Presentation on theme: "2014 The Healthcare Environment"— Presentation transcript:
12014 The Healthcare Environment John Maurer, SASHE, CHFM, CHSPEngineering DepartmentThe Joint Commission1
2Risk Icon Integrated into the Manuals, E-dition, AMP, & FSA Tool Proximity to patientProbability of harmSeverity of harmNumber of patients at riskRisk IconIntegrated into the Manuals, E-dition, AMP, & FSA ToolAll products will display a single icon at the EP levelfor three risk-focused categories:National Patient Safety GoalsAccreditation program-specific risk area standardsSelected direct/indirect impact standardsIn addition, the FSA Tool will use the R icon to identify the fourth risk category:RFI standards from current cycle survey events.
3Standard/NPSG2012 Non Compliance2013 Non ComplianceLS61%52%RC51%LS46%48%EC34%47%IC42%LS39%45%EC40%EC35%LS36%MM
4Standard/NPSG2012 Non Compliance2013 Non ComplianceEC30%34%PC25%27%EC23%MM26%22%EC21%PC19%20%LD17%ECHR16%PC18%
5Top 10 Cited Standards: 2011 - 2013 Standard 2011 2012 2013 LS : Means of Egress#2#1LS : General Bldg Req’s#3EC : Utility Systems Risks#13#10#4LS : Protection#6EC : Fire Safety Systems#5#7EC : Built Environment#11#8LS : Extinguishment#9
6#1 LS EP 13The hospital maintains the integrity of the means of egressAnything in the egress corridor more than 30 minutes is storageDead end corridors may be used for storageLess than or equal to 50sqft spaceCarts Allowed:Crash CartsIsolation CartsChemo Carts
7“If the corridor looks cluttered…it probably is” Educate StaffWhat is the Risk?Patient movementStaff movementAdditional Staff responding to emergency patient care
8Barrier 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 issuesEP 9 Fire Barrier PenetrationsBarrier Management
9Barrier Management Symposium . . .at no cost to the attendee . . .
10Barrier Management Symposium Program Developers:Joint CommissionFirestop Contractors International AssociationUnderwriters LaboratoriesParticipating Organizations:American Society for Healthcare EngineeringAWCI & Gypsum InstituteFire Damper IndustryFire Rated Glazing IndustryNational Concrete Masonry Association
11#4 EC EP 6Ventilation system is unable to provide appropriate pressure relationships, air-exchange rates and filtration efficienciesSpecific areas lacknegative or positive pressures in relationship to adjacent areasi.e. Endoscopy Processing Room should be negative to the egress corridorthe correct number of air changes per hourImproper filtrationMERV = minimum efficiency reporting value
12What is Ventilation?Ventilation is moving air from one location to anotherSupply AirOutside air is conditioned by cooling or heating as the air moves through a series of coilsTo save energy in some systems the returned air is blended with outside airNext the air is cleaned by filters and discharged into the occupied spaceAs the air moves through the building in ducts, the ducts pass through barriers (walls)To protect the barrier dampers are in place
13VentilationExhaust SystemRemoving the air from an occupied space is accomplished by the exhaust systemExhausted air is either removed from the building or re-conditioned and re-usedAs air is removed, it is replaced by supply airThis is how air exchanges occurNew air in, old air out
14VentilationBased on how much air is exhausted and how much air is supplied, the area is either negative, neutral or positiveMore air out, negative pressureSame air in and out, neutralMore air in, positive pressureNormally the cleanest location should be more positive, and the least clean the most negative
15ScreeningTissue test: only to be used as a pre-screening tool to evaluate if further investigation needs to occurTo perform the flutter test take a tissue and let it hang just off the floor near the bottom edge of a doorIf the tissue indicates incorrect air flow, stabilize the area by closing doors and windows, wait a few minutes and re-testIf the organization presents a Testing & Balancing report the following questions should be askedwhen was the balancing done (seasonal issues)are any specific requirements (such as keeping a door closed) needed to achieve satisfactory results
16Survey 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 reviewFollowing LSCS review, the LSCS may contact the Central Office to discuss the possibility of reducing the CLD to SLD, with no change to the findingResolution should include the area affected by the equipment identified as non-compliant, not just the identified room/areai.e. ensure zone is balancedIs there an ongoing process to assess
17HLD Self Contained Units (i.e. GUS) High Level Disinfection (HLD) for semi critical devices are found in and outside the Central Sterile areasGluteraldehyde 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 glovesVentilation Requirements: None. Rooms must meet specific room requirements, howeverStorage: in a manner that will protect from contamination or damage, such as hanging in a cabinet with doors
18Important NoteASHRAE 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.
20#6 LSThe hospital provides and maintains building features to protect individuals from the hazards of fire and smoke.EP2 Hazardous AreasPrimarily door issuesEPs 16 – 23 Smoke Barriers & Doors
21#7 ECThe hospital maintains fire safety equipment and fire safety building features.Features of fire protectionInventory required to ensure all devices are testedDocumentation of testing is required
22Need for Inventory EC.02.03.05 EP 1 – 20: Each device that is required to be tested must be documented in an inventoryIf 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 missedTotal number of devices (quantity) is not adequateLack of an inventory (written, electronic or other) results in a finding at the EPFindings solely for lack of inventory is not scored at EC EP 25
23ECEPs 1 -20:Missing documentation: score the EP as non-compliantAlso write a finding at EP 25 for documentation not being readily available to the AHJIf acceptable documentation appears, finding at EP 1 – 20 might be removed during surveyEP 25 remainsLD EP 4: Staff held accountableIf 3 or more findings at EC EP 1 – 20
24EC.02.03.05 During survey specific documentation is reviewed If the documentation for a specific EP is not available a finding is written as non-compliant for that EPThe documentation should be readily availableIf the organization clarifies after survey:Joint Commission Engineers will review and evaluate complianceLD EP 4 remains24
25#8 EC EP 1 & 13EP 1 Interior spaces meet the needs of the patient population and are safe and suitable to the care, treatment and services providedThe organization must provide a safe environmentUnsecured oxygen cylindersOutdoor safety is scored at EC EP 5
26EC EP 13EP 13 The organization maintains ventilation, temperature and humidity levels suitable for the care, treatment and services providedVentilation:i.e. doors held open by air pressure; odorsTemperature:Hot / Cold callsHumidityPrimary concern is for areas >60%RHMold growth is possibleEP 20: Patient care areas are clean and free of offensive odors
27#9 LS EP 6EP 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
29#11 EC EP 3 – 5EP’s 3 – 5: Personal Protective Equipment and the process to manage hazardous materials and waste handling and exposuresEP’s 6 – 7: Hazardous energy sourcesEscorts to Hot Lab based on organization policyPerspectives, July 2012
30Eye Wash Station Federal Requirements: OSHA Score Eye Wash issues at EC EP 5Risk assess location / application based on OSHA recommendation toreduce the risk of injury from contact with caustic and corrosive materials in areas such asPower PlantLabPlaced so that the eyewash is within 10 seconds or 55 feet from where the corrosive chemicals is usedWeekly flush until clear is requiredAnnual inspection to ensure the system is fully functionalMixing valve recommended to achieve tepidRisk assess potential exposure to determine if cold water only would be acceptable
31Eye 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 6EPs 4 – 7Missed Generator & Automatic Transfer Switch (ATS) Tests12 times per year between 20 & 40 daysEach emergency generator must be tested with a load of at least 30% of nameplateEach ATS must be testedMissed triennial 4 hour test
34#15 EC.02.05.09 EP 3 Medical Gas Systems EP 1: Inspection Testing and MaintainingEP 2: Test when modified, installed or repairedEP 3: ObstructionsEP 3: LabelingContents of pipingAreas servedAccuracy
35# 18 EC.02.03.01 EP 1 & 9 – 10 Fire Safety (EP 1) Open junction boxesMore than 300cuft of nonflammable medical gases (i.e. oxygen) per smoke compartment, open to the egress corridorFire Plan (EP 9 & 10)Lack of fire safety training as per fire planSurgical site fires
36CMS IssueJanuary 2011 the Joint Commission adopted the FGI Guidelines for Design & Construction of Health Care FacilitiesIncluded in the Guidelines is the ASHRAE document with >20% RH lower limitApril 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…”
37RH 20 – 60% RangeCMS 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 ASHRAEReduced 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 providedThe S&C had two criteriaDocument the decisionDeclare at the beginning of a survey the decision
382012 Life Safety Code Update The following are available with certain provisions. These are based on CMS S&C LSC38
39BackgroundThe 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 healthcareCMS 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
40ProcessIf the organization decides to adopt these categorical waivers they mustEnsure full compliance with the appropriate code referenceDocument the decision to adopt the categorical waiverFor 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 surveySee also November 2013 Perspectives
41S&C 13-58-LSC Openings in exit enclosures Emergency generators and standby power systemsDoors, locking arrangementsSuitesExtinguishing requirementsClean waste and patient record recycling containersMedical gas alarmsPlus four: see S&C LSCWheeled equipment in egress corridorsOne alternative kitchen cooking arrangementDirect vent gas fireplaces and solid fuel-burning fireplacesCombustible decorations on walls, doors, and ceilings
422014 The Healthcare Environment Update, Effective January 1 42
43Time RE-Defined The Joint Commission EC chapter defines time as: Daily, weekly, monthly are calendar referencesQuarterly will be once every three months +/- 10 days January 1, 2014Semi-annual is 6 months from the last scheduled event month +/- 20 daysAnnual is 12 months from the last scheduled event month +/- 30 days3 years is 36 months from the last scheduled event month +/- 45 daysNOTE 1: The above does not apply to required frequenciesNOTE 2: An alternative of developing either a unique, written policy or adopting NFPA definitions when available is acceptable
44Quarterly: +/- 10 days Semiannual: +/- 20 days Annual: +/- 30 days Due Date+Due Date+10101010Scheduled MonthScheduled Month2020202030303030QuarterlyJanFebruaryMarchAprSemiannualJuneJulyAugSeptOctNovDecAnnualJanFMAMJJASONDJanFrequencies required by Code may not be modified(e.g. EC EP 4 & 7)
45Medical 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 holdersBetween 300 and 3000ft³ must be stored in a room that is limited construction with doors that can be locked“In use” verses “in storage”Properly secured to a gurney is considered “in use”Properly racked is “in storage”Empty are NOT considered part of the 12 in storageEmpty and full must be stored (racked) separately45
46Medical Gas Safety Score EC.02.06.01 …unsafe condition Unsecured cylindersLaying on top a gurney mattress; leaning against the wallFree standingComingling of full and empty cylindersTransfilling liquid oxygenTransfer 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 ventilatedsprinkleredceramic or concrete flooringseparated with at least 1 hour construction from any patient care areas46
47Medical 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 areasMake sure all repairs are completed by qualified staff.
48Medical 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 feetA 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
50The Alarming ProblemMore and more devices and alarmsMore patients connected to alarms or alarm-based devicesalarms per patient per day in a typical critical care unitAlarm-based devices are not standardized in many organizationsInconsistent use of alarms due to flexible alarm setting features
55NPSG on Alarm Mgmt In Phase I (beginning January 2014) Hospitals will be required to:establish alarms as an organization priority andidentify the most important alarms to manage based on their own internal situations.Input from medical staff and clinical deptsRisk to patients due to lack of response, malfunctionAre specific alarms needed or contributing to noise/fatiguePotential for patient harm based on internal incident historyPublished best practices/guidelines
56NPSG 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 settingsWhen they can be disabledWhen parameters can be changedWho can set and who can change parameters and who can set to “off”Monitoring and response expectationsChecking individual alarm signals for accurate settings, proper operation and detectabilityeducate those in the organization about alarm system management for which they are responsible
60Emergency Management Oversight Address leadership accountability for hospitals and critical access hospitalsFound in EM and LD, effective January 2014:LDEMEMLDSee the July 2013 Perspectives
61Emergency Management Oversight Require the organization to identify a leader to oversee emergency managementRequire the organization to consider input from staff at different levels when evaluating exercises and responses to eventsRequire 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
62LD.04.01.05 EP 12 Someone accountable Staff implementation of the four phases of EMStaff implementation across the six critical areasOrganization-wide collaborationIdentification and collaboration with communityNote: Addresses matters that are not part of incident commander roleSurveyor Training 2012 EC Chapter
63EM.03.01.01 EP 4 Evaluating effectiveness of planning EP 4: The annual emergency management planning reviews are forwarded to senior hospital leadership for reviewNote: 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.
64Organization evaluates effectiveness of EOP EM EP 13: EvaluationOrganization evaluates effectiveness of EOPEvaluate through a multidisciplinary processIncludes relevant input from ALL levels of staff affectedSurveyor Training 2012 EC Chapter
65EM.03.01.03 - Evaluation Organization evaluates effectiveness of EOP Evaluation of exercises and events to include deficiencies and opportunities for improvementDeficiencies 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 evaluationsFuture exercises/events reflect changes made and/or interim measures found in modified EOPSurveyor Training 2012 EC Chapter
66LD EP 25Senior 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.
672014 The Healthcare Environment Update Effective July 1 67
68EC EP 3When 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.”
69EC EP 4Staff 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.”
70CMS IssueJoint Commission met with CMS and discussed manufacturers’ recommendations, Life Safety Code adoption and other issuesCMS has indicated that The Joint Commission may continue to use their current process for equipment and utilities managementState agents will not be so instructedASHE & AAMI met with CMS to continue to discuss the concerns related to equipment managementResponded by clarifying several issues
71S&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; orThe equipment is a medical laser device; orNew equipment without a sufficient amount of maintenance history has been acquired.
72S&C HospitalThe 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 asProvided by the organizations contractorsAvailable publically from nationally recognized sourcesThrough the organizations experience over time
73EC EP 24For [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 lasersImaging 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 evidenceprovided by the [organization’s] contractorsavailable publically from nationally recognized sources, orthrough the [organization’s] experience over time
74EC EP 6For [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] contractorsavailable publically from nationally recognized sources orthrough the [organization’s] experience over time
75S&C 14-07-Hospital: Evaluating Program Effectiveness The equipment management programs must have written policies & proceduresEvaluating 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?
76S&C 14-07-Hospital: Survey Strategies Evaluate the accuracy of the inventoryAre imaging/radiologic equipment and medical laser devices exempt from the alternative maintenance program?Verify the inspection, testing & maintaining activities and frequencies are documentedEvaluate the process for equipment being maintained, including qualified personnelAsk staff questions related to the alternative maintenance programEquipment inclusion processAssignment of maintenance strategies and frequenciesVerify evaluation of the program is occurring and being reported
77EC EP 1At 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…”
78Diagnostic ImagingThree phases of implementation for hospitals, critical access hospitals, and ambulatory care organizationsIncludes ambulatory care organizations that have achieved Advanced Diagnostic Imaging certificationPhase 1, effective July 1, 2014Exceptions: 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 scansPhase 2: fluoroscopy qualifications for non-radiologists performing imaging exams and cone beam CT, and for dental or oral surgical procedures
79Diagnostic 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, 2015Annual performance evaluations of imaging equipment by a medical physicistDocumentation of CT radiation dose in the patient’s clinical recordMeeting the needs of the pediatric population through imaging protocols and by considering patient size or body habitus when establishing imaging protocols
80Diagnostic Imaging Phase 1: Effective July 1, 2014 Management of safety risks in the MRI environmentCollection of data on incidents during which identified radiation dose limits have been exceededMinimum quarterly review of staff dosimetry resultsNew, replacement or modification to roomsMedical physicist to perform structural shielding designNew equipment or rooms where ionizing radiation is emitted or radioactive material is storedMedical physicist to perform radiation protection survey
81Department of Engineering 630 792 5900 George Mills, MBA, FASHE, CEM, CHFM, CHSP, Green BeltDirectorAnne Guglielmo, CFPS, LEED, A.P., CHSPEngineerJohn Maurer, SASHE, CHFM, CHSPEngineerKathy Tolomeo, CHEMEngineerJames Woodson, P.E., CHFMEngineer81
82The 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