Environmental and life safety issues continue to be top compliance issues according to surveys. Proper instrument reprocessing is important for patient safety, but staff sometimes incorrectly assume sterilized instruments are clean. Organizations should focus on training, limiting immediate use sterilization, leadership involvement, loaned equipment policies, and monitoring effectiveness. The leadership session with surveyors now focuses on an organization's path to becoming a high-reliability organization, so leaders should understand high-reliability concepts and discuss efforts to achieve high reliability including medical staff involvement and staff communication.

1. Were You Aware? Latest TJC/CMS Updates May/June 2013
1. Seven of the top ten standards compliance issues for 2012 remain environment of care
and life safety.
o Environmental and Life Safety issues continue to steal the spotlight as high
scoring compliance issues for most organizations. Many of the EC/LS findings
were related to fire safety, maintaining egress and utility systems. The other top
three standards compliance issues were related to infection control, record of care
and medication management. This reinforces that with increased attention by all
surveyors to EC/LS and with increased time spent onsite by Life Safety
Specialists; organizations need to be vigilant about all issues related to EC and
LS. It takes all staff educated and focused on EC/LS to find and report issues so
they can be quickly addressed.
2. Inadequately reprocessed instruments lead to patient safety concerns.
o According to ECRI (Environmental Research Institute) staff falsely believe that
because instruments have been sterilized, they are clean. Unfortunately, this is not
always the case. Reprocessed instruments are a big concern for many
organizations because hundreds or thousands of pieces of equipment are
reprocessed daily. To assure safe processes in your organization, ECRI
recommends:
a. Adequately trained staff
b. Limiting use of immediate use sterilization
c. Leadership involvement
d. Establishing and enforcing practices for loaned equipment and
e. Monitoring the effectiveness of reprocessing
It is also a good idea to foster an atmosphere of teamwork and collaboration. Most
importantly, staff must be encouraged to report discrepancies and concerns and supported
for doing so. To read the entire ECRI article, please follow this link:
https://www.ecri.org/EmailResources/PSO_Monthly_Brief/PSO_Brief_Apr13.pdf
3. There are new expectations during the Leadership Session–are you ready?
In the past, TJC has used the Leadership Session as a time for leaders to discuss their
strengths and opportunities related to the TJC pillars and/or to mitigate findings during
the survey. The Leadership Session is now largely focused on the organization’s path to
becoming a High-Reliability Organization (HRO). Leadership should be aware of the
HRO concepts. Leaders should be able to discuss what elements have helped or hindered
their progress to becoming an HRO. Don’t forget how important the medical staff is in
obtaining HRO status. It is also important to involve staff by letting them know what
HRO is and what the organization is doing to achieve high reliability.
TJC Perspectives, April 2013