Continuous compliance05.01.11 by David L. Stymiest P.E., FASHE, CHFM
Maintaining a constant state of regulatory readiness
Continuous compliance also has been called continuous survey readiness. It involves proactively maintaining a safe health care environment conducive to high-quality patient care. It essentially means having staff at all levels doing the right things for the right reasons because they understand those reasons.
Just about all accrediting agencies conduct unannounced surveys or inspections. Even when organizations think they know approximately when the next unannounced survey is due, there is the potential for random unannounced surveys or a for-cause survey. Thus, continuous survey readiness is crucial. Ongoing training and thorough staff involvement in compliance activities are essential because key managers might be unavailable when the surveyors arrive.
Many hospitals have survey-day tips and checklists for their staff. These include: knowing your role in patient safety; knowing fire and disaster procedures or knowing how to access material safety data sheets; being familiar with policies and procedures; clearing hallways; removing illegal doorstops; and checking doors.
These are all good practices. However, a real event doesn't wait until survey day. A fire can occur anytime on any day, and most survey-day tips are directly related to maintaining patient and staff safety when a fire or other event occurs. The existence of these survey-day tips is in itself a compelling argument for continuous compliance.
Some believe that continuous compliance comes with its own challenges, such as staying current with required inspections and testing, including maintaining adequate survey-friendly records. Reduced resources often are cited as the reason important tasks slip. Experience has shown, however, that an hour spent reviewing records before they are filed can save a day or more closer to survey when some records are shown to be deficient and supporting field data are no longer available. Furthermore, responding to and following up on any resulting adverse survey findings can become even more time-consuming.
Setting aside the time for ongoing compliance education also has been cited as a difficulty. Traveling to conferences has its own budgetary and time constraints, but many believe, with good reason, that the networking itself increases learning. Moreover, several organizations and consultants even will come to a site and provide focused compliance education.
The American Society for Healthcare Engineering (ASHE) and others also have responded by making distance learning available, including the excellent ASHE Managing Life Safety e-learning course. Focused education and certifications that are available for health care construction personnel and new facility staff can go a long way toward improving continuous compliance in health care facilities.
Approaches and tactics
Regularly looking at compliance allows an organization to digest issues and act on them in a timely manner. There are many different approaches to continuous survey readiness. However, the similarities outweigh the differences when they are compared. Common tactics include regularly drilling down to the details to identify compliance gaps, because those details are often where adverse survey findings originate.
Continuous compliance success factors include: leadership buy-in and involvement; structures that facilitate continuous process review and improvement; educated and involved front-line staff; regular mock surveys and tracers; and such periodic compliance reminders as memory aids, drills, and safety and compliance fairs. Staff education and involvement also can be facilitated starting with orientations and continuing with regular mock surveys, annual reviews and management meetings.
Codes, standards and accrediting agencies have many required calendar intervals for ongoing inspections and testing. A health care organization needs an effective process to ensure that required inspection and testing intervals are satisfied. If an interval is missed because the task slipped through a crack or service personnel were called away, it is too late to fix it on survey day or even six months before the anticipated survey.
Plans, policies, procedures and forms should be reviewed regularly and used in staff education, along with the codes, standards and specific requirements that drive them. Maintaining current documents in a central electronic format can ensure that outdated documents are not inadvertently used, thereby creating a potential for adverse survey findings.
Such records as field inspection reports, internal and external test reports, electronic records and filled-out forms always should be reviewed to ensure that they demonstrate full compliance with the pertinent codes, standards, Joint Commission elements of performance (EPs), Centers for Medicare & Medicaid Services' K-Tags and other relevant guidances. This review can be performed by the front-line staff who create them or by supervisory personnel.
All records received from outside service and testing personnel should be reviewed for several reasons before acceptance. The records might show failures or apparent failures that require follow-up by the organization. Rapid repairs, replacement and retesting may be needed. Interim life-safety measure (ILSM) analyses often are required, perhaps followed up by the need for some ILSMs. Furthermore, outside service and testing organizations probably do not know the specific requirements of the EPs and will not be present on survey day to explain what they meant in the inspection or test reports. One also can expect that surveyors will find any failures or unfavorable notations in records that they review.
Characteristics of organizations in continuous compliance include ongoing reviews with aggregated and analyzed data being acted upon.
Evaluations include: annual periodic performance review (PPR) process results; recent survey and inspection findings by accrediting bodies and other authorities having jurisdiction; findings by external consultants; incident reports; internal or external assessments with mock tracers; and input from others. Staff members are familiar with regulations and standards, and able to speak about patient safety and quality goals, including what the organization is doing about them.
Risk assessment is commonplace in health care when options are considered or concerns are encountered, but there is a powerful tool that can be used to identify potential risks that are not even on the table — environment of care (EC) tracers. As the Joint Commission states in the first part of the note associated with EC.02.01.01, EP-1, "Risks are identified from internal sources such as ongoing monitoring of the environment…." EC tracers often involve drilling down to the lowest level. The tracer team will follow a path and ask questions all along the way from an outsider's perspective, never assuming the answer. This process is effective in exposing potential compliance gaps. Tracers for minimizing risks include the following steps:
- Have the staff describe or demonstrate roles and responsibilities for minimizing risk.
- Have the staff describe or demonstrate what they do if a problem or incident occurs, and how to report an incident.
- Assess the physical controls for minimizing risk, such as equipment, alarms and building features; and review the testing, inspection and maintenance associated with these items.
- Assess the human controls for minimizing risk, such as responding to alarms; and review the staff competencies and education related to these human controls.
- Assess the emergency management plan and processes related to the EC risk.
- Assess the plans for responding to utility system disruptions or failures related to the EC risk.
- Assess the response roles by others and review their equipment, competencies and other assets.
Continuous life safety (LS) compliance includes: having accurate, useful up-to-date LS drawings with all necessary information; managing the resolution of LS deficiencies; using risk-based priorities; managing design and construction to ensure code compliance; and maintaining compliance of such operational LS elements as fire-response plans and unobstructed means of egress.
It also involves proactively inspecting or monitoring LS and fire-safety features that are subject to change or damage, as well as maintaining, testing and inspecting fire-safety equipment and fire-safety building features. Many organizations have established rated barrier-management programs and ramped up staff and contractor training, using current LS plans, code requirements and a permit system to reduce ongoing LS deficiencies.
ILSM tracers can involve reviewing the ILSM policy for thoroughness, then reviewing life-safety deficiencies for evidence that the ILSM policy indeed is being followed in everyday practice. This review includes not only construction and renovation projects, but also systems and areas associated with deficiencies found during testing and inspection activities or highlighted in incident reports.
Some organizations prioritize their compliance findings for potential patient impact. Priorities can be based on immediate jeopardy, issues related to multiple areas or a single area, areas that do or do not affect patient safety, and outliers or more process-oriented factors. They can be based on the level of compliance — none or almost there. The priorities also can be based on the potential degree of accreditation impact, such as hot-button issues, the Joint Commission's situational decision rules or direct impact EPs, or previous survey or PPR items. Facility professionals also can ask themselves whether the findings would be permitted to receive "observed but corrected on-site" status, not requiring planning and not posing any patient threat.
Regardless of priority, organizations should close the loop on findings by determining what needs correction, assigning accountability as appropriate, tracking open items until they are completed, and then verifying that the documentation will satisfy surveyors. Always remember — safety first; compliance second.
Sitting on top
Health facility professionals who do not have effective continuous compliance programs often report that the six-month ramp-up to an anticipated survey makes them feel like Atlas with the weight of the world on their shoulders.
This is because years of focus on compliance are being crammed into a few months, amplified by the fear that a survey might occur before they are ready.
This sense of overload and foreboding can be contrasted with an alternative approach that includes the activities described earlier, which allows them to sit on top of the figurative mountain of compliance activities at all times.
David L. Stymiest, P.E., CHFM, FASHE, is a senior consultant at Smith Seckman Reid, Nashville, Tenn., specializing in facilities engineering and regulatory compliance. He can be reached at DStymiest@SSR-inc.com.
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