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Compliance News: ASHE and TJC Provide Joint Assistance with Problematic Compliance Issues

| David Stymiest

Since ASHE and TJC announced their joint effort to address the most problematic physical environment issues at the July 2015 ASHE Annual Conference in Boston, both organizations have been making good on that promise.

The TJC Physical Environment Portal (TJC PE Portal) is available at TJC’s website under the main TOPICS heading.  Interested parties can sign up at that location to obtain TJC e-Alerts on new information when it is issued.  Although the information specifically addresses the most problematic TJC Environment of Care chapter and Life Safety chapter standards and Elements of Performance (EPs), much of it is generic enough to be helpful to those concerned with CMS physical environment and life safety compliance as well. The TJC PE Portal and its related e-Alerts are available to the public.

ASHE’s FOCUS on COMPLIANCE (ASHE FOC) web page is available at ASHE’s website under the main RESOURCES heading.  Interested parties can sign up to receive email alerts from ASHE when new physical environment compliance resources are added, and do not need to be ASHE members to receive the alerts.  The majority of ASHE’s posted resources are available to all persons; however a few of the resources are available only to ASHE members.

Each web page links to the other organization’s web page for easy migration between them.  Both web pages already have helpful resources posted.

The TJC PE Portal has already identified the following problematic PE issues as of the date of this article.  It discusses the requirements, the most commonly-observed adverse findings, and offers advice for improving compliance.

Utility system risk management issues

  • Air pressure, filtration, and air changes in critical care areas
  • Labeling utility system controls to facilitate shutdown
  • Design and installation of utilities to meet patient care and operation needs
  • Clinical impact of related utility issues, along with a discussion of related U.S. Centers for Disease Control (CDC) concerns
  • Expectations for hospital leadership support and oversight of the above issues

Means of egress issues

  • Corridor clutter
  • Locked doors within the direction of egress
  • Clinical impacts due to noncompliances – including fire rescue, employee injuries, and adverse TJC/CMS citations

TJC’s posted schedule for addressing additional PE compliance issues over the next year indicated that they will be addressed in the following order:

  • The built environment
  • Fire protection
  • General life safety requirements in three categories
  • Hazardous materials and waste management

The ASHE FOC web page offers resources addressing the following issues as of the date of this article:

Advice for managing utility system risks

  • Inappropriate room pressurization – 12 separate resources addressing terms and concepts (issues), defining failure modes (risks), identifying patient outcomes (impacts), and providing assessment tools and resources (mitigation)
  • Labeling of utilities – two separate sample policies
  • Lack of emergency lighting – two separate resources addressing summary results from ASHE’s essential electrical system survey and a sample inspection log; ASHE members may also access two additional resources
  • Inappropriate electrical issues (relocatable power taps, also known as power strips) – five separate resources addressing terms and concepts (issues) and sample policies/procedures (mitigation)

Advice for managing the integrity of the means of egress

  • Obstructions for means of egress – seven separate resources addressing terms and concepts (issues) and providing assessment tools/resources (mitigation); also short discussions regarding defining failure modes (risk) and identifying patient outcomes (impacts)
  • Inappropriate locking mechanisms – copy of a presentation discussing locking requirements
  • Improper use or designation of suites – short discussions regarding failure modes and their adverse impacts on patient outcomes

ASHE’s posted schedule for address additional PE compliance issues over the next year indicated that they will be addressed in the same order and time frames as the TJC schedule.

We recommend that the above-linked web locations be bookmarked for future reference.  We also recommend that those interested in obtaining future information when it is posted subscribe to the related (ASHE or TJC or both) email alerts.

Questions regarding this article may be addressed to the author at