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EC, LSC and ligature risks still at Joint Commission survey forefront


November 1, 2018

Highlight the zip codes where employees live so you can have a handy reference of where staff is available 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 in September 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. 

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 in what organizations — such as the CDC or AAMI — 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,” he says. 

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

Suicide Prevention and Ligature Risk

Emily Wells, CSW, MSW, TJC’s project director for Survey Management and Development, said the commission 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 patient 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 immediate threat to life (ITL). 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’s field director for Survey 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, seize up and create a ligature risk, she says. Surveyors test to see if your products work, not that you have them. And improperly installed equipment can result in a patient hurting themselves on something you thought was safe. 

Emergency Management

Jim Kendig, MS, CHSP, CHCM, CHEM, LHRM, also a field director for Survey Management and Development, recommended facilities run zip code tests to determine where most of their employees live. Most staff won’t come to work in during an emergency if their homes and family are in the affected area, he said. Doing a zip code test can tell you ahead of time if you’ll need to call in help from other facilities.

He also said security staff should work with local law enforcement on what to do in the event a hospital becomes a crime scene. There have been instances where a crime was committed in a hospital and police prevented hospital staff from re-entering the facility or move between rooms. That’s a possibility that needs to be dealt with before it happens, he says. 

Physical Environment 

Ken Monroe, PE, CHC, PMP, director of engineering for the Standards Interpretation Group, started off the physical environment and environment of care session with a look at Legionella. There’ve been multiple cases of the bacteria in hospitals, he says, and facilities need to be vigilant to protect their patients.

He also noted that 98% of all surveyed hospitals had at least one finding in the Environment of Care chapter, with ligature risks as the leading driver of immediate threat findings. However, the most common EP finding in the red category was EC.02.02.01, EP 5 — hazardous material handling and storage. 

The updated Life Safety Code also continues to prove challenging, with 97% of hospitals seeing a finding in the Life Safety chapter. LS.02.01.35 (sprinklers) was the most cited. 

Facilities don’t clean their sprinklers or test them, or they put things in the way that could block the spray. Those are all easy ways to get a finding, he said. However, only about 12% of LS findings were in the moderate or high-risk range, with LS.01.02.01, EP 1 (primarily for not having an Interim Life Safety Measures policy) being the most common high-risk finding. 

Executive Briefings: Top 3 challenges in EC, LS, EM chapters

Here are the top three challenges in each of the chapters most often cited within the hospital environment of care, provided during The Joint Commission’s annual Executive Briefing session held in New York City on September 14.

TJC has also begun to provide information on what problems land an RFI within the orange or red zones of the SAFER Matrix-- the areas denoting a high likelihood of harm to health or safety. 

Environment of Care chapter

  • EC.02.06.01 — Hospital establishes and maintains a safe and functional environment
  • EC.02.05.01 — Hospital manages utility system risks
  • EC.02.05.09 — Hospital inspect, tests and maintain medical gas systems

EC.02.06.01 is a catch-all standard and is often where ligature risk problems most often land, according to TJC and consultants. Those problems also are often scored as high risk or an immediate threat to health and safety.

Examples of RFIs cited by TJC under EP 1 for ligature risk and other contributors to patient self-harm include problems with doors and door hardware, beds, drop ceilings, light fixtures, HVAC vents, non-tamper proof screws, sprinkler heads, bathroom fixtures such as toilet paper dispensers and plumbing, grab rails and window treatments.

Life Safety chapter

  • LS.02.01.35 — Hospital provides and maintains system for extinguishing fires
  • LS.02.01.30 — Hospital provides and maintains building features to protect from fire, heat and smoke
  • LS.02.01.10 — Hospital builds and designs building features to protect from fire, heat and smoke

While the above standards were the most challenging for hospitals overall, the following standards and elements of performance were the ones most often cited for creating a high likelihood to harm: 

  • LS.01.02.01, EP 1, requiring hospitals to have a way to protect patients and staff when the Life Safety Code is not met or during periods of construction, for not having an Interim Life Safety Policy
  • LS.02.01.20, EP 1, maintaining the means of egress, for having doors locked in the path of egress
  • LS.02.01.35, EP 5, problems with sprinkler heads

Emergency Management chapter

  • EM.02.01.01 — Hospital must have an Emergency Operations Plan
  • EM.03.01.03 — Hospitals must evaluate the effectiveness of their emergency planning
  • EM.02.02.13 — During emergencies, hospitals may grant privileges to volunteer licensed independent practitioners.

Few hospitals were cited for an immediate threat or high likelihood to health or safety under any EM standard. However, when a hospital was found to pose such a threat, it was under EP 2, which requires a hospital to develop a written EOP based on what to do in a variety of emergencies.


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