(4/17/2018)
It’s tough enough to keep your facilities survey-ready, but even more so when regulators implement changes and you’re scrambling to adjust before you’re hit with a survey finding. With regulatory requirements, you’re either behind the gun or ahead of the curve - there’s really no in-between.
How can healthcare facilities keep ahead of regulatory requirements? Is it realistic to aim for a level of readiness where you routinely put solutions in place before they’re mandated by regulators? It is, in fact.
How blind spots develop
Here’s a curious thing about blind spots: They tend to sprout and accumulate when hospital leaders lack the habit of looking outside of their facilities. The good news is you’re guaranteed to reduce blind spots in all aspects of your facilities if you simply adopt the habit of watching your industry, talking with regulators and peers in other health facilities — particularly those in your region.
There’s also great value in partnering with experts who’ve worked with many different kinds of facilities, and who can come in and view your facilities with fresh, yet experienced eyes. It’s how our client hospitals got ahead of ligature months before it became
this year’s regulatory heavy hitter.
Looking outside and questioning intent
At the time of this writing, we manage 141 hospitals, so we hear a lot about what’s going on with facilities, common and not-so-common survey findings, and interactions with surveyors. Some concerns naturally rise to the top and we start asking peers, colleagues, and regulators: “Is this really true?” or “Can you be more specific?”
Meanwhile, life safety specialists continuously challenge the interpretation of regulations, discussing intent and what’s in the patient’s best interest. Their conclusions then become policy for us: We’ll go ahead and adapt or create policies to meet that standard.
The ligature challenge
The ligature issue came to our attention when we heard of facilities getting hit with it on surveys. At the time, there wasn’t a standardized risk assessment for it. Different facilities were using guidelines from different agencies, clinicians were assessing it from a clinical standpoint but without infrastructure knowledge, and there wasn’t a go-to assessment that would cover all bases and work for everyone.
As soon as we learned this, we created a risk assessment for different types of areas (cafeterias, patient rooms, and so on), as well as general criteria that would apply in every instance. We then refined that as feedback came in, until we had a risk assessment we could use in any space we manage, and which would meet all requirements.
Roughly six to eight months later, The Joint Commission, CMS and other authorities came together and created ligature guidelines as patient suicide emerged among the top three sentinel events. Although our facilities still had to adapt to new guidelines, they were able to do so relatively quickly, because they’d already done much of that work in the previous year.
Without a crystal ball on hand, staying ahead of regulatory requirements comes down to habitual risk mitigation and industry knowledge that can’t be gained if your eyes never leave your facility.