Accreditation Patient safety - Joint Commission


A complimentary publication of The Joint Commission

August 20, 2014

In this issue New survey tool for improving home care pharmacies that compound medicines Breathing easy: The role of HVAC systems in preserving patient safety New on the Web

Accreditation New survey tool for improving home care pharmacies that compound medicines During the survey of home care pharmacies that compound medicines, Joint Commission surveyors are using a new risk assessment tool to more consistently review and help to improve an organization’s compounding processes. Because the number of serious compounding errors has increased nationally, The Joint Commission developed the tool after reviewing the compounding practices at accredited home care organizations and meeting with stakeholders. The tool encompasses:      

Environment: Facilities, equipment, equipment calibration and oversight Products: Selection, storage, and labeling; product testing; beyond-use and extended-use dating Competency: Assessment of compounding staff Infection control: Policies and practices in the compounding facilities Leadership: Overall responsibility for and provision of resources Performance improvement : Monitoring and evaluation of the compounding process

While there are no new requirements, the new tool enhances the survey process for home care pharmacies. (Contact: Wayne Murphy, [email protected])

Patient safety Breathing easy: The role of HVAC systems in preserving patient safety While an organization’s heating, ventilation, and air conditioning (HVAC) system controls temperature, humidity, airflow (pressurization), and filtration, it also plays an essential role in minimizing the spread of contaminants and infection. The Joint Commission addresses how the HVAC system controls airborne contaminants in standard EC.02.05.01, element of performance (EP) 15: In areas designed to control airborne contaminants (such as biological agents, gases, fumes, dust), the ventilation system provides appropriate pressure relationships, air-exchange rates, and filtration efficiencies. Organizations should also refer to the Facility Guidelines Institute’s (FGI’s) Guidelines for Design and Construction of Health Care Facilities, 2010 edition. To comply with Joint Commission standards and other regulations governing ventilation, organizations should: regularly monitor critical areas; check for functioning HVAC equipment, proper temperature, humidity, airflow and filtering; and respond to any potential patient safety hazards. Some areas of specific concern include: 

Directing airflow: Consistent control of directional airflow is a significant factor in preventing the spread of airborne contaminants. Air should move from clean, sterile spaces (e.g., operating rooms) to dirty spaces (e.g., soiled utility rooms). Many hospitals use different methods to ensure that they uphold proper space pressure differentials including simple visual indicators, digital or analog pressure monitors, and/or alarm systems. Managing outside air: The minimum percentage of outside air required is determined by the Centers for Disease Control and Prevention (CDC) and the American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE). Depending on the space, a combination of outside air and

Joint Commission Online Page 2

August 20, 2014

reconditioned internal air is often required. In some cases, 100 percent outside air is permissible, but contaminants such as dirt, allergens, bugs, spores and viruses must be filtered and removed. Reliable filtration: With few exceptions, a hospital HVAC system needs two filter banks in patient care areas. The first houses a primary filter with a Minimum Efficiency Reporting Value of seven (MERV 7) that removes large particulate (lint, leaves) and is necessary to keep the HVAC unit clean. The second filter (which should be a MERV 14) removes particulate small enough to pass through the primary filter, including any additional contamination that might occur from the HVAC equipment. Organizations should regularly check that the correct filters are in place, maintained and functioning normally, and that filters are appropriately reinstalled when replaced. Keeping systems energy efficient while minimizing risk: Organizations can take advantage of new technology that reduces total airflows during periods of nonuse in critical spaces within a hospital, such as operating rooms. However, only a reduction of total airflow is permitted and the space is required to maintain the code-mandated temperature/humidity and pressure differentials relative to surrounding locations. This can be accomplished through dynamic flow control components in both the supply and return/exhaust systems, which are controlled through strategically located sensors and may be connected to an alarm and/or monitoring system.

For more information, see the August issue of Joint Commission Perspectives. (Contact: George Mills, [email protected])

Resources New on the Web  Free teleconference: The Savvy PSC: Review of the 2014 Primary Stroke Center Certification Standards, August 29, noon to 1 p.m. CT.  Blog posts: o Leadership Blog: Share the Extraordinary Moments at your Organization. Mark A. Crafton, M.P.A., MT(ASCP), executive director of Communications and External Relations, asks readers to submit their stories about the remarkable things that nurses and other health care professionals do that touch, improve and heal the lives of patients and their families. o Ambulatory Buzz: The people behind the scenes: Chad Larson. Learn more about Joint Commission Resources’ education programs and publications at or call 877-223-6866.

©2014 Published by the Department of Communications & Corporate Marketing Pamela Schumacher, M.S., editor


Accreditation Patient safety - Joint Commission

A complimentary publication of The Joint Commission August 20, 2014 In this issue New survey tool for improving home care pharmacies that compound m...

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