JCAHO surveyors focus on life safety code compliance

Survey fees to increase next year

As of Jan. 1, 2005, hospitals will be paying an estimated $2700 more in average triennial survey fees. This is due to the need to make further investments in the new accreditation process that was introduced this year, according to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).

In addition, a certified health care engineer will be added to surveys of hospitals with 200 or more beds, which comprise about a third of the hospitals accredited by JCAHO, with an additional survey fee of $3,500. Additional training in life safety code compliance will be given to surveyors of smaller organizations. JCAHO worked with the Chicago, IL-based American Society for Healthcare Engineering to design the training curriculum and determine how to conduct the add-on survey, says Paul Schyve, MD, senior vice president at the Joint Commission.

The goal is to improve the Joint Commission’s ability to evaluate hospital compliance with the life safety code, a specific code of standards issued by the Quincy, MA-based National Fire Protection Association, Schyve says. A recent Government Accounting Office report indicated that of the 167 serious deficiencies identified by the Centers for Medicare & Medicaid Services’ (CMS) validation program from 2000 through 2002 that were not detected by JCAHO, 87 were related to a hospital’s physical environment, which includes life safety code standards for fire prevention and safety. For these three years, JCAHO failed to detect 81% of the serious physical environment deficiencies identified by state agency surveyors, according to the report.

"We have realized for many years that we could do this better," says Schyve. "The conclusion was that we wanted to find better ways to evaluate life safety code compliance, and the best way to do that would be to provide additional training for our surveyors for smaller organizations, but for surveys of some larger organizations to actually add an expert in that area as part of the survey."

Although fires are rare, they can be devastating to patients and staff when they do occur, notes Schyve.

Compliance with the life safety code requirements will definitely be a key focus during future surveys, predicts Judy Homa-Lowry, RN, MS, CPHQ, president of Homa-Lowry Healthcare Consulting in Metamora, MI.

To avoid violations, the best thing you can do is familiarize yourself with the requirements, she advises. "When you look at the environment of care chapter, it is so huge. There are plenty of related regulations that you need to be familiar with, such as the CMS requirements," she says.

Look for problems by doing proactive assessments on the units and eliciting feedback from direct caregivers, recommends Homa-Lowry. "It’s good to look for potential breakdowns up front," she says. "The people working on the units have the best appreciation for what the potential risks to patient safety can be, especially if they understand the processes on the unit involving other departments. They do not necessarily need to know how to fix the process, but just be aware of when there is the potential for a problem."

If problems are discovered, resolve them without delay, Homa-Lowry urges. "If a piece of equipment needs to be tested and was overlooked by the bio-med department, contact them before using it. If there were deficiencies noted during a fire drill, make sure you address them right away, and test the corrective action, instead of waiting for the next committee or waiting for another drill," she says.

Staff should be encouraged to report problems or potential violations, Homa-Lowry says. These might include door latches that don’t work properly, improper storage of oxygen near equipment that is a potential fire hazard, or storing too much oxygen. "Safety is everybody’s responsibility," she says.