With The Joint Commission changing its scoring system in 2017, it may be difficult for hospital quality leaders to anticipate what could go wrong on a survey. Experience will still yield some clues, but the first surveys may provide some insight into what hospitals should expect.
The new scoring system raises many questions, says Ruth Ragusa, RN, vice president of organizational effectiveness at South Nassau Communities Hospital in Oceanside, NY.
“It’s going to be a learning opportunity for all of us, including the surveyors,” Ragusa says. “It’s hard to speak about what was found in the past because there is going to be a whole new game plan. Whatever improvements you thought you had previously, there probably are still going to be more problems with your surveys than in the past.”
The Life Safety Code requirements are one area that has been changed significantly. In the past, hospitals largely had control over how and when physical plant resources were tested and maintained, but TJC now specifies what must be done in that regard. The Life Safety Code requirements were effective November 1, 2016, and include requirements that may be new to some facilities.
For instance, fire sprinkler systems must be present in all high rises, and if a sprinkler system is non-functioning for more than 10 hours, the facility must evacuate or implement a fire watch operation. New construction must have patient room windowsills no higher than 36 inches, and medical gas alarms can be centralized. Water flow alarms must be tested semi-annually and electric mother fire pumps can now be churned monthly instead of weekly.
Beginning January 1, 2017, TJC is introducing the Survey Analysis for Evaluating Risk (SAFER) matrix, which replaces the current scoring methodology by eliminating Category A and Category C findings, as well as direct and indirect effect Elements of Performance (EPs). TJC says that methodology has been confusing, so now surveyors will use their experience and expertise to assign levels of risk in the matrix based on the likelihood that a deficiency will cause harm to patients, staff, or visitors; and the scope of the issue — how widespread the issue is within the organization.
The actual 3×3 SAFER matrix is color-coded, which TJC says should enhance the visual effect of the information and help organizations understand which issues are most critical. The new approach is intended to help hospitals set their priorities for improvement based on the severity of risk for each finding. (For more on the SAFER matrix, go to http://bit.ly/2e4MhWP.)
Ragusa says the changes may be good in the end, but the introduction could be difficult.
“They’ve changed so many things that it’s going to be a really bumpy ride until everyone, including surveyors as well as hospitals, get used to this new process and how to manage it,” Ragusa says. “We’ve been reading all we can about the new process and try to determine where we stand with some things that were on the self-identified list. You want to look at those things that are now out of your hands and make sure you have them all cleaned up.”
TJC publishes a list of the most common problems identified in surveys, and Ragusa says those are still useful in assessing compliance before a survey. But the survey changes make Ragusa and many in her position nervous about how they might fare when TJC surveyors knock on the door next time. (For more on the most challenging requirements for 2015, visit http://bit.ly/2dPNJJB.)
“You have confidence in what you’ve done, but there’s still concern when you don’t know what to expect,” Ragusa says. “My feeling is that there will be many more areas identified than in the past. You may have had 10 or 20 areas identified for improvement in the past, but I believe those numbers are going to be much greater.”
The turnaround time to improve those issues also has been shortened, so Ragusa also wonders if large organizations will be able to change quickly enough. She advises quality leaders to study TJC requirements more than ever before and be ready to discuss them during the survey process. The ability to discuss and address issues after the survey has been sharply curtailed in the new process, she notes.
“It behooves us to be well informed and aware of the new process so we can have meaningful conversations, because everything is going to be decided in the survey process,” Ragusa says. “There’s not going to be a lot of opportunity, as in the past, where you could clarify or challenge things afterward.”
- Ruth Ragusa, RN, Vice President of Organizational Effectiveness, South Nassau Communities Hospital, Oceanside, NY. Telephone: (516) 632-3999. Email: firstname.lastname@example.org.