Invest in Fixes Now or Pay a Higher Price Later


Many hospitals face the same challenges when it comes to maintaining a safe environment and avoiding ‘dings’ from a compliance survey, declining resources remaining one of the most difficult obstacles.  The priority to effectively manage and remediate compliance issues in-between surveys should resonate high amongst healthcare leaders, especially now with shortened remediation timelines enforced by The Joint Commission.  Now it’s time to navigate through the impact these changes are having on your facility and how you can manage them.

The way things were
Until recently, The Joint Commission had its Statement of Conditions (SOC) and Plans for Improvement (PFI) programs, allowing hospitals to self-identify and manage issues over time. Should any violation come to light, you’d get a six-month grace period, with the option to request a waiver or extension for another six. It was easy (perhaps even tempting) to push things down the line, and take your time to address deficiencies.
Changes & impact
As of August 1st, 2016, The Joint Commission no longer considers the PFI process for its Life Safety Chapter and  adopted the same methodology as CMS of “we find it, you fix it within 60 days”, announcing the change during the ASHE conference earlier this summer.
The impact on facilities is tremendous: Previously, you could plan a timeline of cost and remediation, which could be stretched over a year, two, maybe three. Now, it’s limited to a 60-day window, unless it’s a self-identified issue you’ve been tackling for a while.
A waiver, if possible, will be far more difficult to obtain, simply because it now must go through CMS. With TJC as your filter, you’d have to submit the request to TJC first, which would then send it to CMS, return to TJC, then back to you. If CMS denies your request, you have whatever time is left (a couple of weeks?) to complete the repair. It’s going to be extremely difficult. But there’s a better way.
A better way
Although The Joint Commission no longer looks at PFIs, it’s still in your best interest to cultivate that practice, self-identifying issues early and remediating them over months or years before the survey.
It’s really a matter of “pay now, or pay later”—except the “pay later” option, when a surveyor catches the issue and demands resolution within 60 days, is going to be far more expensive, and a much bigger headache.
Costs tend to go up with a shortened timeframe, and contractors can sense the urgency of the situation and charge accordingly. Often, an issue that could be fixed in-house over a long period at a considerably lower cost and stress for everyone involved, has to be outsourced when you’re pressed to get it done in 60 days.
This is especially difficult for organizations whose regulatory strength and focus has been on the clinical side, lacking deep know-how on the facilities side. Your war chest of emergency facilities funds can only go so far, and letting problems snowball into big violations is one sure way to outspend those funds.
Learn from industry trends
Identifying industry survey trends—common deficiencies and the focus areas for TJC—is a relatively simple way to avoid the same high-potential hits when a surveyor steps into your facility. If the trends are showing hospitals are getting hit with A, B and C violations, addressing those same issues in your facility is a great way to try to avoid them. While looking at industry trends can provide a good indication of your survey success, evaluating the trends and only looking at those areas heavily cited in the data should not be used as a replacement for a thorough compliance review within your facility prior to any survey. 

Use the time you have
As the costs of procrastination and shorter timelines mount, facilities will have to trade their practice of postponing improvements and throwing money at them at the last minute for consistent investments and remediation over time.
Although you have no way of knowing exactly when your next survey will be, you typically will have three years between surveys. Use them to your advantage, as an opportunity to spread expenses and avoid needless losses and interruptions—including CMS’ stamp of approval.