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Environment of Care Emergency Management Life Safety

The Joint Commission

ECNewsJuly 2013 Volume 16 Issue 7

Labeling the HazardOSHA to institute “global harmonization” of hazard communications

Under OSHA’s recent revision of the Hazard Communica-

tions Standard (29 CFR 1910.1200), the symbols and frames

presented above will no longer be acceptable as of June 1,

2015. Harmonized pictograms (shown in Figure 1) will

replace such symbols on hazardous chemical labels.

Inside2 Test Your Standards IQ

5 Clarifications and Expectations: Ensuring Full

Compliance with the Life Safety Code®

Tips on meeting recurring compliance issues

7 OSHA & Worker Safety: Protection PartnershipHow health care organizations can better secure the safety of

workers and patients alike

10 Revisions to Applicability of EC Requirements

for Freestanding Ambulatory Infusion and

Rehabilitation Technology Settings in the

Home Care Program(continued on page 3)

Hazardous chemical labels will soon have a newlook—and workers will need to be trained to recognize it.

Beginning shortly, OSHA will require that hazardous chemi-cal containers be labeled with a whole new set of standardizedpictograms (see Figure 1, p. 3). The easily identified symbols willbe the same around the world. Having the symbols “globallyharmonized” will help workers in countries around the planetrecognize exactly what type of hazardous material is in a con-tainer, regardless of what country it was shipped from and whatlanguage it’s in.

The new hazardous chemicals labeling requirements are partof OSHA’s recent revision of the Hazard Communication Stan-dard (HCS), 29 CFR 1910.1200, bringing it into alignmentwith the United Nations’ Globally Harmonized System of Classification and Labelling of Chemicals (GHS).

The revised OSHA standard requires that information aboutchemical hazards be conveyed on labels using quick visual nota-tions to alert the user and provide immediate recognition of thehazards. The label provides information to the workers on thespecific hazardous chemical. Labels must also provide instruc-tions on how to handle the chemical so that chemical users areinformed about how to protect themselves. Specifically, labelsmust contain the following information: product identifier; sig-nal word; hazard statement(s); precautionary statement(s); pic-togram(s); and the name, address, and telephone number of the

www.jcrinc.com2 EC NEWS July 2013

Executive Editor: Kristine M. Miller, MFA

Senior Project Manager: Cheryl Firestone

Manager: Lisa Abel

Executive Director: Catherine Chopp Hinckley, PhD

Contributing Writers: Kathleen Vega, Erik Martin

Technical Support and Review:

Standards Interpretation GroupPatricia Adamski, RN, MS, MBA, Director

Department of EngineeringGeorge Mills, MBA, FASHE, CEM, CHFM,

CHSP, Director

Anne M. Guglielmo, CFPS, CHSP, LEED AP, Engineer

John D. Maurer, CHFM, CHSP, Engineer

Department of Standards and Survey MethodsJohn Fishbeck, RA, Associate Director

Editorial Advisory Board:

David A. Dagenais, CHSP, CHFM, SASHE, Wentworth Douglass Hospital, Dover, NH

Katherine Grimm, MPH, Emergency ManagementCoordinator, Maple Grove Hospital, Maple Grove, MN

David P. Klein, PE, Department of Veterans Affairs,Washington, DC

Michael Kuechenmeister, FASHE, CHFM, CPE,West Chester Medical Center, Cincinnati

William R. (Bill) Morgan, SASHE, CHFM, St. Alphonsus Regional Medical Center, Boise, ID

George A. (Skip) Smith, CHFM, SASHE, Catholic Health Initiatives, Denver

Jen Carlson Steinmetz, MPH, MBA, Manager, Occupational Health and Safety,Northwestern Memorial Hospital, Chicago

Subscription Information:

The 2013 12-issue subscription rates for the UnitedStates, Canada, and Mexico are $319 for both printand online and $299 for online only; for the rest ofthe world, the rates are $410 for both print andonline and $299 for online only. Back issues are $25each (postage paid). Add $25 for airmail delivery.Orders for 20–50 single/back issues receive a 20%discount. Site licenses and multiyear subscriptionsare also available. To begin your subscription, call800-746-6578, fax orders to 218-723-9437, or mailorders to Joint Commission Resources, 16442 Collections Center Drive, Chicago, IL 60693. Formore information, call 800-746-6578. Environment ofCare® News (ISSN 1097-9913) is published monthlyby Joint Commission Resources, 1515 West 22ndStreet, Suite 1300W, Oak Brook, IL 60523.

© 2013 The Joint Commission

No part of this publication may be reproduced ortransmitted in any form or by any means withoutwritten permission.

Joint Commission Resources, Inc. (JCR), a not-for-profit affiliate of The Joint Commission, has beendesignated by The Joint Commission to publishpublications and multimedia products. JCR repro-duces and distributes these materials under licensefrom The Joint Commission.

E-mail us at [email protected] with your articleideas. Visit us on the Web at http://www.jcrinc.com.

To contact the Standards Interpretation Group withstandards questions, phone 630-792-5900.

Time to get sharp on The Joint Commission EC standards and essentialinformation. Use this feature to beef up your knowledge, as a quick reminder ofwhat you already know, or to help educate your staff on a variety of EC, EM, andLS standards and information. You’ll find the answers (if you don’t already knowthem) on page 11. Okay, ready?

1. How frequently must a laboratory monitor hazardous gas andvapor levels?

a. Dailyb. Monthlyc. Yearlyd. At a frequency determined by law and regulation

2. Egress doors in all hospitals must swing in the direction ofegress.

True or False?

3. After granting disaster privileges to a volunteer licensedindependent practitioner, within what time frame must ahospital determine whether the practitioner’s disasterprivileges should continue?

a. 24 hours b. 48 hoursc. 72 hoursd. A week

4. Only hospitals and critical access hospitals must map theirutility systems.

True or False?

5. How frequently must an ambulatory care organization test anyvisual and audible fire alarms present in the facility (includingspeakers)?

a. Once a monthb. Once a quarterc. Every 6 monthsd. Every 12 months

How did you do? Check the answer key on page 11.

Test yourSTANDARDS IQ

The Questions

chemical manufacturer, importer, orother responsible party (see the boxabove and Figure 2, below).

Safety data sheets

In addition, safety data sheets (SDS—formerly referred to as “material safetydata sheets,” or MSDS) will also have anew standardized look that will helpworkers anywhere quickly find andunderstand the information they need.The revised standard requires the use of a16-section SDS format, which providesdetailed information regarding the chem-ical. As with MSDS, OSHA requires that

www.jcrinc.com EC NEWS July 2013 3

Labeling the Hazard

(continued from page 1)

(continued on page 4)

Figure 1. Labels and Pictograms

OSHA will enforce the use of eight of these pictograms on hazardous chemicals.

The environmental pictogram is not mandatory but may be used to provide

additional information.

Figure 2. Hazard Communication Standard Labels

This label contains

all the elements

the new OSHA

regulations

require. You can

use this Quick

Card™ to train

employees about

the new labels.

• Name, address, and telephone

number

• Product identifier

• Signal word

• Hazard statement(s)

• Precautionary statement(s)

• Pictogram(s)

What to Look for on a Label

SDS be kept in work areas where chemi-cals are used and stored. Labels provideimportant information for anyone whohandles, uses, stores, and transports haz-ardous chemicals, but, of course, they are limited by design in the amount of information they can provide. SDS are amore complete resource for detailsregarding hazardous chemicals.

Training

Although the deadline for updating thelabels is June 1, 2015,* the deadline fortraining workers is much sooner:December 1, 2013. Organizations willwant to get their training programs upand running quickly, and OSHA hasprovided training tools including briefsand “Quick Card™” visuals to helpdo that. You can find them athttp://www.osha.gov/dsg/hazcom. Asample Quick Card™ is shown in Figure2. The box at right contains the mini-mum required topics for the training thatmust be completed by December 1,2013.

Joint Commission

requirements

The Joint Commission’s standardEC.02.01.01 and related elements ofperformance (EPs) require that accred-ited organizations manage “risks relatedto hazardous materials and waste.”Specifically, EC.02.01.01, EP 11,requires organizations to have the “safetydata sheets required by law,” andEC.02.01.01, EP 12, requires organiza-tions to label “hazardous materials andwaste. The labels identify the contentsand hazard warnings.” EC


Labeling the Hazard


* Distributors may continue to ship containerslabeled by manufacturers or importers (but not bythe distributors themselves) in compliance withHazCom 1994 until December 1, 2015.

This list contains the minimum required topics for the training that must be

completed by December 1, 2013, according to OSHA.

Training on label elements must include information on the following:

• The type of information the employee would expect to see on the new labels,including the following:✓ Product identifier: how the hazardous chemical is identified. This can be (but is

not limited to) the chemical name, code number, or batch number.

✓ Signal word: used to indicate the relative level of severity of hazard and alert

the reader to a potential hazard on the label. There are only two signal words,

“Danger” and “Warning.” Within a specific hazard class, “Danger” is used for

more severe hazards, and “Warning” is used for less severe hazards.

✓ Pictogram: OSHA has designated eight pictograms under this standard for

application to a hazard category.

✓ Hazard statement: describes the nature of the hazard(s) of a chemical,

including, where appropriate, the degree of hazard. For example: “Causes

damage to kidneys through prolonged or repeated exposure when absorbed

through the skin.”

✓ Precautionary statement: means a phrase that describes recommended

measures that should be taken to minimize or prevent adverse effects

resulting from exposure to a hazardous chemical or improper storage or

handling.

✓ Name, address, and phone number of the chemical manufacturer, distributor,

or importer

• How an employee might use the labels in the workplace, including thefollowing examples:✓ Explain how information on the label can be used to ensure proper storage of

hazardous chemicals.

✓ Explain how the information on the label might be used to quickly locate

information on first aid when needed by employees or emergency personnel.

• General understanding of how the elements work together on a label,including the following examples: ✓ Explain that where a chemical has multiple hazards, different pictograms are

used to identify the various hazards. The employee should expect to see the

appropriate pictogram for the corresponding hazard class.

✓ Explain that when there are similar precautionary statements, the one that

provides the most protective information will be included on the label

Training on the format of the safety data sheets (SDS) must include

information on the following:

• Standardized 16-section format, including the type of information found inthe various sections

• How the information on the label is related to the SDS

Hazard Communications Training Topics

This article was developed through the cooperative efforts of the OSHA/Joint Commission Resources Alliance.


Ensuring Full Compliance with theLife Safety Code®

Tips on meeting recurring compliance issues

Clarifications ExpectationsClarifications Expectationsand

WITH THE JOINT COMMISSION’S DIRECTOR OF ENGINEERING, GEORGE MILLS

The Joint Commission has identified theneed to increase the field’s awareness andunderstanding of the Life Safety Code®*as well as other key environment of careconcepts. To address this need, Environ-ment of Care® News publishes the columnClarifications and Expectations, authoredby George Mills, MBA, FASHE, CEM,CHFM, CHSP, director, Department ofEngineering, The Joint Commission. Thiscolumn clarifies standards expectations andprovides strategies for challenging compli-ance issues, primarily in life safety and theenvironment of care but also in the vitalarea of emergency management. You maywish to share the ideas and strategies in thiscolumn with your organization’s leadership.

Since 1968, The Joint Commissionhas required accredited organiza-tions to comply with the National

Fire Protection Association’s Life SafetyCode®. To help organizations with com-pliance efforts, The Joint Commissioncreated the “Life Safety” (LS) chapter ofthe Comprehensive Accreditation Manual.This chapter supports an organization’sefforts to be fully compliant with thecode.

Because of the size and scope of theLife Safety Code, the LS chapter does notfully delineate every NFPA requirement.

However, it has always been the JointCommission’s intention that health careorganizations comply with the completeset of NFPA requirements in The LifeSafety Code.

To clearly communicate this intent,The Joint Commission includes severalstandards in the LS chapter that relate tothe topic of full compliance. For exam-ple, in Standard LS.02.01.20, whichdeals with means of egress requirements,element of performance (EP) 32 statesthat “the organization meets all other†

Life Safety Code means of egress require-ments related to NFPA 101-2000,18/19.2.” So, if during survey, an organi-zation is found to be noncompliant withone of the means of egress requirementsnot specifically addressed in EPs 1–31, asurveyor would score that noncompli-ance at EP 32.

Recently, The Joint Commission hasnoticed some recurring compliance issuesthat are scored at EP 32 and similar “fullcompliance” EPs in the LS chapter.These EPs include, but are not limitedto, LS.02.01.20, EP 32; LS.02.01.30, EP25; and LS.02.01.34, EP 4.

This article looks at some of thoseissues, so that organizations can be awarethat these topics may be addressed during survey.

Means of egress (LS.02.01.20,

EP 32)

A deficiency scored at EP 32 ofLS.02.01.20 may address door width in

means of egress doors and doors fromsleeping rooms and diagnostic and treat-ment areas, such as x-ray, surgery, physi-cal therapy, and nursery rooms. A means of egress is a continuous andunobstructed way of exit travel from anypoint in a building or structure to a pub-lic way. For existing buildings, the LifeSafety Code requires that these doors not measure less than 32 inches clear width(see NFPA 101-2000,‡ 19.2.3.5). Doorslocated in these areas in new health carebuildings must have a minimum clearwidth of 41.5 inches (see 18.2.3.5). Clearwidth—that is, the unobstructed widthof the door opening without projectionsinto such width—is measured by sub-tracting the door stops built into thedoor frame plus the thickness of the dooritself at the hinge edge from the totaldoor opening. For example, subtractingthe door stop and hinge stile edge from a44-inch door leaf would be 41.5 inchesclear width. (Note that prior to 1994, theLife Safety Code specified door measure-ments for the door leaf width rather thanthe current clear width.)

Smoke barrier doors

(LS.02.01.30, EP 25)

Several issues regarding smoke barrierdoors have been cited at LS. 02.01.30,EP 25. One deals with the fire rating ofsmoke barrier doors. The Life Safety Coderequires that doors found in a smoke barrier be either of substantial construc-

* Life Safety Code® is a registered trademark of theNational Fire Protection Association, Quincy, MA.

† Boldface added for emphasis.

‡ Unless otherwise noted, all NFPA code refer-ences are taken from NFPA 101-2000. (continued on page 6)


tion (for example, 1.75 inches thick,solid-bonded wood core) or of construc-tion that resists fire for not less than 20minutes. Any door that is either not sub-stantial or fails to resist fire for at least 20minutes is not compliant (see18/19.3.7.5 and 18/19.3.7.7).

Another code requirement scored atEP 25 relates to the swing direction ofsmoke barrier doors. Under the code, inexisting construction doors are not re -quired to swing in the direction of egress.Pairs of doors in existing constructionoften swing in the same direction, whichis acceptable under the code. However,in new construction, swinging doorsmust be hung so the doors swing inopposite directions (see 18.3.7.5).

Smoke barrier door width is alsoaddressed at EP 25. Similar to means ofegress doors, smoke barrier doors inexisting health care occupancies mustmeasure 32 inches clear width; they mustmeasure 41.5 inches clear width in newconstruction (see 18.3.7.5 and 19.3.7.7).New construction also requires door edgetreatments, such as rabbets, bevels, orastragals, at the meeting edges of smokebarrier doors (see 18.3.7.8). Door edgetreatments are not required in existingconstruction.

Fire alarms (LS.02.01.34, EP 4)

To comply with the Life Safety Codeunder Standard LS.02.01.34, EP 4, afire alarm system must be activated inone of the following ways:• Manual fire alarm initiation (that is,

someone pulls the alarm)• Automatic detection• Extinguishing system operation

To ensure that the manual fire alarmpull box is easy to get to, the Life SafetyCode requires that the box be alwaysaccessible, unobstructed, and visible.

Accessibility includes travel distance,with travel distance to the manual firealarm pull box not exceeding 200 feet.The pull station must be located in anatural exit access path near each exitfrom an area, unless located at the nurse’sstation (or other continuously attendedstaff location).

Although this requirement may seemstraightforward, an organization mayinadvertently place itself out of compli-ance. For example, suppose an organiza-tion has located the manual fire alarmpull box in the nursing station ratherthan at the unit exit. During a remodel-ing project, the organization moves thenursing station but leaves the manual firealarm pull box in place, about 100 feetfrom an exit. The pull box is no longercorrectly positioned because it is not atthe nursing station and is too far from anexit. This situation results in noncompli-ance for the organization (see 18/19.3.4.2and 9.6.2.1–9.6.2.6).

Automatic sprinkler systems

(LS.02.01.35, EP 14)

If an organization is required to have anautomatic sprinkler system, then it musthave an adequate and reliable water sup-ply to feed the system. Systems that havefire pumps must be tested to ensure thatthere is adequate flow to support thepumps. Standard EC.02.03.05, EP 11,addresses this issue, requiring systemswith fire pumps to be tested annually.

Some fire extinguishing systems arefed directly by a city supply (or othermeans that are out of an organization’scontrol). These systems might face chal-lenges. If the organization experiences areduction in water supply, this becomes aLife Safety Code issue because Section18/19.3.5.1 requires compliance with theStandard for the Installation of SprinklerSystems (NFPA 13-1999), which requiresthat there be an adequate water supply.

If the organization is unable to meet

the minimum requirements of the LifeSafety Code regarding this issue, its sprin-kler system will be considered to be com-promised, and the organization will needto take additional action. For example,one hospital experienced a lack of waterpressure following several constructionprojects. If the organization had left thissituation unaddressed, it could have beencited for noncompliance at StandardLS.02.01.35, EP 14. Fortunately, repip-ing the supply and replacing several 90°turns with 45° turns reduced pipingrestrictions and allowed the system tomeet minimum building requirements.

“No Smoking” signage and

ashtrays (LS.02.01.70, EP 4)

One of the topics that falls withinLS.02.01.70, EP 4, relates to No-smoking signage. The Life Safety Coderequires that no smoking signs be promi-nently displayed at all major entrancesand supported by policy. (SeeEC.02.01.03 for prohibition of smokingexcept in specific circumstances.) If thesigns are not prominently displayed atmajor entrances, then no-smoking sig-nage must be used in any room, ward, orcompartment where flammable liquids,combustible gases, or oxygen is used orstored, and in any other hazardous loca-tion (see 18/19.7.4). A risk of noncom-pliance occurs when no smoking signsare removed from major entrances andoxygen use areas do not haveappropriate signage.(Note that the interna-tional symbol for NOSMOKING, right, maybe used as alternative sig-nage.)

Another issue scored at EP 4 dealswith ashtrays. The Life Safety Coderequires that all areas where smoking isallowed must have noncombustible ash-trays and must also have metal containers


Ensuring Full Compliance with the LifeSafety Code®


www.jcrinc.com EC NEWS June 2013 7

Note: This is Part 2 of a two-part seriesthat explores the significance of mutualpatient and worker safety and ways bothgroups can be better protected.

Aconfused elderly patient attemptsto leave her hospital bed in themiddle of the night to use the

bathroom. A nursing assistant rushes tohelp her return to bed, but the patient slipsfrom her grip and strikes the floor and thebed frame. The patient sustains bruising,and her stay is lengthened, while the nursing assistant experiences back pain andmisses three days of work.

Scenes like this hypothetical one playout in health care settings with alarmingfrequency. Consider that one out of threehospital patients experiences adverseevents during hospitalization.1 And moreworkers in the health care and socialassistance industry sector are injured (5.2out of 100 workers in 2010, on average)than in any other private industry (anaverage of 3.5 out of 100 workers).2

The example also demonstrates thatthe safety of employees and patients inhealth care organizations (HCOs) isinseparably linked. The Joint Commis-sion’s recent monograph, ImprovingPatient and Worker Safety: Opportunitiesfor Synergy, Collaboration and Innovation,is devoted to this concept.3 Understand-ing this synergy, the value of mutualsafety, and how to better protect bothgroups (issues that are explored in Part 1of this series, published last month) is

vital. Equally important, however, arelearning how to increase your organiza-tion’s reliability, stressing incident report-ing and feedback, and creating aneffective safety climate.

High-reliability organizations

Working to improve both worker andpatient safety is essential to becoming ahigh-reliability organization (HRO).HROs have been described as “systemsoperating in hazardous conditions thathave fewer than their fair share of adverseevents.”4

“[HROs] understand that humansfail. Everybody makes mistakes; it’s partof human nature. And it will happenwhen you least want it to,” says Rose-mary Sokas, MD, MOH, professor andchair, Department of Human Science,Georgetown University School of Nurs-ing and Health Studies, Washington,DC. “So you plan for that and createbackup systems to catch failures beforethey can cause a bad outcome. In an[HRO], there’s an obsession ahead oftime with what can go wrong and howyou can prevent it.”

To help with prevention of adverseevents, HROs should respect the experi-ence of workers and train them appropri-ately. “That way, when things do gowrong, you have a trained workforce thatknows how to adapt,” says Sokas. “Youshould also promote teamwork and communication across hierarchies, andinclude frontline workers as safety

monitors who can really tell you if you’re‘walking the walk.’”

The Joint Commission strongly sup-ports health care organizations workingtoward becoming HROs. In fact, TheJoint Commission’s High ReliabilityResource Center webpage is devoted totools, tips, and articles to help organiza-tions in this quest. See the website atjointcommission.org/highreliability.aspx.

Essential changes

HCOs must make the following threeinterdependent, essential changes tobecome highly reliable:1. Leadership must commit to the goal

of high reliability.2. An organizational culture that sup-

ports high reliability must be fullyimplemented.

3. The tools of robust process improve-ment must be adopted.5

For example, per Joint CommissionEnvironment of Care (EC) standards, anHCO aiming to become an HRO shouldcarefully evaluate new types of medicalequipment before initial use and main-tain a written inventory of all medicalequipment. (See EC.02.04.01 andEC.02.04.03.) An HCO should ensurethat it has a reliable emergency electricalpower source for alarm systems, exitroutes, emergency communication sys-tems, essential medical equipment, andclinical care areas. (See EC.02.05.03.)

Protection PartnershipHow health care organizations can better secure the safety ofworkers and patients alike

OSHA & Worker SafetyOSHA



Effective reporting systems

A safe culture and workplace is alsohighly dependent on a proactive surveil-lance system to identify hazards andrisks, evaluate them, prevent futureoccurrences, and mitigate the effects ofbreakthrough occurrences. Managersshould encourage employees and otherstakeholders to report hazards. Hazardidentification will be more effective withan easy-to-use reporting system thatrewards those who choose to file reports.

Essentially, workers want to do a goodjob, “but they need to have the tools,information, and training to do so. Theyalso want to be appreciated for what theydo,” says Sokas. “Encouraging incidentreporting and providing healthy feedbacklets them know they’re appreciated andbuilds trust.”

“Systems for (incident) reporting andinvestigation of individual events as wellas near misses or close calls can generateuseful information to identify opportuni-ties for improvement in local systems andprocesses,” says Barbara Braun, PhD,project director, Department of HealthServices Research, Division of HealthcareQuality Evaluation for The Joint Commission.

Without an effective feedback systemin place, workers either can’t report aproblem or don’t bother because theydon’t expect anything to be done aboutit, Sokas says.

Safety culture club

One of the most significant ways tobecome an HRO and, thus, better pro-tect both patients and workers is to pro-mote an effective culture of safety.According to the Joint Commissionmonograph, a safety culture is a subset ofan organization’s overall climate that doesthe following3:• Focuses on people’s perceptions about

the degree to which the organizationvalues safety for workers, patients,and/or the environment

• Commits resources to safety-relatedinitiatives and equipment

• Promotes safe behaviors A safety culture can serve as a leading

indicator of safety performance, asopposed to error and injury rates, whichare lagging indicators of performance.

“A culture of safety has to start fromthe top and be consistent day after day.There has to be enough trust and theidea that this is a culture where workerscan be respected, where they can be freeto admit mistakes without being afraidthey’ll get in trouble,” Sokas says. “It’shard to establish that level of respect andtrust, and it’s easy to break it if peoplewind up being punished when they madea mistake but intended to do well.”

An inadequate safety culture and poorworking conditions are linked to unfa-

vorable outcomes for workers, which areassociated with poorer patient outcomes,per the Joint Commission monograph.3

Thus, HROs should emphasize bothworker and patient safety, which areinseparably integrated, and identify theirsafety culture strengths and weaknesses(see “Safety Culture Characteristics,”above).

HCOs can improve their safety cul-ture in many ways. For example, theycan train frontline and security staff inassault and violence prevention and man-agement. This training can benefitpatients by leading to fewer injuries andless use of restraint. Such training canhelp workers by reducing anxiety andpromoting teamwork. HCOs can installeffective locks, lights, and video surveil-lance equipment in and around the facil-ity, which can allay patient and staff fearsof violence. HCOs can also enforce bet-ter infection prevention programs by

According to findings of a recent survey by the Agency for Healthcare Research and

Quality (AHRQ),6 most health care organizations (HCOs) that could be considered

to have a culture of safety display four areas of strength.

Areas of strength

1. Teamwork within units—staff support each other, treat each other with respect,

and work together as a team.

2. Supervisors/managers consider staff suggestions for improving patient safety,

praise staff for following patient safety procedures, and do not overlook patient

safety problems.

3. Organizational learning—mistakes have led to positive changes, and changes

are evaluated for effectiveness.

4. Hospital management provides a work climate that promotes patient safety and

shows that patient safety is a top priority.

However, for many HCOs, flaws still remain, specifically in three areas for

improvement.

Areas for improvement

1. Workers should feel that their mistakes and event reports are not held against

them and that mistakes are not kept in their personnel file.

2. Important patient care information should be transferred across hospital units

and during shift changes.

3. There should be enough staff to handle the workload, and work hours should be

appropriate to provide the best care for patients.

Safety Culture Characteristics

Protection Partnership



This article was developed through the cooperative efforts of the OSHA/Joint Commission Resources Alliance.

having workers receive regular immu-nizations, follow recommended hygienepractices, and wear personal protectiveequipment (PPE)—resulting indecreased transmission of pathogensfrom workers to patients and patients topatients.

Setting a good example

Although it’s important to train workersproperly and expect them to followestablished procedures designed to stresssafety, effective modeling from the topdown is necessary.

“As with any other business improve-ment initiative, a proactive approach tosafety and health starts with managementleadership and visibility,” says PatriciaBray, MD, MPH, medical officer for theOffice of Occupational Medicine, Occupational Safety and Health Administration (OSHA). “It is essentialfor management to lead by example andto provide necessary resources to main-tain a safe environment and to encouragesafe behaviors.”

Bray says managers can promote aneffective safety culture in several ways—by wearing PPE, asking workers duringwalk-arounds if they have any safety con-cerns, responding promptly when issuesare raised, and investigating any inci-dents or near misses involving patients,workers, or visitors.

Bray also encourages health careorganizations to enroll in OSHA’s Volun-tary Protection Program (VPP; see http://osha.gov/dcsp/vpp for details). VPP facil-ities have demonstrated a high degree ofeffectiveness in reducing injuries and ill-nesses, and VPP participation can alsolead to lower employee turnover,increased productivity, and cost savings.

References1. Classen D, et al. Global trigger tool shows that

adverse events in hospitals may be 10 timesgreater than previously measured. Health Aff(Millwood). 2011;30(4):581–589.

2. US Department of Labor. Statement from Secre-tary of Labor Hilda L. Solis on reported declinein workplace injuries and illnesses. OSHA NewsRelease: 11-1547-NAT, Oct 20, 2011. Accessed

May 14, 2013. http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=NEWS_RELEASES&p_id=20883.

3. The Joint Commission. Improving Patient andWorker Safety: Opportunities for Synergy, Collabo-ration and Innovation. Oakbrook Terrace, IL:The Joint Commission; 2012. Accessed May 14,2013. http://www.jointcommission.org /improving_Patient_Worker_Safety/.

4. Reason J. Human error. Models and manage-ment. BMJ. 2000 March 18; 320(7237):768–770.

5. Chassin MR, Loeb JM. The ongoing qualityimprovement journey: Next stop, high reliability.Health Aff (Millwood). 2011;30(4):559–568.

6. Agency for Healthcare Research and Quality.Hospital Survey on Patient Safety Culture: 2012User Comparative Database Report. AccessedMay 14, 2013. http://www.ahrq.gov/profession-als/quality-patient-safety/patientsafetyculture/hospital/2012/hospsurv1223.pdf.

EC

with self-closing cover devices into whichashtrays can be emptied. Surveyors havenoticed that in some instances, metalcontainers used for emptying ashtrays failto have self-closing cover devices. Theyare therefore cited as being noncompliant(see 18/19.7.4).

Bedding, curtains, and other

furnishings (LS.02.01.70, EP 4)

Another topic that falls withinLS.02.01.70, EP 4, relates to curtains.The Life Safety Code requires that alldraperies, curtains, and other looselyhanging fabrics serving as furnishings inhealth care occupancies meet NFPA 101-2000 10.3.1, which requires flame resist-

ance ratings demonstrated by testing inaccordance with NFPA 701, StandardMethods of Fire Tests for Flame Propaga-tion of Textiles and Films. The Joint Commission also recognizes CAL 133,Flammability Test Procedure for SeatingFurniture for Use in Public Occupancies,and CAL 117, Requirements, Test Proce-dure and Apparatus for Testing the FlameRetardance of Resilient Filling MaterialsUsed in Upholstered Furniture.

Cubicle curtains are included in thissection and are also discussed in18/19.3.5.5, with a reference to NFPA13-1999, Standard for the Installation ofSprinkler Systems. NFPA 13 requires thathanging cubical curtains not compromisethe 18-inch clear space below the sprin-kler. Noncompliance with this require-ment is scored at LS.02.01.35, EP 6.

Note that organizations often addressthis requirement by designing a cubicalcurtain to have a mesh top (1⁄2-inch diag-onal or a 70% open weave) that extends18 inches below the sprinkler deflector.This solution is compliant withLS.02.01.35, EP 6.

Further concerns

This column offers a brief discussion ofsome compliance issues that surveyorsare seeing, but it does not represent anexhaustive list. Organizations must keepin mind that The Joint Commissionrequires full and complete compliancewith the NFPA’s Life Safety Code. Takingtime to review that document along withthe LS Chapter may be beneficial in fur-thering your organization’s complianceefforts. EC

Ensuring Full Compliance with the LifeSafety Code®



The Joint Commission is com-mitted to an ongoing process ofgathering customer and stake-

holder feedback on current standards. Ituses this feedback to assess standards andclarify, restructure, or delete require-ments based on their value and applica-bility to accredited organizations.

Recently The Joint Commissionreceived comments and questions fromcustomers concerning several Environ-ment of Care (EC) standards and elements of performance (EPs) as theyrelate to two home care settings: free-standing ambulatory infusion (FSAI) andrehabilitation technology (RT). FSAIorganizations provide the dispensing andadministration of drug therapy by infu-sion or inhalation (and other relatedservices) to ambulatory patients underthe supervision of a licensed health careprofessional (for example, a nurse). Theseservices are provided in a room or anoffice that is neither an extension of aphysician office or hospital nor part of alarger ambulatory home care organiza-tion. RT is a component of home med-ical equipment (HME) services thatenhances the lifestyle of physically chal-lenged individuals through the sale andrental of custom medical equipment(such as mobility systems and adaptiveequipment) and ongoing evaluation bytrained rehabilitation technologists. RTservices may be provided in the patient’shome, rehabilitation clinics, or the homecare organization’s facility/office.

Most FSAI and RT services are pro-vided in office settings that are classifiedas business occupancies according toNational Fire Protection Association

(NFPA) guidelines. Business occupancyhealth care settings include facilities inwhich no one stays overnight and, giventhe nature of their treatment, three orfewer individuals are rendered incapableof self-preservation at any time. Becausemost FSAI and RT services are providedin business occupancy settings, they arenot required to follow the same set ofNFPA fire safety guidelines required forother inpatient and outpatient healthcare settings.

In response to customer feedbackrequesting a review of the applicability ofEC standards to these two settings, TheJoint Commission convened an internalgroup of home care representatives (staffand surveyors) and Life Safety Code®*engineers in the fall of 2012. Specific

issues raised by customers focused onstandards that require these organizationsto maintain the following: • Fire safety building features

(EC.02.03.05)• Utility systems (EC.02.05.01)• Emergency communication systems

(EC.02.05.03)• Testing of utility systems before initial

use (EC.02.05.05)• Testing of emergency power systems

(EC.02.05.07)* Life Safety Code® is a registered trademark of theNational Fire Protection Association, Quincy, MA.

The following note was added to the standard:

Note 2: The references to the National Fire Protection Association (NFPA)guidelines noted at the elements of performance are for information only.

EPs 3 and 4 were made “not applicable” for these settings. In place of these EPs,

the following EP was created for FSAI and RT settings:

C 26. � Every 12 months, the organization tests the following:

■ Manual pull stations

■ Smoke detectors

■ Visual and audible fire alarms

The completion date of these tests is documented.

Note: For additional information on performing tests, see NFPA 72, 1999 edition(Table 7-3.2).

Changed “For additional guidance” to “For additional information” wherever this

phrase appears in the Notes to the EPs.

Editorial Revisions to Standard EC.02.03.05 for Home Care

Revisions to Applicability of EC Requirements for Freestanding Ambulatory Infusion and Rehabilitation Technology Settings in the Home Care Program

Changed “For guidance” to “For

information” in the Note to EP 1.

Removed the reference to the LifeSafety Code from EPs 1 and 2.

Editorial Revisions to

Standard EC.02.05.03 for

Home Care



Here are the answers to the questions on page 2. How did you do?

1. D, At a frequency determined by law and regulation. Laboratories, alongwith ambulatory care organizations, hospitals, critical access hospitals, andoffice-based surgeries, must monitor levels of hazardous gases and vapors toverify that they are within safe range. Law and regulation should dictate thefrequency of this effort as well as acceptable ranges. Organizations may wantto consult the websites of the Occupational Safety and Health Administration(OSHA) and the National Institute for Occupational Safety and Health(NIOSH) for guidance in establishing safe ranges.

STANDARDS REFERENCE: EC.02.02.01, EP 10

2. False. Although it is wise to have doors in the means of egress (the path forsafely leaving an area during a fire) open in the direction of egress, this isrequired only for organizations whose occupancy is 50 or more. Having doorsswing in the direction of egress ensures that people can exit an area quicklyand creates a safe path without restrictions. If this requirement were not inplace, egress doors in larger organizations could restrict movement during anemergency. For example, if a press of people is trying to get through a doorquickly, it could be problematic if they have to stop and open the door towardthem prior to leaving. (For full text and any exceptions to this requirement,refer to NFPA 101-2000: 7.2.1.4.2.)

STANDARDS REFERENCE: LS.02.01.20, EP 2

3. C, 72 hours. A hospital has 72 hours in which to decide whether to continue avolunteer licensed independent practitioner’s granted disaster privileges. Tohelp with this determination, organizations must conduct primary sourceverification of licensure as soon as the immediate emergency situation isunder control. If such verification cannot be completed within 72 hours due toextraordinary circumstances, the hospital must document all of the following:• Reason(s) primary source verification could not be performed within 72

hours of the practitioner’s arrival

• Evidence of the practitioner’s demonstrated ability to continue to provideadequate care, treatment, and services

• Evidence of the hospital’s attempt to perform primary source verification assoon as possible

If primary source verification of licensure cannot be completed within 72hours, the standards require that it be performed as soon as possible.

STANDARDS REFERENCE: EM.02.02.13, EPs 7–9

4. False. The need for organizations to map the distribution of their utilitysystems is not limited to hospitals. Standard EC.02.05.01, EP 7, requires allsettings, with the exception of home care organizations, to engage in thisactivity. A utility map should show the operations of all an organization’svarious utility systems, including water; medical gas; heating, cooling, andventilating; and electrical systems. These drawings should show where theutilities enter the building and how they are distributed throughout the facility.They should also show where the end points of use are and where emer gencyinterventions can be performed, if necessary. It’s important for orga nizationsnot only to have such maps but to understand and use them as a referenceduring partial or complete emergency shutdowns. Note that for office-basedsurgery, only those practices that use electrical life support equipment, providepatients with assisted mechanical ventilation, or have blood, bone, and tissuestorage units are required to have utility distribution maps.


5. D, Every 12 months. Ambulatory care organizations that have visual andaudible fire alarms must test those alarms every 12 months and documenttest completion. Annual fire alarm testing is also required for all other settingsexcept laboratories, provided that the organization has visual and audible firealarms in place. To determine the appropriate method for testing,organizations should consult NFPA 72, 1999 edition (Table 7-3.2).


STANDARDS IQ The Answers

Test your

In addition to the internal group’sreview of Joint Commission standardsand related NFPA fire safety guidelinesfor business occupancy settings, theresearch included a review of internaldata collected from various customers.The information gathered was then pre-sented to The Joint Commission’s HomeCare Advisory Group for its review andrecommendations.

The Joint Commission used thisresearch as well as feedback from theHome Care Advisory Group to make

several editorial revisions and removeapplicability for the following EPs deter-mined to be irrelevant to or inappropri-ate for FSAI and RT settings (thoughthey remain applicable to other homecare settings): • EC.02.03.05, EPs 1–14, and 17–20• EC.02.05.01, EPs 3–4• EC.02.05.03, EP 3• EC.02.05.05, EP 1• EC.02.05.07, EPs 3–6

The editorial revisions to the EC stan-dards for all home care settings are sum-

marized in the two boxes on page 10. Allchanges are effective July 1, 2013, andappear in the 2013 Update 1 to theComprehensive Accreditation Manual forHome Care as well as the spring 2013 E-dition® update.

If you have any questions about thehome care EC standards revisions orapplicability changes, contact KathyClark, MSN, RN, associate project direc-tor and home care specialist, Departmentof Standards and Survey Methods, [email protected]. EC

Volume 16, Issue 7, July 2013

Send address corrections to:

EC NewsSuperior Fulfillment

131 W. First St.

Duluth, MN 55802-2065

800-746-6578

ECN07

Written by two of the leading life safety experts in the field, this new book explains how Joint

Commission Life Safety (LS) standards and elements of performance relate to the National

Fire Protection Association (NFPA) Life Safety Code,®* plus other applicable NFPA regulations.

Key Features:

For more information, or to order this publication, please visit ourwebstore at http://store.jcrinc.com or call Customer Service at

877-223-6866. Our Customer Service Center is open from 8 A.M. to 8 P.M. EST, Monday through Friday.

The Joint Commission/NFPA® Life SafetyBook for Health Care Organizations

Order Today!Item Number LSG13

Price: $199

Available July 2013

• Explanation of the LS chapter’s relation to

the NFPA Life Safety Code• Full Joint Commission standards language;

full applicable NFPA code language

• Strategies to help simplify compliance

with the LS chapter and the NFPA codes

• Easy-to-use, easy-to-read format

By George Mills, MBA, FASHE, CEM, CHFM, CHSP, director, Department ofEngineering, The Joint Commission, and James K. Lathrop, FSFPE, vice president, Koffel Associates, Inc.

* Life Safety Code® is a registered trademark of the National Fire Protection Association, Quincy, MA.

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