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EC scoring may herald survey compliance pitfalls


April 24, 2010

Preview of the Hospital Safety Center Symposium

EC scoring may herald survey compliance pitfalls

Although it may not rank high on your chore list, take close reads of the scoring behind the EC standards, because they give you compliance hints.

A significant amount of the EC elements of performance (EP) are designated with a C score, meaning surveyors only have to find two instances of noncompliance to issue a requirement for improvement (RFI), said Steven MacArthur, safety consultant at The Greeley Company, a division of HCPro, Inc., in Marblehead, MA. He spoke during a February HCPro audio conference titled “Physical Environment Compliance 2010: Analyzing The Joint Commission’s Latest Interpretations and Survey Hotspots.”

For example, EC.02.03.05, EP 15, requires hospitals to inspect portable fire extinguishers monthly. If a surveyor finds two extinguishers without proper documentation for the monthly checks, a citation could follow.


Direct impact for some fire safety rules

Although the effects of direct impact EPs aren’t a terrible strain on safety programs, that ranking points to hot spots in the EC standards, said MacArthur, who will also be a featured presenter at the 4th Annual Hospital Safety Center Symposium, which takes place May 6–7 in Las Vegas (go to www.hospitalsafetycenter.com for more details). He’ll discuss the ties between the EC standards and infection control strategies at the symposium.

To quickly review, direct impact requirements—noted by a triangle icon surrounding the number 3 in the standards—are likely to create immediate risks to patient safety. The risks stem from a lack of processes to offset the threats. Under this level, hospitals must submit evidence of standards compliance for cited EPs within 45 days of a survey’s completion to The Joint Commission.

Under EC.02.03.05, there are three direct impact requirements:

  • EP 4, which requires testing visual and audible fire alarm components every 12 months. Hospitals trip up on this provision when they can’t show that all of the individual devices have been tested, MacArthur said. (See “Survey monitor” on p. 8 for more about how this concern came up during a Joint Commission visit.) Often, the problem lies with an over-reliance on outside vendors who perform this testing but don’t provide proper documentation.
  • EP 11, which mandates testing fire pumps under flow every 12 months. This EP was made a direct impact requirement for this year, likely based on the amount of problems with fire pump testing noted in the field.
  • EP 19, which requires testing smoke detection shutdown of HVAC equipment. When testing smoke detection devices on air handlers, verify that the intake and exhaust sides of the units close properly.


Generator testing also brings concerns

Emergency generator requirements under EC.02.05.07 also have implications from direct impact requirements.

“There are a lot of direct impact RFIs lurking in the weeds here,” MacArthur said.

EP 6 requires testing automatic transfer switches 12 times per year, at intervals of at least 20 days apart but no more than 40 days apart. Similar to fire alarm components noted earlier, a common problem with automatic transfer switches is a lack of records showing that each switch underwent testing, MacArthur said.

Also, don’t forget to institute interim measures under EP 9 if a required emergency power system test fails. Follow up on any testing failures immediately and get temporary safeguards in place as needed, MacArthur said.

“Your vendor documentation is of all importance,” he added. Ask vendors for written summaries of any emergency power testing problems they discover.

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