Look out for these to prepare for EOC tracer

Consultants share common problems

Clutter. It's a huge problem. "It's probably the second most scored standard," says Kurt Patton, MS, RPh, CEO of Patton Healthcare Consulting in Glendale, AZ, and former executive director of accreditation services at The Joint Commission. "Hospitals are crowded places, and there is a limited number of pieces of equipment that we are permitted to keep in the hallway. And what I see in hospitals are abandoned beds, stretchers, laundry carts that are left, clean linen carts, dirty linen carts. They are just not moved for hours on end. It's just a mess in hospitals."

Patton's solution is twofold. First, he suggests, there should be an "owner or department owner for a device." If you bring an X-ray machine, for instance, onto the unit, you do your work and take it back. "Transporters might bring a patient on a gurney. They place the patient in the room, and then they have to take that gurney out of there. Then you should have an oversight process, which might be rounds by a safety officer, where every time that person is making their rounds and they see something that hasn't moved in 30 minutes, they call the owner of the department to come and get rid of it," he says.

COWs, or computers on wheels, are on and off the floor. Patton says as long as they "are in use" per The Joint Commission's and Centers for Medicare & Medicaid Services' definition, you're OK. And that is, that the machine is moving at least every 30 minutes.

If a nurse is going from room to room with a medication cart, that fits the definition of "in use." If, however, you take that cart and plug it in to recharge the battery in the hallway at 10 a.m. and the nurse goes to do other things, that violates the "in use" criteria.

Patton says, most often, a nurse or physician surveyor during a clinical tracer will notice stationary equipment. If, for instance, he or she notes it and then is occupied for 45 minutes, then comes back and notes the cart is still there, "it makes it pretty obvious," he says.

Another area The Joint Commission is homing in on is fire safety. Patton says that, previously, documentation of hospitals' fire safety testing was inadequate so The Joint Commission is looking for much more. "That's getting back to the example where the vendor gives you a bill, 'You owe me $4,000. I checked your fire alarms.' But when the surveyor looks and says, 'What alarms were tested? What strobes were tested?', nobody can tell," he says. He suggests looking rigorously at your documentation and asking yourself, "Will this pass muster with The Joint Commission?" He compares it with the stringency The Joint Commission would use looking at clinical components such as the history & physical and noting whether it's dated or timed. Your documentation for environment-of-care components must be as thorough, he says.

Scott Anderson, principal consultant with the Quality Systems Group LLC in Linn, OR, also sees a huge emphasis from The Joint Commission on fire safety. He points to a violation he often sees with penetrations in fire and smoke walls. "The life safety code says you have to divide your building up into compartments, smoke compartments and then larger fire compartments, to keep a fire from spreading, and the integrity of those walls has to be maintained from floor to the deck of the floor above," he explains. "And so, it's largely in the spaces that you can't see above the ceiling." With all the electronic systems for electronic medical records, pharmacy systems, radiology systems, there are a lot of wires "to support those systems, and those wires have to go through the walls and then the patchwork has be to done to make sure that the integrity of that wall is maintained."

He says The Joint Commission will look for this, "but these are unseen dangers from a fire safety standpoint above your head that make it more difficult to track and fix."

In one facility, a Centers for Medicare & Medicaid Services surveyor found penetrations in a closet in the admitting manager's office in the back corner of the admitting department, Anderson says. "I thought, how in the world did they even find this room, let alone that there was [a violation here]?"

CMS surveyors, he says, will actually use a blueprint while inspecting your buildings. "They will take a copy of those drawings and they will highlight as they check each location, area by area. Even with that, that may take them several days, sometimes a team of two or three or even four," Anderson says. "The Joint Commission life safety code specialist surveyors will do the same thing, follow the same methodology. But often they will need to spot check in order to get through the very large buildings in a one- to two-day time frame."

Now, The Joint Commission may give you a pass if you have a penetration and documentation proving you are working on fixing it, says Glenn D. Krasker, MHSA, FACHE, president and CEO of Critical Management Solutions, a consulting firm based in Wilmington, DE. "CMS doesn't have that hole, doesn't have that functionality within, doesn't have that allowance that's in their survey process. So they find one hole, you get written up for it," Krasker says.

Anderson also says another huge area for noncompliance with Joint Commission standards deals with egress corridors. Hospitals should not store anything in egress corridors to allow safe exits in case of fire, Anderson says. If you do have equipment there, such as environmental services carts or EKG carts, he says, it must be on wheels and on one side of the hallway with the same 30-minute "in use" criteria. The two allowable exceptions, he says, are crash carts "because they may be needed at any particular time... and the risk of not having it accessible is considered greater than the risk of fire safety" and patient isolation carts or patient isolation materials.

Why is the egress issue a chronic one for hospitals? "Lots of hospitals were built a long time ago, before we had as much medical technology as we have now. Storage issues are just chronic problems in hospitals. You know, part is maximizing your storage and having them being as organized as you can be in storage." Some hospitals use the Lean approach to redesign and found they don't need all the supplies they have on hand, he says. "They've done better about that," he says.

As for maintenance on machines or equipment, Anderson says, it's best to first check all points of entry. "So for any new equipment, the biomedical engineering staff have to work closely with where that equipment is checked in or where it's coming into the organization, usually through purchasing materials management. That relationship in most hospitals is pretty strong; if it's not, it ought to be." Rented or privately owned equipment should be checked as well, which can be more troublesome, he says.

"The problems with it is, when it is patient-owned, then there are more and different points of entry. It might be after hours through the ED. So it's building those relationships with those points of entry and building knowledge with your nursing staff [or respiratory staff] that any equipment that the patient brings in that is electrical needs to be checked out and to alert biomedical when they see something," he says.