1. “Crosswalking” Hospitals for a Healthy Environment (H2E) & the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) Catherine Zimmer, BSMT, MS MnTAP Healthcare Specialist Fall 2002

2. Overview JCAHO & Standards –General –Environment of Care (EC) –Performance Improvement H2E Goals Using H2E to meet JCAHO

3. What is JCAHO? Accrediting entity for the Healthcare industry –ensures appropriate planning, procedures & policies are enacted and improved upon.

4. JCAHO Standards Leadership (LD) Patient Rights & Organizational Ethics (RI) Assessment of Patients (PE) Care of Patients (TX) Education (PF) Continuum of Care (CC) *Improving Organization Performance(PI) *Management of the Environment (EC) Management of Human Resources (HR) Management of Information (IM) Surveillance, Prevention & Control of Infection (IC) Governance (GO) Medical Staff (MS) Performance Measurement (PM)

5. JCAHO Process “Surveys” –reviews records and documents –interviews staff & patients –observation –interviews leadership –information from public Surveyors – doctors, administrators, nurses

6. EC Standard Areas Safety (General & Staff) Security Hazardous Materials and Waste Emergency Management Life Safety Medical Equipment Utility Systems

7. Environment of Care Standards EC.1 [Plan] EC.1 The organization plans for a safe, accessible, effective and efficient environment consistent with its mission, services, law and regulation. –EC 1.1 The organization plans for a safe environment. EC 1.1.1 The organization plans for worker safety. EC 1.2 The organization plans for a secure environment. EC 1.3 The organization plans for managing hazardous materials and waste.

8. Environment of Care Standards EC.2 [Do] EC.2 The organization provides for a safe, accessible, effective and efficient environment consistent with its mission, services, law and regulation. –EC.2.1 The organization implements its safety plan. –EC.2.2 The organization implements its security plan. –EC.2.3 The organization implements its plan for managing hazardous materials and waste.

9. Environment of Care Standards EC.4 [Check, Act] EC.4 The organization evaluates and improves conditions in the environment. –EC.4.1 the organization collects information about deficiencies and opportunities for improvement in the environment. –EC.4.2 the organization analyzes identified environment issues and develops recommendations for resolving them. –EC.4.3 the organization works to implement recommendations to improve the environment and monitor effectiveness of recommendations’ implementation.

11. EC.1.3 The organization plans for managing hazardous materials and waste Intent: the organization identifies how it manages hazardous materials and waste. –Includes identifying processes for: selecting, handling, storing, transporting, using and disposing of hazardous materials and waste from receipt or generation through use or final disposal; establishing written criteria consistent with applicable law and regulation (example, Environmental Protection Agency) to identify, evaluate and inventory hazardous material and waste…… –Sec 3002(b) RCRA requires waste minimization.

12. Performance Improvement (PI) “.. Goal is to ensure that the organization designs processes well and systematically monitors, analyzes and improves its performance to improve patient outcomes.”* *Joint Commission Resources, Department of Education, “A Beginner’s Guide to Mock Survey Preparation”, 2002.

13. Performance Improvement Environment of Care has a PI component (EC.4). Leaders are required to do PI –PI.1 The leaders establish a planned, systematic, organizationwide approach to process design, and performance measurement, analysis and improvement.

14. Why Should Leaders Choose P2 for PI? PI.1.1 Collaborative and interdisciplinary activity – cross functional bet EC, HR, L and possibly others PI.1.2 (Intent) Pollution Prevention consistent with the organization’s mission as it relates to community health PI.1.2 (Intent) Meets the needs of individuals served, staff and others.(increases patient safety) PI.1.2 Reducing costs associated with waste, pollution and risk are sound business practice PI.1.2 Its easily measurable and implementable.

15. “ Crosswalking” between H2E and JCAHO