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Ligature risk, infection control top concerns at Executive Briefings


December 7, 2019

by A.J. Plunkett (aplunkett@decisionhealth.com)

Widespread ligature risks, incomplete environmental risk assessments, and lack of a mitigation plan are likely going to be the most serious Environment of Care (EC) problems to land you in hot water with The Joint Commission (TJC).

Any ligature finding is going to automatically be a Conditions of Participation (CoP)–level finding, warned Herman A. McKenzie, MBA, CHSP, the new director of TJC’s Department of Engineering, during this year’s Chicago session of the commission’s annual Executive Briefings.

Environment of Care standard EC.02.06.01, element of performance (EP) 1, requiring a safe and functional environment that meets the needs of the patient population, was the most frequently cited EC standard in 2018 and the first six months of 2019, and the top standard overall for immediate threat to life (ITL) findings in 2018, McKenzie noted.

That might change in the next set of top findings. But only because ligature risk as of July 1 is being scored under the revised National Patient Safety Goal (NPSG) 15.01.01, EP 1, McKenzie said. The overall NPSG requires hospitals to identify “safety risks inherent in its patient population,” and under EP 1, that includes doing a risk assessment of the physical environment for things conducive to patient harm.

While ligature risk is an automatic condition-level finding, it doesn’t have to stay that way. McKenzie said surveyors will look for three things that can help lower the finding to standard-level:

  1. Did you do a thorough risk assessment?
  2. Do you have an appropriate mitigation of the risk in place? (There will be a discussion on that, McKenzie warned.)
  3. Have you shown that you are actively working on the problem?

Remember also that fire safety will always trump ligature risk, said McKenzie. (Note that compliance officers have reported having to deal with both.)

Infection control within the environment of care, especially involving maintenance of sterilizing equipment and utility systems, will also be a critical focus of surveyors in the upcoming year, said McKenzie.

According to McKenzie, beyond ligature risk, the most frequent findings leading to ITLs—which can lead to a loss of accreditation and funding from Medicare—involved:

  • Not adopting national or evidence-based guidelines for high-level disinfection (HLD) and sterilization processes
  • Not following manufacturer’s guidelines or instructions for use
  • Failure to conduct or incomplete suicide risk assessments
  • Lack of training, education, and assessment of competency for staff related to HLD and sterilization

Coordinate with your infection prevention and central processing teams to ensure the maintenance of sterilizing equipment is being addressed according to manufacturer instructions. “If there are user tasks that need to occur daily or weekly, make sure those are being done,” he warned.

McKenzie also went through the top problems found under EC and Life Safety (LS) standards that involve a serious or high likelihood for harm.

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