By Rick Joslin, Senior Advisor, Healthcare Strategy & Senior Solutions Architect, Healthcare
There’s the obvious answer to why EOC rounds in healthcare are important: to ensure the safety and well-being of patients, visitors, and staff.
But beyond that, there are many regulations that govern the physical environment of a healthcare organization, and routine inspections can identify areas of concern and begin the remediation process.
Although the CMS (Centers for Medicare/Medicaid) Conditions of Participation (CoP) §482.41 does not directly provide a requirement for the frequency or scheduling of recurring inspections, §482.41(a) does state that “…the condition of the physical plant and overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured.” The Survey Procedures for §482.41(a) do state that the inspectors are to “Review the hospital’s routine and preventive maintenance schedules to determine that ongoing maintenance inspections are performed and that necessary repairs are completed.”
Many deeming authorities that conduct surveys for CMS carry these CoP items into more detail. We’ll focus on one organization and some of their regulations: The Joint Commission (TJC) has published several regulations and tools to help healthcare customers ensure a safe environment and stay compliant with their regulations.
Although there are several areas within TJC publications, we’ll start with the publication that TJC provides as a starting point for EOC compliance: TJC publications Environmental Rounds Tour Form and Questionnaire Sample dtd 12/15/2010. This publication focuses primarily on EC.04.01.01 EP12 and EP13.
Customers should also develop a plan to document respective EPs in EC.04.01.01 EP1-EP15, as well as EC.02.06.01 and EC.04.01.03 (often referred to as the reporting requirement for EOC round results).
Manage the full service process from asset tracking, compliance, and work initiation through planned maintenance and events to execution and completion.
Here are a few things to consider when implementing an EOC Rounds program:
1. Who does what?
Understand that these are regulatory-required rounds, and the indication is that not anybody can perform them. These are also not the regular “let’s look for stuff that’s broken” rounds that most organizations do daily. Because of the importance, it is often leadership (supervisors, managers, etc.) that perform these inspections.
2. Who gets what?
Again, a difference between EOC Rounds and daily rounds are who’s seeing the results. Each completed survey is provided to a varied group of people; the leadership in the area being inspected, the safety/EOC committee (EC.04.01.03 is cited as the genesis for this committee), Engineering leadership, and often C-suite personnel receive the data in some form or fashion.
3. Where is inspected?
While daily rounds may be in general areas, regulated rounds have specific targets. Well, in reality, it’s everywhere, but at least once every six months in all patient care areas, and every twelve months for pretty much everywhere else.
4. How to get it all done?
This is the trick. A healthcare organization will usually stagger the areas needing inspected so that several areas are covered each week. The old “how do you eat an elephant?” approach.
5. Staffing isn’t an excuse.
Staff shortages are not (usually) a justifiable reason for not doing these tours. The regulations state “The hospital conducts…”, not the staff of the hospital. This means that if you don’t want to actually do it, you can hire a qualified company to do it for you.
How can you ensure compliance?
Identify all areas in your environment and group them into the two types of spaces defined: patient and non-patient care. Count the patient care areas and divide by 6; that’s how many spaces need inspected each month. Do the same for the non-patient areas but divide by 12. Add the two together and that’s your monthly work load for inspections.
You need a productive team that does not “sit” on their workload. Use reliable staff or vendors to get the checklists completed and the data to your team when expected and in a usable format. Remember that the EOC Rounds data will often be combined with other EOC data, so paper is usually not a good format.
EC.04.01.03 is very clear; the goal is to inspect, then analyze the results to effect change. You must have the measurements to back things up, and you must be able to show what those are and what you’re doing with them. Developing a robust reporting/analytical package will ensure uniformity of data analytics, prove documentation, and meet this critical need of measurements.
There are so many items to be inspected that the only way to ensure compliance is to develop checklists and then use them. But, electronic checklists are the best since they can be analyzed, tabulated, etc.
How can you handle compliance roadblocks?
As with any regulation, there can be roadblocks and challenges along the way. What can you do to handle compliance roadblocks?
1. Implement Policy.
Develop, execute and communicate clearly defined maintenance policies. Once you’ve established those policies, review them regularly with employees. Then, adjust and amend policies as necessary.
2. Assess Regularly.
Assessing your environment regularly. Most organizations are in constant flux with acquisitions, additions, remodeling, etc., and each change requires you to ensure it is properly inspected.
3. Use Analytics.
Use the data to effect change. If lighting is not adequate, budget for and improve the lighting. If ventilation is no longer adequate due to a renovation then design, budget, and install adequate ventilation. The goal is to make the environment safe for everyone, period.
Still feel lost? Accruent has made compliance easy with pre-built tools that help you get going. Our turnkey EOC Rounds compliance package includes dashboards, reports and snap-ins that ensure documentation and visibility of compliance – and helps you on your way to using that data for effecting change.
Learn more about asset and maintenance management designed for healthcare.