1. Part 7: Meeting the Standards Challenges Healthcare Engineering Consultants Strategies for the Standards Challenges

2. Safety Management Healthcare Engineering Consultants Issue: Proactive Risk Assessments for Safety Tip for Compliance: Think of risk assessments as simply prioritizing potential problems

3. Documenting Risk Assessments Healthcare Engineering Consultants Risk Assessment: “Prioritization and management of resources though an assessment of probability and impact”

4. Why Perform Risk Assessments? Not enough time! Not enough staff! Not enough money! Healthcare Engineering Consultants

5. Calculating Risk Assessments Risk = Probability X Impact Healthcare Engineering Consultants

6. Global Risk Assessments What’s a Global Risk Assessment and What is it’s Purpose? Healthcare Engineering Consultants

7. Performing a Global Risk Assessment Step 1: Identify a “Global” Area to Assess Step 2: Select a Team of Stakeholders Step 3: Brainstorm and List the Risk Elements Step 4: Assign Probability and Impact to the Risk Elements Step 5: Prioritize the Risk Elements Step 6: Perform the Specific Risk Assessments Healthcare Engineering Consultants

8. Documenting Risk Assessments Healthcare Engineering Consultants

9. Example Global Safety Risk Assessment Healthcare Engineering Consultants

10. Example Global Security Risk Assessment Healthcare Engineering Consultants

11. Specific Risk Assessments What’s a Specific Risk Assessment and What is it’s Purpose? Healthcare Engineering Consultants

12. Performing a Specific Risk Assessment Step 1: Identify Issues and Select a Team Step 2: Analyze Factors Step 3: Make a Decision Step 4: Document the Evaluation and Decision Step 5: Make the Necessary Changes Step 6: Monitor and Reassess Healthcare Engineering Consultants

13. Specific Risk Assessment Examples Lock clean supply room doors? Infant/ pediatric abduction measures Safe environment for mental health Medical equipment test tags Utility system PM intervals Security “sensitive areas” Other? Healthcare Engineering Consultants

14. Understanding RCA’s and FMEA’s What’s the Difference Between an FMEA and an RCA? Are They Both Risk Assessments? Healthcare Engineering Consultants

15. Safety Management Healthcare Engineering Consultants Issue: What about recurring operational deficiencies? Tip for Compliance: You can’t improve what you can’t measure!

16. How Do We Solve This Problem? Steps required to reduce operational deficiencies: 1. Determine how to measure the problem severity 2. Establish a numerical baseline score 3. Explain measurement system to area staff 4. Let staff determine an improvement goal 5. Re-measure scores at unscheduled times 6. Provide numerical feedback to staff 7. Celebrate achievement of goal 8. Continue measurement until the culture changes Healthcare Engineering Consultants

17. Solving the Hallway Clutter Problem Healthcare Engineering Consultants Step 1: Determine how to measure the problem severity Solution and Procedure: Assign points to various types of egress corridor deficiencies, based on severity of violation

18. Solving the Hallway Clutter Problem Healthcare Engineering Consultants Point Score Examples Description of DeficiencyPoint Score (per occurrence) Small medical device on wheels (NIBP unit), against wall, charging, not blocking shut-offs 1 Equipment or furniture, not in use, one side of corridor only, not blocking shut-off or fire alarm 3 Large furniture or equipment, on both sides of corridor, not in use, not blocking shut-off/ alarm 5 Large furniture or equipment, in corridor, not in use, blocking emergency shut-off or fire alarm 8 Large furniture or equipment, in corridor, preventing fire or smoke door from closing 10

19. Solving the Hallway Clutter Problem Healthcare Engineering Consultants Step 2a: Establish a numerical baseline score for a specific hospital area (4 West) Procedure: Use the point values for deficiencies that have been assigned and determine total scores by randomly inspecting the area once per day for at least one week

20. Solving the Hallway Clutter Problem Healthcare Engineering Consultants

21. Solving the Hallway Clutter Problem Healthcare Engineering Consultants Point Score Results of Daily Inspections DayMon.Tues.Wed.Thurs.Fri. Points3427394228 Cum. Average 3432333634 This is the baseline number for 4 West

22. Solving the Hallway Clutter Problem Healthcare Engineering Consultants Graphical Results

23. Solving the Hallway Clutter Problem Healthcare Engineering Consultants Graphical Results New goal: 25 pointsDaily Scores

24. Safety Management Healthcare Engineering Consultants Issue: How to solve the smoking dilemma? Tips for Compliance:  Create a practical policy  Recognize the “citation priority”  Monitor smoking compliance

25. Smoking Monitoring Healthcare Engineering Consultants

26. Security Management Healthcare Engineering Consultants Issue: Security Responsibility Appointment Tips for Compliance: Letter provided by leadership Identify security responsibility Include: Coordination Development and implementation Monitoring

27. Security Management Healthcare Engineering Consultants Issue: Security Risk Assessment Tips for Compliance: Include security sensitive areas: ED, OB/ Gyn, Pharmacy, Infectious waste Other areas? Evaluate facility access control Provide training for staff in sensitive areas

28. Security Management Healthcare Engineering Consultants Issue: Security “Special Cases” Tips for Compliance: Consider the following –  Use of firearms or other means of force  Mental health areas  Medication and infectious waste security  Infant/ child abduction prevention and drills  Cell phones with cameras/ privacy issues  Access to unauthorized areas  Security in construction areas

29. Hazardous Materials and Wastes Healthcare Engineering Consultants Issue: MSDS Sheets Tips for Compliance:  Ensure an accurate inventory  Provide staff training  Consider MSDS options: Binder with data sheets 1-800 “Fax-on-Demand” Internet or intranet access

30. Hazardous Materials and Wastes Healthcare Engineering Consultants Issue: Chemical Waste Stream Tips for Compliance:  Ensure disposal procedures for: Chemicals Chemotherapeutics Radioactive materials Medical waste and sharps Waste phamaceuticals  Per applicable laws (OSHA, EPA, NRC, DOT)

31. Hazardous Materials and Wastes Healthcare Engineering Consultants Issue: Compressed Cylinder Storage Tips for Compliance:  For stored gases <300 cubic feet in smoke compartment: - Enclosures not required (NFPA 99, section 9.4.3)  For stored gases >300 but <3,000 cubic feet: - Outdoors: enclosed space with doors or gates (9.4.2.1) - Indoors: an enclosure with minimum ½ hour protection (9.4.2.3)  For stored gases >3,000 cubic feet: - Walls, floors, ceilings, doors at least 1-hour rated (5.1.3.3.2) - Racks, chains or fastenings to secure all cylinders (5.1.3.3.2) - Continuous powered ventilation within 1 foot of floor (5.1.3.3.3)

32. Hazardous Materials and Wastes Healthcare Engineering Consultants Issue: Compressed Cylinder Storage Tips for Compliance:  Requirements for stored gas only, not in-use tanks!  In-use gas includes: - Tanks on code carts - Tanks on wheelchairs - Tanks on gurneys  Empty tanks do not count toward the total  Use of fire-rated cabinets can be used on floors

33. Hazardous Materials and Wastes Healthcare Engineering Consultants Issue: Alcohol-Based Hand Rub Units Requirements Tips for Compliance:  Patient safety goal 7 requires CDC compliance with Category I recommendations, suggests Category II compliance!  When no soiling is present, ABHR units are recommended (Cat I)  ABHR is permitted in a corridor at least 6 feet in width, at least 4 feet apart, and not directly over electrical outlets (6 inches from dispenser)  ABHR dispensers can be used over carpeted surfaces only in sprinklered smoke compartments!  ABHR permissible volumes: - 10 gallons in dispensers/ 5 gallons in storage per smoke compartment - Maximum individual dispenser capacity:.3 gallons - Maximum dispenser size per suite of rooms:.5 gallons

34. Hazardous Materials and Wastes Healthcare Engineering Consultants Issue: Eyewashes and Showers Tips for Compliance:  Use risk assessment to determine placement  ANSI standards have not been officially adopted by the Joint Commission  Testing policy is required – specify test intervals  Documentation of test results is required  Differentiate between eyewash station and “first aid” station, such as mounted bottles

35. Hazardous Materials and Wastes Healthcare Engineering Consultants Issue: Hazardous Vapor Monitoring Tips for Compliance: Clinical lab: formaldehyde and xylene Central supply: ethylene oxide OR’s: nitrous oxide, methyl-methacrylate Respiratory: glutaraldehyde Sleep lab: collodion Monitor and document per OSHA requirements!

36. Approved Changes for 2009 Healthcare Engineering Consultants The organization of the standards : EM.01.01.01: Plans for managing emergencies EM.02.01.01: Develops an emergency operations plan EM.02.02.01: Establishes emergency communication strategies EM.02.02.03: Establishes strategies for managing resources EM.02.02.05: Establishes strategies for managing safety and security EM.02.02.07: Defines and manages staff roles and responsibilities EM.02.02.09: Identifies an alternative means for providing utilities EM.02.02.11: Identifies strategies for patient management EM.02.02.13: Privileges to LIP’s EM.02.02.15: Privileges to volunteer staff EM.03.01.01: Annual effectiveness review EM.03.01.03: Regularly tests the emergency operations plan

37. Emergency Management Healthcare Engineering Consultants EM.01.01.01: The organization plans for managing the consequences of emergencies Medical and clinical staff participate in planning A Hazard Vulnerability Analysis (HVA) is performed and documented The hazards are prioritized Communication of emergency plan with community responders Mitigation, Preparedness, Response, Recovery Assets and resources are inventoried and documented (CAP) Asset and resource inventories are monitored during emergencies (CAP) The emergency management program is evaluated annually (S,O,P,E)

38. Emergency Management Healthcare Engineering Consultants Tips for Compliance with EM.01.01.01: Appoint a physician and administrative representative to actively participate on the emergency management planning committee Perform and document the Hazard Vulnerability Analysis (HVA) for all geographically separate facilities – review annually! Be ready to describe the Mitigation, Preparedness, Response and Recovery procedures in the EOP Ensure that emergency resources are inventoried (PPE, utility and medical supplies and pharmaceuticals) and monitored Evaluate the emergency management program annually (S,O,P,E) and report the results to the safety committee

39. Emergency Management Healthcare Engineering Consultants EM.02.01.01: The organization develops and maintains an Emergency Operations Plan (EOP) Written EOP includes an “all hazards” command structure An incident command structure (ICS) is established and is consistent with the community plan The ICS identifies a reporting structure Activation of ICS is identified Activation of ICS phases is identified The EOP identifies the organization response when community non- support may occur for up to 96 hours (CAP) Alternative care sites are identified

40. Emergency Management Healthcare Engineering Consultants Tips for Compliance with EM.02.01.01  Create a written emergency operations plan (EOP) that describes the incident command structure and process that is in use (HICS 4?) as well as how ICS integrates into the six critical core areas: 1. Emergency communications 2. Resources and assets 3. Safety and security 4. Staff roles and responsibilities 5. Management of utilities 6. Clinical and support activities  The EOP can either describe the ICS and core area integration in detail or reference existing documents

41. Emergency Management Healthcare Engineering Consultants Incident Commander Public Info Officer Liaison Officer Safety Officer Med/ Tech Specialist(s) Operations Section Chief Planning Section Chief Logistics Section Chief Finance/ Admin Section Chief HICS Organizational Chart

42. Emergency Management Healthcare Engineering Consultants Tips for Compliance with EM.02.01.01  Create two color-coded timeline charts the indicate how long utilities will be operational and how long consumable supplies will be available in the event of an emergency in which no re-supply is possible  Ensure that decisions are made to determine whether any utility or supply changes will be implemented to extend “green zones”  Create two 96-hour plans that assume the following scenarios: PLAN A: Supplies are available and are ordered and received PLAN B: Internal supply shortages or utility failures require partial or total patient evacuation PLAN C: Shortages and/ or utilities are not sufficient to continue normal patient care, although evacuation is not possible

43. Emergency Management Healthcare Engineering Consultants Critical Utilities and Supplies Timeline Assume external help is not available Create timeline for utilities and critical supplies, such as food and medications Determine time-dependent status: - Green: Continue all services as usual - Yellow: Transition to conservation mode - Red: Discontinue patient treatment, evacuate

44. Emergency Management Healthcare Engineering Consultants

45. Emergency Management Healthcare Engineering Consultants

46. Emergency Management Healthcare Engineering Consultants EM.02.02.01: The organization establishes emergency communications strategies Staff notification procedures are created Provisions for ongoing staff communication during the emergency Process to notify external authorities Communication with patients and their families Communication with the community and media Communication with vendors and suppliers (CAP) Sharing information with other health care providers Providing information about patients to third-parties (FEMA, CDC, etc.) Communication with alternative care sites Establishment of back-up communication systems and technologies

47. Emergency Management Healthcare Engineering Consultants Tips for Compliance with EM.02.02.01  Create notification charts with phone numbers, email addresses, etc.  Include for staff, external authorities, community, media, vendors  Determine what information will be shared with other health care providers in the area  Ensure that liaisons are established with government agencies  Verify that MOU’s for alternative care sites are updated  Establish and check operation of back-up communication systems, such as the internet, cell phones, two-way radios, emergency land lines, and amateur radio operators

48. Emergency Management Healthcare Engineering Consultants EM.02.02.03: The organization establishes strategies for managing resources and assets during emergencies Plans for obtaining medications and non-clinical supplies Replenishing medical supplies and equipment during the emergency Replenishing pharmaceutical supplies Replenishing non-medical supplies (food, water, fuel, linens, etc.) Managing staff and family support activities Sharing of resources with other health care organizations in and outside of the local community (CAP) Horizontal, vertical and total evacuation (CAP), including transportation of patients, medications, equipment, staff and medical record information

49. Emergency Management Healthcare Engineering Consultants Tips for Complying with EM.02.02.03  Plans should be in place to stockpile and reorder critical clinical and non-clinical supplies  Written procedures should describe how the needs of staff and families of staff will be met during an emergency  A plan to share community resources and assets should be in place  A practical patient evacuation plan that includes horizontal and vertical movement within the facility as well as partial or total evacuation outside of the facility is required  Logistics for evacuation should include: 1) transportation; 2) staffing; 3) medications; 4) equipment, and; 5) the medical record

50. Emergency Management Healthcare Engineering Consultants EM.02.02.05: The organization establishes strategies for managing safety and security during emergencies Internal safety and security measures are established Role of community security agencies is established with the healthcare organization and means of coordination is identified (CAP) Processes for handling hazardous materials and waste are developed (CAP) Plans are developed for radioactive, biological, chemical decontamination Patients susceptible to wandering are identified (CAP) Access into and out of the facility are controlled Movement of staff and patients is controlled within the facility Traffic accessing the facility is controlled

51. Emergency Management Healthcare Engineering Consultants Tips for Complying with EM.02.02.05  Security staffing plans during emergencies must be established  Expectations with outside police agencies should be identified  Plans to dispose of infectious and hazardous waste must be created  Procedures to treat contaminated patients must be written (radioactive, biological and chemical)  Methods to lock down the facility to prevent entry must be provided  Methods to minimize staff and patients from leaving the facility must be planned  Plans must be in place to control traffic accessing the facility

52. Emergency Management Healthcare Engineering Consultants EM.02.02.07: The organization defines and manages staff roles and responsibilities Staff roles and responsibilities are defined for the critical areas (communications, resources and assets, safety and security, utilities, clinical activities) Staff are trained relative to their responsibilities (CAP) Roles of LIP’s are specifically defined (CAP) Care providers and command center staff are identified (ID badges, vests, caps, etc.)

53. Emergency Management Healthcare Engineering Consultants Tips for Complying with EM.02.02.07 Review and update as necessary, the ICS organizational chart and job action sheets (check after each drill)  Ensure that hospital staff have participated in NIMS training  Discuss emergency expectations with the independent physicians who have privileges at the hospital  Select the primary and back-up command center locations  Have a method to identify incident command staff (ID badges, vests, caps, etc.)

54. Emergency Management Healthcare Engineering Consultants EM.02.02.09: The organization establishes strategies for managing utilities during emergencies, such as: Electricity Potable and non-potable water Fuel for building operations or transport vehicles (CAP) Other essential utility needs, such as: - HVAC equipment - Medical gas and vacuum systems - Fire systems - Sewer

55. Emergency Management Healthcare Engineering Consultants Tips for Complying with EM.02.02.09  Complete the utility 96-hour timeline chart  Determine which utilities require additional supplies, especially water and fuel  Determine the feasibility of redundant systems or supplies Examples: Water – on-site well, water tower or nearby lake Electricity – additional generators installed Boilers – portable boiler “on a truck” Medical gas – low pressure external connection, manifold

56. Emergency Management Healthcare Engineering Consultants EM.02.02.11: The organization establishes strategies for managing clinical and support activities during emergencies, including: Patient scheduling, triage, assessment, treatment admission, transfer, discharge and evacuation Clinical services for vulnerable patients, such as: pediatric, geriatric, disabled or serious chronic conditions or addictions Personal hygiene and sanitation Mental health needs (CAP) Mortuary services (CAP) Tracking and documenting patient information (CAP)

57. Emergency Management Healthcare Engineering Consultants Tips for Complying with EM.02.02.11  Identify which patients in the hospital are considered “vulnerable” (neonatal intensive, pediatric, geriatric, dementia, behavioral health)  Plan for patient and staff hygiene and sanitation without water or sewer  Determine mortuary needs in the event of a pandemic  Evaluate back-up methods to track patient information in the event that the electronic information system fails

58. Emergency Management Healthcare Engineering Consultants EM.02.02.13: During disasters, the organization may grant privileges to licensed independent practitioners Privileges granted only when EOP has been activated Medical staff bylaws indicate to who and how to grant privileges, and policies will indicate how performance will be evaluated Minimum privileging requirements include: 1. Current picture ID and license to practice 2. Must be a member of a recognized disaster response group 3. Proof of government authority to provide services during a disaster Hospital determines within 72 hours if privileges should continue

59. Emergency Management Healthcare Engineering Consultants EM.02.02.15: During disasters, the organization may assign disaster responsibilities to volunteer practitioners Hospital assigns responsibilities only when EOP has been activated Hospital identifies in writing who is eligible and how to assign disaster responsibilities to non-LIP’s Minimum requirements to assist during disasters include: 1. Current picture ID and license to practice professional specialty 2. Must be a member of a recognized disaster response group 3. Confirmation by hospital staff the individual is qualified Hospital determines a method to evaluate performance and decide within 72 hours if responsibilities should continue

60. Emergency Management Healthcare Engineering Consultants EM.03.01.01: The organization evaluates the effectiveness of its emergency management planning activities The Hazard Vulnerability Analysis (HVA) is evaluated annually to determine if revisions are necessary The Emergency Operations Plan (EOP) is evaluated annually with regard to the Scope, Objectives, Performance and Effectiveness of the program The hospital conducts an annual review of the inventory process with regard to emergency supplies, and documents the results

61. Emergency Management Healthcare Engineering Consultants EM.03.01.03: The organization regularly tests its emergency operation plan Twice over 12 months, either as a drill or actual emergency Once per year in a business occupancy One “influx of patient” drill per year One escalation per year to test community “non-support” One “community-wide” drill per year Drills are realistic and based on the HVA A dedicated, trained individual must evaluate the drill

62. Emergency Management Healthcare Engineering Consultants EM.03.01.03: The organization regularly tests its emergency operation plan (continued) The six critical areas are monitored: 1) Communication; 2) Resource mobilization; 3) Safety and security; 4) Staff roles and responsibilities; 5) Utility systems, and; 6) Patient clinical and support activities Exercises are critiqued with a multi-disciplinary group, including leadership, physician and support staff and evaluate deficiencies The operations plan is revised based on the drill findings Subsequent exercises evaluate the improvements to the EOP Drill evaluations are reported to the hospital safety committee

63. Emergency Management Healthcare Engineering Consultants Tips for Compliance with EM.03.01.03  Two drills per rolling 12-month period should be performed, based on the HVA  At least one drill per 12 months in a business occupancy  At least one “influx” drill for a disaster receiving station  Community-wide and influx drills can be performed concurrently  The community 96-hour “non-support” drill can be a tabletop  Trained staff, including a physician and leadership, must evaluate the drill and must document the six core areas in the evaluation  Infant abduction (EC.2.10) and patient surge (IC.6.10) drills are highly recommended

64. Fire Prevention Healthcare Engineering Consultants Issue: Fire Drills Tips for Compliance:  Healthcare and ambulatory: 1 drill per shift per quarter  Business occupancy: 1 drill per shift per year  Drill monitoring as defined in the plan  Evaluate effectiveness annually in written report

65. Fire Prevention Healthcare Engineering Consultants Issue: Interim Life Safety Measures Tips for Compliance: A policy must describe the program Document whether ILSM is or is not required Determine ILSM applicability for PFI’s! Document which measures are applicable Document required inspections Failure to meet ILSM provisions: CON04!

66. Medical Equipment Management Healthcare Engineering Consultants Issue: Equipment Test Scoring Tips for Compliance:  100% PM completion for “life support” devices, based on scoring (A)  90% PM completion for “non-life support” devices (C)  Determine test interval by “PM effectiveness” and MTBF data  Test tags with due dates recommended, but not required! What about Ongoing PM vs. initial test only?

67. Medical Equipment Management Healthcare Engineering Consultants Issue: Other Medical Equipment Issues Tips for Compliance:  Patient-owned equipment Diagnostic and therapeutic (example: CPAP) Personal use (iPods, cell phones, blackberries)  Rental devices  Demo, loaner and trial equipment  Radio-frequency interference

68. Utility Systems Management Healthcare Engineering Consultants Issue: Waterborne Pathogens Tips for Compliance: Waterborne pathogens policy must include: 1. Patient risk assessment for pathogen vulnerability 2. Operational description of measures to reduce waterborne pathogens 3. Remediation procedures if hospital-acquired waterborne infection is determined

69. Utility Systems Management Healthcare Engineering Consultants Issue: Airborne Pathogens Tips for Compliance: An airborne pathogens policy must exist that describes: Air filter maintenance, room air exchange rate and pressure relationships for operating rooms, delivery rooms, special procedure rooms, patient isolation rooms, clinical laboratories, sterile supply rooms and pharmacies Note: Refer to AIA document for requirements Note: “Grandfathering” permitted for air handlers

70. Utility Systems Management Healthcare Engineering Consultants Issue: Utility System Test Scoring Tips for Compliance:  All devices included in the utility systems management program must be at least initially tested  Expected PM completion rate for “critical life support” and “critical infection control” components based on “A” scoring: 100%  Expected PM completion rate for “critical non-life support” components based on “C” scoring: 90%  “Non-critical” components are not scored

71. Appropriate Environment Healthcare Engineering Consultants Issue: The “General Duty Clause” Tips for Compliance:  Patient areas are safe, clean, comfortable  Lighting is suitable  Ventilation provides for acceptable temperature  Locks and restraints per regulation  Emergency access for locked spaces

72. Appropriate Environment Healthcare Engineering Consultants Issue: New Construction Tips for Compliance:  AIA document, 2001 edition (2006 soon?)  Applicable federal, state or local guidelines  Equivalent design criteria

73. Appropriate Environment Healthcare Engineering Consultants Issue: Pre-Construction Risk Assessment (PCRA) Tips for Compliance: Include all of the items listed below in the PCRA evaluation Noise Vibration Air quality Infection control Emergency procedures Utility failures Interim life safety measures

74. Infection Control Risk Assessment (ICRA) Healthcare Engineering Consultants Risk Criteria for Infection Control Type AType BType CType D Group 1 (lowest) III III Group 2 (medium) IIIIIIIV Group 3 (medium high) IIIII IV Group 4 (highest) III IIIIV Construction Type Patient Risk

75. Appropriate Environment Healthcare Engineering Consultants Issue: Ongoing Monitoring Tips for Compliance: Controls include measures to reduce risk and minimize the impact of the construction activities Daily monitoring checklist is recommended Consider posting required PCRA permits, such as hot work, ICRA, above-the-ceiling work, etc. on door entrance to construction area