© Copyright, The Joint Commission 2014 T HE H EALTHCARE E NVIRONMENT John Maurer, SASHE, CHFM, CHSP...

© C

opyr

ight

, The

Joi

nt C

omm

issi

on

2014

THE HEALTHCARE ENVIRONMENT

John Maurer, SASHE, CHFM, CHSP

Engineering Department

The Joint Commission

Department of Engineering 2014 - 2

© C

opyr

ight

, The

Joi

nt C

omm

issi

on

RISK ICON

Integrated into the Manuals, E-dition, AMP, & FSA Tool All products will display a single icon at the EP level

for three risk-focused categories:1. National Patient Safety Goals2. Accreditation program-specific risk area standards3. Selected direct/indirect impact standards

In addition, the FSA Tool will use the R icon to identify the fourth risk category:

4. RFI standards from current cycle survey events.

Risk• Proximity to patient• Probability of harm• Severity of harm• Number of patients at risk


© C

opyr

ight

, The

Joi

nt C

omm

issi

on

Standard/NPSG 2012 Non Compliance 2013 Non Compliance

LS.02.01.20 61% 52%

RC.01.01.01 51% 52%

LS.02.01.10 46% 48%

EC.02.05.01 34% 47%

IC.02.02.01 42% 46%

LS.02.01.30 39% 45%

EC.02.03.05 40% 45%

EC.02.06.01 35% 39%

LS.02.01.35 34% 36%

MM.03.01.01 35% 35%


© C

opyr

ight

, The

Joi

nt C

omm

issi

on

Standard/NPSG 2012 Non Compliance 2013 Non Compliance

EC.02.02.01 30% 34%

PC.01.03.01 25% 27%

EC.02.05.07 23% 23%

MM.04.01.01 26% 22%

EC.02.05.09 23% 21%

PC.03.01.03 19% 20%

LD.01.03.01 17% 19%

EC.02.03.01 19% 19%

HR.01.02.05 16% 19%

PC.02.01.03 25% 18%


© C

opyr

ight

, The

Joi

nt C

omm

issi

on

TOP 10 CITED STANDARDS: 2011 - 2013

Standard 2011 2012 2013

LS.02.01.20: Means of Egress #2 #2 #1

LS.02.01.10: General Bldg Req’s #3 #3 #3

EC.02.05.01: Utility Systems Risks #13 #10 #4

LS.02.01.30: Protection #4 #6 #6

EC.02.03.05: Fire Safety Systems #5 #5 #7

EC.02.06.01: Built Environment #11 #7 #8

LS.02.01.35: Extinguishment #10 #9 #9


© C

opyr

ight

, The

Joi

nt C

omm

issi

on

#1 LS.02.01.20 EP 13

The hospital maintains the integrity of the means of egress

Anything in the egress corridor more than 30 minutes is storage

Dead end corridors may be used for storage Less than or equal to 50sqft space

Carts Allowed:Crash Carts Isolation CartsChemo Carts


© C

opyr

ight

, The

Joi

nt C

omm

issi

on

“IF THE CORRIDOR LOOKS CLUTTERED…IT PROBABLY IS”

Educate StaffWhat is the Risk?

Patient movement Staff movement Additional Staff responding to emergency

patient care


© C

opyr

ight

, The

Joi

nt C

omm

issi

on

#3 LS.02.01.10 EP 5 – 7 & 9

Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat.EPs 5 – 7 Door issuesEP 9 Fire Barrier Penetrations

Barrier Management


© C

opyr

ight

, The

Joi

nt C

omm

issi

on

BARRIER MANAGEMENT SYMPOSIUM . . .at no cost to the attendee . . .


© C

opyr

ight

, The

Joi

nt C

omm

issi

on

BARRIER MANAGEMENT SYMPOSIUM Program Developers:

Joint CommissionFirestop Contractors International AssociationUnderwriters Laboratories

Participating Organizations:American Society for Healthcare Engineering AWCI & Gypsum InstituteFire Damper IndustryFire Rated Glazing IndustryNational Concrete Masonry Association


© C

opyr

ight

, The

Joi

nt C

omm

issi

on

#4 EC.02.05.01 EP 6

Ventilation system is unable to provide appropriate pressure relationships, air-exchange rates and filtration efficiencies Specific areas lack

negative or positive pressures in relationship to adjacent areas • i.e. Endoscopy Processing Room should be

negative to the egress corridor the correct number of air changes per hour Improper filtration

• MERV = minimum efficiency reporting value


© C

opyr

ight

, The

Joi

nt C

omm

issi

on

WHAT IS VENTILATION? Ventilation is moving air from one location to another Supply Air

Outside air is conditioned by cooling or heating as the air moves through a series of coils To save energy in some systems the returned air

is blended with outside air Next the air is cleaned by filters and discharged into

the occupied space As the air moves through the building in ducts, the

ducts pass through barriers (walls) To protect the barrier dampers are in place


© C

opyr

ight

, The

Joi

nt C

omm

issi

on

VENTILATION

Exhaust SystemRemoving the air from an occupied space

is accomplished by the exhaust systemExhausted air is either removed from the

building or re-conditioned and re-usedAs air is removed, it is replaced by supply

air This is how air exchanges occur New air in, old air out


© C

opyr

ight

, The

Joi

nt C

omm

issi

on

VENTILATION

Based on how much air is exhausted and how much air is supplied, the area is either negative, neutral or positiveMore air out, negative pressureSame air in and out, neutral More air in, positive pressure

Normally the cleanest location should be more positive, and the least clean the most negative


© C

opyr

ight

, The

Joi

nt C

omm

issi

on

SCREENING Tissue test: only to be used as a pre-screening tool to

evaluate if further investigation needs to occur To perform the flutter test take a tissue and let it hang

just off the floor near the bottom edge of a door If the tissue indicates incorrect air flow, stabilize the area

by closing doors and windows, wait a few minutes and re-test

If the organization presents a Testing & Balancing report the following questions should be asked

• when was the balancing done (seasonal issues) • are any specific requirements (such as keeping a

door closed) needed to achieve satisfactory results


© C

opyr

ight

, The

Joi

nt C

omm

issi

on

SURVEY PROCESS EC.02.05.01 EP 6 will generate a CLD

If the organization can repair the process that led to non-compliance the LSCS may review

Following LSCS review, the LSCS may contact the Central Office to discuss the possibility of reducing the CLD to SLD, with no change to the finding

Resolution should include the area affected by the equipment identified as non-compliant, not just the identified room/area i.e. ensure zone is balanced Is there an ongoing process to assess


© C

opyr

ight

, The

Joi

nt C

omm

issi

on

HLD SELF CONTAINED UNITS (I.E. GUS) High Level Disinfection (HLD) for semi critical devices are found in

and outside the Central Sterile areas Gluteraldehyde User Stations (GUS) disinfection soak stations, or

similar self contained HLD units such as those using 0.55% ortho-phthalaldehyde (OPA)

The Joint Commission will focus on the processes and Personal Protective Equipment (PPE) Many of the chemical disinfectants are potentially toxic and may

require adequate precautions, including face/eye shields and gloves

Ventilation Requirements: None. Rooms must meet specific room requirements, however

Storage: in a manner that will protect from contamination or damage, such as hanging in a cabinet with doors


© C

opyr

ight

, The

Joi

nt C

omm

issi

on

IMPORTANT NOTE

ASHRAE voted in July 2013 to move endoscopy procedure rooms from positive to N/A, in Addendum W.

Therefore, if an organization had made a documented decision based on risk assessment to no longer monitor endoscopy procedure rooms as per the 2013 ASHRAE action, we would accept this.

If the organization has not made a documented decision, the room should be evaluated as per the below table and construction date.

No change to bronchoscopy procedure rooms.


© C

opyr

ight

, The

Joi

nt C

omm

issi

on

GUIDELINES VENTILATION TABLE: ENDOSCOPY & BRONCHOSCOPY

ENDOSCOPY BRONCHOSCOPY

EditionPROCEDURE PROCESSING (CLEANING) PROCEDURE

PRESSURE DIRECT EXHAUST PRESSURE DIRECT EXHAUST PRESSURE DIRECT

EXHAUST

2014 (pending) N/A N/A Negative (-) YES Negative (-) YES

2010 Positive (+) N/A Negative (-) YES Negative (-) YES

2006 Neutral N/A Negative (-) YES Negative (-) YES

2001 Negative (-) N/A N/A N/A Negative (-) YES

1996/97 N/A N/A N/A N/A Negative (-) YES

1992/93 N/A N/A N/A N/A N/A N/A

1987 N/A N/A N/A N/A N/A N/A

1979 N/A N/A N/A N/A N/A N/A


© C

opyr

ight

, The

Joi

nt C

omm

issi

on

#6 LS.02.01.30

The hospital provides and maintains building features to protect individuals from the hazards of fire and smoke.EP2 Hazardous Areas

Primarily door issuesEPs 16 – 23 Smoke Barriers &

Doors


© C

opyr

ight

, The

Joi

nt C

omm

issi

on

#7 EC.02.03.05

The hospital maintains fire safety equipment and fire safety building features.Features of fire protection

Inventory required to ensure all devices are tested

Documentation of testing is required


© C

opyr

ight

, The

Joi

nt C

omm

issi

on

NEED FOR INVENTORY EC.02.03.05 EP 1 – 20:

Each device that is required to be tested must be documented in an inventory If x devices were tested last year, and x-1 were tested

this year, which device was missed?• Each device must be on the inventory to identify

which device was missed• Total number of devices (quantity) is not adequate

Lack of an inventory (written, electronic or other) results in a finding at the EP Findings solely for lack of inventory is not scored at

EC.02.03.05 EP 25


© C

opyr

ight

, The

Joi

nt C

omm

issi

on

EC.02.03.05EPs 1 -20: Missing documentation: score the EP as non-

compliant Also write a finding at EP 25 for documentation

not being readily available to the AHJ• If acceptable documentation appears, finding

at EP 1 – 20 might be removed during survey• EP 25 remains

LD.04.01.05 EP 4: Staff held accountable If 3 or more findings at EC.02.03.05 EP 1 – 20


© C

opyr

ight

, The

Joi

nt C

omm

issi

on

EC.02.03.05

During survey specific documentation is reviewed

If the documentation for a specific EP is not available a finding is written as non-compliant for that EPThe documentation should be readily available

If the organization clarifies after survey:Joint Commission Engineers will review and

evaluate complianceLD.04.01.05 EP 4 remains


© C

opyr

ight

, The

Joi

nt C

omm

issi

on

#8 EC.02.06.01 EP 1 & 13

EP 1 Interior spaces meet the needs of the patient population and are safe and suitable to the care, treatment and services providedThe organization must provide a safe

environment Unsecured oxygen cylinders Outdoor safety is scored at

EC.02.01.01 EP 5


© C

opyr

ight

, The

Joi

nt C

omm

issi

on

EC.02.06.01 EP 13 EP 13 The organization maintains ventilation,

temperature and humidity levels suitable for the care, treatment and services provided

Ventilation: • i.e. doors held open by air pressure; odors

Temperature: • Hot / Cold calls

Humidity• Primary concern is for areas >60%RH

− Mold growth is possible EP 20: Patient care areas are clean and free of offensive

odors


© C

opyr

ight

, The

Joi

nt C

omm

issi

on

#9 LS.02.01.35 EP 6

EP 9: There are 18” or more of open space maintained below the sprinkler deflector to the top of storage.

NOTE: Perimeter wall and stack shelving may NFPA 13-1999, 5-6.6


© C

opyr

ight

, The

Joi

nt C

omm

issi

on

18” RULE

18”18”

OK OK OKWrong

Wall Wall

Ceiling

Perimeter Shelving Perimeter

Shelving


© C

opyr

ight

, The

Joi

nt C

omm

issi

on

#11 EC.02.02.01 EP 3 – 5

EP’s 3 – 5: Personal Protective Equipment and the process to manage hazardous materials and waste handling and exposures

EP’s 6 – 7: Hazardous energy sourcesEscorts to Hot Lab based on organization

policy Perspectives, July 2012


© C

opyr

ight

, The

Joi

nt C

omm

issi

on

EYE WASH STATION FEDERAL REQUIREMENTS: OSHA

Score Eye Wash issues at EC.02.02.01 EP 5 Risk assess location / application based on OSHA recommendation to

reduce the risk of injury from contact with caustic and corrosive materials in areas such as Power Plant Lab

Placed so that the eyewash is within 10 seconds or 55 feet from where the corrosive chemicals is used

Weekly flush until clear is required Annual inspection to ensure the system is fully functional Mixing valve recommended to achieve tepid

Risk assess potential exposure to determine if cold water only would be acceptable


© C

opyr

ight

, The

Joi

nt C

omm

issi

on

EYE WASH STATION: RECOMMENDED LOCATIONS (I.E. OSHA)

Medical services and first aid 1910.151(c) The eyes or body of any person may be exposed to injurious corrosive

materials, suitable facilities for quick drenching or flushing of the eyes and body shall be provided within the work area for immediate emergency use.

Formaldehyde 1910.1048(i)(3) If there is any possibility that an employee's eyes may be splashed with

solutions containing 0.1 percent or greater formaldehyde, the employer shall provide acceptable eyewash facilities within the immediate work area for emergency use.

Battery charging and changing 1917.157(i) Facilities for flushing the eyes, body and work area with water shall be

provided wherever electrolyte is handled, except that this requirement does not apply when employees are only checking battery electrolyte levels or adding water.


© C

opyr

ight

, The

Joi

nt C

omm

issi

on


© C

opyr

ight

, The

Joi

nt C

omm

issi

on

#13 EC.02.05.07 EP 6

EPs 4 – 7 Missed Generator & Automatic Transfer

Switch (ATS) Tests12 times per year between 20 & 40 days

Each emergency generator must be tested with a load of at least 30% of nameplate

Each ATS must be tested Missed triennial 4 hour test


© C

opyr

ight

, The

Joi

nt C

omm

issi

on

#15 EC.02.05.09 EP 3

Medical Gas SystemsEP 1: Inspection Testing and MaintainingEP 2: Test when modified, installed or repaired EP 3: ObstructionsEP 3: Labeling

Contents of piping Areas served

• Accuracy


© C

opyr

ight

, The

Joi

nt C

omm

issi

on

# 18 EC.02.03.01 EP 1 & 9 – 10

Fire Safety (EP 1) Open junction boxesMore than 300cuft of nonflammable medical

gases (i.e. oxygen) per smoke compartment, open to the egress corridor

Fire Plan (EP 9 & 10)Lack of fire safety training as per fire plan

Surgical site fires


© C

opyr

ight

, The

Joi

nt C

omm

issi

on

CMS ISSUE

January 2011 the Joint Commission adopted the 2010 FGI Guidelines for Design & Construction of Health Care Facilities Included in the Guidelines is the ASHRAE 170-

2008 document with >20% RH lower limit April 2013 CMS Issued S&C-13-25-LSC & ASC

which is “a categorical LSC waiver permitting new and existing ventilation systems to operate with a RH of >20 percent, instead of >35 percent…”


© C

opyr

ight

, The

Joi

nt C

omm

issi

on

RH 20 – 60% RANGE CMS first issued a Categorical Waiver in S&C 13-25-LSC &

ASC to align with the 2010 FGI Guidelines for Design & Construction of Health Care Facilities use of ASHRAE 170-2008 Reduced the relative humidity (RH) in certain areas to a

range of 20 – 60% This 2013 CMS action matched the Joint Commission’s

1/2011 adoption of the 2010 Guidelines and the 20 – 60% RH range provided

The S&C had two criteria1. Document the decision 2. Declare at the beginning of a survey the decision

© C

opyr

ight

, The

Joi

nt C

omm

issi

on

2012 LIFE SAFETY CODEUPDATE

THE FOLLOWING ARE AVAILABLE WITH CERTAIN PROVISIONS.

THESE ARE BASED ON CMS S&C 13-58-LSC


© C

opyr

ight

, The

Joi

nt C

omm

issi

on

BACKGROUND

The Joint Commission provided CMS with a list of items, based on later editions of the Life Safety Code, that would immediately have a positive impact on all healthcare

CMS acted on the Joint Commission recommendation in the form of a State & Certification letter (S&C 13-58-LSC)The action is a series of Categorical Waivers


© C

opyr

ight

, The

Joi

nt C

omm

issi

on

PROCESS

If the organization decides to adopt these categorical waivers they must1. Ensure full compliance with the appropriate code reference2. Document the decision to adopt the categorical waiver

For Life Safety Code items annotate the “Additional Comments” Section in the Statement of Conditions™ Basic Building Information (BBI)

For Environment of Care items document by Minutes in discussion at the Environment of Care Committee (or equivalent)

3. Declare the decision at the beginning of any survey See also November 2013 Perspectives


© C

opyr

ight

, The

Joi

nt C

omm

issi

on

S&C 13-58-LSC

1. Openings in exit enclosures2. Emergency generators and standby power systems3. Doors, locking arrangements4. Suites5. Extinguishing requirements6. Clean waste and patient record recycling containers7. Medical gas alarmsPlus four: see S&C 12-21-LSC8. Wheeled equipment in egress corridors9. One alternative kitchen cooking arrangement10. Direct vent gas fireplaces and solid fuel-burning fireplaces11. Combustible decorations on walls, doors, and ceilings

© C

opyr

ight

, The

Joi

nt C

omm

issi

on

2014


UPDATE, EFFECTIVE JANUARY 1


© C

opyr

ight

, The

Joi

nt C

omm

issi

on

TIME RE-DEFINEDThe Joint Commission EC chapter defines time as:

Daily, weekly, monthly are calendar references Quarterly will be once every three months +/- 10 days

January 1, 2014 Semi-annual is 6 months from the last scheduled event

month +/- 20 days Annual is 12 months from the last scheduled event

month +/- 30 days 3 years is 36 months from the last scheduled event

month +/- 45 daysNOTE 1: The above does not apply to required frequenciesNOTE 2: An alternative of developing either a unique, written policy or adopting

NFPA definitions when available is acceptable


© C

opyr

ight

, The

Joi

nt C

omm

issi

on

QUARTERLY: +/- 10 DAYSSEMIANNUAL: +/- 20 DAYS

ANNUAL: +/- 30 DAYSDue Date

Due Date

Scheduled Month

Scheduled Month20 202020

30 303030

July Sept OctAug NovJune Dec

Jan F M A J J O N

Semiannual

Annual

+ +

JanM A S D

Frequencies required by Code may not be modified (e.g. EC.02.05.07 EP 4 & 7)

10 10 10 10

Jan February March AprQuarterly


© C

opyr

ight

, The

Joi

nt C

omm

issi

on

Score EC.02.03.01 EP 1 …fire risk12 ‘E’ cylinders (<300ft³) per smoke compartment (22,500ft²) may be

open to the egress corridor in a rack or appropriate holdersBetween 300 and 3000ft³ must be stored in a room that is limited

construction with doors that can be locked “In use” verses “in storage”

Properly secured to a gurney is considered “in use” Properly racked is “in storage” Empty are NOT considered part of the 12 in storage Empty and full must be stored (racked) separately

MEDICAL GAS SAFETY


© C

opyr

ight

, The

Joi

nt C

omm

issi

on

Score EC.02.06.01 …unsafe condition Unsecured cylinders

Laying on top a gurney mattress; leaning against the wall Free standing Comingling of full and empty cylinders

Transfilling liquid oxygen Transfer of any gases from one cylinder to another in patient care areas

of health care facilities is prohibited. Transfilling of liquid oxygen only in an area that is:

• mechanically ventilated• sprinklered• ceramic or concrete flooring• separated with at least 1 hour construction from any patient care

areas

MEDICAL GAS SAFETY


© C

opyr

ight

, The

Joi

nt C

omm

issi

on

MEDICAL GAS SAFETY

5 Key Steps to ensuring Medical Gas Safety Make sure all medical gas cylinders are always

secured. Make sure full and partial or empty cylinders are

physically separated to prevent staff confusion when retrieving a cylinder during an emergency.

Consider any open cylinders as “empty” and keep these cylinders physically separated from full cylinders.

Monitor and manage the amount of nonflammable medical gases stored in patient care areas

Make sure all repairs are completed by qualified staff.


© C

opyr

ight

, The

Joi

nt C

omm

issi

on

MEDICAL GAS SAFETY

Minimizing fire risk NFPA 99-2005 Section 9.4.3 (see also CMS S&C-07-10)

allows up to 300 cubic feet of nonflammable medical gas in cylinders to be available to an egress corridor. One e-cylinder holds approximately 25 cubic feet

A full E cylinder with a malfunctioning valve could create an oxygen enriched environment, resulting in a potential fire risk. Adding additional full gas cylinders to the area may present even a greater fire risk, so organizations must comply with the limit of 12 E cylinders open to the means of egress.

See also December 2012 Perspectives


© C

opyr

ight

, The

Joi

nt C

omm

issi

on


© C

opyr

ight

, The

Joi

nt C

omm

issi

on

THE ALARMING PROBLEM

More and more devices and alarms More patients connected to alarms or

alarm-based devices 150-400+ alarms per patient per day in a

typical critical care unit Alarm-based devices are not standardized

in many organizations Inconsistent use of alarms due to flexible

alarm setting features


© C

opyr

ight

, The

Joi

nt C

omm

issi

on


© C

opyr

ight

, The

Joi

nt C

omm

issi

onNATIONAL PATIENT SAFETY GOAL


© C

opyr

ight

, The

Joi

nt C

omm

issi

on

NPSG ON ALARM MGMT

In Phase I (beginning January 2014) Hospitals will be required to:

establish alarms as an organization priority and identify the most important alarms to manage based on

their own internal situations. Input from medical staff and clinical depts Risk to patients due to lack of response, malfunction Are specific alarms needed or contributing to

noise/fatigue Potential for patient harm based on internal incident

history Published best practices/guidelines


© C

opyr

ight

, The

Joi

nt C

omm

issi

on

NPSG ON ALARM MGMT

In Phase II (beginning January 2016) Hospitals will be expected to:

develop and implement specific components of policies and procedures that address at minimum: Clinically appropriate settings When they can be disabled When parameters can be changed Who can set and who can change parameters and who

can set to “off” Monitoring and response expectations Checking individual alarm signals for accurate settings,

proper operation and detectability educate those in the organization about alarm system

management for which they are responsible


© C

opyr

ight

, The

Joi

nt C

omm

issi

onRESOURCES


© C

opyr

ight

, The

Joi

nt C

omm

issi

on

OTHER RESOURCES

AAMI website page on Clinical Alarms: http://www.aami.org/htsi/alarms/index.html

ECRI website page on Alarm Management resources: https://www.ecri.org/Forms/Pages/Alarm_Safety_Resource.aspx

Pennsylvania Patient Safety Authority: http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2011/sep8(3)/Pages/105.aspx (physiologic alarm management)

Healthcare Technology Foundation: http://thehtf.org/clinical.asp (national clinical alarm survey)

http://www.aami.org/htsi/alarms/index.html

https://www.ecri.org/Forms/Pages/Alarm_Safety_Resource.aspx

https://www.ecri.org/Forms/Pages/Alarm_Safety_Resource.aspx

http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2011/sep8(3)/Pages/105.aspx

http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2011/sep8(3)/Pages/105.aspx

http://thehtf.org/clinical.asp


© C

opyr

ight

, The

Joi

nt C

omm

issi

on

EMERGENCY MANAGEMENT OVERSIGHT

Address leadership accountability for hospitals and critical access hospitals

Found in EM and LD, effective January 2014:LD.04.01.05EM 03.01.01EM.03.01.03LD.04.04.01

See the July 2013 Perspectives


© C

opyr

ight

, The

Joi

nt C

omm

issi

on

EMERGENCY MANAGEMENT OVERSIGHT Require the organization to identify a leader to

oversee emergency management Require the organization to consider input from

staff at different levels when evaluating exercises and responses to events

Require senior hospital leaders to review EM planning activities, performance in exercises, and responses to actual events to facilitate improved communication of problem areas and implementation of hospitalwide solutions


© C

opyr

ight

, The

Joi

nt C

omm

issi

on

LD.04.01.05 EP 12

Someone accountableStaff implementation of the four phases of EMStaff implementation across the six critical

areasOrganization-wide collaboration Identification and collaboration with

community

Note: Addresses matters that are not part of incident commander role


© C

opyr

ight

, The

Joi

nt C

omm

issi

on

EM.03.01.01 EP 4

Evaluating effectiveness of planning

EP 4: The annual emergency management planning reviews are forwarded to senior hospital leadership for review Note: Senior hospital leadership refers to those

leaders with responsibility for organization-wide strategic planning and budgets (vice presidents and officers). The hospital may determine that all senior hospital leaders participate in reviewing emergency management reviews, or it may designate specific senior hospital leaders to review this information.


© C

opyr

ight

, The

Joi

nt C

omm

issi

on

EM.03.01.03 EP 13: EVALUATION

Organization evaluates effectiveness of EOPEvaluate through a multidisciplinary process Includes relevant input from ALL levels of staff

affected


© C

opyr

ight

, The

Joi

nt C

omm

issi

on

EM.03.01.03 - EVALUATION

Organization evaluates effectiveness of EOP Evaluation of exercises and events to include

deficiencies and opportunities for improvement Deficiencies and opportunities for improvement are

communicated to the improvement team responsible for monitoring environment of care issues and to senior hospital leadership.

(See also EC.04.01.03, EP 1; EC.04.01.05, EP 3; LD.04.04.01, EP 25) Modifications to EOP based on evaluations Future exercises/events reflect changes made and/or

interim measures found in modified EOP


© C

opyr

ight

, The

Joi

nt C

omm

issi

on

LD.04.04.01 EP 25

Senior hospital leadership directs implementation of selected hospital-wide improvements in emergency management based on the following: Review of the annual emergency management planning reviews (See

also EM.03.01.01, EP 4) Review of the evaluations of all emergency response exercises and all

responses to actual emergencies (See also EM.03.01.03, EP 15) Determination of which emergency management improvements will

be prioritized for implementation, recognizing that some emergency management improvements might be a lower priority and not taken up in the near term.


© C

opyr

ight

, The

Joi

nt C

omm

issi

on

EC.02.03.03 EP 3

When quarterly fire drills are required, at least 50% are unannounced. Fire drills are held at unexpected times and under varying conditions.

Added: “Fire drills are held at unexpected times and under varying conditions.”


© C

opyr

ight

, The

Joi

nt C

omm

issi

on

EC.02.03.03 EP 4

Staff who work in buildings where patients are housed or treated participate in drills according to the hospital’s fire response plan.

Note: When drills are conducted between 9:00 p.m. and 6:00 a.m., the hospital may use

alternative methods to notify staff instead of activating audible alarms.

Replaced “building’s fire alarm system.”


© C

opyr

ight

, The

Joi

nt C

omm

issi

on

CMS ISSUE

Joint Commission met with CMS and discussed manufacturers’ recommendations, Life Safety Code adoption and other issuesCMS has indicated that The Joint Commission may

continue to use their current process for equipment and utilities management State agents will not be so instructed

ASHE & AAMI met with CMS to continue to discuss the concerns related to equipment management Responded by clarifying several issues


© C

opyr

ight

, The

Joi

nt C

omm

issi

on

S&C 14-07-HOSPITAL

S&C 12-07-Hospital Superceded A hospital may adjust its maintenance, inspection, and testing

frequency and activities for facility and medical equipment from what is recommended by the manufacturer, based on a risk-based assessment by qualified personnel, unless: Other Federal or state law; or hospital Conditions of

Participation (CoPs) require adherence to manufacturer’s recommendations and/or set specific requirements. • For example, all imaging/radiologic equipment must be

maintained per manufacturer’s recommendations; or The equipment is a medical laser device; or New equipment without a sufficient amount of maintenance

history has been acquired.


© C

opyr

ight

, The

Joi

nt C

omm

issi

on

S&C 14-07-HOSPITAL The organization inspects, tests & maintains new

medical equipment or operating components of utility systems in accordance with manufacturers’ recommendations with insufficient maintenance history to support the use of alternative maintenance strategies. Maintenance history may be gathered from

documented evidence such as Provided by the organizations contractors Available publically from nationally recognized

sources Through the organizations experience over time


© C

opyr

ight

, The

Joi

nt C

omm

issi

on

EC.02.04.03 EP 24

For [organizations] that use Joint Commission accreditation for deemed status purposes: The [organization] inspects, tests, and maintains the following in accordance with manufacturers’ recommendations (See also EC.02.04.01, EPs 3 and 4):

Medical lasers Imaging and radiologic equipment (whether used for diagnostic or

therapeutic purposes) New medical equipment with insufficient maintenance history to

support the use of alternative maintenance strategies. Note: Maintenance history may be gathered from documented

evidence provided by the [organization’s] contractors available publically from nationally recognized sources, or through the [organization’s] experience over time


© C

opyr

ight

, The

Joi

nt C

omm

issi

on

EC.02.05.05 EP 6

For [organizations] that use Joint Commission accreditation for deemed status purposes: The [organization] inspects, tests, and maintains new operating components of utility systems in accordance with manufacturers’ recommendations with insufficient maintenance history to support the use of alternative maintenance strategies. Note: Maintenance history may be gathered from documented evidence:

provided by the [organization’s] contractors available publically from nationally recognized sources

or through the [organization’s] experience over time


© C

opyr

ight

, The

Joi

nt C

omm

issi

on

S&C 14-07-HOSPITAL: EVALUATING PROGRAM EFFECTIVENESS

The equipment management programs must have written policies & procedures

Evaluating the program: How is equipment evaluated to ensure no

degradation of performance? How are equipment-related incidents investigated?

How to sequester equipment deemed unsafe? Is there a performance process to evaluate if

modifications to the maintenance strategy is needed?


© C

opyr

ight

, The

Joi

nt C

omm

issi

on

S&C 14-07-HOSPITAL: SURVEY STRATEGIES

Evaluate the accuracy of the inventory Are imaging/radiologic equipment and medical laser devices

exempt from the alternative maintenance program? Verify the inspection, testing & maintaining activities and

frequencies are documented Evaluate the process for equipment being maintained, including

qualified personnel Ask staff questions related to the alternative maintenance

program Equipment inclusion process Assignment of maintenance strategies and frequencies

Verify evaluation of the program is occurring and being reported


© C

opyr

ight

, The

Joi

nt C

omm

issi

on

EC.02.05.07 EP 1

At least monthly, the hospital performs a functional test of battery-powered lights required for egress for a minimum duration of 30 seconds. The completion date of the tests is documented.

Replaced “At 30 day intervals…”


© C

opyr

ight

, The

Joi

nt C

omm

issi

on

DIAGNOSTIC IMAGING

Three phases of implementation for hospitals, critical access hospitals, and ambulatory care organizations Includes ambulatory care organizations that have achieved

Advanced Diagnostic Imaging certification Phase 1, effective July 1, 2014

Exceptions: not applicable to dental cone beam CT radiographic imaging studies performed for diagnosis of conditions affecting the maxillofacial region or to obtain guidance for the treatment of such conditions.

Phase 1.5: minimum qualifications for radiologists performing CT scans

Phase 2: fluoroscopy qualifications for non-radiologists performing imaging exams and cone beam CT, and for dental or oral surgical procedures


© C

opyr

ight

, The

Joi

nt C

omm

issi

on

DIAGNOSTIC IMAGING

Phase 1: Effective July 1, 2014 Computed tomography (CT), nuclear medicine (NM),

positron emission tomography (PET), and magnetic resonance imaging (MRI)

Minimum competency for radiology technologists, including registration and certification by July 1, 2015

Annual performance evaluations of imaging equipment by a medical physicist

Documentation of CT radiation dose in the patient’s clinical record

Meeting the needs of the pediatric population through imaging protocols and by considering patient size or body habitus when establishing imaging protocols


© C

opyr

ight

, The

Joi

nt C

omm

issi

on

DIAGNOSTIC IMAGING

Phase 1: Effective July 1, 2014 Management of safety risks in the MRI environment Collection of data on incidents during which identified

radiation dose limits have been exceeded Minimum quarterly review of staff dosimetry results

New, replacement or modification to rooms Medical physicist to perform structural shielding

design New equipment or rooms where ionizing radiation is

emitted or radioactive material is stored Medical physicist to perform radiation protection

survey


© C

opyr

ight

, The

Joi

nt C

omm

issi

on

DEPARTMENT OF ENGINEERING630 792 5900

George Mills, MBA, FASHE, CEM, CHFM, CHSP, Green Belt

Director

Anne Guglielmo, CFPS, LEED, A.P., CHSP

Engineer

John Maurer, SASHE, CHFM, CHSP

Engineer

Kathy Tolomeo, CHEM Engineer

James Woodson, P.E., CHFM

Engineer


© C

opyr

ight

, The

Joi

nt C

omm

issi

on

These slides are current as of 4/7/2014. The Joint Commission reserves the right to change the content of the information, as appropriate.

These slides are only meant to be cue points, which were expounded upon verbally by the original presenter and are not meant to be comprehensive statements of standards interpretation or represent all the content of the presentation. Thus, care should be exercised in interpreting Joint Commission requirements based solely on the content of these slides.

These slides are copyrighted and may not be further used, shared or distributed without permission of the original presenter or The Joint Commission.

THE JOINT COMMISSION DISCLAIMER

© Copyright, The Joint Commission 2014 T HE H EALTHCARE E NVIRONMENT John Maurer, SASHE, CHFM, CHSP...

Documents

Transcript of © Copyright, The Joint Commission 2014 T HE H EALTHCARE E NVIRONMENT John Maurer, SASHE, CHFM, CHSP...