification, and communication in transitions of care – fail routinely; and clearly preventable adverse events – such as surgery on the wrong patient or body part, fires in ORs, retained foreign objects, infant abductions, and inpatient suicides – still occur.

But when we look around, we find other high-risk industries – such as air travel – that manage very serious hazards extremely well – they are “highly reliable.” These industries have certain characteristics in common: highly effective process improvement, a fully functional safety culture, and early discovery and fixing of unsafe conditions. 

Because healthcare is different than these other industries – and is probably the most complex of all – many of the techniques that these industries use to achieve the characteristics of high reliability cannot be simply adopted in healthcare. However, working with experts in healthcare and these other high reliability industries, The Joint Commission has identified those critical changes that healthcare can (and must) make to achieve high reliability in our care of patients: leadership commitment to zero patient harm, a fully embedded safety culture, and use of robust process improvement to create and sustain highly reliable safety processes. Dr. Mark Chassin, president of The Joint Commission, and the late Jerod Loeb recently published a report on “High-Reliability Health Care: Getting There from Here” in The Milbank Quarterly that describes how we can achieve high reliability in healthcare – for the sake of our patients and their families, and of ourselves. 

We cannot, however, “get there from here” without the commitment – and leadership – of physicians.  Some additional resources that are relevant to achieving high reliability in healthcare are available on The Joint Commission website. We – physicians – owe it to our patients, to society, and to ourselves, to help our healthcare organizations advance on this pathway to providing better, safer care.