This member-only article appears in the July issue of Patient Safety Monitor Journal.
There’s one facet of accreditation that every patient safety provider ought to know about: Immediate Jeopardy (IJ).
The CMS State Operations Manual defines Immediate Jeopardy as “a situation in which 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 resident.”
It works like this: CMS catches wind of a severe safety violation at your facility and places it under IJ. You are then given a deadline to fix the problem and come up with a plan to ensure it never happens again—and if you don’t, CMS will revoke your facility’s Medicare and Medicaid funding.
CMS is the largest payer for most facilities, so losing your accreditation can financially cripple your hospital or even force it to shut down. In addition, the loss can negatively impact a hospital’s insurance rates, among other things.
“[You] lose community support because you are no longer certified or accredited,” says Victoria Fennel, PhD, RN-BC, CPHQ, director of accreditation and clinical compliance at Compass Clinical Consulting. “You start seeing some effects with physicians who may not want to send their patients to that hospital because [it] may affect their payments as well. Then you start to see staff leaving the organization. It really erodes the whole infrastructure if an organization loses its accreditation/certification.”
This is why, for accreditation and compliance folks, the words “Immediate Jeopardy” carry roughly the same meaning as “why is the tiger cage empty?” It means something has gone very wrong and if you don’t act fast, it’ll get exponentially worse.
Richard Curtis, RN, MS, HACP, is CEO of the Center for Improvement in Healthcare Quality (CIHQ) and a nationally recognized expert on the CMS Conditions of Participation and certification and survey process.
“There are literally dozens of situations that can cause an IJ,” Curtis said in an email. “The most common that we’ve seen involve failure to maintain a fire-safe environment (e.g., an inoperable monitoring system), failure to protect a patient from abuse or neglect (e.g., staff physically or verbally abusing a patient), failure to adequately monitor a patient (e.g., a patient in restraint), and failure to assure RN supervision of care.”
CMS surveyors have a set of principles they follow when determining if a situation calls for an IJ rating. That list includes the following:
Only “one individual” needs to be at risk to declare an IJ rating
Nobody has to be physically hurt for IJ to be declared; the potential for harm is enough
Psychological harm is equally as bad as physical harm
An IJ rating will be declared for any case of abuse, even if the abuser doesn’t work at the hospital
An IJ rating will be declared for any case of neglect
The situation that caused the IJ rating could have happened in the past, be happening in the present, or be likely to happen in the future
“For example, there was a hospital that was undergoing construction that required closure of multiple exits,” says Curtis. “The hospital failed to change the exit signage, which meant that in the event of a fire, staff and patients would have followed those exits into a dead end. That was an isolated occurrence but a severe breach of safety.”