Your Physical Environment

Your Physical Environment

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Joint Commission standard:

EC.02.06.01 The hospital establishes and maintains a safe, functional environment.

If you are in or around the healthcare environment you know that when people hear the words “Joint Commission” they tend to get nervous. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO), an independent, nonprofit organization, conducts a quality assessment of about 80 percent of all hospitals in the United States every three years. While the decision to become an accredited organization with the Joint Commission is voluntary, many do it to qualify for some of their government funding.

While JCAHO focuses on many areas during their assessments, one of the main benefits of accreditation is the focus that is places on the organization and strengthening of patient safety efforts. Strengthening patient safety efforts when it comes to life safety is especially important to JCAHO. This is one area they don’t take lightly. They developed a set of life safety codes for hospitals to abide by, which includes the “plans for improvement” or PFI process for hospitals.

If your safety team discovers a life safety deficiency within the hospital, JCAHO allows you three options to pursue:

  • Correct the problem immediately
  • Enter it into your work order system and complete the repair within 45 days of discovery
  • Add a PFI for the deficiency to the Joint Commission Connect (JCC)

The first two options are straightforward but what about the third? The determination that a deficiency needs to become a PFI is the easy part, but what is the process for submitting and recording a PFI on the JCC?

Several factors play into adding your PFIs to the JCC. Your management team needs to look at the time-frame for completing the deficiency, develop the budget, create an Interim Life Safety Measure (ILSM), and manage the process once the PFIs are uploaded to the JCC.

It is extremely important to create a process for managing PFIs once on the JCC. This is where a hospital can get themselves in trouble. Many facilities take a reactive approach to PFIs only making them a priority when they are an emergency or their due date is approaching fast. It is imperative that you designate someone or a small team to monitor the repair work for the PFIs and the closures on the JCC. You are setting your facility up for failure if you wait to evaluate this work until they are due.

PFIs need to be managed on a daily basis to stay ahead of the work. Budgeting for the PFI should be set at the end of the previous year, purchase need to be generated and approved, and workers need time to correct the deficiency. Be proactive by planning monthly meetings to prepare your team for what is coming due the following month and weekly follow-up meetings should be encouraged. JCAHO can come back at anytime to survey your facility. Ignoring your PFIs and your process can jeopardizing your accreditation if you are not careful.

~Kristen Price