How to become a joint commission surveyor
Using “cheat sheets” during a Joint Commission survey on fire response
Q: Three –four years ago I wrote to The Joint Commission asking about the use of cheat sheets when responding to surveyor questions about PASS, RACE, and other emergency procedures. Their response was they had no problem with staff using written prompts during surveys. Has their position changed?
A: I’m not certain how your question was interpreted, but I can tell you that I’ve personally received feedback from surveyors that while the sheets are OK for many (and perhaps most) staff competencies, the thought that staff would not be able to articulate their response to a fire situation without the use of a reference is no longer considered acceptable.
Now this may very well be surveyor preference, but when confronted with that expectation, I could not, in good conscience, disagree that (at least for fires) folks should “know” how to respond, not merely be able to retrieve the information.
To be honest, if at this point, you have folks that still need to a reference for fire response, I would look very closely at the effectiveness of the education program. Admittedly, this strays into the land of gray, but this is also one risk that I feel is “minimized to the extent possible” when everyone knows what to do in the instant in which they would have to do it.
Which reminds me – I think with the increasing influence of CMS in the conduction of TJC surveys, we are going to be seeing many more absolute expectations, especially when it comes to life safety concerns. Much like maintaining appropriate corridor widths (as opposed to the “old” keeping things on one side of the corridor) and maintaining immediate accessibility to all building emergency equipment (fire alarm pull stations, fire extinguishers, medical gas zone shut-off valves, etc.), I think the expectations of front-line staff performance are being raised (as an advocate for safety, I can’t really disagree).
About the Author. Steve MacArthur is a safety consultant based in Bridgewater, Mass. He brings more than 30 years of healthcare management and consulting experience to his work with hospitals, physician offices, and ambulatory care facilities across the country. He is the author of HCPro's Hospital Safety Director's Handbook and is contributing editor for Briefings on Hospital Safety. Contact Steve at firstname.lastname@example.org .
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I disagree with the expectation that people should memorize RACE, PASS, etc. if questioned by a surveyor. While most people probably have it memorized, there are always people in an actual emergency who panic or freeze and cannot recall or perform even the most basic of routines. My facility has the “RACE/PASS” information clipped to the back of our ID badges. That way, the information is always with the employee and can be used to prompt a correct response or action. Thank you.
I absolutely respect your right and ability to disagree with the expectation, but one thing that may need clarification – this is not something that I’ve dreamed up on my own (though I will stipulate, at least for this one time, that I am in concurrence with this as an expectation) – this is indeed a
TJC survey finding that has occurred within the last month.
That said, this is by no means a memory activity – this is a response that is to be purposefully earned; I find that memorization is only useful if the end goal is for the regurgitation of information, but not so much when that information is to be used as a means of responding to an emergency. Nor is this something we teach solely for the sake of responding appropriately to a surveyor, or indeed because it is a requirement in a standards book or some regulatory code.
The overarching concept is that there are certain emergency response activities that should occur without having to “think” about what you’re doing and response to a fire, is a most apropos activity for well-learned and readily-articulated response. It does tie back across a pure compliance standpoint to the “why” of fire drills, but it makes it no less an appropriate expectation.
We know that folks perishing in hospital fires is a very, very small subset of fire events in hospitals, and from that information one could intuit that at least one of the reasons for this “success rate” is because appropriate response to a fire is so ingrained in the healthcare collective mind, that it is (I daresay) instinctive. In my practice, any educational strategy is valid – as an educational strategy; there needs to be a point in which the little birdies can fly on their own, at least for some basic activities. I would number fire response in that list of basic activities. But hey, I’m just one person.
The problem with the “cheat sheets” isn’t the answer but the question. Instead of asking what are your actions in a fire emergency, we ask do you know what RACE means? Invariably they go to the card to read what RACE means.
I concur with Steve on this issue. I too have seen surveyor reports where the surveyor has cited a hospital where the staff member could not explain their response to a fire without looking at the card on their ID badge. This is a departure from previous surveys, and possibly it is surveyor preference. But there have been multiple changes in the Joint Commission’s interpretations in the past few years and I do not expect these changes to discontinue. Like it or not, it’s they way things have become.
I would argue that when a surveyor says that “cheat sheets” should not be used that we remind them that the Job Action Sheets (JAS) used for HICS are exactly the same thing to be used in an emergency and help to ‘ground’ the person to see the best steps for insuring important tasks get accomplished when the stuff hits the fan. I believe this to be the same thing and well worth having as a reminder on the back of ID badges and is something that we also do for RACE. Same thing as a JAS. A fire or disaster response is not business as usual for any of our team members and is the very reason JAS were first developed for HIECS and continue to be used successfully by many today.
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