• Clarifications and Expectations: Clarifying Changes in the Life Safety Survey Process by George Mills  EC News, October 2016, Vol 19, #10, Pg 5 – In light of Project Refresh, a number of changes in the Life Safety Survey Process will also be occurring particular with regard to the clarification process, the Statement of Conditions, Interim LIfe Safety Measures, Time-Limited Waivers and Equivalencies. See why having your documentation in order and readily available during survey will be all the more important.
  
• Click here for our REVIEW(Mbr/Guest); the FULL TJC ARTICLE(Mbr); to share a COMMENT(Mbr/Guest).

**RECOMMENDED READING:

1. PR: The SAFER Matrix and Changes to the Post-Survey Process … (PDF)[REF: SC]
2. TS: Infection Prevention and Control Standards Update for 2017 (PDF)[REF: IC, SC]
3. EC: C&E: Clarifying Changes in the Life Safety Survey Process (PDF)[REF: AOM, EC]
4. EC: Performance Improvement and the Environment of Care (PDF)[REF: EC, Tool]

**USEFUL UPDATES, LINKS & DOWNLOADS:

• TJC: As of January 1, 2017, the only RFIs eligible for the 10-Day Clarification Process are those RFIs that the customer believes were cited in error, because the organization believes it was in compliance at the time of the survey.
• TJC: The Customer Value Assessment (CVA) has been replaced by a new, 5 minute or less Surveyor and Reviewer Evaluation to be sent to the organization via link at the end of survey. [Perspectives V36#10pg5]
• TJC: CMS has made changes in its Hospital IQR program for 2017 , but TJC’s list of eCQMs only includes 13 of CMS’s15 and freestanding psychiatric hospitals will continue to report on the 4 required HBIPS (HBIPS-1, HBIPS-2, HBIPS-3, HBIPS-5) – [Perspectives V36#10pg7]
  
• TJC: Key Def – “The Joint Commission defines high-alert medications as those medications involved in a high percentage of errors and/or sentinel events, as well as medications that carry a higher risk for abuse or other adverse outcomes. Examples of high-alert medications include investigational medications, controlled medications, medications not on the approved US Food and Drug Administration (FDA) list, medications with a narrow therapeutic range, psychotherapeutic medications, and look-alike/sound-alike medications. Hazardous medications are those in which studies in animals or humans indicate that exposures to them have a potential for causing cancer, developmental or reproductive toxicity, or harm to organs.”  [Source, v14#10pg2]
• CMS: [CMS–3178–F] Medicare and Medicaid Programs; Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers
  
• Latest TJC Blogs: Physician Leader Monthly – Leadership Blog
  

**SupporTips

PR: 

This article provides an overview of SAFER. It summarizes points of change:
• No more designation of Direct or Indirect EPs, A or C categories
• No more Opportunities for Improvement (OFIs)
• No submission of Measures of Success (MOS) for due dates after 1/1/17.
• No more 45-day ESCs
• “As of January 1, 2017, the only RFIs eligible for the 10-Day Clarification Process are those RFIs that the customer believes were cited in error, because the organization believes it was in compliance at the time of the survey.”
and a couple key features that will remain the same.
• The 60-day ESC will continue and be applied to all/any SAFER findings
•  10-day post-survey clarification opportunity
It also reviews the relationship of matrix findings and post survey follow-up requirements in a handy chart (see below).
Tip1: For more details see SPHCC review and comments on The SAFER Matrix: A New Scoring Methodology Perspectives, May 2016, Vol 35, #9, Pg 1
Tip2: Leave a comment on your survey experience with SAFER

*TS: The Road Ahead Understanding Infection Prevention and Control Standards Update for 2017 (PDF)[REF: IC, SC] The Source, October 2016, Vol 14, #10, Pg 1 JCs1610_B2

5 of the 131 EPs deleted as a part of Project Refresh came from the IC Chapter. This article provides a table listing those EP and the reason they were eliminated. Since most of deletions were because of redundancy, there is no significant impact om what is required. The exception is IC.01.05.01, EP3 that removes the requirement for having a written description of the process for evaluating your  IC Plan. The balance of the article provides a review of SAFER and an example of IC standard placement in a SAFER Matrix.
Tip: It is still important to have, be able to describe and show evidence of a systematic process for routine (at least annual) evaluation of your IC Plan and its goals.

* EC: Clarifications and Expectations: Clarifying Changes in the Life Safety Survey Process by George Mills (PDF)[REF: AOM, EC] EC News, October 2016, Vol 19, #10, Pg 5 JCe1610_B3

In light of Project Refresh, a number of changes in the Life Safety Survey Process will also be occurring.
Re: Clarification
• In the past, about half of all hospital surveys involve clarification attempts and more than half of those are related to documentation that was unavailable for some reason during survey. Effective 1/1/17, inability to produce required documentation during survey will not be an acceptable basis for a clarification.  And, with the elimination of Category C EPs, the ability to clarify an RFI by audit has also been eliminated.
Re: Documentation
• Effective 1/1/17 unmet requests for required documents will result in an RFi (that cannot be clarified).
Re: Statement of Conditions (SOC)
• Since 8/1/16 TJC stopped using PFIs and BBIs as a part of (or with impact on) the survey process and findings.  Portions of the SOC and BBI may be used by surveyors for orientation purposes only. The History Audit Trail may be used to assist in follow-up of any equivalencies.
Re: Interim Life Safety Measures (ILSM)
• Deficiencies requiring an ILSM may not be cited during survey, but failure to follow your ILSM Policy (LS.01.02.01) can/will be cited.
Re: Time-Limited Waivers (TLC)
• PFIs have been eliminated from the survey process because they allowed organizations to set their own timeframes for correction which conflicted with the 60-day CMS requirement found in Federal Register, §488.28(d),x “All LS deficiencies are now documented as RFIs.” and all RFIs require correction in 60 days.
Re: Equivalencies
• TJC says that going forward, it will no longer process pro-active equivalencies (i.e., equivalencies not related to a/the current survey event). These need to be managed first through CMS and may call for creation an Survey-related Plan for Improvement (SPFI) if more than 60 days are required for completion.
Re LS.01.01.01
• The article provides a description of  EPs 1-3 for LS.01.01.01 that repenting final approval. (See comments for details)
Tip1: Access and utilize the “exhaustive” Checklist of Required Documentation created by TJC to help ensure your awareness and availability of all required documents during survey.
Tip2: See Clarifying Clarifications – The 10-Day Clarification Process is Changing! (Note: You must first log into TJC Connect)

* EC: Performance Improvement and the Environment of Care (PDF)[REF: EC, Tool] EC News, October 2016, Vol 19, #10, Pg 8 JCe1610_B4

The key example of EOC-related PI is the fire drill. This article describes a 30 question checklisted Fire Drill Summary Report used by Carilion Franklin Memorial Hospital (CFMH) in Rocky Mount, Virginia. x
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Tip: Consider improving the structure and quality of your fire drill evaluations by adapting relevant aspects of the report illustrated on page 9 and 10 of this article.
Request: A copy of our mock up of the Fire Drill Summary Report based on this article.