Get ready! The Joint Commission Environment of Care survey process for hospitals has changed in 2021. Previously, there was a one hour session on the hospital survey agenda dedicated to the Environment of Care review. TJC eliminated that session effective January 1, 2021.
Joint Commission Environment of Care Review: What’s Different?
The change for hospitals in 2021 is the Life Safety surveyor will now cover the relevant Environment of Care standards during the Document Review session and Building Assessment. There’s an additional hour on his agenda to cover those EOC standards.
As a result, the Environment of Care Document List and Review Tool is expanded. It now includes additional EOC documents to prepare for the Life Safety surveyor. For example: Environment of Care management plans, annual evaluations, and risk assessments. See the TJC 2021 Survey Activity Guide for this new Document List.
In addition, the clinical surveyors will cover EOC related topics during their tracers. These often include safety issues they identify during their unit tours – such as ligature risks or blocked egress corridors.
(Important Note: The Joint Commission Environment of Care session remains on the agenda for Behavioral Health organizations surveyed under the Behavioral Health standards.)
Joint Commission Environment of Care Review: What’s the Same?
Although the official one hour Environment of Care session is gone for hospitals, the requirements for managing the hospitalwide Environment of Care program remain the same. These include the following:
- Management Plans for Environmental Safety, Security, Hazardous Materials, Fire Safety, Medical Equipment, and Utility Systems (EC.01.01.01)
- Annual Evaluation of these Management Plans (EC.04.01.01)
- Safety and Security Risk Assessments (EC.02.01.01)
- Taking action to mitigate identified risks and resolve environmental safety issues (EC.04.01.05)
- Inventory of hazardous materials and waste (EC.02.02.01)
Why the Change?
TJC Field Director for Survey Management James Kendig recently discussed this new approach: “One reason for this change is to allow surveyors to focus more on emergency management in light of the ongoing COVID-19 public health emergency.”
Indeed, we’ve seen this COVID-19 focus take center stage on recent surveys. During the opening session, surveyors explore the organization’s response to the pandemic. And, moreover, how the organization critiqued their response and what they learned.
As one Survey Coordinator reported: “The surveyors were very impressed with our COVID-19 response when we described it in our opening session. However, where we fell short was that we hadn’t completed a written evaluation of our response. Ultimately, that’s what they were looking for.”
On a related note, TJC recently issued an FAQ on Emergency Response Exercise Requirements During the COVID-19 Public Health Emergency. Specifically, it addresses whether you can use your COVID-19 response as one of your required emergency management drills.
Given this change to the Joint Commission Environment of Care Review, here’s the survey strategies we’re recommending to our clients:
- Carefully review the new Environment of Care Document List and Review Tool in the 2021 Survey Activity Guide. Have all the documents ready and well organized for the Life Safety surveyor.
- Make sure that documents such as Safety Committee minutes, risk assessments, and annual evaluations can “speak for themselves.” Since there’s no sit-down EOC session, there’s much less opportunity to dialogue with the surveyor about what’s in those documents.
- Take the time to critique your COVID-19 response in writing. Be specific about what worked and what didn’t. Identify the changes you’re making to your Emergency Management Plan as a result. Review the critique in your Safety Committee and document it in your minutes.
In addition, stay up to speed on the FAQs that TJC issues on Environment of Care topics. Two particularly helpful ones from 2020 were:
- Joint Commission Requirements for Environment of Care Committees
- Requirements for Annual Evaluation of EOC Management Plans
Barrins & Associates Consultation
We’re now conducting both onsite and virtual Mock Surveys and Life Safety Reviews. Most importantly, we’re covering all these recent updates to the Joint Commission survey process. As always, our goal is to make sure you’re prepared and confident come survey time!