Best Practices and Programs: Getting “Survey Ready” in 2014

Best Practices and Programs: Getting “Survey Ready” in 2014
HFMADV Annual Conference Radisson Hotel - Philadelphia, Pennsylvania October 7, 2014 Best Practices and Programs Presented by: Gary D. Slack, PE, CCE Healthcare Engineering Consultants

Typical Survey Activities Include:
The Survey Process Typical Survey Activities Include: Communication to hospital by JC liaison with tentative agenda, number of surveyors, survey days Extranet posting (by 7:30 AM local time) Survey arrival, ID verification Surveyors include a Physician, Nurse(s), Life Safety Surveyor; others may include an administrator and specialty surveyors (lab, behavioral health, home health care, ambulatory, etc.) Opening Conference (15 minutes) Organization Orientation (30 to 60 minutes) Preliminary Planning Session (1 hour) Healthcare Engineering Consultants 2

Survey Activities (continued)
The Survey Process Survey Activities (continued) On-Site Survey Activities (including tracers) Special Issue Resolution (end of day, 30 minutes) Daily Briefing (end of day, 30 minutes) Critical Survey Activities for the “Physical Environment” (Life Safety Surveyor - minimum of two days for any hospital survey; >1.5 million square feet – 3 days; additional day for every three healthcare buildings! - Environment of Care - Life Safety - Emergency Management CEO Exit Briefing (15 minutes) Organization Exit Conference (30 minutes) Healthcare Engineering Consultants 3

Accreditation Categories
Preliminary Accreditation: early survey policy Accredited: in compliance with all standards Accreditation with Follow-Up Survey: follow-up survey required within 30 to 180 days Contingent Accreditation: follow-up survey within 30 days (replaces conditional accreditation) Preliminary Denial of Accreditation: immediate threat or failure to resolve requirements Denial of Accreditation: Organization denied accreditation; appeals exhausted Healthcare Engineering Consultants 4

The Unannounced Survey Timeline
Unannounced Surveys will Occur: Between 18 and 36 months from the date of the previous unannounced survey Note: The chance of a survey is not equally distributed from 18 to 36 months from the previous survey The timing of all surveys after the previous survey may be based on Priority Focus Process (PFP) data, sentinel events and other factors Very high probability surveys will occur between the 33 and 36 month anniversary date, but some surveys are scheduled earlier than expected! Prior to the survey (usually 6 weeks to 3 months), a discussion with the JC liaison to review the surveyor team members and agenda will occur Healthcare Engineering Consultants 5

The Unannounced Survey Surprise
Surveys Can Also Occur Due To: One year follow-up survey for newly accredited organizations that provide high risk or critical services Sentinel event follow-up Adverse media coverage of specific issue Complaint from the public Any other time that the JC decides it’s appropriate! Healthcare Engineering Consultants 6

Understanding Survey Scoring Decisions
Healthcare Engineering Consultants 7

Healthcare Engineering Consultants
Scoring Decisions Some scoring changes in the in the EC, EM and LS chapters have occurred for 2014; also, remember the inclusion of the identified risk (R) icon “A” and “C” scores remain (changes to “C” scores) Four levels of scoring risk exist (surveyor discretion on 1): 1. Immediate Threat to Health and Safety: results in preliminary DOA until follow-up evidence of compliance 2. Situation Decision: results in preliminary DOA or CA 3. Direct Impact Requirements: immediate care impact; must submit ESC within 45 days 4. Indirect Impact: no immediate risk; ESC submission within 60 days Healthcare Engineering Consultants 8

Explanation of Scoring Levels
Immediate Threat to Health and Safety 1. Immediate Preliminary Denial of Accreditation 2. Action expected during survey 3. After PDA official notification, 72 hours to eliminate the threat; 23 day maximum time with abatement measures 4. Follow-up abatement survey conducted 5. Upon resolution, status changes to Conditional Accreditation based on follow-up survey 6. Triggered by unaddressed issues with: Fire alarm or extinguishing system - Emergency power system - Medical gas master panel - Serious Life Safety deficiencies Healthcare Engineering Consultants 9

Examples of “Immediate Threat” Finding Life Safety Blocked or locked exit Potential for serious injury or death to patients, staff or visitors Serious construction safety deficiencies Fire detection or extinguishing system Fire system disconnected without interim measures Fire system not functioning properly without ILSM Fire pump “out of service” without alternate pump Fire alarm signal not connected or not functioning Healthcare Engineering Consultants 10

Examples of “Immediate Threat” Finding Emergency Power System Generators unreliable or not repaired without implementing “interim utility system measures” (IUSM) One or more generators “out of service” without an alternate generator connected Aware of contaminated fuel that may not power the generators, but no action taken Medical Gas and Vacuum System Unresolved leaks in the liquid oxygen system Non-functioning master or area alarms without IUSM Serious particulate or algae growth in the medical air system Uncorrected deficiencies without IUSM Healthcare Engineering Consultants 11

“Situational” Decision Rule 1. Immediate Preliminary Denial of Accreditation or Conditional Accreditation issued 2. ESC submission required within 45 days 3. Follow-up survey occurs to validate corrective action Only two scored “Situation Decision” items in the Physical Environment: - Failure to evaluate, implement or document interim life safety measures - Failure to meet PFI timelines on SOC after grace period Healthcare Engineering Consultants 12

Direct Impact Requirements 1. If non-compliance is likely to have an impact on patient safety or quality of care 2. ESC submission required within 45 days 3. A single Direct Impact “EP” results in the entire standard being non-compliant Examples include: - Failure to address safety risks - Improper disposal of hazardous medications - Insufficient PM on life support equipment Healthcare Engineering Consultants 13

Indirect Impact Requirements 1. Based on planning and care processes 2. If non-compliance is likely to have an increased risk to patient safety or quality of care 3. ESC submission required within 60 days 4. Examples include: - Incomplete management plan - Non-compliance to smoking policy - Insufficient fire drills performed or critiqued - Insufficient disaster drills Healthcare Engineering Consultants 14

Joint Commission Scoring Decisions
“EC”, “EM” and “LS” Scoring Categories Performance Category Number Immediate Threat Situation Decision 2 Direct Impact 66 Indirect Impact 311 Note: Some changes in scoring categories occurred effective July 2, 2014 Healthcare Engineering Consultants 15

Joint Commission Standards Scoring
“A” Scores: One and done! “C” Scores: Three strikes and you’re out! “R” Icon: An identified risk for the Focused Standards Assessment (FSA) “D” Icon: Documentation required Changed on 7/1/14!! Score Rule: “2” – Situation Decision “3” – Direct Impact “4” – Indirect Impact Healthcare Engineering Consultants 16 16

Explanation of New Scoring
Effective on July 1, 2014 1. “C”-scored items are no longer “three strikes and you’re out!” 2. A single identified deficiency will now be scored as an “OFI” – “opportunity for improvement”, and will be listed on the final report 3. A second identified deficiency will be listed on the report as a “RFI” – “requirement for improvement” and will require corrective action through an “ESC” – evidence of standards compliance Healthcare Engineering Consultants 17 17

Timeframe Test Interval Expectations Trienniel: 36 months +/- 45 days from the previous test month Annual: 1 year +/- 30 days from the previous test month Semiannual: 6 months +/- 20 days from the previous test month Quarterly: 4 times per year, each quarter, +/- 10 days from the previous test month (change for 2014!) Monthly: within the calendar month Healthcare Engineering Consultants 18

Timeframe Test Interval Expectations Weekly: Defined as Sunday 12:01 AM through midnight Saturday Daily: once per day, beginning at 12:01 AM Other definitions take priority, if they are in the regulatory requirements Note: These will be default test interval expectations unless the organization defines other acceptable intervals in a policy that is approved by the safety committee Healthcare Engineering Consultants 19

Challenging Physical Environment Standards
What have been the most challenging recent “PE” standards for hospitals? EC , EP6 (53%) – ventilation, pressure relationships LS , EP13 (52%) – means of egress EC , EP13 (51%) – unsecured cylinders, temperature and humidity EC , EP1-20 (50%) – fire device testing LS , EP5,6,7,9 (49%) – compartmentation LS , EP (46%) – hardware, hazardous areas Healthcare Engineering Consultants 20 20

Challenging Physical Environment Standards
What have been the most challenging recent “PE” standards for hospitals? (cont’d) LS , EP4, 5, 14 (44%) – sprinkler piping and heads EC , EP3-5 (36%) - PPE, eyewashes, hot lab security EC , EP3 – medical gas systems EC , EP6 – emergency power Note: 90% of the “Top 10” citations are “PE-related for hospitals! Healthcare Engineering Consultants 21

The Top Recent Sentinel Events
Description Number Wrong patient, site or procedure 60 Unintended object retention 56 Delay in treatment Patient Falls 48 Unanticipated events 40 Operative/ Post-op complication 37 Suicide 35 Assault/ rape/ homicide 26 Healthcare Engineering Consultants 22

The Top Health Technology Hazards
Alarm hazards Medication errors from infusion pumps CT radiation burns in pediatric patients Patient/ data mismatches in EHR Radiation hazards in hybrid OR’s Inadequate reprocessing of endoscopes and surgical instruments Problems with changes to inter-related networked devices Pediatric risk due to adult technologies Insufficient training for robotics Retained devices/ unretrieved fragments Healthcare Engineering Consultants 23

Priority Focus Areas Assessment and Care/ Services Communication Credentialed Practitioners Equipment Use Infection Control Information Management Medication Management Organizational Structure Orientation and Training Patient Safety Physical Environment Quality Improvement Expertise/ Activities Rights and Ethics Staffing Healthcare Engineering Consultants 24

Possible ISO Option As a response to DNV, the Joint Commission may be unveiling a new “ISO Certification Option” In the 2014 Hospital Accreditation manual, it states: “The Joint commission continues to evaluate the integration of an ISO Certification Option in its accreditation process. At the publication deadline for this manual, no decision has been made. As soon as information becomes available, the field will be notified through official Joint Commission communication channels (for example, manual updates, Perspectives and JCOnline)” Healthcare Engineering Consultants 25

Changes for the LSS in 2014 Life Safety Surveyor Responsibilities
With the “on-site” time that the Life Safety Surveyor will have scheduled (2-days minimum), it is likely to result in: Additional facility tour time, including visits to the OR and Central Sterile Supply areas Additional documentation review, especially on fire systems, emergency power and medical gas and vacuum Conducting the Physical Environment Interview Conducting the Emergency Management Interview Healthcare Engineering Consultants 26

Changes for the LSS in 2014 Life Safety Surveyor Responsibilities (cont’d) With the hiring of Jim Kendig, the new Field Manager for the Life Safety Surveyors, additional changes will include: A standardized agenda to require the documentation review first, followed by the facility tour Additional focus on other areas, such as OSHA and DOT Some leniency in fixing problems found during the survey Pressure tests (tissue) in the OR, CSR and Endo Additional focus on falls reduction New LSS hires will have “broader” credentials Surveyors will have access to older codes to verify “grandfathering” of HVAC and pressure relationship issues Jim does not report to George Mills! Healthcare Engineering Consultants 27 27

“PE”-Related Patient Safety Goals
Ambulatory, Behavioral Health and Hospital Facilities Goal #6: Reduce harm associated with Clinical Alarm Systems Goal #7: Reduce the risk of health care associated infections Goal #9: Reduce the risk of patient harm resulting from falls Goal #15: The organization identifies safety risks inherent in its patient population (identify suicide risk – relates to patients being treated for emotional and behavioral disorders) This applies to all areas of the hospital where behavioral patients are treated – don’t forget about the ED and outpatient areas! (refer to Sentinel Event Alert #46) Healthcare Engineering Consultants 28

Critical Clinical Alarms
Patient Safety Goal #6: NPSG Phase I: - Effective January 1, 2014 - Establish alarms as an organizational priority - Identify the critical alarms to manage (issue: alarm fatigue) Phase II: - Effective January 1, 2016 - Develop applicable alarm policies and procedures - Implement components of procedures - Provide alarm system management education Healthcare Engineering Consultants 29

New Changes for Emergency Management
Effective January 1, 2014 Appointment of an individual who has specific emergency management accountability for MPRR and the six critical areas; implementation and collaboration across clinical and operational areas, and identification and planning with community response partners (LD ) Effectiveness of emergency management program planning reviewed by senior leadership (EM ) Drill monitoring includes LIP’s as well as staff affected by the drill or actual event; review of drill by leadership (EM ) Leadership establishes priorities for improvement in the emergency management program (LD ) Healthcare Engineering Consultants 30

Compressed Gas Cylinders Compressed Gas Cylinder Storage
EMPTY and FULL cylinders must be physically separated Segregated = physically separated with separate racks, physical barriers or color codes to indicate FULL and EMPTY Unopened cylinder = FULL; Opened cylinder = EMPTY Don’t store partially filled cylinders with FULL cylinders Noncompliance cited under EC , EP1 Solutions? Reference: EC News, February 2014 issue, pages 5-6 Healthcare Engineering Consultants 31

Medical Equipment Management
Issue: New Power Strip Requirements Expectations include: - Effective immediately per CMS and Joint Commission - Not permitted for medical devices (diagnostic, therapeutic and clinical analytical) in patient care areas - Patient care areas include “areas in which patients are intended to be examined or treated” May permit RPT’s on consolidated equipment on a rack in anesthetizing locations (reference: NFPA 99, 1999 edition, section , exception 2 NFPA 99, 2012 edition permits mounting on a movable rack, table, cart or pedestal in any patient care area (reference: section ) (“regular” electrical and mechanical verification is required) Healthcare Engineering Consultants 32 32

CMS Medical Equipment Guidance
Issue: Changes in Medical Equipment Maintenance Requirements, effective December 20, 2013 Description: Permits a facility to adjust maintenance testing procedures and intervals from manufacturer recommendations if a documented risk assessment is utilized, unless: Other Federal or State laws require manufacturer recommendations The equipment is a medical laser, imaging or radiologic device New equipment does not have sufficient maintenance history Healthcare Engineering Consultants 33

Issue: Changes in the Medical Equipment Standards Effective July 2, 2014 What’s New? Whether manufacturer recommendations are followed (EC , EP5) Criteria that is used for the Alternate Equipment Management (AEM) program (EC , EP6) An inventory list of devices in the AEM program (EC , EP7) Inventory classifications now termed “high risk” and “non-high risk” (EC , EP2, 3) Healthcare Engineering Consultants 34

Issue: Changes in the Medical Equipment Standards Effective July 2, 2014 What’s the Impact of the Changes? All medical equipment must now be included in the biomed inventory (Note: “Fixed and portable equipment used for the diagnosis, treatment, monitoring, and direct care of individuals”) - EC , EP2 Test procedures and PM intervals must be defined for all items on the inventory - EC , EP4 All “high risk” devices must now have an on-time PM completion rate of 100%! – EC , EP2 Reference: EC News, September, issue Healthcare Engineering Consultants 35

Other Important Definitions:
Medical Equipment Management Other Important Definitions: Life Support Equipment: “Any device used for the purpose of sustaining life and whose failure to perform its primary function, when used according to the manufacturer’s instructions and clinical protocol, will leas to patient death in the absence of immediate intervention” High-Risk Equipment: “Any device or components of building utility systems for which there is a risk of serious injury or death to a patient or staff member if the device or component fails” Joint Commission “High Risk” = CMS “Critical” Equipment Reference: EC News, September, issue Healthcare Engineering Consultants 36

An AEM Notebook is recommended that includes the following sections: 1. A copy of the medical equipment management plan that includes a description of the AEM program An inventory of the devices included in the AEM program A copy of the process used to determine that a device does not have to meet the recommended test procedure or PM interval from the manufacturer A list of staff who are qualified to determine which devices may be included in the AEM program Healthcare Engineering Consultants 37

Issue: Expectations for Clinical Engineering Departments from the Joint Commission Expectations include: - How the inventory was created and maintenance strategies are devised - How the PM and program effectiveness is measured - How well biomed staff understand the maintenance process - How the work schedule and repeat repairs are managed Healthcare Engineering Consultants 38

Issue: Expectations for Clinical Engineering Departments from the Joint Commission Expectations include: - How equipment reliability is determined - How “customers” rate response time to work order calls - Training for equipment users and maintainers - Monitoring of contract services Clinical alarm audibility and “alarm fatigue” Whether an AEM program exists and how it is managed Healthcare Engineering Consultants 39

Utility Systems Management
Issue: Impact of the AAMI ST-79 Standard, Section 3.3 and the ASHRAE Standard 170 What’s expected? Central sterile supply areas must: - Include physically separated clean and dirty work areas - Adequate work space is required - Clean and dirty sides must include sinks - Surveyor will perform a “tissue test” at the pass-through Endoscopy must have a specific room for equipment cleaning that is properly sized, has a sink, negative air pressure in reprocessing, 10 total and 2 outside air changes, clean/ dirty separation and scope storage areas Healthcare Engineering Consultants 40

Issue: Changes to the Utility Management Standards, effective July 2, 2014 What’s New? Whether manufacturer recommendations are followed (EC , EP5) Criteria that is used for the Alternate Equipment Management (AEM) program (EC , EP6) An inventory list of utility equipment in the AEM program (EC , EP7) Inventory classifications now termed “high risk”, “infection control” and “non-high risk” (EC , EP3, 4, 5) Healthcare Engineering Consultants 41

Issue: Changes to the Utility Management Standards, effective July 2, 2014 What’s New? All utility systems must now be included in the inventory (EC , EP2) Utility Systems Definition: “Building systems that provide support to the environment of care, including electrical distribution and emergency power; vertical and horizontal transport; heating, ventilating and air conditioning (HVAC); plumbing, boiler and steam; refrigeration; piped gases; vacuum systems; fire alarm and suppression systems, and; communication systems, including data exchange systems” Healthcare Engineering Consultants 42

Reference: EC News, September, 2014 issue
Utility Systems Management Issue: Changes to the Utility Management Standards, effective July 2, 2014 What’s New? Test procedures and PM intervals must be defined for all items on the inventory - EC , EP4 All “high risk” devices must now have an on-time PM completion rate of 100%! – EC , EP3 Reference: EC News, September, issue Healthcare Engineering Consultants 43

Healthcare Facilities
Issue: Publication of NFPA 101, the edition What’s New? Effective date of NFPA 101, the 2012 edition, was August 31, 2011 Wheeled equipment is now permitted in the corridor (Section ) if: 1. The equipment does not reduce the clear width to less than 5 feet 2. Staff are trained to move the wheeled equipment during an emergency 3. The equipment is limited to carts “in use” (no time limit), emergency equipment and patient lifts and transport equipment Impact: Additional flexibility if CMS or the Joint Commission adopts the 2012 edition of NFPA 101 (JC will accept CMS “Categorical Waivers”) Healthcare Engineering Consultants 44 44

Issue: Publication of NFPA 101, the edition What’s New? Fixed furniture is permitted in the corridor if: 1. The clear corridor width is no less than 6 feet 2. The furniture is securely attached to the floor or wall and on one side only 3. Smoke detection is installed and the smoke compartment is fully sprinkled Impact: Additional flexibility if CMS or the Joint Commission adopts the 2012 edition of NFPA 101 (JC will accept CMS “Categorical Waivers”) Healthcare Engineering Consultants 45 45

Issue: Publication of NFPA 101, the edition What’s New? Other significant changes in the 2012 edition include: Clarification for business or ambulatory occupancies that are contiguous to healthcare facilities Revisions to egress requirements for sleeping and non-sleeping suites Relaxed requirements for cooking facilities that are used for food warming or limited cooking, such as in obstetrics, long-term care or hospice areas Changes to alcohol-based hand dispensers to permit 1-inch clearance to electrical receptacle or switch (automatically accepted by JC now!) Healthcare Engineering Consultants 46 46

Issue: Publication of NFPA 101, the edition What’s New? Other significant changes in the 2012 edition include: Fewer restrictions for the use of direct vent and solid fuel burning fireplaces Exceptions permitting the use of some combustible decorations Exceptions to the 32 gallon requirement for containers used for recycling clean waste and patient records awaiting shredding (96 gallons permitted) Impact: Additional flexibility if CMS or the Joint Commission adopts the 2012 edition of NFPA 101(JC will accept CMS “Categorical Waivers”) Healthcare Engineering Consultants 47 47

Issue: Publication of NFPA 99, the edition What’s New? NFPA 99 is now a Code rather than a Standard The 2012 edition is a “risk-based” document, based on patient risk, which now includes categories 1 through 4 (category 1 is highest risk) Occupancy chapters have been eliminated Changes in test requirements for medical gas and vacuum systems have been adopted (refer to section and Table B.5.1) Operating rooms are considered “wet locations” unless a risk assessment is performed by the governing body (section ) RPT’s would be permitted if they are permanently attached to movable racks, pedestals, tables or carts and are regularly tested (section ) Healthcare Engineering Consultants 48 48

Issue: Publication of NFPA 99, the edition What’s New? Medical equipment leakage tests have been reduced and incoming equipment tests for non-patient care-related equipment now only require visual inspections! (section ) New chapters cover information technology, plumbing, HVAC, security management and features of fire protection Impact: Significant changes for electrical and medical gas and vacuum systems if CMS or the Joint Commission adopts the 2012 edition of NFPA 99 Healthcare Engineering Consultants 49 49

Issue: CMS Adoption of NFPA 101 and NFPA 99, the editions What’s New? – Proposed changes! Revised definition of “healthcare” in NFPA 101 to include a single patient who is rendered incapable of self-preservation, rather than four or more Elimination of the emergency management chapter in NFPA 99, due to new CMS emergency management proposals (2017?) Other possible changes Proposal period closed - were due by June, 2014 Possible adoption date? Healthcare Engineering Consultants 50 50

CMS “Categorical Waivers”
Issue: Relative humidity in anesthetizing locations Description: Reduces the requirement for relative humidity in anesthetizing locations from 35% to 20% Code Reference: Addendum D of ASHRAE 170 Healthcare Engineering Consultants 51

Issue: Medical gas master alarms Description: Allows a centralized computer system to be used for one of the two required Category 1 medical gas master alarms Code Reference: NFPA 99, 2012 edition, section Healthcare Engineering Consultants 52

Issue: Openings in exit enclosures Description: Permits existing openings in exit enclosures to mechanical equipment spaces if they are protected by fire-rated door assemblies, the area is fully sprinkled and there are no combustibles stored Code Reference: NFPA 101, 2012 edition, section (9)(c) Healthcare Engineering Consultants 53

Issue: Emergency generator annual load test Description: Reduces the load test (when required) from 2 to 1.5 hours, and requires the load to be 30 minutes and 60 minutes Code Reference: NFPA 110, 2010 edition, section Healthcare Engineering Consultants 54

Issue: Door locking arrangements Description: Allows door locking exceptions in areas where there are clinical needs, security risks or specialized protective measures required for safety Code Reference: NFPA 101, 2012 edition, section 18/ Healthcare Engineering Consultants 55

Issue: Multiple delayed egress locks Description: Allows more than one delayed-egress lock in the egress path where the clinical needs require specialized security measures or when a patient requires specialized protective measures for safety Code Reference: NFPA 101, 2012 edition, section 18/ ; Healthcare Engineering Consultants 56

Issue: Relaxation of suite requirements Description: Allows: 1) suite egress through another suite; 2) one of the two suite exits to be an exit stair, exit passageway or exit door to the exterior, and; 3) an increase in sleeping suite size up to 10,000 square feet Code Reference: NFPA 101, 2012 edition, section 18/ Healthcare Engineering Consultants 57

Issue: Fire system waterflow alarm and fire pump churn test intervals Description: Permits vane and pressure-switch type waterflow alarm devices to be tested semiannually (from quarterly) and electric fire pumps to be churn tested monthly (from weekly) Code Reference: NFPA 25, 2011 edition, sections 5.3 and 8.3 Healthcare Engineering Consultants 58

Issue: Clean waste and confidential records recycling container sizes Description: Containers outside of a hazardous storage area used for recycling clean waste or confidential patient records can be 96 gallons rather than the previous limit of 32 gallons (.5 gallons per square foot does not apply for these containers) Code Reference: NFPA 101, 2012 edition, section 18/ Healthcare Engineering Consultants 59

Issue: Items stored in an egress corridor Description: Permits crash carts, patient lifts and patient transport devices (beds, gurneys and wheelchairs) to be placed in an egress corridor without “in-use” restrictions; also permits “fixed furniture” – does not apply to non-medical equipment such as housekeeping carts and computers on wheels Code Reference: NFPA 101, 2012 edition, section 18/ Healthcare Engineering Consultants 60

Issue: Kitchens open to the corridor Description: Allows alternative cooking arrangements, including kitchens, to be open to corridors if they are in smoke compartments with no more than 30 beds Code Reference: NFPA 101, 2012 edition, section 18/ through 18/ Healthcare Engineering Consultants 61

Issue: Gas fireplaces in common areas Description: Allows that installation of direct vent gas fireplaces in smoke compartments with patient sleeping rooms (not in the room) and solid fuel fireplaces in other than patient sleeping areas Code Reference: NFPA 101, 2012 edition, section 18/ Healthcare Engineering Consultants 62

Issue: Combustible decorations Description: Increases the wall space that may be covered with combustible decorations up to 50% in patient rooms if fully sprinkled Code Reference: NFPA 101, 2012 edition, section 18/ Healthcare Engineering Consultants 63

How to Adopt “Categorical Waivers” Step 1: Make sure that the hospital meets all of the applicable code provisions of the categorical waiver Step 2: Create a hospital letter that describes the categorical waiver(s) and have it approved by the safety committee and signed by the CEO Step 3: For Joint Commission approval, list the adopted categorical waivers in the “Comments” section of the e-BBI questionnaire Step 4: Announce at the opening conference of a CMS or Joint Commission survey which waivers have been adopted Healthcare Engineering Consultants 64

Joint Commission Changes in 2014
Issue: Safety, Hazmat and Medical Equipment Related changes effective on July 1, 2014 Description: Safety in the MRI environment (EC , EP14) Management of MRI safety risks (EC , EP16) Quarterly review of staff radiation levels (EC , EP17) Quality and maintenance of diagnostic images (EC , EP7, 17) Delayed until July 1, 2015! Healthcare Engineering Consultants 65

Joint Commission Changes in 2014
Issue: Safety, Hazmat and Medical Equipment Related changes effective on July 1, 2014 Description: Annual performance evaluation of CT, MRI, NM, PET (EC , EP19-23) Physicist determines shielding requirements for new installations of CT, PET and NM and performs radiation protection survey (EC , EP4, 6) Qualifications and training for CT and MRI services staff (HR , HR ) Full text at: Delayed until July 1, 2015! Healthcare Engineering Consultants 66

Organizational Function Overview
Human Resources (HR) Staff training, competency and performance Leadership (LD) Compliance, resources, patient safety, oversight of contracts/ services Performance Improvement (PI) Data collection, aggregation, analysis , action Information Management (IM) Data collection, aggregation, security Infection Prevention and Control (IC) Measurement and reduction of infections Healthcare Engineering Consultants 67

Competition for the Joint Commission
DNV (Det Norske Veritas) Healthcare has received CMS “Deemed Status” Headquarters; Oslo, Norway; 9,000 employees, 300 offices, in 100 countries Approximately 350 accredited hospitals Integrates ISO 9001 standards with CMS Conditions of Participation in annual survey Averages three surveyors, including Life Safety Focus on processes to manage patient safety and quality practices Accredited or Not Accredited outcome Healthcare Engineering Consultants 68

Competition for the Joint Commission
Health Facilities Accreditation Program (HFAP) Originally intended for Osteopathic Hospitals First program introduced in 1943; received “Deemed Status” in the 1960’s Has accredited over 200 hospitals Requirements closely parallel the CMS “Conditions of Participation” Accreditation levels include: - Full Accreditation - Interim Accreditation - Denial of Accreditation Healthcare Engineering Consultants 69

The Survey Process and Standards Changes for 2014 and 2015
Questions? Healthcare Engineering Consultants 70

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