Preparing for the Survey

Scheduling safety and security audits to complement the accreditation process can be a wise strategy

In the not-too-distant past, preparing for a survey by The Joint Commission meant ensuring that not only the facility but also all policies, procedures and documentation were well-prepared and ready for scrutiny during one specific week every three years. Anyone who has worked in a hospital knows how stressful this was and how the survey process has changed in recent years.

With an assessment approach that requires institutions to be in a state of “continuous survey readiness,” The Joint Commission has raised the bar on performance throughout the entire three-year accreditation cycle. Today, its survey team can show up at your facility anytime before the end of the tri-annual accreditation cycle.

Unless a facility’s intelligence-gathering is perfect, most are not able to plan for the commission’s unannounced inspection. Gone are the days of choreographing how best to delay the inspectors while planning maintenance repairs and communicating to the staff to look their best, keep their space clean and to be even more polite and friendly on that fateful day. Now, healthcare providers have to prepare for inspections proactively.

According to the 2009 “Joint Commission Perspectives” survey, the most common types of Joint Commission standards citations given to hospitals were for life safety code violations. In fact, life safety code-related violations were the first, second, fourth and sixth most frequently cited, including failure to maintain an egress as well as failing to protect people from smoke and fire. These findings are likely to result partially from the commission’s increased focus in this area and the addition of life safety specialists to the inspection team.

10 Easy Fixes
What made the study interesting was that many of the citations are easily preventable through improved staff awareness or the use of affordable solutions. Below is a list of 10 typical life safety violations along with solutions that can help keep facilities safer for patients, visitors and staff while reducing the potential for receiving requirement for improvements (RFI) citations during the next inspection.

1. Obstructed openings. Sometimes a stopgap solution to the problem of having excess supplies is placing them next to the door and stocking them later. Even with these good intentions, patient and staff safety can be affected because this may allow the spread of smoke and fire beyond the confines of smoke compartments. Keep doorways clear.

2. Obstructed hallways. Wheelchairs, gurneys and carts in hallways may impede access to stairwells and exit doors. Make sure the hallways stay clear.

3. Broken door locks. Although not necessarily a life safety code issue, broken and inoperable door locks can create risks in healthcare facilities. Not only can they create opportunities for theft, but they may also expose sensitive business information or confidential patient information to unauthorized people, which may result in a HIPAA violation. Educate staff members on whom to notify for maintenance and be proactive in surveying access points for damage.

4. Improper fire rating on doors. Painted-over or missing fire rating labels is consistently one of the top violations. Ensuring that painters understand the importance of not covering door and frame labels can significantly reduce the potential for this violation. Where necessary, replace damaged doors with doors that have proper fire ratings. Regardless of the training provided to painters or specifications given to companies replacing doors, never close out a project without an inspection and commissioning process.

5. Broken door seals. Wear and tear will affect all doors, eventually. A door that might close but not seal properly may allow smoke and fire to penetrate an opening much more quickly. Make sure they are properly sealed.

6. Doors that do not properly close. A door that doesn’t close is a door that can’t be latched or prevent the spread of fire. Often, fixing a broken door is as simple as replacing a broken lever or adjusting a hinge.

7. Doors that don’t self-close properly. In many places, life safety code requires doors to close and latch on their own, without impediment. If doors are designed to close and latch without human intervention but fail to do so, the closing device should be repaired or replaced immediately.

8. Worn door hardware. Loose hardware that could fail, corroded hinges that could snap, or worn, jagged levers that can catch on clothing should all be replaced or repaired.

9. Missing or unmarked designated fire exits. Exits that are not clearly marked create a dangerous condition, particularly in smoke-filled hallways. In an emergency, occupants need to have clearly designated and identified egress routes.

10. The devil is in the details. The smallest infraction can endanger the safety of your occupants. Be thorough.

Currently, The Joint Commission and Centers for Medicare & Medicaid Services are enforcing the 2000 edition of the National Fire Protection’s Life Safety Code. Make sure to check with your AHJ to see what is mandated for your facility.

Preparing for a Joint Commission Survey
There are many strategies to consider when planning for an unannounced Joint Commission inspection, but here are two primary ways to prepare your facility. The first is to assess, plan, prepare, practice and improve. When a hospital continuously assesses its organizational performance, a Joint Commission survey may not be as alarming.

Hospitals running simulated hospital surveys are best prepared for the real thing. The “surveyor,” much like the Joint Commission counterpart, arrives unannounced and begins the methodical process of reviewing compliance with each standard. This process should mimic those used by actual surveyors, following patient activities, inspecting, testing, questioning, reviewing, clarifying and challenging.

Educating the staff is vital. By sharing results and findings, each department and the organization as a whole can understand potential deficiencies and address them effectively. The bottom line includes both passing the real survey and, most importantly, improving patient care.

Hardware and equipment rarely notify anyone when they break or malfunction.

It is important for hospital staff to report a door opening problem as soon as it is discovered. Preventive inspections and maintenance programs can certainly help identify issues; however, these are often limited to specific schedules. Staff reporting is critical.

When staff members report problems, they expect that these problems will be resolved in a timely manner.

When issues are not resolved, staff eventually get frustrated and tired of calling, and either find their own solution or work around the problem.

When a lock is not functioning properly and the lock shop is too busy to get to it, the door will be propped open.

When the magnetic door release -- tied to the fire alarm system -- will not hold the door open, staff will find their own way to keep it open, which may be a violation of fire code. Tracking maintenance requests, setting priorities and communicating with staff is essential in garnering their ongoing cooperation.

To ensure patient, visitor and staff safety, any malfunctioning or broken equipment should be reported and scheduled for repair as soon as possible.

The “that just happened” excuse seldom works with the surveyors.

What is a Security Audit, and Why Should a Hospital Conduct One?
How can a hospital ensure that it is at the top of its game at all times? What if the survey team shows up today? The easy answer is to undertake periodic audits.

Audits are important because they help ensure that a facility is prepared for a survey and, more importantly, safe and secure for its occupants. From the time a patient hands over his or her medical information to the follow-up consultations after a procedure, every step of the journey takes policies, protocols and precise execution in order to ensure a successful experience.

Healthcare providers should take great care and extensive measures to make certain not only that the patient is well cared for but that they also provide a physical environment that is an asset to the patient and is safe and secure for everyone who walks through the facility’s doors.

Not only must hospitals go to great lengths to enforce adopted rules and measures, but they also must spend a fair amount of time analyzing and reviewing their policies and procedures to ensure they are meeting these regulations.

Security audits assess the organization’s compliance with standards they are required to meet or have agreed to abide by. If a policy and procedure have been written, an audit determines whether the organization is doing what it has said it will do. For example, if a hospital has determined that it should practice an emergency lockdown twice a year, it must do so.

The actual audit process also identifies needs and helps determine whether those needs are being effectively addressed.

For instance, if, during a lockdown exercise, it is determined that the process took 20 minutes instead of the expected three minutes, the assessment should identify specific areas of improvement, make recommendations to correct, then outline the plan for correction and, most likely, call for followup lockdown exercises to determine that performance has been improved.

Depending on the results, hospitals typically follow the recommendations and update the security. Hardware repair, equipment replacement, policy changes, retraining, procedure drills and follow-up audits and assessments could all be a part of the next phase.

Security audits vary in size and scope. Some audits might cover all aspects of security while others might be scheduled to analyze a single segment of the process. Audits can be something as small as an examination of paperwork.

Such scheduling usually depends on the performance of the previous audit, with exceptions, including an administrator’s desire for unpredictability.

Is it Necessary?a
All hospitals know that continuous self-check activities are important, but some are more vigilant than others.

Some hospitals consider security audits vital to their prosperity. Not every hospital performs at the same level, which means some facilities need a little more effort to maintain efficiency than others.

Such levels of performance also determine the frequency of security audits, if and when they are scheduled.

What all facilities have in common is that they need to have a safe environment for patients, visitors and staff while complying with regulatory requirements. Since accrediting bodies such as The Joint Commission have decided not to schedule their inspections, hospitals should work every day to maintain optimal efficiency and provide the best environment possible for their patients and staff.

This article originally appeared in the June 2011 issue of Security Today.


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