Joint Commission Surveyor Focus Remains on EC, LS, Ligature Risks

This member-only article appears in the November issue of Patient Safety Monitor Journal.

Highlight the ZIP codes where employees live so you can have a handy reference of staff availability in emergencies, keep policies consistent and updated with the most relevant references, and focus suicide prevention efforts on making your physical environment ligature-resistant.

Those were some of the top takeaways for environment of care and other healthcare and quality professionals attending The Joint Commission’s (TJC) annual Hospital Executive Briefings held September 14 in New York City. The state of healthcare “is not good,” said Ana Pujols McKee, MD, TJC’s chief medical officer, rattling off uncomfortable facts such as the U.S.’s rising maternal mortality rate and that medical errors are the third leading cause of death. She urged attendees to accept nothing less than achieving zero harm in their hospitals and facilities.

She did say that efforts to reduce redundancy and simplify the survey process have been paying off. In particular she noted the SAFER Matrix had changed how people talked about problems in their facilities—from survey “dings” to safety “risks.”

Attendee Brian Pitt, safety director of SUNY Downstate Medical Center, said his biggest takeaway from the briefings was that there are a lot of opportunities to make changes and improve. That was particularly true for the areas of environment of care and infection control, which never seem to get full administrative support, he noted. Among other things, the briefing taught him the need for consistency regarding which organizations—such as the CDC or the Association for the Advancement of Medical Instrumentation—you reference in your hospital policies.

“These policies can be used against us if you don’t keep it consistent and follow a consistent national standard,” said Pitt.

Here are some brief highlights from the day’s topics.

Suicide prevention and ligature risk
There are still 1.125 million suicide attempts a year, says Emily Wells, CSW, MSW, TJC’s project director of surveyor management and development. She also said the accreditor has realized that no environment can be “ligature-free,” so it’s changed the terminology to “ligature-resistant.” That said, you still need to do risk assessments and have protocols to keep patients safe, including removing as many ligature risks from a patient room as reasonably possible. Facilities should pay extra attention to standard EC.02.06.01, EP 1, which was the most cited standard related to calls for Immediate Threat to Life. The standard requires hospitals to maintain a safe environment, and common RFIs under EP 1 were identified for self-harm risks like door hinges, beds, and drop ceilings.

Kathryn Petrovic, MSN, RN-BC, TJC field director of surveyor management and development, stressed the need to test ligature-resistant products to ensure they’re properly installed. Buying special anti-pinch point doorknobs doesn’t matter if they’re put in the wrong way, then seize up and create a ligature risk, she says. Surveyors test to see whether your products work, not just whether you have them. And improperly installed equipment can result in a patient being hurt on something you thought was safe.

Medication Management
One bit of good news came from Robert Campbell, PharmD. He announced facilities were doing “a great job on antimicrobial stewardship.”
“Either hospitals have been doing a lot of work [on this] or none at all,” he says, but overall there’s been consistently low scoring in this area.

The rest of the news wasn’t as good– 81% of surveyed hospitals had at least one RFI in the medication management chapter. People struggle the most to meet standards MM.03.01.01, EP 2 and MM.04.01.01, EP 13—medication storage and ordering respectively.

He notes that everything currently cited under PC 02.01.03 EP 7 will be moved to MM 06.01.01 on January 1. PC.02.01.03, EP 7 requires that care, treatment, and services are provided using the most recent patient orders— which is already specified in the MM chapter. This means the most cited list for this chapter is going to look a lot different in 2019.

And for anyone worrying about pre-spiked IV bags, he had a simple message. Don’t.

“Our surveyors aren’t going around looking for pre-spiked IV bags,” he says.

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