Avoid Safety Pitfalls that Lead to Immediate Jeopardy Status


Tragically, in recent years hospitals have faced dangerous situations including fires, infection outbreaks and violent attacks against health care workers and patients. These events emphasize the dangers that can affect any type of hospital in the country. In addition to the everyday task of caring for and treating patients, hospitals must also be constantly vigilant to protect their patients and health care staff from dangerous or unforeseen incidents. One way hospitals can protect themselves and their patients is through successful accreditation compliance. If hospitals run afoul of compliance regulations, they can be slapped with an immediate jeopardy status by CMS.

Immediate jeopardy occurs when the provider’s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death to a patient.

“CMS is holding organizations accountable in order to stay certified,” said Diana Scott, MHA, RN, CPHQ, senior director of accreditation advisory services at Vizient. “Their goal is to keep patients safe and avoid any type of hazardous scenario, so it’s important to ensure your organization is prepared and committed to implementing necessary safety measures.”

While avoiding a significant single event might be a hospital’s chief concern, immediate jeopardy can also occur if there is evidence of a pattern of small issues of negligence or inattentiveness.

“If CMS is present at your organization and has identified immediate jeopardy, they will focus on the issue and not leave the premises until there is a corrective action plan put in place to mitigate that particular situation,” said Scott. “You will need to attend to the issue immediately, and now your window of time to address the problem is very short. Your hospital has 10 days to show CMS how you’re going to fix and fully resolve it.”

Threats to compliance

While the types of hazardous situations that can arise in a hospital are numerous, three distinct examples have moved to the forefront of accreditation and compliance experts’ radar:

1. Prevention of violence in the hospital. Whether it’s directed from patients or family members against staff or against each other, or even staff against staff, these types of events represent a failure to keep patients and staff safe and can result in immediate jeopardy. One strategy hospitals could incorporate into their initial admission assessment process is evaluating if a patient has any psychosocial issues such as a suicide ideation or presenting a danger to others. In addition, providers’ awareness of any family dynamic issues presents another opportunity to spot the potential for violence.

2. Hospital-acquired infections caused by failure to sterilize. These types of hospital-acquired infections are also a clear-cut case of immediate jeopardy. “I recommend engaging the infection control leader because they are going to be one of the key people taking the lead on identifying all areas where high-level disinfection and sterilization of medical devices or instrumentation is occurring, conducting a comprehensive process assessment, implementing improvements, monitoring compliance and reporting out to senior leadership,” Scott said.

3. Fire safety, prevention and suppression. “This is probably the most common issue that quickly results in immediate jeopardy,” Scott said. “A critical piece of this relates to clear egress routes, as well as the proper functioning of doors that provide fire compartments in the building. If the doors don’t do what they are supposed to do from a fire suppression standpoint, the entire facility is at risk of being consumed in a fire. Fire and smoke will spread quickly if you don’t have the appropriate confinement features in place.” At other times exit routes may no longer be accessible due to construction or renovations, and staff may not know the new exit routes, endangering staff and patients.

An additional fire safety issue is also related to facility renovations or new construction. “I have seen many organizations that have completed renovation projects and even new construction and then find out too late that their fire plans no longer match the existing facility. That poses a problem because those plans are the first thing the fire department refers to when an alarm sounds,” said Scott. Schematic drawings show where the fire barriers are and where the rated walls are, so it’s critical to have those be accurate and up to date.

Other times, hospitals may have an alarm system that doesn’t work correctly, hasn’t been tested or doesn’t reach the fire department. All of these scenarios can result in immediate jeopardy if left unattended.

Fostering a culture of safety

A key to steering clear of immediate jeopardy is pursuing a culture of safety where staff can speak freely and surface issues to their superiors. Moving toward a culture of safety is a monumental undertaking that doesn’t happen overnight, but is necessary to maintain accreditation. And a shift in culture must start from the top.  

“The C-suite has an obligation to pay attention to their internal measures,” Scott said. “For example, every hospital has a risk management department that is constantly looking at near-miss events and those that actually happened. The C-suite must review these events and look specifically at root causes to identify any commonalities from event to event. They need to be aware of what’s happening in their organization.”

One popular method of keeping a finger on the pulse of the organization is participation in a daily huddle for department heads. Leaders want to know what is happening and many of them have implemented daily huddles to listen to concerns, gather information and discuss what happened in their hospital over the last 24 hours. What happened correctly and what potentially could have led to something significant? A C-suite member who participates in these meetings sends the message that a safety culture is a top priority.

In addition, Vizient offers members multiple options to ensure their organizations remain accredited. In the event of an immediate jeopardy situation, Vizient can also assist on the long-term corrective initiatives.

“Take advantage of the resources available through Vizient,” Scott said. “Offerings include high-level resources at the education program level such as our advanced accreditation webinar series, and members can also receive individualized consultations with our advisory team and see where they stand in terms of compliance. The advantages of an objective, external, fresh-eyes look at your organization are significant.”

For more details on accreditation services, click here.

*Bureau of Labor Statistics (BLS), 2013 data. These data cover three broad industry sectors: ambulatory health care services, hospitals, and nursing and residential care facilities.

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