Centering compliance efforts on frequently cited concerns

A few years ago, the Joint Commission and ASHE noticed a stubborn pattern that we wanted to change: The same life safety and environment of care citations were listed year after year as the most commonly cited issues in health care facilities.

We needed a solution, and we tried a focused approach to tackle one of the most challenging standards — barrier management. ASHE and the Joint Commission, along with other groups, created the Barrier Management Symposium. The solution worked. Barrier management, which was consistently No. 3 or 4 on the list, has fallen as low as No. 7 (and we are working to continue this trend).

ASHE has expanded its collaboration with the Joint Commission on an even larger project that will provide facility professionals the information, resources and tools needed to avoid life safety and environment of care citations in their hospitals through Our Focus on Compliance website (www.ashe.org/compliance).

Our approach to this project is twofold. First, we want to provide specific information on each topic so facility professionals can understand the issue, Joint Commission expectations and how to comply. This information — distributed on both the ASHE Focus on Compliance website and the Joint Commission Physical Environment Portal — will help facility managers to get a better handle on these issues.

There’s a second component as well. As you probably know, one of the top causes of noncompliance can be the age of hospital buildings. It can be difficult to create a high-reliability organization when the facility contains older systems. So, in addition to informing facility professionals about these issues, we also felt it was important to involve hospital leaders. We hope that leaders recognize that life safety and environment of care issues have wide-ranging consequences, such as high-quality patient care, and as such need to be a priority.

Every two months, ASHE and the Joint Commission will focus on a new standard:

• August/September 2015: Utility systems (EC.02.05.01)

• October/November 2015: Means of egress (LS.02.01.20)

• December/January 2016: Built environment (EC.02.06.01)

• February/March 2016: Fire protection (EC.02.03.05)

• April/May 2016: General requirements (LS.02.01.10)

• June/July 2016: Life safety protection (LS.02.01.30)

• August/September 2016: Automated suppression systems (LS.02.01.35)

• October/November 2016: Hazardous materials and waste management (EC.02.02.01).

Dale Woodin, CHFM, FASHE, is ASHE's senior executive director.

ASHE INSIGHTS

Important monographs available from ASHE

Following are two recently released monographs that can be accessed by ASHE members as free PDFs at www.ashe.org/resourcelibrary.

• HCAHPS Scores, the Patient Experience, and the Affordable Care Act from the Facility Perspective. This new ASHE monograph explores how the health care physical environment and facility professionals can improve patient satisfaction scores.

• Risk Assessment of Medical Equipment. A key part of the Joint Commission’s environment of care management plans, risk assessments of medical equipment are covered in this new ASHE monograph. It presents a framework for facilities professionals to follow.

Design guidelines available to industry through ASHE

The 2014 editions of the Facility Guidelines Institute’s Guidelines for Design and Construction of Hospitals and Outpatient Facilities and the Guidelines for Design and Construction of Residential Health, Care, and Support Facilities can be purchased at www.ASHEstore.com.