Presentation is loading. Please wait.

Presentation is loading. Please wait.

© Copyright, The Joint Commission 2011 Joint Commission Findings, Impact & Update Joint Commission & CMS: Issue Resolution George Mills, Sr. Engineer Standard.

Similar presentations


Presentation on theme: "© Copyright, The Joint Commission 2011 Joint Commission Findings, Impact & Update Joint Commission & CMS: Issue Resolution George Mills, Sr. Engineer Standard."— Presentation transcript:

1 © Copyright, The Joint Commission 2011 Joint Commission Findings, Impact & Update Joint Commission & CMS: Issue Resolution George Mills, Sr. Engineer Standard Interpretation Group The Joint Commission

2 SIG Engineering 2011 - 2 © Copyright, The Joint Commission Top 5 Most Cited Standards in 2010 Hospitals 1. 62%RC.01.01.01 2. 50%LS.02.01.20 3. 44%LS.02.01.10 4. 38%EC.02.03.05 5. 37%LS.02.01.30 Critical Access Hospitals 1. 47%EC.02.03.05 2. 44%LS.02.01.10 3. 40%EC.02.05.07 4. 33%LS.02.01.20 5. 27%EC.02.06.01

3 SIG Engineering 2011 - 3 © Copyright, The Joint Commission #2: LS.02.01.20 (50%) The hospital maintains the integrity of the means of egress. EP 13 Corridor Clutter EP 12 Projections EPs 16 – 22 Suites issues Equivalize > 5000 sq ft EP 1 Doors locked in means of egress

4 SIG Engineering 2011 - 4 © Copyright, The Joint Commission Corridor Storage If the corridor looks cluttered…it probably is Corridor clutter is not a PFI issue Carts Allowed: Crash Carts Isolation Carts Chemo Carts Based on a HITF Interpretation (TJC, CMS & other AHJs) the following carts are not allowed: Linen Hampers Latex Carts Anything in the egress corridor more than 30 minutes is storage

5 SIG Engineering 2011 - 5 © Copyright, The Joint Commission Corridor Storage Dead end corridors may be used for storage Less than or equal to 50sqft space Converting patient room: Long term include door closure Surge issue: based on policy patients may be treated in the egress corridor during surge conditions

6 SIG Engineering 2011 - 6 © Copyright, The Joint Commission #3: LS.02.01.10 (44%) Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat. EP 9 Penetrations EPs 5 – 7 Door issues EPs 1 & 2 Building Type issues EP 8 Duct issues

7 SIG Engineering 2011 - 7 © Copyright, The Joint Commission #4: EC.02.03.05 (38%) The hospital maintains fire safety equipment and fire safety building features. Features of fire protection NOTE: #1 for Critical Access Hospitals

8 SIG Engineering 2011 - 8 © Copyright, The Joint Commission #5: LS.02.01.30 (37%) The hospital provides and maintains building features to protect individuals from the hazards of fire and smoke. EPs 16 – 23 Smoke Barriers & Doors EP 2 Hazardous Areas

9 SIG Engineering 2011 - 9 © Copyright, The Joint Commission Life Safety Code Specialist LSCS Background Facilities or Environment of Care based Prefer CHFM certification LSCS Agenda On-Site Two Days Interfaces with survey team member(s) LSCS Survey Focus Life Safety Chapter EC.02.05.03 EC.02.05.07 EC.02.05.09 Other Observations

10 SIG Engineering 2011 - 10 © Copyright, The Joint Commission Life Safety Code Specialist May also survey LD.04.01.05 EP 4 Accountability LD.04.04.01 EP 2 Hi-Priority LD.01.03.01 EP 5 Resources All HAP and CAH will be surveyed for a minimum of 2 days by a LSCS Greater than 1.5 million sq ft will be surveyed for a third day by the LSCS An additional day is added for every three buildings that are classified as healthcare Example: for a HAP organization with 2 million square feet of healthcare occupancy and 5 buildings classified as healthcare occupancy: the number of LSCS days would be 4

11 SIG Engineering 2011 - 11 © Copyright, The Joint Commission LD.04.01.05 EP 4: What to do when the documentation isnt there… During survey specific documentation is reviewed If the documentation is not available write the observation as non-compliant Also score LD.04.01.05 EP 4 If the documentation becomes available later in the survey to the survey team, the team can: Consider removing the previous finding if documentation confirms the activity was completed as per the EP LD.04.01.05 EP 4 may also be removed during survey If the survey team would prefer not to evaluate the documentation the organization can submit clarification If the organization clarifies after survey: SIG Engineers will review and evaluate compliance LD.04.01.05 EP 4 remains

12 SIG Engineering 2011 - 12 © Copyright, The Joint Commission What Triggers ITL (Immediate Threat to Life) Significantly compromised fire alarm system Significantly compromised sprinkler system Significantly compromised emergency power supply system Significantly compromised medical gas master panel Significantly compromised exits Other situations that place patients, staff or visitors at extreme danger

13 SIG Engineering 2011 - 13 © Copyright, The Joint Commission What Triggers AFS 13 AFS 13 is only related to previously accepted PFIs Failure to make sufficient progress (LS.01.01.01 EP 2) Failure to implement appropriate ILSMs (LS.01.02.01 EP 3) Failure to manage previously accepted PFIs affects the Joint Commission Both organizations are aware of deficiencies that have been managed using the PFI process

14 SIG Engineering 2011 - 14 © Copyright, The Joint Commission Deficiency Resolution Resolution to a deficiency: Resolve it immediately Correct it within 45 days: Management process that documents the deficiency and actions to resolve ILSM must be considered Plan For Improvement located in the Statement of Conditions Corrected within 6 months of the Projected Completion Date ILSM must be considered

15 SIG Engineering 2011 - 15 © Copyright, The Joint Commission 45 Day Corrective Action Documented Origination date Completion date Kept available for rolling 3 years Life Safety deficiencies Must not exceed 45 days If greater than 45 days create a Plan For Improvement (PFI) If originally a work order, close out as complete and generate the PFI Must be made available to the Joint Commission During survey to confirm management of the deficiency During CMS/Joint Commission validation process upon request

16 SIG Engineering 2011 - 16 © Copyright, The Joint Commission How Many Open PFIs Are Too Many? The PFI process was created to allow organizations to self assess and create a Plan for Improvement The self disclosure has never defined how many is too many The ILSM process was created to allow both the organization and The Joint Commission to be aware of Life Safety Code deficiencies Failure to make progress on previously accepted PFIs, including failure to implement ILSMs results in Conditional Accreditation

17 SIG Engineering 2011 - 17 © Copyright, The Joint Commission How Many Open PFIs Are Too Many? Survey Process: Evaluate both closed and currently open PFIs in the View All screen Spot check during building tour both some closed and open PFIs to evaluate how well the organization is managing the PFI process Evaluate the scope of PFI entries Are there life safety deficiencies Are they greater than maintenance items (i.e. screws missing from a door hinge)

18 SIG Engineering 2011 - 18 © Copyright, The Joint Commission Statement of Conditions: PFI PFIs should be related to the LS Chapter Corridor clutter is not a legitimate PFI PFIs should provide specific information No blanket statements …penetrations on 3 rd floor Specific references to Life Safety Drawings is acceptable 32 penetrations as identified on LS Drawing 3 rd Floor, Center Tower dated 3/3/2010 Projected Completion Date is for all listed items (i.e. 32 penetrations)

19 SIG Engineering 2011 - 19 © Copyright, The Joint Commission Equivalencies The Joint Commission accepts two forms of equivalencies Traditional Equivalency A process of field verification identifying alternative methods of fire safety that off- set the identified deficiency Fire Safety Evaluation System (FSES) A process of calculating the features of life safety and deducting any deficiencies, with the outcome determining if the building is equivalized based on the FSES

20 SIG Engineering 2011 - 20 © Copyright, The Joint Commission History Audit Trail The History Audit Trail is used by SIG Engineers when considering extensions or other activities related to an organization Prior to surveying, the surveyor must preview the History Audit Trail to discover if equivalencies or other actions have occurred by SIG Engineers When surveying, brief but accurate information entered in the File Room is important

21 © Copyright, The Joint Commission Building Maintenance Program (BMP) The BMP is no longer available to offset findings during survey, but is considered best practice All EPs related to the original ten BMP items are C categories

22 SIG Engineering 2011 - 22 © Copyright, The Joint Commission Contingency Planning Utilities exist to provide a safe and comfortable environment of care Failure of utilities could directly impact patient care delivery Activities associated with managing utilities are designed to ensure the reliability of the systems day to day Contingency plans are developed to ensure reliability of utilities systems Contingency plans address at least two issues: Utility/Equipment failure or disruption Emergency related failures or disruption

23 SIG Engineering 2011 - 23 © Copyright, The Joint Commission Contingency Planning: Survey Organizations ensure their contingency plans are current and accurate Discuss the organization Memorandum of Understanding and its impact in the community Evaluate against Standards & Elements of Performance Suggest the organization include exercising these contingency plans with their Emergency Exercise

24 SIG Engineering 2011 - 24 © Copyright, The Joint Commission EC.02.05.01 Utilities Mgmt. EP 7 The hospital maps the distribution of utility systems EP 8 The hospital labels controls for a partial or complete emergency shutdown EP 9 The hospitals has procedures for responding to utility system disruptions EP 10 The hospitals' procedures address shutting off the malfunctioning system and notifying staff in affected areas EP 11 The hospitals procedures address performing emergency clinical interventions during utility systems disruptions EP 12 The hospitals procedures addresses the following: How to obtain emergency repair services EP 13 The hospital responds to utility system disruptions as described in its procedures

25 SIG Engineering 2011 - 25 © Copyright, The Joint Commission EM.02.02.09: Utility Disruption Emergency Operations Plan identifies alternative means of providing: EP 2 electricity EP 3 water needed for consumption and essential care activities EP 4 water needed for equipment and sanitary purposes EP 5 fuel required for building operations or essential transport activities EP 6 medical gas/vacuum systems EP 7 Utility systems defined as essential, such as Vertical & horizontal transport Heating & cooling systems Steam for sterilization EP 8 Utility needs identified in the HVA

26 SIG Engineering 2011 - 26 © Copyright, The Joint Commission Time Defined The Joint Commission EC chapter defines time as: Daily, weekly, monthly and quarterly are calendar references Semi-annual is 6 months from the last scheduled event +/- 20 days Annual is 12 months from the last scheduled event +/- 30 days 3 years is 36 months from the last scheduled event +/- 45 days NOTE 1: The above does not apply to required frequencies such as emergency generator testing (see EC.02.05.07 EP 4 & 8) NOTE 2: An alternative of developing either a unique, written policy or adopting NFPA definitions when available is acceptable

27 SIG Engineering 2011 - 27 © Copyright, The Joint Commission Semiannual: +/- 20 days Annual: +/- 30 days Due Date Scheduled Month 20 30 JulySeptOctAugNov June Dec JanFMAJJON Semiannual Annual + + JanMASD Frequencies required by Code may not be modified (i.e. EC.02.05.07 EP 4 & 8)

28 SIG Engineering 2011 - 28 © Copyright, The Joint Commission Does Every mean Every ? EC.02.03.05 EP 13 Every 6 months the hospital inspects any automatic fire extinguishing systems in a kitchen. The completion date of the test is documented. Every 6 months +/- 20 days EP 12 Every 12 months the hospital tests visual and audible alarms, including speakers. The completion date of the test is documented. Every 12 months +/- 30 days At least monthly the hospital inspects portable fire extinguishers. The completion dates of the inspections are documented. Tested within the calendar month

29 SIG Engineering 2011 - 29 © Copyright, The Joint Commission PRA EC.02.06.05 EPs 2 & 3 Preconstruction Risk Assessment (PRA) Construction or renovation in occupied healthcare facilities can result in environmental problems such as: Noise Vibration Creation or spread of contaminants Disruption of essential services Emergency Procedures Air quality

30 SIG Engineering 2011 - 30 © Copyright, The Joint Commission Interim Life Safety Measures Order of Standards (LS.01.02.01) EP 1 & 2 regardless of ILSM policy EP 3 must clearly define the ILSM policy including AFS 13 Process When to implement What to do to protect occupants Both construction related and non- compliance with the LSC EPs 4 – 14 align with policy and implementation strategies

31 SIG Engineering 2011 - 31 © Copyright, The Joint Commission Fire Watch An organization experiencing a compromising situation (4 out of 24 hours) must implement a fire watch until the fire alarm system or sprinkler system has been returned to service or is stable. In many situations, this distinction comes down to whether an event or activity is scheduled or unscheduled. A scheduled activity would be an event known to and under the knowledge of and control of organization staff a construction project servicing or upgrading the fire alarm system or sprinkler system.

32 SIG Engineering 2011 - 32 © Copyright, The Joint Commission Service Situation Fire Watch Required? ILSM Evaluation Required? Putting a shield over one smoke detector to prevent dust/false alarms for more than 4 hours NoRecommended Rationale: Other features of fire protection are not compromised during the event, such as additional smoke detectors or sprinkler heads in the affected area. Covering all smoke detectors during a controlled event, such as only during the time contractors are working in an affected area, although after hours, the entire area is fully operational NoYes Rationale: During a controlled event the organization is managing the deficien­cy. The area would be continually monitored, and ILSM should be implemented as per policy. Shutting off a zone valve to the sprinkler system or disabling a fire alarm zone for more than 4 hours Scheduled event (that is, working on, servicing, or upgrading fire alarm system or sprinkler system) Not in all cases Yes (emphasis on occupant notification) Rationale: During a controlled event, the organization is managing the defi­ciency. The area would be continually monitored, and ILSM would be implemented as per policy. Unscheduled event (that is, shutting off a zone valve to the sprinkler system or disabling a smoke zone for more than 4 hours in response to a system failure) Yes

33 SIG Engineering 2011 - 33 © Copyright, The Joint Commission EC.02.06.05 EP 1 Effective 1/1/2011 the Joint Commission will recognize the Facilities Guidelines Institute (FGI) Guidelines for Design & Construction of Health Care Facilities ASHRAE 170 has been attached to the Guidelines Ventilation Table 20 – 60 % RH requirement of relative humidity in seven affected areas of the Surgical Environment, and one in Diagnostic & Treatment. NOTE CMS has not adopted this, but remains at 35 – 60%RH The established 60% upper range however should be maintained for issues such as mold growth.

34 SIG Engineering 2011 - 34 © Copyright, The Joint Commission RH% Treatment Areas Class A Operating/Procedure room Class B and C operating rooms Operating/surgical cystoscopic rooms Delivery room (Caesarean) Treatment rooms Trauma room (crisis or shock) Laser eye room Diagnostic & Treatment: Gastrointestinal Endoscopy Procedure Room

35 SIG Engineering 2011 - 35 © Copyright, The Joint Commission General Life Safety Interpretations ASHRAE 188 Prevention of Legionellosis Associated with Building Water Systems This 29 page DRAFT document provides guidance related to Legionella mitigation Site survey to identify risk points i.e. water towers Mitigation strategies Water treatments what to do if contamination occurs, such as secondary treatment

36 SIG Engineering 2011 - 36 © Copyright, The Joint Commission Central Sterile Layout Physically separated soiled and clean work rooms Soiled Work Room: Work surface, sink, washer/sterilizer decontaminators Soiled room is not to have direct contact with the OR Clean assembly /work room Hand washing station Sufficient workspace and equipment Self-closing door or pass through is acceptable between soiled and clean work rooms Storage provisions for humidity, temperature, and ventilation Location of storage may be within the clean assembly/ workroom in a permanently designated space Guidelines for Design & Construction of Health Care Facilities FGI 2010 edition 3.7-5.1.2 - 3.7-5.1.2.3

37 SIG Engineering 2011 - 37 © Copyright, The Joint Commission Ventilation (Table 7-1) Function Pressure Relationship Min Outdoor ACH Minimum Total ACH All Room Air Exhausted Directly Outdoors Relative Humidity Design Temp. °F Equip. Room NegativeN/R10YesN/R Soiled or Decontam Negative26YesN/R72 – 78 Clean Work Room Positive24N/RMax 6072 – 78 Sterile Storage Positive24N/RMax 6072 – 78 ANSI/ASHRAE/ASHE Standard 170-2008 Table 7-1

38 SIG Engineering 2011 - 38 © Copyright, The Joint Commission Changes to EC.02.03.05 EP 2 Existing: Every six months the hospital tests valve tamper switches and water-flow devices. The completion date of the tests is documented. NOTE: for additional guidance on performing tests see NFPA 72- 1999 (Table 7-3.2)

39 SIG Engineering 2011 - 39 © Copyright, The Joint Commission Changes to EC.02.03.05 EP 2 Revised: EP2 For hospitals that use Joint Commission accreditation for deemed status purposes: At least quarterly the hospital tests water-flow devices. Every 6 months the hospital tests valve tamper switches. The completion date is documented. NOTE: For additional guidance on performing tests see NFPA 25-1998 (Section 2-1.3 & 2.3.3) and NPFA 72-1999 (Table 7-3.2 and Section 7-5.2).

40 SIG Engineering 2011 - 40 © Copyright, The Joint Commission Changes to EC.02.03.05 EP 2 EP 2 (continued) For hospitals that do not use accreditation for deemed status purposes: Every 6 months, the hospital tests valve tamper switches and water- flow devices. The completion date of the tests is documented. Note: For additional guidance on performing tests, see NFPA 72, 1999 edition (Table 7-3.2).

41 SIG Engineering 2011 - 41 © Copyright, The Joint Commission NEW: EC.02.03.05 EP 25 For hospitals that use Joint Commission accreditation for deemed status purposes: Documentation of maintenance, testing, and inspection activities for fire alarm and water-based fire protection systems includes the following: Next Slide for Contents Note: For additional guidance on documenting activities: NFPA 25, 1998 edition (Section 2-1.3) NFPA 72, 1999 edition (Section 7-5.2)

42 SIG Engineering 2011 - 42 © Copyright, The Joint Commission NEW: EC.02.03.05 EP 25 Continued Text: Name of the activity Date of the activity Required frequency of the activity Name and contact information, including affiliation, of the person who performed the activity NFPA standard(s) referenced for the activity Results of the activity

43 SIG Engineering 2011 - 43 © Copyright, The Joint Commission NEW: EC.02.03.05 EP 25 For hospitals that use Joint Commission accreditation for deemed status purposes: Documentation of maintenance, testing, and inspection activities for fire alarm and water-based fire protection systems includes the following: Note: For additional guidance on documenting activities: NFPA 25, 1998 edition (Section 2-1.3) NFPA 72, 1999 edition (Section 7-5.2)

44 SIG Engineering 2011 - 44 © Copyright, The Joint Commission Fire & Smoke Damper Inspections Ensure inaccessible dampers truly are by random sampling Confirm ILSM policy is implemented for any horizontal exits or egress enclosures that are compromised by inaccessible dampers Evaluate adequacy of damper accessibility plan

45 SIG Engineering 2011 - 45 © Copyright, The Joint Commission LS.02.01.34 EP 2 Master Alarm Panel The master fire alarm control panel is located in a protected environment (an area enclosed with 1-hour fire- rated walls and ¾ hour fire rated doors) that is continuously occupied OR in an area with a smoke detector. NFPA 72-1999 1-5.6 & 3-8.4.1.3.3.2

46 SIG Engineering 2011 - 46 © Copyright, The Joint Commission Fire Extinguisher: Dating Month, day year and initials of inspector as per NFPA 10-1998 EC.02.03.05 EP 15 4-3.4 Inspection Recordkeeping. 4-3.4.1 Personnel making inspections shall keep records of all fire extinguishers inspected, including those found to require corrective action. 4-3.4.2 At least monthly, the date the inspection was performed and the initials of the person performing the inspection shall be recorded. 4-3.4.3 Records shall be kept on a tag or label attached to the fire extinguisher, on an inspection checklist maintained on file, or in an electronic system (e.g., bar coding) that provides a permanent record. DO NOT COUNT DAYS, BUT ENSURE MONTHLY INSPECTION

47 SIG Engineering 2011 - 47 © Copyright, The Joint Commission General Life Safety Interpretations Perimeter shelving and sprinkler provision: Are perimeter wall shelving that extends to the ceiling required to be fastened to the wall? NO Shelving is not required for storage There is no correlation between Shelving Clearance The need to secure any shelving

48 SIG Engineering 2011 - 48 © Copyright, The Joint Commission 18 rule 18 OK Wrong Wall Ceiling Perimeter Shelving

49 SIG Engineering 2011 - 49 © Copyright, The Joint Commission General Life Safety Interpretations Rated doors must have legible labels on the door and jambs Jambs prior to 1966 may not have a rating label Are ILSM in place where non- compliant door assemblies are found?

50 SIG Engineering 2011 - 50 © Copyright, The Joint Commission General Life Safety Interpretations Firestop: Existing application is acceptable when It was installed in a manner consistent with original design specifications It is in acceptable condition currently If the firestop is cracking, etc, then it is to be removed and repaired using current technologies

51 SIG Engineering 2011 - 51 © Copyright, The Joint Commission General Life Safety Interpretations Expanding foam used for insulation purposes is NOT an acceptable firestop in any fire or smoke barrier This product does have a UL label: for insulation properties Easily ignited Toxic gases may occur when burned NOTE: There are several acceptable fire stop products that expand when installed

52 SIG Engineering 2011 - 52 © Copyright, The Joint Commission Non Flammable Medical Gas Volume & Storage: Scoring Score EC.02.03.01 EP 1 …fire risk 12 E cylinders (<300ft³) per smoke compartment (22,500ft²) may be open to the egress corridor in a rack or appropriate holders Between 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

53 SIG Engineering 2011 - 53 © Copyright, The Joint Commission Non-Flammable Gas Storage: NFPA 99-2005 NFPA 99-2005 edition has additional language regarding O 2 storage requirements, specifically: Storage of nonflammable gases: 9.4.1> 3000 cubic feet 9.4.2300 – 3000 cubic feet 9.4.30 - 300 cubic feet Other: 5.1.3.3.2 design and construction 5.1.3.3.3ventilation of locations for manifolds 5.1.3.3.3.2ventilation for motor driven equipment 5.1.3.3.3.3ventilation for outdoors NOTE: CMS also recognizes 9.4.3 reference

54 SIG Engineering 2011 - 54 © Copyright, The Joint Commission Non-Flammable Medical Gas Unsafe Conditions: Scoring Score EC.02.06.01 …unsafe condition Unsecured cylinders Laying on top a gurney mattress; leaning against the wall Free standing 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 shall be performed in an area that is mechanically ventilated sprinklered ceramic or concrete flooring separated with at least 1 hour construction from any patient care areas

55 SIG Engineering 2011 - 55 © Copyright, The Joint Commission Tank Farm EC.02.05.09 EP 1 states the hospital tests, inspects and maintains critical components of the piped medical gas systems. Tank Farm is included in this EP The bulk storage tank(s) and associated systems are critical components of the piped medical gas system Tanks above ground, not on roofs No electrical service above tanks 10 Clear from vehicles & sidewalks 50 from wood frame buildings At least 1-0 from other buildings At least 10 form any opening in wall of adjacent structures Concrete pads at all spill points (3 min) Permanent signage: OXYGEN – NO SMOKING – NO OPEN FLAMES Access controlled (i.e. locked)

56 SIG Engineering 2011 - 56 © Copyright, The Joint Commission General Life Safety Interpretations Q. Is a UPS used to condition power or supply power when normal power is interrupted until emergency power is established a SEPSS? A. The UPS in this application is a bridging device, and is not a SEPSS

57 SIG Engineering 2011 - 57 © Copyright, The Joint Commission NFPA 110: Emergency & Standby Power Systems Automatic Transfer Switches (ATS) are self-acting devices that have normal electrical power entering and leaving the ATS The power continues on to distribution panels When a ATS senses a disruption in power it sends a signal to the alternative power source seeking power This start circuit initiates the emergency generator starter The ATS is also equipped with a test switch to simulate the power disruption Recommended practice is to rotate which ATS initiates the start circuit to the emergency generator

58 SIG Engineering 2011 - 58 © Copyright, The Joint Commission General Life Safety Interpretations Generator Loading The 30% requirement assures the diesel engine achieves correct operating temperature The output of the EPSS is not as critical as the operating temperature during the generator tests Two common ratings on the nameplate: KW & Amps The diesel engine drives the alternator, creating electrical charge Power factor and the nameplate ratings With a static load the power factor is 1.0 With a dynamic load the power factor is.8 The nameplate rating measures the capacity of the system with a diesel engine driving the alternator The 30% is taken from the nameplate without calculating the power factor EPs 5 & 8: …uses a dynamic or static load that is at least 30% of the nameplate rating…

59 SIG Engineering 2011 - 59 © Copyright, The Joint Commission General Life Safety Interpretations Electrical Unlocked distribution panels in patient care areas Based on policy Consider risk assessment Score EC.02.01.06 EP 1 Open junction boxes Score at EC.02.03.01 EP 1 Risk: arcing resulting in fire or loss of service

60 SIG Engineering 2011 - 60 © Copyright, The Joint Commission General Life Safety Interpretations Supervisory Signals: EC.02.03.05 EP 1 At least quarterly, the hospital tests supervisory signal devices (except valve tamper switches). The completion date of the tests is documented. Note: For additional guidance on performing tests, see NFPA 72, 1999 edition (Table 7-3.2). Table 7-3.2 actually only states that Supervisory Signal Devices must be tested quarterly The Table does not actually define the specific devices

61 SIG Engineering 2011 - 61 © Copyright, The Joint Commission General Life Safety Interpretations EC.02.03.05 EP 1: NFPA 72-1999, 2-9 lists Supervisory Signal Initiating Devices: 2-9.1 Control Valve Supervisory Signal Initiating Devices 2-9.2 Pressure Supervisory Signal Initiating Devices 2-9.3 Water Level Supervisory Signal Initiating Devices 2-9.4 Room Temperature Supervisory Signal Initiating Devices This is further reinforced by the listing in NFPA 72-1999, Table 7-2.1, 13.h as devices addressed in NFPA 72- 1999

62 SIG Engineering 2011 - 62 © Copyright, The Joint Commission General Life Safety Interpretations Staff Safety EC.02.02.01 EP 3: Precautions & PPE EP 4: Spill procedures EPs 5 – 10: minimizes risk EC.04.01.01 EP 1: Monitoring & Reporting EPs 2 – 11: Specifics Manifests: EP 11 DOT training for those signing

63 SIG Engineering 2011 - 63 © Copyright, The Joint Commission General Life Safety Interpretations Unsafe Conditions & Suicide Risk EC.02.06.01 EP 1: Interior Spaces meet the need of the patient population and are safe and suitable to the care, treatment and services provided. Any unsafe condition can be scored here, provided it is in the patient care interior spaces Suicide risk may be addressed by clinical interventions or policies Work with other survey team members

64 SIG Engineering 2011 - 64 © Copyright, The Joint Commission Outdoor Safety EC.02.01.01 EP 5 The hospital maintains all grounds and equipment Grounds includes Sidewalks Parking lots Park ways Picnic and patio areas Play structures

65 SIG Engineering 2011 - 65 © Copyright, The Joint Commission Outdoor Safety EC.02.01.01 EP 5 The hospital maintains all grounds and equipment Equipment includes Lawn maintenance equipment Snow removal equipment Maintenance equipment Paving Road repair Lighting

66 SIG Engineering 2011 - 66 © Copyright, The Joint Commission CE: Lessons Learned from 2010 Scope issues Contamination issues Alarm Hazards Disabled or otherwise compromised Telemetry Infusion pumps Surgical Site Fires Sentinel Event Alert

67 © Copyright, The Joint Commission Defibrillators: FAQ Q. Are defibrillators considered life support equipment? A. YES. Maintenance activities then must be identified for equipment on the inventory A maintenance strategy for defibrillators could include a range of activities from a visual inspection of the single-use AED (automatic external defibrillator) to the scheduled PM maintenance of a defibrillator Note: the daily and weekly observations are assessed as per policy (see PC.02.01.11 EP2)

68 SIG Engineering 2011 - 68 © Copyright, The Joint Commission Emergency Management: Key Concepts All hazards approach Collaboration with community partners Situational awareness Active mitigation and preparation, not just a written plan Monitor and evaluate

69 SIG Engineering 2011 - 69 © Copyright, The Joint Commission Pre-Session documents Emergency Operations Plan All hazards approach Addresses the six critical areas Inventory of resources and assets Hazard Vulnerability Analysis (HVA) Mitigation and preparedness activities for the top 2 or 3 events Disaster drill and real event evaluations Monitors and evaluates the six critical areas

70 SIG Engineering 2011 - 70 © Copyright, The Joint Commission Conducted by EM Committee/Team Use Multi-disciplinary Approach Experts within your facility Community Share information with: Community-prioritizes events Hospital Leadership For each emergency, the organization defines Mitigation, Preparation, Response, Recovery Directs the survey process related to EM Hazard Vulnerability Analysis

71 SIG Engineering 2011 - 71 © Copyright, The Joint Commission Six Critical Areas 1. Communication 2. Resources & Assets 3. Safety & Security 4. Staff Responsibilities 5. Utilities Management 6. Patient Clinical & Support Activities

72 SIG Engineering 2011 - 72 © Copyright, The Joint Commission Overview of the 2011 EM Changes Stand alone EM session Up to 90 minutes Focus on mitigation and preparedness No disaster scenarios; use hospital disaster critiques Data collection tool and EM Tips document Focused discussion on six critical areas Look at resources and assets inventory; appropriate storage, expirations, training

73 © Copyright, The Joint Commission Questions?

74 SIG Engineering 2011 - 74 © Copyright, The Joint Commission SIG Engineers: 630 792 5900 George Mills, MBA, FASHE, CEM, CHFM, CHSP Senior Engineer SIG Michael Chisholm, CPE, CHFM Engineer SIG Anne Guglielmo, CFPS, LEED, A.P., CHSP Engineer SIG

75 SIG Engineering 2011 - 75 © Copyright, The Joint Commission The Joint Commission Disclaimer These slides are current as of 4/22/2011. 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.

76 © Copyright, The Joint Commission Surveying Maintenance Strategies Medical Equipment Utilities Systems

77 SIG Engineering 2011 - 77 © Copyright, The Joint Commission Changes to EC.02.03.05 EP 2 Existing: Every six months the hospital tests valve tamper switches and water-flow devices. The completion date of the tests is documented. NOTE: for additional guidance on performing tests see NFPA 72- 1999 (Table 7-3.2)

78 SIG Engineering 2011 - 78 © Copyright, The Joint Commission Changes to EC.02.03.05 EP 2 Revised: EP2 For hospitals that use Joint Commission accreditation for deemed status purposes: At least quarterly the hospital tests water-flow devices. Every 6 months the hospital tests valve tamper switches. The completion date is documented. NOTE: For additional guidance on performing tests see NFPA 25-1998 (Section 2-1.3 & 2.3.3) and NPFA 72-1999 (Table 7-3.2 and Section 7-5.2).

79 SIG Engineering 2011 - 79 © Copyright, The Joint Commission Changes to EC.02.03.05 EP 2 EP 2 (continued) For hospitals that do not use accreditation for deemed status purposes: Every 6 months, the hospital tests valve tamper switches and water- flow devices. The completion date of the tests is documented. Note: For additional guidance on performing tests, see NFPA 72, 1999 edition (Table 7-3.2).

80 SIG Engineering 2011 - 80 © Copyright, The Joint Commission NEW: EC.02.03.05 EP 25 For hospitals that use Joint Commission accreditation for deemed status purposes: Documentation of maintenance, testing, and inspection activities for fire alarm and water-based fire protection systems includes the following: Next Slide for Contents Note: For additional guidance on documenting activities: NFPA 25, 1998 edition (Section 2-1.3) NFPA 72, 1999 edition (Section 7-5.2)

81 SIG Engineering 2011 - 81 © Copyright, The Joint Commission NEW: EC.02.03.05 EP 25 Continued Text: Name of the activity Date of the activity Required frequency of the activity Name and contact information, including affiliation, of the person who performed the activity NFPA standard(s) referenced for the activity Results of the activity

82 SIG Engineering 2011 - 82 © Copyright, The Joint Commission NEW: EC.02.03.05 EP 25 For hospitals that use Joint Commission accreditation for deemed status purposes: Documentation of maintenance, testing, and inspection activities for fire alarm and water-based fire protection systems includes the following: Note: For additional guidance on documenting activities: NFPA 25, 1998 edition (Section 2-1.3) NFPA 72, 1999 edition (Section 7-5.2)

83 SIG Engineering 2011 - 83 © Copyright, The Joint Commission Fire & Smoke Damper Inspections Ensure inaccessible dampers truly are by random sampling Confirm ILSM policy is implemented for any horizontal exits or egress enclosures that are compromised by inaccessible dampers Evaluate adequacy of damper accessibility plan

84 SIG Engineering 2011 - 84 © Copyright, The Joint Commission LS.02.01.34 EP 2 Master Alarm Panel The master fire alarm control panel is located in a protected environment (an area enclosed with 1-hour fire- rated walls and ¾ hour fire rated doors) that is continuously occupied OR in an area with a smoke detector. NFPA 72-1999 1-5.6 & 3-8.4.1.3.3.2

85 SIG Engineering 2011 - 85 © Copyright, The Joint Commission Fire Extinguisher: Dating Month, day year and initials of inspector as per NFPA 10-1998 EC.02.03.05 EP 15 4-3.4 Inspection Recordkeeping. 4-3.4.1 Personnel making inspections shall keep records of all fire extinguishers inspected, including those found to require corrective action. 4-3.4.2 At least monthly, the date the inspection was performed and the initials of the person performing the inspection shall be recorded. 4-3.4.3 Records shall be kept on a tag or label attached to the fire extinguisher, on an inspection checklist maintained on file, or in an electronic system (e.g., bar coding) that provides a permanent record. DO NOT COUNT DAYS, BUT ENSURE MONTHLY INSPECTION

86 SIG Engineering 2011 - 86 © Copyright, The Joint Commission CMS Conditions of Participation 42 CFR 482.41 Hospital must maintain adequate facilities for its services 42 CFR 482.41(c)(2) Facilities, supplies and equipment must be maintained to ensure an acceptable level of safety and quality. The CMS Interpretive Guideline states the hospital must monitor, test, calibrate and maintain equipment periodically in accordance with the manufacturers recommendation and Fed and State law.

87 SIG Engineering 2011 - 87 © Copyright, The Joint Commission CMS Conditions of Participation The Interpretive Guideline states the hospital must monitor, test, calibrate and maintain equipment periodically in accordance with the manufacturers recommendation and Federal and State law. Medical Equipment includes Biomedical equipment Radiological equipment Patient beds, stretchers IV infusion equipment Ventilators Laboratory equipment Etc.

88 SIG Engineering 2011 - 88 © Copyright, The Joint Commission CMS Conditions of Participation The Interpretive Guideline states the hospital must monitor, test, calibrate and maintain equipment periodically in accordance with the manufacturers recommendation and Federal and State law. Utility Systems and Equipment includes Elevators Generators Air handlers Medical gas systems Air compressors Vacuum systems Etc.

89 SIG Engineering 2011 - 89 © Copyright, The Joint Commission Manufacturers Recommendations In January 2010 a formal complaint was made to CMS regarding this issue The Joint Commission advocated to CMS the importance of allowing the organizations to continue using the Joint Commission process Based on these discussions, CMS noted that they understand the principles behind applying risk assessment and hospital experience to the frequency of hospital preventive maintenance

90 SIG Engineering 2011 - 90 © Copyright, The Joint Commission CMS Response CMS technical review team has completed its review if the Joint Commissions submission of surveyor instructions and survey protocol for evaluating an organizations preventive maintenance schedule. The purpose of this review was to ensure that Joint Commissions surveyors were properly trained to evaluate the adequacey of an organizations recommended frequency of preventive maintenance.

91 SIG Engineering 2011 - 91 © Copyright, The Joint Commission CMS Response I am happy to inform you that the Joint Commissions approach of utilizing a preventive maintenance schedule has been approved. Thank you for your cooperation and collaboration. CMS Deputy Director July 26, 2010

92 SIG Engineering 2011 - 92 © Copyright, The Joint Commission EC.02.04.01 EP 2 The hospital maintains either a written inventory of all medical equipment or a written inventory of selected equipment categorized by physical risk associated with use (including all life-support equipment) and equipment incident history. The hospital evaluates new types of equipment before initial use to determine whether they should be included in the inventory. (See also EC.02.04.03, EPs 1 and 3)

93 SIG Engineering 2011 - 93 © Copyright, The Joint Commission EC.02.05.01 EP 2 The hospital maintains a written inventory of all operating components of utility systems or maintains a written inventory of selected operating components of utility systems based on risks for infection, occupant needs, and systems critical to patient care (including all life-support systems). The hospital evaluates new types of utility components before initial use to determine whether they should be included in the inventory. (See also EC.02.05.05, EPs 1, 3-5)

94 SIG Engineering 2011 - 94 © Copyright, The Joint Commission Maintaining Medical Equipment Inventory is populated based on one of two strategies: All equipment inclusion Physical risk based process For example, evaluating: Function Risk Levels Maintenance Requirement Utilize resources, i.e. the FDA MAUDE report All life support equipment is included All new types of equipment evaluated for inclusion

95 SIG Engineering 2011 - 95 © Copyright, The Joint Commission Maintaining Utilities Equipment Inventory is populated based on one of two strategies: All equipment inclusion Based on physical risks for Infection Occupant needs Systems critical to patient care All life support equipment is included All new types of equipment is evaluated for inclusion

96 SIG Engineering 2011 - 96 © Copyright, The Joint Commission Joint Commission Medical Equipment Medical equipment includes equipment used in Life support, such as anesthesia machines ventilators defibrillators heart-lung machines Monitoring, such as Bedside monitors Telemetry monitors

97 SIG Engineering 2011 - 97 © Copyright, The Joint Commission Joint Commission Medical Equipment Treatment, such as Electrosurgery Lasers Diathermy Diagnostic, such as Laboratory analyzers Radiology equipment Endoscopes Patient support, such as Patient beds Specialty beds Lifts Taken from the Environment of Care Handbook Chapter 5 (page 73) 3 rd edition

98 SIG Engineering 2011 - 98 © Copyright, The Joint Commission Joint Commission Utilities Equipment Utility System as defined in the Accreditation Manuals Glossary and EC.02.05.03 include: Electrical distribution Emergency Power Supply System (EPSS) Vertical & Horizontal Transport Heating, Ventilation & Air Conditioning Plumbing Boiler and Steam Piped Gases Vacuum Systems Communication Systems & Data Exchange

99 SIG Engineering 2011 - 99 © Copyright, The Joint Commission Joint Commission Utilities Equipment Specific Utility Systems include Features of Fire Safety (EC.02.03.01) Alarm and Notification (LS.02.01.34) Suppression Systems (LS.02.01.35) Design criteria (EC.02.05.01) Power Distribution System (EC.02.05.03) Emergency Power Supply Systems (EC.02.05.07) Medical Gases (EC.02.05.09) Specific populations of equipment Life support systems (EC.02.05.05) Infection Control utility systems (EC.02.05.05)

100 SIG Engineering 2011 - 100 © Copyright, The Joint Commission EC.02.04.01 EP 3 The hospital identifies the activities, in writing, for maintaining, inspecting, and testing for all medical equipment on the inventory. (See also EC.02.04.03, EPs 2 and 3) Note: Hospitals may use different strategies for different items as appropriate. For example, strategies such as predictive maintenance, reliability-centered maintenance, interval-based inspections, corrective maintenance, or metered maintenance may be selected to ensure reliable performance.

101 SIG Engineering 2011 - 101 © Copyright, The Joint Commission EC.02.05.01 EP 3 The hospital identifies, in writing, inspection and maintenance activities for all operating components of utility systems on the inventory. (See also EC.02.05.05, EPs 3 - 5; EC.02.05.09, EP 1) Note: Hospitals may use different approaches to maintenance. For example, activities such as predictive maintenance, reliability- centered maintenance, interval-based maintenance, corrective maintenance, or metered maintenance may be selected to ensure dependable performance.

102 SIG Engineering 2011 - 102 © Copyright, The Joint Commission Maintaining Equipment: Strategies Written strategies identify the activities for Maintaining Inspection Testing Strategies may include Predictive maintenance Reliability-centered maintenance Interval based maintenance Corrective maintenance Metered maintenance Other recognized strategy Manufactures recommendations

103 SIG Engineering 2011 - 103 © Copyright, The Joint Commission Maintenance Strategies Preventive Maintenance The scheduled activities designed to extend equipment reliability based on performing activities prior to equipment failure based on risk levels and organization experience Interval Based Maintenance The scheduled activities are based on a preset schedule that is established regardless of need Determine Interval Time: Manufacturers guidelines Accepted industry practices Regulatory code requirements Organizations past experiences Most preventive maintenance software programs are Interval-Based

104 SIG Engineering 2011 - 104 © Copyright, The Joint Commission Maintenance Strategies Reliability-Centered Maintenance Based on historical analysis of the reliability of equipment Anticipated maintenance activities to extend the reliability based on intersecting historical failure Metered Maintenance Based on established amount of time the equipment has operated rather than a calendar schedule

105 SIG Engineering 2011 - 105 © Copyright, The Joint Commission Maintenance Strategies Corrective Maintenance Equipment is not serviced based on preventive models, but allowed to run until repairs are needed Also includes response to any corrective measures related to the physical environment Other, such as manufacturers recommendations Always during warranty period Evaluate against other strategies

106 SIG Engineering 2011 - 106 © Copyright, The Joint Commission EC.02.04.01 EP 4 The hospital identifies, in writing, frequencies for inspecting, testing, and maintaining medical equipment on the inventory based on criteria such as manufacturers recommendations risk levels current hospital experience (See also EC.02.04.03, EPs 2 and 3)

107 SIG Engineering 2011 - 107 © Copyright, The Joint Commission EC.02.05.01 EP 4 The hospital identifies, in writing, the intervals for inspecting, testing, and maintaining all operating components of the utility systems on the inventory, based on criteria such as Manufacturers recommendations Risk levels hospital experience (See also EC.02.05.05, EPs 3-5)

108 SIG Engineering 2011 - 108 © Copyright, The Joint Commission Maintenance Frequencies Manufacturers Recommendations New equipment that has no operating history should follow manufacturers recommendations until enough history and level of risk has been established Industry experience has established that often manufacturers recommendations are based on worse-case situations and may exceed the normal operating condition level maintenance activity

109 SIG Engineering 2011 - 109 © Copyright, The Joint Commission Maintenance Frequencies Risk levels Evaluating the potential risk of equipment failure is a significant part of evaluating maintaining, inspecting and testing requirements Based on physical risks impact for Infection Occupant needs Systems critical to patient care

110 SIG Engineering 2011 - 110 © Copyright, The Joint Commission Maintenance Frequencies Hospital experience Evaluating the benefits of maintaining, inspecting and testing activities based on history may contribute to increasing or extending those activity periods

111 SIG Engineering 2011 - 111 © Copyright, The Joint Commission Case Study #1 A manufacturers recommendation for telemetry monitors required the Clinical Engineer open the monitor case and inspect for dust Hospital experience identified that those monitors that were opened tended to fail before those monitors that were not opened the factory assembly was essentially air and dust free, once opened the seal was compromised Should the organization continue to open the monitor cases? Would it be acceptable to conduct a visual inspection of the case and service on an as needed basis?

112 SIG Engineering 2011 - 112 © Copyright, The Joint Commission Case Study #2 A manufacturers recommendation for an air handler required the Building Engineer to change the filters on a quarterly frequency based on the manufacturers industrial application Hospital experience identified that those filters were not soiled to the point where they needed to be changed at the end of the quarter Slightly soiled filters actually increase the efficiencies The organization determined that by measuring the pressure differential across the filter bank the filters could be replaced semi-annually Should the organization continue to change the filters quarterly?

113 SIG Engineering 2011 - 113 © Copyright, The Joint Commission Case Study #3 A manufacture of a device that may be used in either an ambulance or in an ICU created its manufacturers recommendations The manufacturers recommendations were based on the unit being used in the field, which would be the more extreme environment Would the manufacturers recommendations be appropriate for the device in the ambulance? Would the manufacturers recommendations be appropriate for the device on the ICU?

114 SIG Engineering 2011 - 114 © Copyright, The Joint Commission Case Study #4 Manufacturers recommendations for greasing a 165# washer is 2 strokes of the grease gun per week to the main bearing This was based on industrial laundry applications running two shifts per day, 6 days per week The Facility Director determined that the frequency was excessive as the hospital laundry is operated one shift per day for 5 days per week Should the organization change to every other week grease application although the manufacturers recommendations is weekly?

115 SIG Engineering 2011 - 115 © Copyright, The Joint Commission EC.02.04.03 The hospital inspects, tests, and maintains medical equipment EP 2. The hospital inspects, tests, and maintains all life support equipment. These activities are documented. (See also EC.02.04.01, EPs 3 and 4; PC.02.01.11, EP 2) EP 3. The hospital inspects, tests, and maintains non-life support equipment identified on the medical equipment inventory. These activities are documented. (See also EC.02.04.01, EPs 2-4 and PC.02.01.11, EP 2)

116 SIG Engineering 2011 - 116 © Copyright, The Joint Commission EC.02.05.05: The hospital inspects, tests, and maintains utility systems EP 2. The hospital inspects, tests, and maintains the following: Life support utility system components on the inventory. These activities are documented. (See also EC.02.05.01, EPs 2-4) EP 3. The hospital inspects, tests, and maintains non-life support equipment identified on the medical equipment inventory. These activities are documented. (See also EC.02.04.01, EPs 2-4 and PC.02.01.11, EP 2) EP 4. The hospital inspects, tests, and maintains the following: Infection control utility system components on the inventory. These activities are documented. (See also EC.02.05.01, EPs 2-4)

117 SIG Engineering 2011 - 117 © Copyright, The Joint Commission Survey Process Document Review Evaluate the Management Plan Determine the Maintenance Strategies applied to the inspection, testing and maintenance of the equipment Evaluate the work completion rates (% complete) To compute the percent complete divide the number of devices completed by the number of scheduled work orders Example: 795 devices completed out of 825 scheduled = 96.4% 795 ÷ 825 = 96.36

118 SIG Engineering 2011 - 118 © Copyright, The Joint Commission Survey Process: Medical Equipment Evaluate the program documentation Logs are completed and reflect both Life Support devices and non-life support devices Accuracy of Inventory All Life Support equipment must be represented on the inventory Preventive maintenance frequencies must be clearly defined in writing Confirm work done as per scheduled activities Ensure appropriate work is scheduled based on maintenance strategies Evaluate device failure against scheduled actions

119 SIG Engineering 2011 - 119 © Copyright, The Joint Commission Survey Process: Utility Systems Evaluate the program documentation Logs are completed and reflect both Life Support Systems, Infection Control equipment, and Non-life support equipment on the inventory Accuracy of Inventory All Life Support equipment must be represented on the inventory Preventive maintenance frequencies must be clearly defined in writing Confirm work done as per scheduled activities Ensure appropriate work is scheduled based on maintenance strategies Evaluate equipment failure and scheduled actions

120 SIG Engineering 2011 - 120 © Copyright, The Joint Commission Survey Process: Staff Interviews Department Leader Establish how the inventory was created Establish the Maintenance Strategies used Evaluate the Monitoring processes Evaluate the effectiveness of the program Equipment Maintainers Evaluate their understanding of the maintenance process/strategies Evaluate competencies based on repeat work orders Evaluate work scheduled against completed

121 SIG Engineering 2011 - 121 © Copyright, The Joint Commission Survey Process: Staff Interview Users of the Equipment Evaluate equipment reliability Evaluate response time when equipment fails Evaluate emergency response process Evaluate Culture of Safety Appropriate training of staff related to equipment use Customer satisfaction with department Contract Services Evaluate reliability of equipment serviced Evaluate integration of the process

122 SIG Engineering 2011 - 122 © Copyright, The Joint Commission Survey Process Evaluate the effectiveness of the program to maintain the equipment Repeat work orders Equipment turn-around time Completion rates Evaluate confidence of the users while using equipment

123 © Copyright, The Joint Commission Questions?

124 SIG Engineering 2011 - 124 © Copyright, The Joint Commission SIG Engineers: 630 792 5900 George Mills, MBA, FASHE, CEM, CHFM, CHSP Senior Engineer SIG Michael Chisholm, CPE, CHFM Engineer SIG Anne Guglielmo, CFPS, LEED, A.P., CHSP Engineer SIG

125 SIG Engineering 2011 - 125 © Copyright, The Joint Commission The Joint Commission Disclaimer These slides are current as of 4/22/2011. 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.


Download ppt "© Copyright, The Joint Commission 2011 Joint Commission Findings, Impact & Update Joint Commission & CMS: Issue Resolution George Mills, Sr. Engineer Standard."

Similar presentations


Ads by Google