Arizona ASHE

November 2016 Newsletter  

Joint Commission Scoring Changes
May Result in More Findings

Beginning January 1, 2017, the Joint Commission will be eliminating the current Category A and C scoring designations from all Elements of Performances (EPs). Category A EPs are typically related to structural requirements and are currently scored as either insufficient or satisfactory compliant. Category C EPs are frequency-based requirements, and are scored based on the number of times a deficiency is discovered: insufficient (3 or more occurrences of noncompliance), partial (2 occurrences of noncompliance), or satisfactory compliant (one or zero occurrences of noncompliance). Under the new process, the Joint Commission will be performing a real-time, on-site evaluation of deficiencies-essentially a "see it, cite it" survey process. For example, under the current system a hospital with 5 occurrences of noncompliance for a Category C EP would be scored as insufficient for that EP-and in some cases surveyors who cite 3 instances of noncompliance on an EP may stop looking for additional instances of noncompliance since the EP would be categorized as insufficient regardless of the number of additional findings. Under the new system, all 5 findings would be recorded as individual deficiencies and surveyors would continue identifying instances of noncompliance, which could raise the number further. Because of the elimination of Category A and C scoring designations, hospitals may see a greater quantity of findings during surveys after January 1, 2017, especially in common Category C finding areas such as fire doors; barrier penetrations; items on sprinkler piping or supports; or dust and foreign materials on sprinkler heads.
As part of the changing scoring system, the Joint Commission is rolling out a new SAFER matrix, which stands for survey analysis for evaluating risk. The matrix helps categorize EPs based on the likelihood of harm to patients, visitors, or staff as well as on how widespread the problem is. The SAFER matrix can help hospitals focus on those items that pose the greatest risk foremost while still managing all of the deficiencies.
In a separate change made earlier this year to align with new Conditions of Participation, the Joint Commission stated that all findings after August 1, 2016, must be corrected within 60 days of the survey unless the organization provides justification for a time-limited waiver handled through regional offices of the Centers for Medicare & Medicaid Services (CMS). This change means that the Joint Commission is no longer considering previous Plans for Improvement (PFIs), which previously gave hospitals more time to correct deficiencies.
Key Points for Hospital Leadership:
  1. Many hospitals will see an increase in cited deficiencies due to a scoring change starting in 2017, but that does not equate to a decrease in safety for patients, staff, and visitors.
  2. The use of the SAFER Matrix will allow hospitals to place proper emphasis on all deficiencies noted during a survey, and to focus efforts on deficiencies that pose the greater risk to patients.
  3. The removal of the Joint Commission's PFI process will require all deficiencies to be corrected within 60 days of the survey, which may require the appropriation of resources in conjunction with a survey.
  4. Health care organizations should continue to be proactive in managing known life safety and environment of care deficiencies and should focus on continuous compliance.
Upcoming Events 
November 17, 2016
EnergyStar & Energy to Care workshop
Come learn how to load your utility data into portfolio manager and begin benchmarking.
The Atruim 4:00pm-5:30pm
5099 E Grant Road, Tucson AZ
December 9, 2016
Tucson & Southern Arizona CEO Round Table
Discussion - A look at the changes in Southern
Arizona Healthcare.
Sheridan Hotel conference center
5151 E Grant Road, Tucson




 Education Opportunities
Free Energy Webinar
Dec. 7 2016 12:00pm CST
Learn How Combined Heat and Power Can Help Save You Money and Increase Your Energy Reliability

Combined Heat and Power (Cogeneration) is a great opportunity to reduce energy costs, save money and improve the resilience of hospitals. The Department of Energy's CHP Technical Assistance Partnerships are leading a webinar on the opportunities and applications for CHP at health care facilities.
Please join us to learn about these CHP benefits, federally funded engineering services, case studies and opportunities for your hospital.

o Learn about different CHP technologies
o Learn about federally funded Technical Assistance
o Free CHP screening of your facility
o Free 3rd party reviews of vendor proposals
o Hear case studies of operating CHP at hospitals from hospitals staff
o Current and future rebates, incentives and tax advantages available for customers that install CHP

Who should attend?
* Hospital Administrators
* Hospital Facility Managers
* Energy Managers
* Service/maintenance staff
* Contractors
* Engineer

Presented by the Pacific CHP TAP and the Southwest CHP TAP. 

Thanks to all of our 2016 Gold Sponsors

Thanks to all of our 2016 Bronze Sponsors