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2014 The Healthcare Environment

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1 2014 The Healthcare Environment
John Maurer, SASHE, CHFM, CHSP Engineering Department The Joint Commission 1

2 Risk Icon Integrated into the Manuals, E-dition, AMP, & FSA Tool
Proximity to patient Probability of harm Severity of harm Number of patients at risk Risk Icon Integrated into the Manuals, E-dition, AMP, & FSA Tool All products will display a single icon at the EP level for three risk-focused categories: National Patient Safety Goals Accreditation program-specific risk area standards Selected direct/indirect impact standards In addition, the FSA Tool will use the R icon to identify the fourth risk category: RFI standards from current cycle survey events.

3 Standard/NPSG 2012 Non Compliance 2013 Non Compliance LS 61% 52% RC 51% LS 46% 48% EC 34% 47% IC 42% LS 39% 45% EC 40% EC 35% LS 36% MM

4 Standard/NPSG 2012 Non Compliance 2013 Non Compliance EC 30% 34% PC 25% 27% EC 23% MM 26% 22% EC 21% PC 19% 20% LD 17% EC HR 16% PC 18%

5 Top 10 Cited Standards: 2011 - 2013 Standard 2011 2012 2013
LS : Means of Egress #2 #1 LS : General Bldg Req’s #3 EC : Utility Systems Risks #13 #10 #4 LS : Protection #6 EC : Fire Safety Systems #5 #7 EC : Built Environment #11 #8 LS : Extinguishment #9

6 #1 LS EP 13 The hospital maintains the integrity of the means of egress Anything in the egress corridor more than 30 minutes is storage Dead end corridors may be used for storage Less than or equal to 50sqft space Carts Allowed: Crash Carts Isolation Carts Chemo Carts

7 “If the corridor looks cluttered…it probably is”
Educate Staff What is the Risk? Patient movement Staff movement Additional Staff responding to emergency patient care

8 Barrier Management #3 LS.02.01.10 EP 5 – 7 & 9
Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat. EPs 5 – 7 Door issues EP 9 Fire Barrier Penetrations Barrier Management

9 Barrier Management Symposium
. . .at no cost to the attendee . . .

10 Barrier Management Symposium
Program Developers: Joint Commission Firestop Contractors International Association Underwriters Laboratories Participating Organizations: American Society for Healthcare Engineering AWCI & Gypsum Institute Fire Damper Industry Fire Rated Glazing Industry National Concrete Masonry Association

11 #4 EC EP 6 Ventilation system is unable to provide appropriate pressure relationships, air-exchange rates and filtration efficiencies Specific areas lack negative or positive pressures in relationship to adjacent areas i.e. Endoscopy Processing Room should be negative to the egress corridor the correct number of air changes per hour Improper filtration MERV = minimum efficiency reporting value

12 What is Ventilation? Ventilation is moving air from one location to another Supply Air Outside air is conditioned by cooling or heating as the air moves through a series of coils To save energy in some systems the returned air is blended with outside air Next the air is cleaned by filters and discharged into the occupied space As the air moves through the building in ducts, the ducts pass through barriers (walls) To protect the barrier dampers are in place

13 Ventilation Exhaust System Removing the air from an occupied space is accomplished by the exhaust system Exhausted air is either removed from the building or re-conditioned and re-used As air is removed, it is replaced by supply air This is how air exchanges occur New air in, old air out

14 Ventilation Based on how much air is exhausted and how much air is supplied, the area is either negative, neutral or positive More air out, negative pressure Same air in and out, neutral More air in, positive pressure Normally the cleanest location should be more positive, and the least clean the most negative

15 Screening Tissue test: only to be used as a pre-screening tool to evaluate if further investigation needs to occur To perform the flutter test take a tissue and let it hang just off the floor near the bottom edge of a door If the tissue indicates incorrect air flow, stabilize the area by closing doors and windows, wait a few minutes and re-test If the organization presents a Testing & Balancing report the following questions should be asked when was the balancing done (seasonal issues) are any specific requirements (such as keeping a door closed) needed to achieve satisfactory results

16 Survey Process EC.02.05.01 EP 6 will generate a CLD
If the organization can repair the process that led to non-compliance the LSCS may review Following LSCS review, the LSCS may contact the Central Office to discuss the possibility of reducing the CLD to SLD, with no change to the finding Resolution should include the area affected by the equipment identified as non-compliant, not just the identified room/area i.e. ensure zone is balanced Is there an ongoing process to assess

17 HLD Self Contained Units (i.e. GUS)
High Level Disinfection (HLD) for semi critical devices are found in and outside the Central Sterile areas Gluteraldehyde User Stations (GUS) disinfection soak stations, or similar self contained HLD units such as those using 0.55% ortho-phthalaldehyde (OPA) The Joint Commission will focus on the processes and Personal Protective Equipment (PPE) Many of the chemical disinfectants are potentially toxic and may require adequate precautions, including face/eye shields and gloves Ventilation Requirements: None. Rooms must meet specific room requirements, however Storage: in a manner that will protect from contamination or damage, such as hanging in a cabinet with doors

18 Important Note ASHRAE voted in July 2013 to move endoscopy procedure rooms from positive to N/A, in Addendum W. Therefore, if an organization had made a documented decision based on risk assessment to no longer monitor endoscopy procedure rooms as per the 2013 ASHRAE action, we would accept this. If the organization has not made a documented decision, the room should be evaluated as per the below table and construction date. No change to bronchoscopy procedure rooms.

19 Guidelines Ventilation Table: Endoscopy & Bronchoscopy
Edition Procedure Processing  (Cleaning) Pressure Direct Exhaust 2014 (pending) N/A Negative (-) YES 2010 Positive (+) 2006 Neutral 2001 1996/97 1992/93 1987 1979

20 #6 LS The hospital provides and maintains building features to protect individuals from the hazards of fire and smoke. EP2 Hazardous Areas Primarily door issues EPs 16 – 23 Smoke Barriers & Doors

21 #7 EC The hospital maintains fire safety equipment and fire safety building features. Features of fire protection Inventory required to ensure all devices are tested Documentation of testing is required

22 Need for Inventory EC.02.03.05 EP 1 – 20:
Each device that is required to be tested must be documented in an inventory If x devices were tested last year, and x-1 were tested this year, which device was missed? Each device must be on the inventory to identify which device was missed Total number of devices (quantity) is not adequate Lack of an inventory (written, electronic or other) results in a finding at the EP Findings solely for lack of inventory is not scored at EC EP 25

23 EC EPs 1 -20: Missing documentation: score the EP as non-compliant Also write a finding at EP 25 for documentation not being readily available to the AHJ If acceptable documentation appears, finding at EP 1 – 20 might be removed during survey EP 25 remains LD EP 4: Staff held accountable If 3 or more findings at EC EP 1 – 20

24 EC.02.03.05 During survey specific documentation is reviewed
If the documentation for a specific EP is not available a finding is written as non-compliant for that EP The documentation should be readily available If the organization clarifies after survey: Joint Commission Engineers will review and evaluate compliance LD EP 4 remains 24

25 #8 EC EP 1 & 13 EP 1 Interior spaces meet the needs of the patient population and are safe and suitable to the care, treatment and services provided The organization must provide a safe environment Unsecured oxygen cylinders Outdoor safety is scored at EC EP 5

26 EC EP 13 EP 13 The organization maintains ventilation, temperature and humidity levels suitable for the care, treatment and services provided Ventilation: i.e. doors held open by air pressure; odors Temperature: Hot / Cold calls Humidity Primary concern is for areas >60%RH Mold growth is possible EP 20: Patient care areas are clean and free of offensive odors

27 #9 LS EP 6 EP 9: There are 18” or more of open space maintained below the sprinkler deflector to the top of storage. NOTE: Perimeter wall and stack shelving may NFPA , 5-6.6

28 18” rule Perimeter Shelving Perimeter Shelving Ceiling 18” 18” Wall
OK OK OK Wrong

29 #11 EC EP 3 – 5 EP’s 3 – 5: Personal Protective Equipment and the process to manage hazardous materials and waste handling and exposures EP’s 6 – 7: Hazardous energy sources Escorts to Hot Lab based on organization policy Perspectives, July 2012

30 Eye Wash Station Federal Requirements: OSHA
Score Eye Wash issues at EC EP 5 Risk assess location / application based on OSHA recommendation to reduce the risk of injury from contact with caustic and corrosive materials in areas such as Power Plant Lab Placed so that the eyewash is within 10 seconds or 55 feet from where the corrosive chemicals is used Weekly flush until clear is required Annual inspection to ensure the system is fully functional Mixing valve recommended to achieve tepid Risk assess potential exposure to determine if cold water only would be acceptable

31 Eye Wash Station: Recommended locations (i.e. OSHA)
Medical services and first aid (c) The eyes or body of any person may be exposed to injurious corrosive materials, suitable facilities for quick drenching or flushing of the eyes and body shall be provided within the work area for immediate emergency use. Formaldehyde (i)(3) If there is any possibility that an employee's eyes may be splashed with solutions containing 0.1 percent or greater formaldehyde, the employer shall provide acceptable eyewash facilities within the immediate work area for emergency use. Battery charging and changing (i) Facilities for flushing the eyes, body and work area with water shall be provided wherever electrolyte is handled, except that this requirement does not apply when employees are only checking battery electrolyte levels or adding water.


33 #13 EC EP 6 EPs 4 – 7 Missed Generator & Automatic Transfer Switch (ATS) Tests 12 times per year between 20 & 40 days Each emergency generator must be tested with a load of at least 30% of nameplate Each ATS must be tested Missed triennial 4 hour test

34 #15 EC.02.05.09 EP 3 Medical Gas Systems
EP 1: Inspection Testing and Maintaining EP 2: Test when modified, installed or repaired EP 3: Obstructions EP 3: Labeling Contents of piping Areas served Accuracy

35 # 18 EC.02.03.01 EP 1 & 9 – 10 Fire Safety (EP 1)
Open junction boxes More than 300cuft of nonflammable medical gases (i.e. oxygen) per smoke compartment, open to the egress corridor Fire Plan (EP 9 & 10) Lack of fire safety training as per fire plan Surgical site fires

36 CMS Issue January 2011 the Joint Commission adopted the FGI Guidelines for Design & Construction of Health Care Facilities Included in the Guidelines is the ASHRAE document with >20% RH lower limit April 2013 CMS Issued S&C LSC & ASC which is “a categorical LSC waiver permitting new and existing ventilation systems to operate with a RH of >20 percent, instead of >35 percent…”

37 RH 20 – 60% Range CMS first issued a Categorical Waiver in S&C LSC & ASC to align with the 2010 FGI Guidelines for Design & Construction of Health Care Facilities use of ASHRAE Reduced the relative humidity (RH) in certain areas to a range of 20 – 60% This 2013 CMS action matched the Joint Commission’s 1/2011 adoption of the 2010 Guidelines and the 20 – 60% RH range provided The S&C had two criteria Document the decision Declare at the beginning of a survey the decision

38 2012 Life Safety Code Update The following are available with certain provisions. These are based on CMS S&C LSC 38

39 Background The Joint Commission provided CMS with a list of items, based on later editions of the Life Safety Code, that would immediately have a positive impact on all healthcare CMS acted on the Joint Commission recommendation in the form of a State & Certification letter (S&C LSC) The action is a series of Categorical Waivers

40 Process If the organization decides to adopt these categorical waivers they must Ensure full compliance with the appropriate code reference Document the decision to adopt the categorical waiver For Life Safety Code items annotate the “Additional Comments” Section in the Statement of Conditions™ Basic Building Information (BBI) For Environment of Care items document by Minutes in discussion at the Environment of Care Committee (or equivalent) Declare the decision at the beginning of any survey See also November 2013 Perspectives

41 S&C 13-58-LSC Openings in exit enclosures
Emergency generators and standby power systems Doors, locking arrangements Suites Extinguishing requirements Clean waste and patient record recycling containers Medical gas alarms Plus four: see S&C LSC Wheeled equipment in egress corridors One alternative kitchen cooking arrangement Direct vent gas fireplaces and solid fuel-burning fireplaces Combustible decorations on walls, doors, and ceilings

42 2014 The Healthcare Environment Update, Effective January 1

43 Time RE-Defined The Joint Commission EC chapter defines time as:
Daily, weekly, monthly are calendar references Quarterly will be once every three months +/- 10 days January 1, 2014 Semi-annual is 6 months from the last scheduled event month +/- 20 days Annual is 12 months from the last scheduled event month +/- 30 days 3 years is 36 months from the last scheduled event month +/- 45 days NOTE 1: The above does not apply to required frequencies NOTE 2: An alternative of developing either a unique, written policy or adopting NFPA definitions when available is acceptable

44 Quarterly: +/- 10 days Semiannual: +/- 20 days Annual: +/- 30 days
Due Date + Due Date + 10 10 10 10 Scheduled Month Scheduled Month 20 20 20 20 30 30 30 30 Quarterly Jan February March Apr Semiannual June July Aug Sept Oct Nov Dec Annual Jan F M A M J J A S O N D Jan Frequencies required by Code may not be modified (e.g. EC EP 4 & 7)

45 Medical Gas Safety 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 45

46 Medical Gas Safety Score EC.02.06.01 …unsafe condition
Unsecured cylinders Laying on top a gurney mattress; leaning against the wall Free standing Comingling of full and empty cylinders Transfilling liquid oxygen Transfer of any gases from one cylinder to another in patient care areas of health care facilities is prohibited. Transfilling of liquid oxygen only in an area that is: mechanically ventilated sprinklered ceramic or concrete flooring separated with at least 1 hour construction from any patient care areas 46

47 Medical Gas Safety 5 Key Steps to ensuring Medical Gas Safety
Make sure all medical gas cylinders are always secured. Make sure full and partial or empty cylinders are physically separated to prevent staff confusion when retrieving a cylinder during an emergency. Consider any open cylinders as “empty” and keep these cylinders physically separated from full cylinders. Monitor and manage the amount of nonflammable medical gases stored in patient care areas Make sure all repairs are completed by qualified staff.

48 Medical Gas Safety Minimizing fire risk
NFPA Section (see also CMS S&C-07-10) allows up to 300 cubic feet of nonflammable medical gas in cylinders to be available to an egress corridor. One e-cylinder holds approximately 25 cubic feet A full E cylinder with a malfunctioning valve could create an oxygen enriched environment, resulting in a potential fire risk. Adding additional full gas cylinders to the area may present even a greater fire risk, so organizations must comply with the limit of 12 E cylinders open to the means of egress. See also December 2012 Perspectives


50 The Alarming Problem More and more devices and alarms More patients connected to alarms or alarm-based devices alarms per patient per day in a typical critical care unit Alarm-based devices are not standardized in many organizations Inconsistent use of alarms due to flexible alarm setting features




54 National patient safety goal

55 NPSG on Alarm Mgmt In Phase I (beginning January 2014)
Hospitals will be required to: establish alarms as an organization priority and identify the most important alarms to manage based on their own internal situations. Input from medical staff and clinical depts Risk to patients due to lack of response, malfunction Are specific alarms needed or contributing to noise/fatigue Potential for patient harm based on internal incident history Published best practices/guidelines

56 NPSG on Alarm Mgmt In Phase II (beginning January 2016)
Hospitals will be expected to: develop and implement specific components of policies and procedures that address at minimum: Clinically appropriate settings When they can be disabled When parameters can be changed Who can set and who can change parameters and who can set to “off” Monitoring and response expectations Checking individual alarm signals for accurate settings, proper operation and detectability educate those in the organization about alarm system management for which they are responsible

57 resources


59 Other Resources AAMI website page on Clinical Alarms: ECRI website page on Alarm Management resources: Pennsylvania Patient Safety Authority: (physiologic alarm management) Healthcare Technology Foundation: (national clinical alarm survey)

60 Emergency Management Oversight
Address leadership accountability for hospitals and critical access hospitals Found in EM and LD, effective January 2014: LD EM EM LD See the July 2013 Perspectives

61 Emergency Management Oversight
Require the organization to identify a leader to oversee emergency management Require the organization to consider input from staff at different levels when evaluating exercises and responses to events Require senior hospital leaders to review EM planning activities, performance in exercises, and responses to actual events to facilitate improved communication of problem areas and implementation of hospitalwide solutions

62 LD.04.01.05 EP 12 Someone accountable
Staff implementation of the four phases of EM Staff implementation across the six critical areas Organization-wide collaboration Identification and collaboration with community Note: Addresses matters that are not part of incident commander role Surveyor Training 2012 EC Chapter

63 EM.03.01.01 EP 4 Evaluating effectiveness of planning
EP 4: The annual emergency management planning reviews are forwarded to senior hospital leadership for review Note: Senior hospital leadership refers to those leaders with responsibility for organization-wide strategic planning and budgets (vice presidents and officers). The hospital may determine that all senior hospital leaders participate in reviewing emergency management reviews, or it may designate specific senior hospital leaders to review this information.

64 Organization evaluates effectiveness of EOP
EM EP 13: Evaluation Organization evaluates effectiveness of EOP Evaluate through a multidisciplinary process Includes relevant input from ALL levels of staff affected Surveyor Training 2012 EC Chapter

65 EM.03.01.03 - Evaluation Organization evaluates effectiveness of EOP
Evaluation of exercises and events to include deficiencies and opportunities for improvement Deficiencies and opportunities for improvement are communicated to the improvement team responsible for monitoring environment of care issues and to senior hospital leadership. (See also EC , EP 1; EC , EP 3; LD , EP 25) Modifications to EOP based on evaluations Future exercises/events reflect changes made and/or interim measures found in modified EOP Surveyor Training 2012 EC Chapter

66 LD EP 25 Senior hospital leadership directs implementation of selected hospital-wide improvements in emergency management based on the following: Review of the annual emergency management planning reviews (See also EM , EP 4) Review of the evaluations of all emergency response exercises and all responses to actual emergencies (See also EM , EP 15) Determination of which emergency management improvements will be prioritized for implementation, recognizing that some emergency management improvements might be a lower priority and not taken up in the near term.

67 2014 The Healthcare Environment Update Effective July 1

68 EC EP 3 When quarterly fire drills are required, at least 50% are unannounced. Fire drills are held at unexpected times and under varying conditions. Added: “Fire drills are held at unexpected times and under varying conditions.”

69 EC EP 4 Staff who work in buildings where patients are housed or treated participate in drills according to the hospital’s fire response plan. Note: When drills are conducted between 9:00 p.m. and 6:00 a.m., the hospital may use alternative methods to notify staff instead of activating audible alarms. Replaced “building’s fire alarm system.”

70 CMS Issue Joint Commission met with CMS and discussed manufacturers’ recommendations, Life Safety Code adoption and other issues CMS has indicated that The Joint Commission may continue to use their current process for equipment and utilities management State agents will not be so instructed ASHE & AAMI met with CMS to continue to discuss the concerns related to equipment management Responded by clarifying several issues

71 S&C 14-07-Hospital S&C 12-07-Hospital Superceded
A hospital may adjust its maintenance, inspection, and testing frequency and activities for facility and medical equipment from what is recommended by the manufacturer, based on a risk-based assessment by qualified personnel, unless: Other Federal or state law; or hospital Conditions of Participation (CoPs) require adherence to manufacturer’s recommendations and/or set specific requirements. For example, all imaging/radiologic equipment must be maintained per manufacturer’s recommendations; or The equipment is a medical laser device; or New equipment without a sufficient amount of maintenance history has been acquired.

72 S&C Hospital The organization inspects, tests & maintains new medical equipment or operating components of utility systems in accordance with manufacturers’ recommendations with insufficient maintenance history to support the use of alternative maintenance strategies. Maintenance history may be gathered from documented evidence such as Provided by the organizations contractors Available publically from nationally recognized sources Through the organizations experience over time

73 EC EP 24 For [organizations] that use Joint Commission accreditation for deemed status purposes:  The [organization] inspects, tests, and maintains the following in accordance with manufacturers’ recommendations (See also EC , EPs 3 and 4): Medical lasers Imaging and radiologic equipment (whether used for diagnostic or therapeutic purposes) New medical equipment with insufficient maintenance history to support the use of alternative maintenance strategies. Note: Maintenance history may be gathered from documented evidence provided by the [organization’s] contractors available publically from nationally recognized sources, or through the [organization’s] experience over time

74 EC EP 6 For [organizations] that use Joint Commission accreditation for deemed status purposes: The [organization] inspects, tests, and maintains new operating components of utility systems in accordance with manufacturers’ recommendations with insufficient maintenance history to support the use of alternative maintenance strategies. Note: Maintenance history may be gathered from documented evidence: provided by the [organization’s] contractors available publically from nationally recognized sources or through the [organization’s] experience over time

75 S&C 14-07-Hospital: Evaluating Program Effectiveness
The equipment management programs must have written policies & procedures Evaluating the program: How is equipment evaluated to ensure no degradation of performance? How are equipment-related incidents investigated? How to sequester equipment deemed unsafe? Is there a performance process to evaluate if modifications to the maintenance strategy is needed?

76 S&C 14-07-Hospital: Survey Strategies
Evaluate the accuracy of the inventory Are imaging/radiologic equipment and medical laser devices exempt from the alternative maintenance program? Verify the inspection, testing & maintaining activities and frequencies are documented Evaluate the process for equipment being maintained, including qualified personnel Ask staff questions related to the alternative maintenance program Equipment inclusion process Assignment of maintenance strategies and frequencies Verify evaluation of the program is occurring and being reported

77 EC EP 1 At least monthly, the hospital performs a functional test of battery-powered lights required for egress for a minimum duration of 30 seconds. The completion date of the tests is documented. Replaced “At 30 day intervals…”

78 Diagnostic Imaging Three phases of implementation for hospitals, critical access hospitals, and ambulatory care organizations Includes ambulatory care organizations that have achieved Advanced Diagnostic Imaging certification Phase 1, effective July 1, 2014 Exceptions: not applicable to dental cone beam CT radiographic imaging studies performed for diagnosis of conditions affecting the maxillofacial region or to obtain guidance for the treatment of such conditions. Phase 1.5: minimum qualifications for radiologists performing CT scans Phase 2: fluoroscopy qualifications for non-radiologists performing imaging exams and cone beam CT, and for dental or oral surgical procedures

79 Diagnostic Imaging Phase 1: Effective July 1, 2014
Computed tomography (CT), nuclear medicine (NM), positron emission tomography (PET), and magnetic resonance imaging (MRI) Minimum competency for radiology technologists, including registration and certification by July 1, 2015 Annual performance evaluations of imaging equipment by a medical physicist Documentation of CT radiation dose in the patient’s clinical record Meeting the needs of the pediatric population through imaging protocols and by considering patient size or body habitus when establishing imaging protocols

80 Diagnostic Imaging Phase 1: Effective July 1, 2014
Management of safety risks in the MRI environment Collection of data on incidents during which identified radiation dose limits have been exceeded Minimum quarterly review of staff dosimetry results New, replacement or modification to rooms Medical physicist to perform structural shielding design New equipment or rooms where ionizing radiation is emitted or radioactive material is stored Medical physicist to perform radiation protection survey

81 Department of Engineering 630 792 5900
George Mills, MBA, FASHE, CEM, CHFM, CHSP, Green Belt Director Anne Guglielmo, CFPS, LEED, A.P., CHSP Engineer John Maurer, SASHE, CHFM, CHSP Engineer Kathy Tolomeo, CHEM Engineer James Woodson, P.E., CHFM Engineer 81

82 The Joint Commission Disclaimer
These slides are current as of 4/7/ 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. 82

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