Nervous about your next Joint Commission survey?
Not sure if you’re addressing all areas of concern when it comes
to a surge emergency? Facing questions from hospital staff about
ligature risks? These compliance and safety questions were among
the topics addressed during the 5th Annual NYC Hospital,
Outpatient Facilities & Medical Office Buildings Summit held in
Tools for planning for surge emergencies
article from event organizer
SquareFootage.net, surge emergencies are on
the forefront of emergency planning right now, so there
is an increase in tools available to help you plan.
Nick Gabriele, Vice President of RPA /A
Jensen Hughes Co. described medical surge as the ability
to provide adequate medical evaluation and care during
events that exceed the limits of the normal medical
infrastructure of an affected community.
Surge capacity is the ability to
manage a volume of patients, while surge capability is
specific to managing patients with unique issues, such
as Ebola. Both terms encompass healthcare organizations’
ability to survive a hazard impact and maintain, or
rapidly recover, operations that were compromised.
Multiple companies today provide
software and dashboards that can help organizations
analyze and plan surge capacity and capability.
Key considerations around medical
surge capacity include ensuring continuity of care,
getting the right staff-to-patient ratios, managing
supply issues throughout the chain, among other factors,
while meeting the 96-hour assessment
requirement—assuming a waiver from
section 1135 of the
Social Security Act isn’t in place.
Gabriele, Vice President, RPA Jensen Hughes Co.
Resources for mitigating ligature risks
Ligature risk has become a major emphasis for The Joint
Commission in the last year. Michael S. Bernstein, Life
Safety Code surveyor for The Joint Commission, explained
why: “A facility surveyed [first quarter 2017] had
ligature risks identified during survey, and before they
could be mitigated there were two successful suicides.”
To better prevent these risks,
Bernstein encouraged FMs to not confuse value and price
when it comes to ligature-resistant products. He
encouraged his audience of listeners to ensure they’re
picking products that are durable and that will what
they are supposed to do. To meet this last requirement,
Bernstein advised speaking to people using the products
daily at other facilities before purchasing for your own
In addition, Bernstein recommended
reviewing guidelines that address ligature risks,
starting with state rules and regulations and including:
Michael S. Bernstein, MSE, MBA,
PE, CCE, CHFM-Life Safety Code Surveyor, The Joint
Tips for Life Safety Code survey success
Bernstein offered some additional tips for
ensuring TJC survey success:
- Organize your testing document binder
in the same order as your checklist.
- Once you close all open issues, place
the work orders right behind the report.
- Schedule 1 fire drill per shift per
quarter. While these must be more than an hour apart,
Bernstein recommended scheduling these drills every
three months, plus or minus 10 days. The best practice,
he said, is to vary days.
- Place central station and Fire
Department Connection checks on your fire drill form.
This saves time and money and eliminates missed annual
and quarterly requirements.
For more tips and insight from the summit,
read the full recap at