Ensuring healthcare facility compliance is one of the most important aspects of keeping facilities safe and functional. Every year, Medxcel prepares for The Joint Commission’s (TJC) tri-annual inspections, which are based on the Standards and Elements of Performance of TJC. These inspections check to make sure that all safety processes and equipment are functioning properly. The visits also include a review of Medxcel’s FMOS™ and Emergency Management documentation, which involves an annual inventory of PPE equipment and resource management policies.
By adequately preparing to meet and exceed compliance standards, Medxcel was able to have steps in place when COVID-19 hit. These plans, inventories and risk assessments provided a guide on how facilities would be able to respond to a surge of patients. Planning for an excess of patients involved setting up tents, holding decontamination trainings, assessing usage of empty spaces and much more.
Navigating upcoming compliance reviews can become a challenge when not all parts of a facility are accessible due to COVID-19 restrictions. TJC paused inspections for two months during the height of the pandemic to allow facilities to focus on preparing and caring for patients, but we continued to ensure compliance in order to prevent delays once these visits resumed.
As Mike Lagnese, Director of Strategic Resources and MEP Compliance
for Medxcel shared, “We talked as a team internally about the areas in facilities that were going to miss the window of having inspections and talked about how we could go in – if the individual hospital would allow us under their guidance – and conduct the inspection in specific areas. Trying to do this work with travel restrictions was complicated. The compliance group is very hands-on with the health ministries to solve problems, and we had to get creative on ways to monitor areas we would not have access to.”
Instead of allowing travel restrictions to slow compliance efforts, the Medxcel team stepped up, going above and beyond to serve facilities during the pandemic. In fact, some of our compliance team members were deployed to facilities outside their hometowns and stayed in hotels for several weeks while the COVID-19 pandemic spread.
These dedicated team members supported our safety teams to monitor spaces that were changed to support COVID-positive patients. As one of these team members, Kathy Neal, Manager of Facilities Support
for Medxcel explained, “When you’re on incident command, you’re on call 24 hours a day, and you do
get calls 24 hours a day. We traveled frequently and stayed on-site throughout the weekends to ensure the job was done and done well.” Tasks included setting up negative pressure spaces, ensuring PPE was being properly worn, and much more.
Direction from TJC played a big role in preventing the spread of the virus and managing emergency operations. The impact of the pandemic is continuing to change some of our systems and emergency management structure at state, local and federal levels based on lessons learned from COVID-19. By adapting during and after a crisis, teams are able to better prepare for the next emergency.
Compliance is vital year-round, and while a lot has changed in the face of the pandemic, focusing on compliance and emergency preparedness has not. At Medxcel, the safety and well-being of our patients and associates will always be our top priority. We are so proud of our teams for working around-the-clock to prepare the physical environment of our facilities to maintain safe and effective healing spaces.
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