Greeley Response to Recent CMS Statements about Temporary Privileges

Recent public statements by CMS representatives have raised questions about the mechanism a hospital should use to authorize /approve temporary privileges. Specifically, that the CMS CoPs do not allow the CEO to sign off on temporary privileges and that only the governing body can grant privileges (including temporary privileges).  These statements have caused a great deal of discussion in the field.  We are monitoring the discussion and provide the following analysis:

The CMS Conditions of Participation (“CoPs”) require that a hospital’s Governing Body approve each practitioner’s Medical Staff privileges. Neither the CoPs nor the corresponding CMS interpretive guidelines specify the method that must be used for such Governing Body approval. Most Governing Bodies appoint a Chief Executive Officer (“CEO”) to act on its behalf to award privileges on a temporary basis (e.g., until the next Board or Board Committee meeting for new applicants or when necessary to meet urgent patient care needs) … just as the Board empowers the CEO to enter into contracts and perform other governance functions on the Board’s behalf.

Greeley is working with CMS, the Joint Commission, Healthcare Facilities Accreditation Program, the American Health Lawyers Association, and others to resolve this situation. We recognize that hospital Boards must have a reliable and safe mechanism to award privileges in the face of urgent patient care needs: whether it be to treat patients during a community wide disaster, to enable a sub-specialist to perform a rare or new procedure on a hospital’s patient, or to assure that there are sufficient physicians to examine and treat patients presenting to the emergency department. Awarding temporary privileges has been a mechanism used for decades to safely and reliably meet this need. We also recognize the Board’s responsibility to oversee the Medical Staff credentialing and privileging process and to assure that each practitioner to whom it awards privileges is fully qualified (by credentials and proof of current competence).

We will continue our discussions and keep our consultants and clients advised in the days and weeks ahead.

Sally Pelletier, Chief Credentialing Officer


High Level Disinfection: Challenges with Infection Prevention and Control Standards

By now everyone should be well aware that two categories of standards rise to the top in the volume of regulatory findings. These are Environment of Care and Infection Prevention and Control.  One standard in particular receives a lot of citations varying widely in range: Joint Commission Infection Prevention and Control standard IC.02.02.01.  However, while a variety of findings roll up under this standard, a common theme is evident:  high-level disinfection and/or sterilization. This is also a high vulnerability focus area from a CMS compliance issue.

Let’s consider for a moment the challenges associated with high-level disinfection. The process is:

  • Problem prone – numerous steps with varying requirements for each
  • High risk – if not performed correctly, patient harm can occur
  • Potentially widespread throughout an organization
  • Often is not well-standardized across the organization (even in locations using the same products on similar equipment)

One of the first steps to ensuring high-level disinfection is performed in a safe and compliant manner is to determine the current state of the processes within the organization. On the surface this sounds simple, but there are numerous types of equipment undergoing high-level disinfection in any facility as well as a variety of high-level disinfectants.  Take a thorough and accurate inventory of all locations and staff performing high-level disinfection, the types of equipment undergoing the process and all of the disinfectant products in use.  Be sure to include a compilation of all manufacturer guidelines for both the equipment being disinfected, equipment utilized in the disinfecting process as well as the disinfectant itself.

As with all processes the simpler the process is to perform, the better compliance will be; so consider adopting a policy that covers high-level disinfection globally with posting of manufacturer guidelines for the equipment and disinfectant specific to each location that address the individual nuances of the process accordingly.

It is also important to have a sound process for assurance of staff competence and ongoing job-specific education and training, particularly when equipment or disinfectant is changed. Lastly, will be the oversight provided for the process(es) and incorporation of this into the overall Quality program.

Nancy White, Greeley Consultant

FDA Bans Powdered Gloves: Avoiding a Leadership Citation

You may have heard in passing that the FDA banned the use of powdered gloves in January 2017 due to patient and employee safety. You may have moved on thinking the use of these antiquated gloves was not an issue for you. Think you are safe? Who uses or orders powdered gloves anymore?  Think again.

Powdered gloves still exist. One key will be to check existing stock, especially as your organization acquires older physician offices, surgical centers, or therapy practices. (Think high shelves in older physician offices where staff would say “I don’t know what that is up there.”) Previously privately-owned organizations may have continued to order powdered gloves or may have suffered from “we can’t throw away perfectly good stuff” syndrome.  Or, as health care professionals, we are famous for having an area of expired or no longer used items on the premises for Dr. Smith’s next mission trip.  (An honorable mention that results in a win in the ‘no good deed goes unpunished’ category.)  Finally, the other key is to remember that just because the FDA has banned the gloves for use does not mean that general stores or Materials Management or Supply Chain Management does not have access to order the powdered gloves.

WHAT DO YOU NEED TO DO? Contact your Environment of Care Committee and individuals with responsibility for new acquisitions to ensure they search for the banned gloves. Contact Materials Management/Supply Chain Management to ensure they do not stock powdered gloves but have flagged this item as not acceptable for ordering. These actions will save you a painful Leadership citation from The Joint Commission!

Beth VanOrsdale, Greeley Consultant

Yes, you can still clarify Joint Commission findings – Part 2

How to clarify

Don’t get hung up on the clarification format. Sometimes explanations don’t fit well into the Joint Commission’s “who, when, what, how, and why” outline and your explanation won’t be clear.

Future posts will walk you through specific examples of successful clarifications, but overall you will need to demonstrate:

  • that the hospital had a process that complied with the actual requirement in place at the time of survey;
  • that the process was approved by the right folks at the hospital;
  • that the process was implemented using an effective implementation process (education, reinforcement, etc.);
  • that the process had been in place for a significant amount of time prior to survey (ideally for at least the previous year); and
  • why you believe this process complied with the requirement at the time of survey.

Do your homework

Before you decide whether to clarify what seems to be a misinterpretation of the requirement, check the facts.

  • Read the element of performance carefully. What does it really require.
  • Read the relevant portions of the CMS interpretive guidelines.
  • Read recommendations from nationally recognized standard-setting bodies such as CDC, AORN, AAPIC or other relevant entity.
  • Read recent literature.

If this homework validates that the finding is inaccurate, then please put this information into the clarification.

If this homework uncovers a disparity between your process and CMS requirements or recognized guidelines, you will want to change your process instead of trying to clarify the RFI.

What if you miss the 10-day clarification window?

The hospital has ten business days after the survey report is posted to submit a clarification. But, what if you realize that the finding was inaccurate after the ten-day window has closed? Then, reflect the existing, compliant process in your evidence of standards compliance.

After doing your homework, explain what you will do going forward to comply with the requirement. The fact that what you will do going forward is the same as the process in place at the time of survey is irrelevant. Your proposed evidence is either sufficient (shows compliance with the requirement), or it is not.

Important: balance safety, experience and efficiency

Whether clarifying a survey finding, crafting evidence of standards compliance, or fixing a problem you found yourself, it is extremely important that the process at the heart of this clarification or fix is:

  • safe (and compliant)
  • promotes a positive experience for patients, staff members and providers, and
  • is efficient.

If the fix (or the existing process) does not meet all three of these criteria, then you are not done; a better process design is indicated. (More about the three features of a reliable process in later blog posts.)

In future posts …

We will give examples of how to clarify specific common findings. Findings like medication security, care planning, abuse and neglect screening and many more.

So stay tuned.

Bud Pate, VP Content Development, Consulting

Yes, you can still clarify Joint Commission findings.

Rumor has it that the Joint Commission removed the option to clarify survey findings. This rumor is not true. It is more important than ever to make sure that corrective actions are based on accurate findings lest we get off track by trying to fix things that are not broken.

What went away at the first of 2017:

There are no more rate-based or “Type C” elements of performance in the Joint Commission’s Hospital standards manual. Therefore, there is no longer the opportunity to “audit” a finding away by measuring performance at the time of the survey to prove that the defect observed was present less than 10% of the time. So, type C rate-based clarifications are gone, along with measures of success that were required to demonstrate and 90% or higher rate of compliance over a four-month period. (Hooray!)

There is also no opportunity to clarify a RFI based on a document that was found by hospital personnel after the survey was complete. It therefore behooves the hospital to have required documents at the ready and to dedicate resources during the survey for last-minute scavenger hunts. This, too, makes sense.

However, if a finding is just wrong, the hospital can and should clarify. You damage yourself, and, you damage the institution, by trying to fix something that is not broken.

We’ve helped clients with hundreds of survey reports of all kinds in the last decade, and we know that most survey reports have some level of inaccuracy … this is not a criticism of the survey process, it’s just a recognition of the human condition: “to err is human …”

When to clarify

  • Clarify when the observation documented in the survey report is not accurate.
  • Clarify when the observation is accurate, but the hospital nevertheless complies with the standard.

Even if there are 20 observations under one element of performance and only 1 of them is wrong, clarify. Say thank you for the 19 observations that were accurate, but get the 20th inaccurate observation removed. Why? Well, the RFI may not go away, but your post survey improvement efforts will focus on real issues.

Don’t fall into the trap of thinking that the Joint Commission is offended by clarifications.

Some of us are loathe to object to a survey finding. Don’t be. The Joint Commission doesn’t mind. Be courteous and respectful for sure, but don’t hesitate to let the Joint Commission know when you think a survey finding is wrong. There are two possible outcomes as a result of submitting a clarification:

  1. You will get the errant finding removed from the report (or, if you miss the formal clarification window, the citation will be “corrected” by merely demonstrating the compliance of existing systems), or
  2. You will be educated about why what you thought was an erroneous finding was actually correct.

Either way, the discussion is worth having. The next post will focus on how to clarify Joint Commission findings.

Bud Pate, VP Content Development, Consulting


Proposed Changes to the Joint Commission’s Suicide Prevention Safety Goal

The Joint Commission has proposed some changes to it’s national patient safety goal for suicide prevention. The proposed requirements were posted for comments on Monday, March 20 and comments will be accepted as part of the filed review through May 1, 2017.

The suicide safety goal continues to apply only to patients in behavioral health institution and patients in hospitals who are being treated for emotional or behavioral disorders. The proposed standard calls for the use of evidence-based assessment tools for screening and for a more in-depth assessment when patients are screened as a potential suicide risk.

What the proposed standard does NOT do is provide clarity about patients in the emergency department who are being medically screened and when the fundamental decision about whether to place the patient on an involuntary hold is being made. These new standards may provide an opportunity to provide clarity for this problematic issue.

Stay tuned for our final analysis and a copy of our comments, which will be posted on this site in the near future.

Click HERE to visit the Joint Commission web page related to the field review of these proposed standards.

Tynisha Smallwood,  Associate Consultant


Happy Anniversary Life Safety Code 2012!

As we move ever onwards towards the close of our first year “under” the 2012 Life Safety Code, there was one item of deadline that I wanted to touch upon before it got too, too much further into the year. And that, my friends, is the requirement for an annual inspection of fire and smoke door assemblies – the first go-round of this activity must be completed by July 5, 2017.

For those of you keeping track for Joint Commission purposes, this activity falls under the EC chapter under the standard in which all those other pesky life safety-related inspection, testing & maintenance activities live – EC.02.03.05. Some important things to keep track of as you prepare for this as a surveyable event:

  • Don’t forget to make sure that your WRITTEN documentation of the door assembly inspection includes the appropriate NFPA standards reference – in this case you have quite a few to track: NFPA 101-2012 for the general requirements; NFPA 80-2010 for the fire door assemblies; and, NFPA 105-2010 for the smoke door assemblies).
  • Please make sure that the individual(s) conducting these activities can “demonstrate knowledge and understanding of the operating components of the door being tested” (if this sounds like it might be a competency that might need to be included in a position description and performance evaluation, I think you just might be barking up the correct tree).
  • The testing is supposed to begin with a pre-test visual inspection, with the testing to include both sides of the opening.
  • If you are thinking that this is yet another task that will be well-served by having an inventory, by location, of the door assemblies, you would indeed be correct (to the best of my knowledge). As a caveat for this one, please also keep in mind that this would include shaft access doors, linen and trash chute – while not exactly being endless, the list can be pretty extensive. At the moment, from all I can gather, fire rated access panels are optional for inclusion, though I don’t know that I wouldn’t be inclined to have a risk assessment in one’s back pocket outlining the decision to include or not to include (that is the question!?!) the access panels in the program.

I’m thinking you will probably want to encourage your facilities and safety folks to “capture” this as a recurring activity in your organization’s work order system, as well as developing a documentation form. A couple of things that you should make sure are in the inspection/testing acitivity are:

  • Making sure that there are no open holes or breaks in the surfaces of either the door or the frame
  • Making sure that door clearances (also known as undercuts – basically the distance between the bottom edge of the door and the surface beneath it) are in compliance (no more than ¾ inches for fire doors; no more than 1 inch for corridor doors; no more than ¾ inches for smoke barrier doors in new buildings)
  • Making sure that the gap between the meeting edges of door pairs are no more than 1/8 inch wide
  • Making sure there are no unapproved protective plates greater than 16 inches from the bottom of the door
  • Making sure the latching hardware works properly
  • If the door has a coordinator, making sure that the inactive door leaf closes before the active leaf
  • Making sure meeting edge protection, gasketing and edge seals (if they are required – depends on the door) are inspected to make sure they are in place and intact

I think the other piece of the equation here is that the folks coordinating this activity need to keep in mind that “annual” is a minimum frequency for this activity; ultimately, the purpose of this whole exercise is to develop performance data that will allow you to determine the inspection frequency that makes the most sense for compliance and overall life safety. Some doors (and I suspect that you could rattle off a pretty good list of them without even thinking about it too much) are going to need a little more attention because they “catch” more than their fair share of abuse (crash, bang boom!).

Please reach out to your Membership Director (  if you have any questions or concerns in this regard, including on-site visits to help ensure ongoing compliance with this process – and all your other accreditation needs!

Steven A. MacArthur  – Senior Consultant



Do you Gemba?

Have you heard of the term Gemba walk? If you or your organization is involved in LEAN initiatives, you are familiar with this term. The Gemba walk means quite literally getting close to where the work happens and making first-hand observations. Problems and issues are often brought to the leadership table to discuss and make decisions; however, do we truly understand the work, the space, and the people surrounding the issue? The Gemba walk is in order so that we can see the problem first hand and discuss with the staff what they are experiencing. A fundamental of the Gemba walk is to go to where the work is done prior to any discussion of potential resolutions. We must resist the temptation to enact solutions thinking that we are trained professionals who have solved many similar problems in the past. Get out of the board room and our offices! While out and about making observations, know the two other fundamentals of the Gemba walk—ask why and show respect to all people.

In our consulting work with The Greeley Company, we often will make recommendations about a service line or area that is working in cramped quarters. (And we all know what a commodity space is in every hospital!) In making the recommendation that the space be evaluated, we generally will ask “Have you been in that area when the staff are performing their essential duties?” If a leader has been to the area, generally that visit took place in off hours; however, the “answer” that we receive most often varies from the sound of “crickets” to leaders looking down while furiously writing notes.  I would imagine if any of us worked for a day in one of those cramped departments, we would have a long list of improvements and efficiencies from having worked alongside our colleagues and truly spent time talking with them and asking why.

Another area where the Gemba walk will serve you well in your leadership duties is when you have findings on a TJC or CMS survey. While the typical plan of correction response is required to be written quickly, the implementation deserves a Gemba walk. The Gemba walk, by asking why, will flesh out inefficiencies and keep us from creating another problem while trying to solve the initial problem.  In addition, we will be able to determine what unique workarounds have come into being that led to deviation from our policy (and probably led to the citation.) The Gemba walk will help us address  what equipment and training are needed as well as other locations that may have the same issue.

In working recently with an organization to refine sterile processes, the organization had completed multiple steps to ensure safe sterilization of instruments. When all steps had been completed, all surgical instruments were to be reprocessed to ensure all instruments were safe and ready to use, as well as be ready for a regulatory review.  Knowing that reprocessing all surgical instruments would be a monumental undertaking, I was quite surprised on my return trip three days later to hear that everything was reprocessed.  I asked about how much overtime the job took, and I received a blank stare.  Time for a Gemba walk!  What sterile processing had heard was that all surgical “boxes” had to be reprocessed, so they had only reprocessed a few instruments—no trays, and no single peel packs. Imagine that regulatory disaster! As the director and I walked through the area, he understood the task his team really had to undertake.  And here is where the next fundamental of Gemba comes in—show respect.  While the job of reprocessing all instruments was obvious to me and the leaders of the organization, it definitely was not obvious to him.  I owned part of that misunderstanding and showing respect to him as a fellow colleague was fundamental. During this high-stress time, not only was showing respect the right thing to do, showing disrespect through angry words or attitude would only hamper this situation.

How do you incorporate Gemba into your already time-challenged day?

  • Schedule a Gemba round on your calendar. It’s not negotiable.
  • Explain to the leader what you are doing and that no one is in trouble. If you round regularly, this issue will be easy to overcome. If you are new to this area of responsibility or have not rounded regularly, attend a staff meeting and explain what you are doing.
  • Have a game plan by knowing the department and what is important to them. Know their metrics and successes. Take a patient story to help connect their department to the care of the patient. Take candy!
  • Your Gemba round is to make observations and talk to staff:
    • What is going well?
    • What are your struggles in your department?
    • Do you have the tools and equipment to do your job?
  • Finally, celebrate any successes the area has experienced. Thank them for the opportunity to have spent time with them and for their role in the organization. And of critical importance, explain that any deviation that was found or discussed will not be punitive, and keep your word!

What you will find by using the Gemba walk is more time on your calendar through the elimination of continually having to revisit the same old problems. Finally, the Gemba walk produces many other effects including building trust with our colleagues at the bedside, giving us the opportunity to re-share first-hand the goals of the organization, and celebrate successes of the team.  Isn’t that what leadership is about?

Beth VanOrsdale DNP, MHA, CPHRM


Negligent Credentialing: Avoid Being in the Headlines

I always look forward to the mail on Friday because it usually includes the newest issue of People Magazine.  I know what you might be thinking but reading about all the latest “gossip” as well as leading news is my guilty pleasure.   Many times, I do find the articles to be quite informative, not all of them are centered on the Hollywood drama.  So, I’m sure you can appreciate my surprise when a recent issue included an article by Christine Pelisk titled “Serial Killer Doctor Deadly Revenge”, Dec 12, 2016.

A physician, Dr. Anthony Garcia has been convicted of killing 4 people in what the author describes as “a twisted plot of vengeance”. The first murder occurred March 13, 2008 in Omaha, Nebraska.  The son and housekeeper of Dr. Garcia’s previous pathology residency program director, William Hunter, MD, were found dead in their home.  The second murder occurred five years later, May 14, 2013, Roger Brumback, MD, the former chair for the Department of Pathology at Creighton, and his wife, Mary, were both found dead.

The case is certainly very sad and unfortunate for the lives lost and the families affected by their unnecessary deaths. However, it has intrigued my curiosity just a bit.   As I read the article and then did some additional research, I continuously questioned, “How did this disturbed physician continue to move around, apply and get accepted to different training programs?”   It is obvious that his history of behavior and continuously failing to fully disclose his various training programs and the reasons for leaving them eventually caught up with him and lead to the murders.

So, now I ask, “What can we learn from this?” First, I’d like to briefly review what is required from a regulatory stand point related to primary source verification.  Regardless of what regulatory agency your organization is accredited by, the standards for credentialing practitioners are fairly similar in identifying at a minimum what is required. Healthcare organizations are required to primary source verify core elements of an applicant, i.e. education, training, current license status, competence and ability to perform privileges requested.  If you are doing that, you will be compliant with what is required.  However, is there more your organization can do and/or should do to ensure that qualified and quality practitioners are being appointed?  The answer is yes.

The Greeley Company has developed The Greeley Evolving Credentialing Standard, best practices in credentialing. I’d like to review a few “best practices” that would have quickly identified some of Dr. Garcia’s questionable history.

First, in addition to verifying completed training programs, primary source verify incomplete training programs.  The majority of the time, you will find that physicians simply change their minds as to what specialty of medicine they want to pursue, which is perfectly acceptable.  However, in some cases, the example of Dr. Garcia, you may find that an applicant has been terminated from his/her program due to behavior issues or not performing well.  Reasons behind an applicant not completing a training program may be very crucial in the decision making process.

Second, verify all state medical licenses not just the license in your state. Why?  Because having verification of lifetime licensure will provide you with a report from each state(s) a physician has practiced in or simply applied to and more importantly was that license in “good standing” and without restrictions.  At the time of renewal, primary source verify any active license, again even those outside of your own state.

Third, run a criminal background check, which are now becoming standard practice within credentialing. If your organization is not requiring a criminal background check, you are no longer the norm, therefore, putting your organization at risk.  Negligent credentialing attorneys know that the new norm is that most organizations are running criminal background checks on all initial applications; some are now even running them at the time of renewal.

Fourth, conduct an internet search. It doesn’t have to be anything complicated but a quick search will provide you with information that may be important to that particular applicant.  A search may alert you to discrepancies in the application or criminal activity.

Establishing a higher standard within your organization by going above and beyond the minimum requirements and implementing best practices will provide your medical staff leadership with a more thorough application, allowing him/her to make a more objective recommendation. In addition, your organization will have a better stand against negligent credentialing lawsuits or completely avoid making the headlines by not appointing questionable practitioners.

Unfortunately, despite the verification process by the different training programs and the different state medical licensing boards, lives were lost due to a very disturbed Dr. Anthony Garcia. However, the case emphasizes the importance of the verification process and why healthcare organizations have such a responsibility in patient safety, ensuring good quality practitioners are being appointed.

Frances Ponsioen, CPMSM, CPCS

Credentialing Resolutions for the New Year

January is a time when many of us reflect on the happenings of the previous year and will set new goals for 2017.   Some of the top resolutions include spending more time with family and friends, exercise more, learn something new, and get organized.  As MSPs, it is also a good time to evaluate current processes to ensure continued compliance and identify ways in which to increase efficiency and effectiveness of those processes.

Meeting applicable regulatory and accreditation requirements reflects an organization’s compliance with an industry-recognized set of standards. When working with healthcare organizations, my first priority is to identify areas of concern or risk related to CMS and any applicable accrediting body.   Below are several areas that I frequently see organizations overlook with regards to the credentialing and privileging process for you to keep in mind.

  • Reappointment cycles – many healthcare organizations are required to adhere to a reappointment cycle that does not exceed two years, but some may inadvertently be extending that timeframe by an extra day because they do not consider that a two year timeframe does not begin and end on the same day. A compliant two year reappointment cycle would be two years less one day, e.g. February 1, 2017 through January 31, 2019.
  • Practitioner identity – specific to TJC-accredited organizations, validating the identity of a practitioner prior to delivering patient care must be performed by a representative of the healthcare organization by physically viewing an appropriate form of identification and confirming it matches the individual that appears before him or her. A copy of the actual identification is not required to be maintained, but many organizations utilize a template form or database fields to document compliance. It is important to recognize that a notarized copy of a driver’s license or passport does not meet the intent of this standard.
  • Telemedicine – while both CMS and TJC require that the distant site practitioner is licensed by the state where the patient is located, CMS requires that organizations must also verify that the distant site practitioner is licensed by the state where the practitioner is located (CoP 482.11(c)). So to ensure full compliance, be sure this CMS requirement is evident in your policies and procedures as well.

Implementing leading practices that exceed regulatory and accreditation requirements is also a common goal of many MSPs to achieve a more risk-adverse and efficient credentialing and privileging process. Consider incorporating the following components into your policies:

  • Background checks and drug screens – while these elements are standard operating procedure for employees, many organizations do not consider performing these for all medical staff members and advanced practitioner professionals. While not required by any regulator or accreditor, these elements have become an industry standard practice and if an organization is not performing them, it may be at higher risk for negligent credentialing claims.
  • Internet search – the volume of data available at the tip of our fingers is astounding. MSPs can easily obtain additional information on an initial applicant that may be useful when considering a new practitioner for membership or privileges. Keep in mind that any data element, either positive or negative, should not be used solely to make a decision, but is merely another piece of the puzzle that MSPs attempt to solve through the credentialing process.
  • Reappointment references – while obtaining professional references is critical at initial appointment, they are not required at reappointment. The information collected through your internal monitoring processes should provide your organization with sufficient information to determine the competence of your active practitioners. Streamline the reappointment process by only requiring references for those practitioners that perform limited to no volume of patient activity within your organization.

For more opportunities to enhance your credentialing program, be sure to review The Greeley Evolving Credentialing Standard, available on our website at

Amy Niehaus, CPMSM, CPCS, MBA

The song remains the same – only the tempo has changed!

As we move into the final weeks of 2016 (and towards the promise of a very different 2017 regulatory landscape in the aftermath of the presidential election), it is very clear that each healthcare organization will continue to experience (endure?!?) an elevated focus on the management of the physical environment. And the clarity is based on a number of factors that have created something of a “perfect storm”, but first a little history lesson.

Way back (or it seems like a really long time ago) in 2015, we covered a couple of issues relating the management of the physical environment in healthcare, the first being Mark Pelletier’s (Joint Commission COO) exhortations to the leaders of each healthcare organization to focus more on the management of the environment (if you care to re-visit those halcyon days, you can check out the January 2015 blog here: ). I’m not sure that his utterances were truly taken to heart, but the mid-2015 survey results did not seem to bear out much attention to Mr. Pelletier as 9 of the top 10 most frequently cited standards revolved around the environment of care (with a dollop of infection control/prevention thrown in for good measure – details here: Https:// ).

Which brings us squarely to the present and our little storm of regulatory challenges.

  • EC/LS standards remain among the most frequently cited during TJC surveys (7 out the 10 most frequently cited standards for the period January – June 2016 – please check out the September 2106 issue of Joint Commission Perspectives for the details!
  • CMS, in its report card to Congress identified the Physical Environment as the largest “gap” of oversight during all accreditation organization surveys (that’s not just TJC, that’s everyone else as well – DNV, HFAP, CIHQ, etc. – see Table 13 on page 44 of the document posted here: )
  • Also in its report card to Congress, CMS singled out TJC as lagging behind their competition when it comes to improving their identification of deficiencies relative to the Conditions of Participation (see Table 7 on Page 38 – same link as above; TJC is the only accreditor that did not improve their disparity rate in the most recent period). It appears that the season of beating up on TJC is not over yet…
  • CMS adoption of the 2012 Life Safety Code (effective survey date of November 1, 2016) will create some level of confusion and uncertainty that always accompanies “change” – remember, it’s not just “us” that has to learn the practical application of the new stuff – the surveyors have to catch up as well!
  • TJC is in the process of revising their Environment of Care and Life Safety chapters to more closely reflect CMS requirements; starting January 5, 2017, nearly 250 (244 rough count) performance elements were revised in the EC/LS chapters and nearly 40 (39 rough count) performance elements were newly created. Again, we are on the hook for managing that learning curve!
  • Recent TJC survey reports indicate an increasing focus (and resulting vulnerabilities) on outpatient locations, particularly those engaging in high-level disinfection and/or surgical procedures. The physical environment in all areas in which patients receive care, treatment and services are generating up to 60% of the total physical environment findings in those recent surveys.
  • CMS published its Final Rule on Emergency Preparedness (effective November 2016 with full implementation of requirements due November 2017); while organizations in compliance with current TJC Emergency Management standards will be in substantial compliance with the new Rule, there will be some potential vulnerabilities relative to some of the specific components of the Rule.
  • Introduction of TJC’s SAFER matrix which will result in every deficiency identified during the survey process being included in the final survey report; formerly, there was a section (Opportunities For Improvement) for the single findings that didn’t “roll up” into a Requirement For Improvement. With the SAFER matrix, everything they find goes into the report.
  • As a final “nail” in the survey process coffin, effective January 2017, Joint Commission will no longer provide for the clarification of findings once the survey has been completed. This shift is the result of two key programmatic elements – the availability of compliance documentation during survey (previously, documentation that was “found” after survey could be submitted for clarification); and the retiring of the “C” performance element category (previously, an audit of compliance could be submitted to clarify survey findings).

In my mind (which is a barren wasteland most of the time), particularly as a function of CMS calling out the physical environment as an area of concern, the stuff noted above indicates the likely result of the next 12-24 survey months as a continued focus on the physical environment by the entire survey team (not just the Life Safety surveyor) and a likely continued plateau or increase in findings relating to the physical environment. Eventually the regulatory focus will drift back more towards more patient care-related issues, but right now the focus on the physical environment is generating a ton of findings, and since that appears to be their primary function (generating findings), there’s always lots to find in the environment. As I like to tell folks, there are no perfect buildings/environments, so there’s always stuff to be found – mostly fairly small items on the risk scale, but they are all citable. The fact of the matter is that there will be findings in the physical environment during your next survey, so the focus will shift to include ensuring that the corrective action plans for those findings are appropriate, but also can demonstrate consideration of sustained compliance over time. Preparing for the survey of the physical environment must reflect an ongoing process for managing “imperfections” – not just every 36 (or so) months, but every day.

Steven A. MacArthur, Greeley Senior Consultant