Preparing for the Survey
Scheduling safety and security audits to complement the accreditation process can be a wise strategy
- By Matthew Conrad
- Jun 01, 2011
In the not-too-distant past, preparing for a survey by The Joint Commission
meant ensuring that not only the facility but also all policies, procedures
and documentation were well-prepared and ready for scrutiny during
one specific week every three years. Anyone who has worked in a hospital
knows how stressful this was and how the survey process has changed in
With an assessment approach that requires institutions to be in a state of
“continuous survey readiness,” The Joint Commission has raised the bar on performance
throughout the entire three-year accreditation cycle. Today, its survey
team can show up at your facility anytime before the end of the tri-annual accreditation
Unless a facility’s intelligence-gathering is perfect, most are not able to plan for
the commission’s unannounced inspection. Gone are the days of choreographing
how best to delay the inspectors while planning maintenance repairs and communicating
to the staff to look their best, keep their space clean and to be even more
polite and friendly on that fateful day. Now, healthcare providers have to prepare
for inspections proactively.
According to the 2009 “Joint Commission Perspectives” survey, the most common
types of Joint Commission standards citations given to hospitals were for
life safety code violations. In fact, life safety code-related violations were the first,
second, fourth and sixth most frequently cited, including failure to maintain an
egress as well as failing to protect people from smoke and fire. These findings are
likely to result partially from the commission’s increased focus in this area and the
addition of life safety specialists to the inspection team.
10 Easy Fixes
What made the study interesting was that many of the citations are easily preventable
through improved staff awareness or the use of affordable solutions. Below
is a list of 10 typical life safety violations along with solutions that can help keep
facilities safer for patients, visitors and staff while reducing the potential for receiving
requirement for improvements (RFI) citations during the next inspection.
1. Obstructed openings. Sometimes a stopgap solution to the problem of having
excess supplies is placing them next to the door and stocking them later. Even with
these good intentions, patient and staff safety can be affected because this may
allow the spread of smoke and fire beyond the confines of smoke compartments.
Keep doorways clear.
2. Obstructed hallways. Wheelchairs, gurneys and carts in hallways may impede
access to stairwells and exit doors. Make sure the hallways stay clear.
3. Broken door locks. Although not necessarily a life safety code issue, broken
and inoperable door locks can create risks in healthcare facilities. Not only can
they create opportunities for theft, but they may also expose sensitive business information
or confidential patient information to unauthorized people, which may
result in a HIPAA violation. Educate staff members on whom to notify for maintenance
and be proactive in surveying access points for damage.
4. Improper fire rating on doors. Painted-over or missing fire rating labels is consistently
one of the top violations. Ensuring that painters understand the importance
of not covering door and frame labels can significantly reduce the potential
for this violation. Where necessary, replace damaged doors with doors that have
proper fire ratings. Regardless of the training provided to painters or specifications given to companies replacing doors, never close out a project without an inspection
and commissioning process.
5. Broken door seals. Wear and tear will affect all doors, eventually. A door that
might close but not seal properly may allow smoke and fire to penetrate an opening
much more quickly. Make sure they are properly sealed.
6. Doors that do not properly close. A door that doesn’t close is a door that can’t
be latched or prevent the spread of fire. Often, fixing a broken door is as simple as
replacing a broken lever or adjusting a hinge.
7. Doors that don’t self-close properly. In many places, life safety code requires
doors to close and latch on their own, without impediment. If doors are designed
to close and latch without human intervention but fail to do so, the closing device
should be repaired or replaced immediately.
8. Worn door hardware. Loose hardware that could fail, corroded hinges that
could snap, or worn, jagged levers that can catch on clothing should all be replaced
9. Missing or unmarked designated fire exits. Exits that are not clearly marked
create a dangerous condition, particularly in smoke-filled hallways. In an emergency,
occupants need to have clearly designated and identified egress routes.
10. The devil is in the details. The smallest infraction can endanger the safety of
your occupants. Be thorough.
Currently, The Joint Commission
and Centers for Medicare & Medicaid
Services are enforcing the 2000 edition
of the National Fire Protection’s Life
Safety Code. Make sure to check with
your AHJ to see what is mandated for
Preparing for a Joint Commission Survey
There are many strategies to consider
when planning for an unannounced
Joint Commission inspection, but here
are two primary ways to prepare your
facility. The first is to assess, plan, prepare,
practice and improve. When a
hospital continuously assesses its organizational
performance, a Joint Commission
survey may not be as alarming.
Hospitals running simulated hospital
surveys are best prepared for the real
thing. The “surveyor,” much like the
Joint Commission counterpart, arrives
unannounced and begins the methodical
process of reviewing compliance
with each standard. This process should
mimic those used by actual surveyors,
following patient activities, inspecting,
testing, questioning, reviewing, clarifying
Educating the staff is vital. By sharing
results and findings, each department
and the organization as a whole
can understand potential deficiencies
and address them effectively. The bottom
line includes both passing the real
survey and, most importantly, improving
Hardware and equipment rarely
notify anyone when they break or malfunction.
It is important for hospital
staff to report a door opening problem
as soon as it is discovered. Preventive
inspections and maintenance programs
can certainly help identify issues; however,
these are often limited to specific
schedules. Staff reporting is critical.
When staff members report problems,
they expect that these problems
will be resolved in a timely manner.
When issues are not resolved, staff
eventually get frustrated and tired of
calling, and either find their own solution
or work around the problem.
When a lock is not functioning properly
and the lock shop is too busy to get
to it, the door will be propped open.
When the magnetic door release -- tied
to the fire alarm system -- will not hold
the door open, staff will find their own
way to keep it open, which may be a
violation of fire code. Tracking maintenance
requests, setting priorities and
communicating with staff is essential in
garnering their ongoing cooperation.
To ensure patient, visitor and staff
safety, any malfunctioning or broken
equipment should be reported and
scheduled for repair as soon as possible.
The “that just happened” excuse
seldom works with the surveyors.
What is a Security Audit, and Why Should a Hospital Conduct One?
How can a hospital ensure that it is at the
top of its game at all times? What if the
survey team shows up today? The easy
answer is to undertake periodic audits.
Audits are important because they
help ensure that a facility is prepared
for a survey and, more importantly,
safe and secure for its occupants. From
the time a patient hands over his or her
medical information to the follow-up
consultations after a procedure, every
step of the journey takes policies, protocols and precise execution in order to
ensure a successful experience.
providers should take great care
and extensive measures to make certain
not only that the patient is well cared
for but that they also provide a physical
environment that is an asset to the patient
and is safe and secure for everyone
who walks through the facility’s doors.
Not only must hospitals go to great
lengths to enforce adopted rules and
measures, but they also must spend a
fair amount of time analyzing and reviewing
their policies and procedures
to ensure they are meeting these regulations.
Security audits assess the organization’s
compliance with standards
they are required to meet or have agreed
to abide by. If a policy and procedure
have been written, an audit determines
whether the organization is doing what
it has said it will do. For example, if a
hospital has determined that it should
practice an emergency lockdown twice
a year, it must do so.
The actual audit process also identifies
needs and helps determine whether
those needs are being effectively addressed.
For instance, if, during a lockdown
exercise, it is determined that the
process took 20 minutes instead of the
expected three minutes, the assessment
should identify specific areas of improvement,
make recommendations to
correct, then outline the plan for correction
and, most likely, call for followup
lockdown exercises to determine
that performance has been improved.
Depending on the results, hospitals
typically follow the recommendations
and update the security. Hardware repair,
equipment replacement, policy
changes, retraining, procedure drills
and follow-up audits and assessments
could all be a part of the next phase.
Security audits vary in size and
scope. Some audits might cover all aspects
of security while others might be
scheduled to analyze a single segment of
the process. Audits can be something as
small as an examination of paperwork.
Such scheduling usually depends on the
performance of the previous audit, with
exceptions, including an administrator’s
desire for unpredictability.
Is it Necessary?a
All hospitals know that continuous
self-check activities are important, but
some are more vigilant than others.
Some hospitals consider security audits
vital to their prosperity. Not every hospital
performs at the same level, which
means some facilities need a little more
effort to maintain efficiency than others.
Such levels of performance also
determine the frequency of security
audits, if and when they are scheduled.
What all facilities have in common
is that they need to have a safe
environment for patients, visitors and
staff while complying with regulatory
requirements. Since accrediting bodies
such as The Joint Commission have
decided not to schedule their inspections,
hospitals should work every day
to maintain optimal efficiency and provide
the best environment possible for
their patients and staff.