On September 27th, The Joint Commission published their list of elements of performance to be deleted from the accreditation standards, effective January 1, 2017.  The list contained some surprises in the Environment of Care.  The deletion of these elements of performance by TJC doesn't mean you should delete these practices from your organization.  Carefully review the deletions and make the best strategic choice for your organization to be safe beyond compliance.  Let us explain:

First, a recap of those EPs to be deleted:

  • EC.02.04.01 EP 8:  FDA Safe Medical Device Act
    • Rationale:  Required by law and regulation
  • EC.02.05.01 EP 12:  Obtaining emergency repair services for utilities
    • Rationale:  Left to organization discretion
  • EC.02.06.01 EP 23:  Emergency access to locked, occupied spaces
    • Rationale:  Left to organization discretion
  • EC.03.01.01 EP 1:  Staff knowledge on eliminating or minimizing physical risks in the environment of care
    • Rationale:  Left to organization discretion
  • EC.03.01.01 EP 3:  Staff knowledge on how to report environment of care risks
    • Rationale:  Left to organization discretion
  • EC.04.01.01 EP 12:  Semiannual environmental tours in patient care areas
    • Rationale:  Left to organization discretion
  • EC.04.01.01 EP 13:  Annual environmental tours in non-patient care areas
    • Rationale:  Left to organization discretion
  • EC.04.01.01 EP 14:  Use of environmental tours to identify deficiencies, hazards, and unsafe practices
    • Rationale:  Left to organization discretion
  • EC.04.01.03 EP 1:  Clinical, administrative, and support services on EOC Committee
    • Rationale:  Left to organization discretion
  • EC.04.01.05 EP 1:  Evaluation of changes to resolve EOC issues
    • Rationale:  Implicit in EC.04.01.05 EP 1

Although some of the deletions seem to make sense, such as the SMDA deletion and the evaluation of efforts to improve the environment of care, we at MSL are particularly concerned with the deletion of the environmental tour requirements and the EP on composition of the Environment of Care Committee.

Discussion with Joint Commission leadership revealed that these elements of performance were infrequently scored on survey.  This contradicts the MSL experience at hundreds of hospitals, and would suggest that these elements of performance haven't been a priority.  We also believe that the EOC Committee and environmental tours are the glue that holds the EOC program together.  Removing these requirements gives healthcare organizations enough rope to hang themselves.

The Environment of Care Committee is intended to be a vital and important committee in a healthcare organization.  It has always represented a cross-section of the organization and demonstrated leadership involvement. 

MSL observes that, although organization leadership may be on the committee roster, there are many times when leadership attendance is highly infrequent or sporadic.  This is understandable, to some extent, based on the numerous demands on the time of the organization’s leaders.  But it also is essential that leadership sets the standards for safety in the organization.  Their presence and attendance at the EOC Committee meetings demonstrates their commitment to a safe environment and a culture of safety in the organization.  Without this requirement, leadership attendance and participation is likely to dwindle.  And with that, so may participation by a cross-section of the organization.

Now for environmental tours.  These required tours accomplish much more than meeting a Joint Commission requirement if they are conducted and used appropriately.  They get members of the EOC team out and about in the organization to see how practices and requirements are being implemented.  If properly used, they provide a wealth of performance monitoring data in the EOC, albeit frequently untapped.

Eliminating the requirements for environmental tours will likely cause some organizations not to do them at all.  Yes, they are sometimes difficult to schedule.  Yes, they are time consuming.  But they do provide valuable information on the effectiveness of the program and implementation of requirements when used correctly.  If the areas of the organization are surveyed and the checklists are put in a book, it is true that the tours are of little value and are only done to comply with the Joint Commission requirements.  But tracking and trending the data, comparing departments, and determining the most frequent, most improved, and poorest performance will direct the committee on it’s activities to improve the culture of safety in the organization.

These elements of performance will be gone on January 1, 2017.  They will not be scored by The Joint Commission, nor will they be scored by MSL on mock surveys.  But, MSL strongly believes in performance improvement and making your hospital safe beyond compliance.  We will continue to uphold environmental tours and an organization-wide Environment of Care Committee with leadership representation and participation as a best practice.

Please feel free to contact us if you have questions or would like to schedule support services.  We are here to do everything we can to make the healthcare environment safer!

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