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Create a library of device manuals and documents to maintain compliance


January 1, 2018

New EP: Avoid RFIs by keeping documents and service manuals in library

“If it wasn’t documented, it wasn’t done.” It’s a phrase that every accreditation professional should know by heart. It’s a phrase that should be drilled into every doctor, nurse, and caregiver. It’s a phrase in the mind of every surveyor.

The second, lesser-known phrase that everyone should know is: “It doesn’t do me any good if I can’t find it.”

That’s the philosophy behind one of The Joint Commission’s newest Environment of Care elements of performance (EP). Starting on January 1, 2018, healthcare organizations will need to create and maintain an accessible library of service manuals, instructions for use, technical bulletins, and other information manufacturers provide, and keep it as rigorously updated as other required documentation of tests, inspections, and maintenance.

During the annual Executive Briefings session, held just outside Chicago September 29, John D. Maurer, Joint Commission acting director, Department of Engineering, said the requirement for a library of information is one of the most important of the new EPs under EC.01.01.01, and is among the continuing revisions of the Environment of Care and Life Safety standards.

Newest changes effective January 1

The latest revisions, which are still a response to last year’s adoption by CMS of the 2012 NFPA 101 Life Safety Code® and the NFPA 99 Health Care Facilities Code, will go into effect January 1, 2018.

Having a library of technical instructions on-site for workers to reference is part of the NFPA codes, and hospitals will be expected to have them accessible to staff whether they are inspected by Joint Commission surveyors or officials with other authorities having jurisdiction.

“This is code driven,” emphasized Maurer, who has taken over in the interim as The Joint Commission looks for a replacement for its longtime engineering director George Mills, who has gone on to the private sector as a consultant and lobbyist.

Maurer began his presentation by emphasizing the importance of having “go-ready” documentation updated and available when surveyors arrive. In 2016, half of the hospitals undergoing survey requested the opportunity to clarify information when an RFI was imminent, and half of those clarifications involved the EC and LS chapters, Maurer noted.

Of those clarifications, 65% were because the facility could not present documentation on request.

And that was before the spike in the number of RFIs following the recent CMS-required changes to The Joint Commission’s survey process that has created a “see it, cite it” inspection culture.

Use Joint Commission checklist to review documentation

In a change announced in 2016, if a Joint Commission inspector asks for LS or EC documentation that is required under NFPA code, and that documentation is unavailable, it will be an RFI and will not be available for clarification, said Maurer.

To put it in high school terms: If you finish your essay on time but go to class without it, the teacher will now give you an automatic F instead of letting you turn it in on Monday.

He urged facilities to review the checklist of required documentation set out in The Joint Commission’s Survey Activity Guide, as well as the document list and review tool available at the end of the guide (see link at end of article). The library of service manuals and other information should also be diligently updated, Maurer said.

To highlight its importance, the new EP was inserted under EC.01.01.01 as a new EP 3, moving all the other EPs back a slot under that standard, which requires hospitals to have a plan to minimize risk within the environment of care.

Access, comfort, organization

When it comes to actual bookkeeping, healthcare organizations have a fair amount of leeway in how they organize their library, provided that it’s accessible and the information can be found easily.

Maurer explained that the library can be online or physically somewhere in the facility, but it should always be available to staff when needed, he said. Workers should know where the information is and how to use it, he added.

Brad Keyes, CHSP, owner of Keyes Life Safety Compliance, Inc., says that healthcare organizations should use whatever system (online or hard copy) they feel most comfortable with when managing their documents.
“Once you have chosen your format on how to store these documents, make sure you have multiple people aware where these documents are stored and how to access them,” he says. “I kept these documents in my office, and there were probably three or four other people who knew where they were and how to get them if I was not present on survey day.”

Marge McFarlane, PhD, MT(ASCP), CHSP, CHFM, CJCP, HEM, MEP, CHEP, principal of Superior Performance in Eau Claire, Wisconsin, and senior consultant with Compass Clinical Consulting in Cincinnati, notes that there’s no firm rule on how long you should keep your documents.

That said, during a survey, you should only present surveyors with documents from the last 12 months. Preferably, these documents should be sorted by calendar year instead of fiscal year, since it’s simpler for most surveyors (and people in general) to wrap their heads around.

However, The Joint Commission can ask for documents from a facility’s previous survey, so McFarlane recommends keeping the last three years’ worth of documents at least.

“The exception to that is damper testing,” she says. “Because dampers are only tested every six years in healthcare occupancies, and every four years in business and nursing home occupancies. So every six years for damper testing if you do them all at once. Some facilities are so large they do a portion of them every year. So it’s 12 months’ worth or the last time it was tested.”

Follow TLW instructions closely

The emphasis on documentation and service manuals was just part of a long list of changes and tweaks to the survey process announced by Maurer, including an overview of the proposed but as yet unapproved changes to the Emergency Management standards to align with new emergency preparedness Conditions of Participation.

One recurring theme throughout Maurer’s presentation was to be careful to ensure that fixes you make don’t create other problems. For instance, if you find cables wrapped around fire sprinkler lines above the ceiling tiles, make sure the work done to move those cables doesn’t damage the sprinkler system, he said.
He also urged hospitals to create a survey-related plan for improvement as soon as possible, to launch the process to request a time-limited waiver (TLW).

Since TLWs must now be approved by CMS and there are no extensions, it is important to begin the process early to allow The Joint Commission time to work with the federal agency on approval, Maurer said.

Note: It is important to follow all of the instructions under the TLW tab on The Joint Commission’s extranet system to ensure the waiver is not kicked back on a technicality, warned Maurer. Currently, about half of the TLWs are being rejected because the instructions were not followed, he said. Your facilities staff should know within 30 days if they will be able to get something repaired within the 60-day deadline, Maurer said, so the TLW requests should be submitted as soon as possible.

A.J. Plunkett contributed to this story.


The Joint Commission’s 2017 Survey Activity Guide: www.jointcommission.org/assets/1/18/2017_Organization_SAG.pdf
Prepublished revisions to EC and LS standards, effective January 1, 2018: www.jointcommission.org/assets/1/6/Life_Safety_Code_Prepub_HAP_Jan2018.pdf
Documentation: Getting the details right www.hcpro.com/ACC-328518-16/Documentation-Getting-the-details-right.html
Q&A: Managing LS, EC, and EM documentation www.hcpro.com/ACC-328592-16/QA-Managing-LS-EC-and-EM-documentation.html

Seven tips to reduce administrative and recordkeeping burdens
Hospitals can reduce their documentation problems by taking some bold but commonsense steps, says Brad Keyes, CHSP, engineering advisor on emergency management, physical environment, and life safety for the Healthcare Facilities Accreditation Program. He recommends the following:

1. Know what documents you need to keep to demonstrate compliance. These may include test reports, work orders, or service tickets from vendors.

2. Know what documents you should not keep because they will take up space. This includes items such as purchase orders, invoices, or letters stating compliance.

3. Restrict access to your documents to those whom you’ve authorized to fill in for you when you’re not there. “Once, the CEO’s office called me and asked me to bring my records over to his office so he could review them,” Keyes says. “His office was in another building located on campus, but I knew if I took them over, it may be weeks before I got them back. So I declined and said, ‘If the CEO wants to review my books, he can come to my office.’ This may be why I’m not working there anymore!”

4. Keep one year’s worth of three-ring binders to store the test/inspection reports. At the start of a new year, begin with a new set of binders.

5. Keep all of the test/inspection reports that demonstrate compliance with a standard in the three-ring binders. Some of your coworkers may want to retain certain logs or test records (e.g., weekly generator test sheets, monthly generator load tests, monthly fire pump test records, etc.) next to the equipment. It’s better to retain all these records in one place so you’re not running around the facility looking for test records on survey day.

6. If you use consultants in your survey preparation, they can review your documentation and make suggestions on how to improve it. If you don’t use consultants, contact your counterpart in a neighboring healthcare facility and ask him or her to review your documents—while offering to reciprocate.

7. Above all, demonstrate to the surveyor that you are organized and in control. Having these documents all in one place so the surveyor does not have to wait to review them is critically important for a positive survey.

Emergency Management documents are a different beast
Marge McFarlane, PhD, MT(ASCP), CHSP, CHFM, CJCP, HEM, MEP, CHEP, principal of Superior Performance in Eau Claire, Wisconsin, draws a distinction between managing Life Safety (LS) and Environment of Care (EC) documents and managing Emergency Management (EM) documents. Both the LS and EC chapters require proactive maintenance done on a set schedule, she says. There’s no rush and it’s not a surprise, because most of these activities are planned and orderly.

By their very nature, though, it’s impossible to tell when you’ll need to fill out EM documents. These documents focus on actions taken by facilities whenever there is a need for more resources: a sudden influx of patients, a disaster situation, etc. This makes them much harder to maintain, particularly at the beginning of an event when people are scrambling to get information.

“When I think about emergency management in the beginning, it’s all about communication, collaboration, and coordination: What’s happening, who needs to know, and what resources are needed at this time?” she says. “And I think that is the biggest challenge, and with the new CMS emergency management regulations, the focus is on everybody being trained, everybody being able to participate in the incident command.”

Unlike with LS and EC documents, McFarlane says having multiple hard-copy EM binders can be a hindrance during a crisis—partially because people won’t know where the binders are or what they say. Instead, she recommends storing EM documents and job action sheets digitally, on online folders or flash drives that can be powered up on a laptop or iPad if the main computer system goes down. She also suggests assigning someone to help wrangle some of the EM documents and keep them organized.

When it comes to EM resources, McFarlane wholeheartedly endorses the Hospital Incident Command System (HICS), which is a nationally recognized and vetted model and the best free EM resource for hospitals, particularly for smaller facilities.

“HICS just gives you a checklist of important tasks that prompts your memory, because during a disaster, a real disaster, you may not think about these questions,” she says. “You may just go down the checklist going, ‘Did that, thought of that, need to do that, not applicable to this event,’ and move on.”

In 2014, the HICS combined five EM forms into one situation report. The report allowed people to document times, decisions, and actions in one place. It’s a useful tool for the after-action report, McFarlane says, and one that she doesn’t think people are in the habit of using.

“I printed that [form] out and required that whoever was in charge at night—so house supervisors usually or whoever the administrator on duty was—that they had a copy of that form,” she says. “And the moment they get the call, ‘We just heard there was a bus rollover [or] a steam leak in the basement,’ they can [start] writing down. They’re going to take notes about the information anyways; why not pull this out their notebook so they know where all the open beds are? Pull this piece of paper out [and] they can put down the exact time, who called, and really give you the situation, and the decision and actions they make.”

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