Stuck on the same refrain: Outpatient! Outpatient! Outpatient!
By Steve MacArthur, Hospital Safety Consultant
I’m hoping to break the spell in kind of a reverse Beetlejuice invocation…
As we try to obtain some level of clarity relative to the Joint Commission survey process moving forward, there is some indication (and a fair amount of it as far as I’m concerned) that they will be focusing even more closely (thoroughly, exhaustively, etc.) on documentation, which means the survey devil will be, as it always has been, in the details. And one of the truisms of spending more time with the documents is the element of interpretation that surveyors will be bringing to the table and what they will consider evidence of compliance. At the moment, it’s not clear who will be engaging in the document review for the outpatient settings if they are not defined as a healthcare or ambulatory healthcare occupancy, but there is most definitely a movement afoot to include LS/EOC documentation for all care locations. Now, the applicability of the document review is going to be based on what systems, protections, etc., are present at each of the care locations, but the clear expectation is that any system that is present will be maintained in accordance with the applicable code and/or regulation. For example, if you have an outpatient care location that has a fire department connection, then you need to make sure that you have the appropriate documentation of that inspection activity. Likewise, if you have sprinklers, then you better make sure that the sprinkler list is up to date and all pertinent information is available for inspection.
It seems that every week I’m thinking that I can set this aside and each week something else pops up that I feel is worth sharing (have you done an eyewash assessment yet for your outpatient care locations?) and I suspect that we’ve not reached the end of this conversation. That said, I think there is going to be increased focus on generating more findings and you could say that outpatient locations represent a whole mess of opportunities for doing just that. We know they’re coming, we just need to get ahead of the curve. Hope these are helping you strategize.
Be well and stay safe until next time…
About the Author: Steve MacArthur is a safety consultant with The Greeley Company in Danvers, Mass. He brings more than 30 years of healthcare management and consulting experience to his work with hospitals, physician offices, and ambulatory care facilities across the country. He is the author of HCPro's Hospital Safety Director's Handbook and is contributing editor for Healthcare Safety Leader. Contact Steve at stevemacsafetyspace@gmail.com.