The Joint Commission - MHCEA

Loading...

2015

George Mills, Director Engineering Department The Joint Commission

© Copyright, The Joint Commission

Challenging Standards & Updates

Performance Improvement to improve the Environment of Care  Performance Improvement should result in improved performance  The Environment of Care Standards purpose is to improve patient safety  The Physical Environment can contribute to a successful patient outcome

Engineering Department 2015- 2

© Copyright, The Joint Commission

 Use EC.04.01.01 – EC.04.01.05 as a road map

Dashboard Status

Action Plan

EC.02.06.01

2E, 2W

Patient rooms cold: Begin trap program

EC.02.05.01

OR 1, 4 & 5

Upgrade AHU controls; update monitoring software

LS.02.01.20

OK

EC.02.03.05

OK

LS.02.01.10

OK

LS.02.01.30

Problematic

Attend Barrier Mgmt Symposium

LS.02.01.35

3W; 4N

Train 3W & 4N staff regarding shelved storage

EC.02.02.01

OK

EC.02.05.09

OK

EC.02.05.07

OK

See February 2015 Perspectives

Q1

Q2

Q3

Q4

Start Start

OK OK

OK

Engineering Department 2015- 3

© Copyright, The Joint Commission

Standard

© Copyright, The Joint Commission

Survey Process Enhancements

Improvements Pilot Tested  Revised agenda for Life Safety surveyor  Evaluation starts upon arrival  Specified OR Survey time  A single document list and tracking tool for  Time allotted for primary surveyor

responsibilities Engineering Department 2015- 5

© Copyright, The Joint Commission

both customers and surveyors

Life Safety Survey Improvement Goals Increase thoroughness of Life Safety survey  Promote consistency of Life Safety survey experience across surveyors  Promote efficiency, allowing more time for building tour  Encourage customer readiness  Define mandatory Life Safety surveyor activities  Establish guidelines for when Life Safety surveyor should conduct EC and EM sessions Engineering Department 2015- 6

© Copyright, The Joint Commission



Life Safety Survey Improvements 1. On arrival the first day of survey:

Request facilities representative escort to check fire alarm  Review eSOC (building plan & PFIs), waivers and equivalencies (History Audit Trail), ILSM P&P, fire response plan Join team for Opening (abbreviated attendance; ask to be excused) Skip team Surveyor Planning Session; conduct LS/EC focused Document Review Survey ORs for pressure relationships immediately after Document Review (provides HCO with max. time to correct) Conduct Building Tour (increase sample size)

2. 3. 4. 5.

Engineering Department 2015- 7

© Copyright, The Joint Commission



Primary LSCS Survey Responsibilities  LS.01.01.01 (SOC)  LS.01.02.01 (ILSM)

 EC.02.03.01 (Fire Response Plan)  EC.02.03.03 (Fire Drills)  EC.02.03.05 (Fire Equipment Maintenance)  EC.02.05.07 (Emergency Power Testing)

 EC.02.05.09 (Piped Medical Gas Testing)

Engineering Department 2015- 8

© Copyright, The Joint Commission

 EC.02.05.01 (EP 15 – Pressure Relationships)

Survey Resource Activity Guide has been updated to include “Life Safety and Environment of Care—Document List and Review Tool”  This new resource is located on The Joint Commission website at http://www.jointcommission.org/life_safety_ code_information__resources/  This resource is also at the Joint Commission Connect™ extranet site Engineering Department 2015- 9

© Copyright, The Joint Commission

 To prepare for document review, the Survey

LS Pre-Survey Planning Tool data recording tool  Identifies information to gather from existing resources needed for survey  Aids in planning onsite activity

Engineering Department 2015- 10

© Copyright, The Joint Commission

 Surveyor designed

LS/EC Document List & Review Tool  Same tool for surveyor and

organization  Serves as organization prep tool

and tracking tool during survey  Identifies frequency requirements  Relates to standard/EP

Engineering Department 2015- 11

© Copyright, The Joint Commission

 Request reflects scope of survey

EC Documents  If Primary Survey

Engineering Department 2015- 12

© Copyright, The Joint Commission

Responsibility completed and LSCS will be conducting the EC Session, review these documents



Reflects what a tour should include



Lists related standards/EPs



Only guidance



Does not reflect touring order

Engineering Department 2015- 13

© Copyright, The Joint Commission

Building Tour Guidance

Relocatable Power Taps (RPT)

© Copyright, The Joint Commission

(aka Power Strips)

 CMS is permitting a categorical waiver to allow for the use of power strips in existing and new health care facility patient care areas, if you are in compliance with all applicable 2012 LSC power strip requirements and with all other 2000 LSC electrical system and equipment provisions.  The organization must follow all requirements of the categorical waiver process  This includes identifying where they are located at the unit level Engineering Department 2015- 15

© Copyright, The Joint Commission

S&C: 14-46-LSC 9/26/2014

Requirements pedestal-or cart-mounted patient care-related electrical equipment assemblies, provided all of the following conditions are met, as required by section 10.2.3.6:  The receptacles are permanently attached to the equipment assembly.  The sum of the ampacity of all appliances connected to the receptacles shall not exceed 75 percent of the ampacity of the flexible cord supplying the receptacles.  The ampacity of the flexible cord is suitable in accordance with the current edition of NFPA 70, National Electric Code.  The electrical and mechanical integrity of the assembly is regularly verified and documented through an ongoing maintenance program.  Means are employed to ensure that additional devices or nonmedical equipment cannot be connected to the multiple outlet extension cord after leakage currents have been verified as safe. Engineering Department 2015- 16

© Copyright, The Joint Commission

 Power strips may be used in a patient care vicinity to power rack-, table-,

If the organization decides to use categorical waivers they must 1. Ensure full compliance with the appropriate code reference 2. Document the decision to adopt the categorical waiver  LS issues document in the SOC BBI Additional Comments  For Environment of Care items document by Minutes in discussion at the Environment of Care Committee (or equivalent) 3. Declare the decision at the beginning of any survey See also November 2013 Perspectives

Engineering Department 2015- 17

© Copyright, The Joint Commission

Categorical Waiver Process

S&C 13-58-LSC 1. 2. 3. 4. 5. 6. 7.

Openings in exit enclosures Emergency generators and standby power systems Doors, locking arrangements Suites Extinguishing requirements Clean waste and patient record recycling containers Medical gas alarms

1. 2. 3. 4. 5.

Wheeled equipment and lifts in egress corridors Fixed seating in egress One alternative kitchen cooking arrangement Direct vent gas fireplaces and solid fuel-burning fireplaces Combustible decorations on walls, doors, and ceilings Engineering Department 2015- 18

© Copyright, The Joint Commission

Plus five previous: see S&C 12-21-LSC

Relative Humidity (RH)  FGI Guidelines (2010) allows expanding the

RH range from 35 – 60% to 20 – 60% RH > 35 % RH is based on NFPA 99-1999, Section 54.1.1  20 – 60% RH is based on ASHRAE 170-2008  See EC.02.06.05 EP 1

 CMS S&C 15-27-Hospital, CAH & ASC letter

dated 2/20/2015 

S&C 13-25-LSC & ASC permits hospitals and CAH to use a LSC categorical waiver to establish Engineering Department 2015- 19

© Copyright, The Joint Commission



Relative Humidity (RH)  CMS S&C 15-27-Hospital, CAH & ASC letter

dated 2/20/2015 stated S&C 13-25-LSC & ASC permits hospitals and CAH to use a LSC categorical waiver to establish an RH level <35% in anesthetizing (i.e. OR) locations  Before electing to use the categorical waiver hospitals and CAHs are expected to ensure the humidity levels in their ORs are compatible with manufactures instructions for use (IFUs) for supplies and equipment used in that setting Engineering Department 2015- 20

© Copyright, The Joint Commission



CMS Information  Adoption of a more current Life Safety

Code® The proposal to adopt the 2012 Life Safety Code® is currently under internal review

 Emergency Management  There is an “end of year” deadline for publication that needs to be met

Engineering Department 2015- 21

© Copyright, The Joint Commission



Score EC.02.03.01 EP 1 …fire risk (volume)  12 ‘E’ cylinders (<300ft³) per smoke compartment (22,500ft²) may be open to the egress corridor in a rack or appropriate holders  Between 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 storage

Engineering Department 2015- 22

© Copyright, The Joint Commission

MEDICAL GAS SAFETY

MEDICAL GAS SAFETY 





Unsecured cylinders  Laying on top a gurney mattress; leaning against the wall  Free standing  Comingling of full and empty cylinders Transfilling liquid oxygen  Transfer 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 ventilated • sprinklered • ceramic or concrete flooring • separated with at least 1 hour construction from any patient care areas Engineering Department 2015- 23

© Copyright, The Joint Commission

Score EC.02.06.01 EP 1 Unsafe condition

Standard

2014

2015

EC.02.06.01: Built Environment

#1

#1

EC.02.05.01: Utility Systems Risks

#2

#3

LS.02.01.20: Means of Egress

#4

#4

LS.02.01.30: Protection

#8

#6

LS.02.01.10: General Bldg Req’s

#7

#7

LS.02.01.35: Extinguishment

#9

#8

EC.02.03.05: Fire Safety Systems

#6

#9

EC.02.02.01: HazMat & Waste

#10

#10

Engineering Department 2015- 24

© Copyright, The Joint Commission

Top Eight Cited Standards: 2014 – 2015 [RANKING FROM ALL SURVEYS]

#1 EC.02.06.01 EP 1 & 13

58.75%

population and are safe and suitable to the care, treatment and services provided  The organization must provide a safe environment  Unsecured oxygen cylinders • Segregation  Ligature/self harm risks (i.e. BHC) Note: Outdoor safety is scored at EC.02.01.01 EP 5 Engineering Department 2015- 25

© Copyright, The Joint Commission

 EP 1 Interior spaces meet the needs of the patient

EC.02.06.01 EP 13 temperature and humidity levels suitable for the care, treatment and services provided  Ventilation: • i.e. doors held open by air pressure; odors  Temperature: • Hot / Cold calls  Humidity • Primary concern is for areas >60%RH o Mold growth is possible  EP 20 Patient care areas are clean and free of offensive odors Engineering Department 2015- 26

© Copyright, The Joint Commission

 EP 13 The organization maintains ventilation,

#3 EC.02.05.01 EP 15

53%

pressure relationships, air-exchange rates and filtration efficiencies  Specific areas lack  negative or positive pressures in relationship to adjacent areas • i.e. Endoscopy Processing Room should be negative to the egress corridor  the correct number of air changes per hour  Improper filtration • MERV = Minimum Efficiency Reporting Value Engineering Department 2015- 27

© Copyright, The Joint Commission

 Ventilation system is unable to provide appropriate

What is Ventilation?  Ventilation is moving air from one location to another 





Outside air is conditioned by cooling or heating as the air moves through a series of coils  To save energy in some systems the returned air is blended with outside air Next the air is cleaned by filters and discharged into the occupied space As the air moves through the building in ducts, the ducts pass through barriers (walls)  To protect the barrier dampers are in place Engineering Department 2015- 28

© Copyright, The Joint Commission

 Supply Air

 Exhaust System  Removing the air from an occupied space is accomplished by the exhaust system  Exhausted air is either removed from the building or re-conditioned and re-used  As air is removed, it is replaced by supply air  This is how air exchanges occur  New air in, old air out

Engineering Department 2015- 29

© Copyright, The Joint Commission

Ventilation

Screening evaluate if further investigation needs to occur  To perform the flutter test take a tissue and let it hang just off the floor near the bottom edge of a door  If the tissue indicates incorrect air flow, stabilize the area by closing doors and windows, wait a few minutes and retest  If the organization presents a Testing & Balancing report the following questions should be asked • when was the balancing done (seasonal issues) • are any specific requirements (such as keeping a door closed) needed to achieve satisfactory results Engineering Department 2015- 30

© Copyright, The Joint Commission

 Tissue test: only to be used as a pre-screening tool to

Survey Process 





If the organization can repair the process that led to non-compliance the LSCS may review Following LSCS review, the LSCS may contact the Central Office to discuss the possibility of reducing the CLD to SLD, with no change to the finding Resolution should include the area affected by the equipment identified as non-compliant, not just the identified room/area  i.e. ensure zone is balanced  Is there an ongoing process to assess Engineering Department 2015- 31

© Copyright, The Joint Commission

 EC.02.05.01 EP 15 will generate a CLD

#4 LS.02.01.20 EP 1 49.5% at latch or lock that requires the use of a tool or key from the egress side.  Exception: locking based on clinical needs of the patients requiring security measures for their safety  Staff must be able to readily unlock such doors  Exception 2 & 3: delayed (1) and access controlled doors allowed Engineering Department 2015- 32

© Copyright, The Joint Commission

 Doors in a means of egress are not equipped with

#4 LS.02.01.20 EP 13

49.5%

egress  Anything in the egress corridor more than 30 minutes is storage  Dead end corridors may be used for storage  Less than or equal to 50sqft space  Carts Allowed:  Crash Carts  Isolation Carts  Chemo Carts Engineering Department 2015- 33

© Copyright, The Joint Commission

 The hospital maintains the integrity of the means of

“If the corridor looks cluttered… …it probably is” 

What is the Risk?  Patient movement  Staff movement  Additional Staff responding to emergency patient care

Engineering Department 2015- 34

© Copyright, The Joint Commission

Educate Staff

#6 LS.02.01.30

45.5%

 The hospital provides and maintains building

Engineering Department 2015- 35

© Copyright, The Joint Commission

features to protect individuals from the hazards of fire and smoke.  EP2 Hazardous Areas  Primarily door issues  EP 11 Corridor Doors

#7 LS.02.01.10 EP 5 & 9

45%

 Building and fire protection features are

designed and maintained to minimize the effects of fire, smoke, and heat.  EP 5 Door issues  EP 9 Fire Barrier Penetrations

Engineering Department 2015- 36

© Copyright, The Joint Commission

Barrier Management

Barrier Management Symposium

Engineering Department 2015- 37

© Copyright, The Joint Commission

. . .at no cost to the attendee . . .

Barrier Management Symposium

 Participating Organizations:  American Society for Healthcare Engineering  AWCI & Gypsum Institute  Fire Damper Industry  Fire Rated Glazing Industry  National Concrete Masonry Association

Engineering Department 2015- 38

© Copyright, The Joint Commission

 Program Developers:  Joint Commission  Firestop Contractors International Association (FCIA)  Underwriters Laboratories

#8 LS.02.01.35

42.5%

 EP 4: Piping for the AASS is not used to support

any other item  EP 14: Meets all other Life Safety Code automatic

Engineering Department 2015- 39

© Copyright, The Joint Commission

extinguishing requirements related to NFPA 1012000

LS.02.01.35, EP 14  Missing escutcheons

 Ceiling tiles misplaced in rooms  Blocked access to fire extinguishers

 Missing signage required in NFPA 13-1999

in patient sleeping smoke compartments

Engineering Department 2015- 40

© Copyright, The Joint Commission

 Quick response sprinklers mixed with other types

Engineering Department 2015- 41

© Copyright, The Joint Commission

EC.02.03.05 EP 4 Inadequate Inventory

#9 EC.02.03.05

38.7%

and fire safety building features.  Features of fire protection  Inventory required to ensure all devices are tested  Documentation of testing is required Engineering Department 2015- 42

© Copyright, The Joint Commission

 The hospital maintains fire safety equipment

Need for Inventory 



Each device that is required to be tested must be documented in an inventory  If 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 missed • Total number of devices (quantity) is not adequate Lack of an inventory (written, electronic or other) results in a finding at the EP  Findings solely for lack of inventory is not scored at EC.02.03.05 EP 25 Engineering Department 2015- 43

© Copyright, The Joint Commission

 EC.02.03.05 EP 1 – 20:

EPs 1 -20:  Missing documentation: score the EP as noncompliant  Also write a finding at EP 25 for documentation not being readily available to the AHJ • If acceptable documentation appears, finding at EP 1 – 20 might be removed during survey • EP 25 remains  LD.04.01.05 EP 4: Staff held accountable  If 3 or more findings at EC.02.03.05 EP 1 – 20 Engineering Department 2015- 44

© Copyright, The Joint Commission

EC.02.03.05

#10 EC.02.02.01 EP 5

37.7%

 EP 5: Personal Protective Equipment and

Engineering Department 2015- 45

© Copyright, The Joint Commission

the process to manage hazardous materials and waste handling and exposures

Eye Wash Station Federal Requirements: OSHA recommendation to  reduce the risk of injury from contact with caustic and corrosive materials in areas such as  Power Plant  Lab  Placed so that the eyewash is within 10 seconds or 55 feet from where the corrosive chemicals is used  Weekly flush until clear is required  Annual inspection to ensure the system is fully functional  Mixing valve recommended to achieve tepid  Risk assess potential exposure to determine if cold water only would be acceptable Engineering Department 2015- 46

© Copyright, The Joint Commission

 Score Eye Wash issues at EC.02.02.01 EP 5  Risk assess location / application based on OSHA

Equipment Management Medical Equipment: EC.02.04.01, EC.02.04.03 Utility Systems: EC.02.05.01, EC.02.05.05

© Copyright, The Joint Commission

APPLIES TO HOSPITAL & CAH PROGRAMS

EC.02.05.01

EC.02.05.01 EP 1 The hospital designs and installs utility systems that meet patient care and operational needs. (See also EC.02.06.05, EP 1)

Engineering Department 2015- 48

© Copyright, The Joint Commission

Standard EC.02.05.01 The hospital manages risks associated with its utility systems.

EC.02.05.01 EP 2 components of utility systems or maintains a written inventory of selected operating components of utility systems based on risks for infection, occupant needs, and systems critical to patient care (including all life-support systems). The hospital evaluates new types of utility components before initial use to determine whether they should be included in the inventory. For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital maintains a written inventory of all operating components of utility systems. (See also EC.02.05.05, EPs 1, 3-5) Engineering Department 2015- 49

© Copyright, The Joint Commission

 The hospital maintains a written inventory of all operating

Utility Systems & Operating Components  Utility Systems are those systems that support the

use and function of the physical environment, such as the  

heating system the cooling system water distribution system

Engineering Department 2015- 50

© Copyright, The Joint Commission



Utility Systems & Operating Components physical environment, such as the  heating system  the cooling system  water distribution system  Components on the inventory would include the equipment that is performance-related and delivers a measurable outcome.  For example, the heating system may have the following components:  boiler, DA tank (de-aeration tank), feed water pumps, distribution (including circulation pumps, piping, and condensate return).  Support parts to the components, such as belts, filters and steam traps, might not need to be individually listed, although they would likely be part of a preventive maintenance program.  Support parts of components such as pumps and motors might also be considered sub-components and may or may not be reflected on the inventory, depending on the maintenance strategies used. Engineering Department 2015- 51

© Copyright, The Joint Commission

 Utility Systems are those systems that support the use and function of the

The hospital identifies high-risk operating components of utility systems on the inventory for which there is a risk of serious injury or death to a patient or staff member should the component fail. Note: High-risk utility system components include life-support equipment.

Engineering Department 2015- 52

© Copyright, The Joint Commission

EC.02.05.01 EP 3

EC.02.05.01 EP 4

Engineering Department 2015- 53

© Copyright, The Joint Commission

The hospital identifies the activities and associated frequencies, in writing, for inspecting, testing and maintaining all operating components of utility systems on the inventory. These activities and associated frequencies are in accordance with manufacturers’ recommendations or with strategies of an alternative equipment maintenance (AEM) program. Note 1: The strategies of an AEM program must not reduce the safety of equipment and must be based on accepted standards of practice.  An example of guidelines for physical plant equipment maintenance is the American Society for Healthcare Engineering (ASHE) book Maintenance Management for Health Care Facilities. Note 2: For guidance on maintenance and testing activities for Essential Electric Systems (Type I), see NFPA 99, 1999 edition (Section 3-4.4).

For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital’s activities and frequencies for inspecting, testing, and maintaining the following items must be in accordance with manufacturers’ recommendations:  Equipment subject to federal or state law or Medicare Conditions of Participation in which inspecting, testing, and maintaining be in accordance with the manufacturers’ recommendations, or otherwise establishes more stringent maintenance requirements  New operating components with insufficient maintenance history to support the use of alternative maintenance strategies Engineering Department 2015- 54

© Copyright, The Joint Commission

EC.02.05.01 EP 5

EC.02.05.01 EP 5  Note: Maintenance history includes any of the

Engineering Department 2015- 55

© Copyright, The Joint Commission

following documented evidence:  Records provided by the hospital’s contractors  Information made public by nationally recognized sources  Records of the hospital’s experience over time

For hospitals that use Joint Commission accreditation for deemed status purposes: A qualified individual(s) uses written criteria to support the determination whether it is safe to permit operating components of utility systems to be maintained in an alternate manner that includes the following:  How the equipment is used, including the seriousness and prevalence of harm during normal use  Likely consequences of equipment failure or malfunction, including seriousness of and prevalence of harm  Availability of alternative or back-up equipment in the event the equipment fails or malfunctions  Incident history of identical or similar equipment  Maintenance requirements of the equipment For more information on defining staff qualifications, refer to Standard HR.01.02.01 Engineering Department 2015- 56

© Copyright, The Joint Commission

EC.02.05.01 EP 6

For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital identifies operating components of utility systems on its inventory that is included in an alternative equipment maintenance program.

Engineering Department 2015- 57

© Copyright, The Joint Commission

EC.02.05.01 EP 7

EC.02.05.01 EP 14

Engineering Department 2015- 58

© Copyright, The Joint Commission

The hospital minimizes pathogenic biological agents in cooling towers, domestic hot-and cold-water systems, and other aerosolizing water systems.

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. Note: Areas designed for control of airborne contaminants include spaces such as  operating rooms  special procedure rooms  delivery rooms for patients diagnosed with or suspected of having airborne communicable diseases (for example, pulmonary or laryngeal tuberculosis)  patients in "protective environment" rooms (for example, those receiving bone marrow transplants), laboratories, pharmacies, and sterile supply rooms Engineering Department 2015- 59

© Copyright, The Joint Commission

EC.02.05.01 EP 15

EC.02.05.05 EP 1

Engineering Department 2015- 60

© Copyright, The Joint Commission

The hospital tests utility system components on the inventory before initial use and after major repairs or upgrades. The completion date of the tests is documented. (See also EC.02.05.01, EP 2)

Documentation is completed for High-risk, life support and non-life support devices on the inventory  Accuracy of Inventory  All High-risk and Life Support equipment must be on the inventory and identified  Preventive maintenance frequencies must be clearly defined in writing  Confirm work done as per scheduled activities  Ensure appropriate work is scheduled based on maintenance strategies  Evaluate equipment failure and scheduled actions

Engineering Department 2015- 61

© Copyright, The Joint Commission

Equipment Survey Process

Evaluating Program Effectiveness  The equipment management programs must have written





How is equipment evaluated to ensure no degradation of performance?  Consider mis-calibration of equipment  Consider test equipment calibration confirmation How are equipment-related incidents investigated?  Could the malfunction have been avoided?  Did the alternative maintenance strategy contribute to the malfunction?  How to sequester equipment deemed unsafe? Engineering Department 2015- 62

© Copyright, The Joint Commission

policies & procedures  Evaluating the program:

Evaluating Program Effectiveness: Miscellaneous Topics  Survey should focus on High-risk equipment

Are appropriate operation manuals and maintenance schedules available?  Verify the inspection, testing & maintaining activities and frequencies are documented  Evaluate the various maintenance strategies used  Are they appropriate?  Are they effective?  Is the equipment reliable? Engineering Department 2015- 63

© Copyright, The Joint Commission



New Resource:

http://www.jointcommission.org/topics/ the_physical_environment.aspx

© Copyright, The Joint Commission

JCPEP

High Reliability in the Physical Environment  Three Objectives

Ensure life safety  Ensure device stability  Ensure continuity of the organization’s mission  System Elements  Design  Installation  Equipment  Inspection, Testing, and Maintaining Engineering Department 2015- 65

© Copyright, The Joint Commission



Physical Environment as a Priority the organization cannot be met if the physical environment fails  Leadership must show support to those responsible for the EC/LS programs  Current physical environment requirements may be difficult to achieve with the current building technologies  Facilities staff must be fully educated in operating and maintaining building systems 

Includes code compliance and energy awareness Engineering Department 2015- 66

© Copyright, The Joint Commission

 Leadership must be aware that the clinical needs of

Leadership Challenge  Why are Environment of Care compliance issues

Engineering Department 2015- 67

© Copyright, The Joint Commission

consistently and routinely out of compliance?  What can be done to help hospitals come into compliance with these areas?  How does non-compliance with these areas correlate with clinical risks?

Voice of the Customer Discussion  Fire Safety

LS.02.01.20  EC.02.03.05  LS.02.01.35  Barriers  LS.02.01.10  LS.02.01.30  Environment of Care  EC.02.05.01  EC.02.06.01  EC.02.02.01

Engineering Department 2015- 68

© Copyright, The Joint Commission



Voice of the Customer Discussion: Key Stakeholders  Health Systems Corporate Liaisons  Hospital Advisory Council  HAC-HSCL Subgroup

 Consultants’ Forum  Focus Groups

Surveyors  Hospital Staff

Engineering Department 2015- 69

© Copyright, The Joint Commission



Voice of the Customer Comments Hospital Staff Need Education       

Create BoosterPaks on Barriers, Fire Safety, Environment of Care Add forms, checklists, and other tools to the Leading Practice Library Provide Facilities Managers with their own copies of EC News and Perspectives Encourage surveyors to do more teaching during the survey, to explain why compliance is important Reinstate the requirement for the building maintenance program Develop a repository for Life Safety and Environment of Care resources Conduct short, concise webinars on achieving standards compliance Engineering Department 2015- 70

© Copyright, The Joint Commission

The Joint Commission should do the following:

Voice of the Customer Comments Hospital Leaders Need to Be Engaged:       

Include Facilities Management as a module for newly hired leadership orientation Use performance improvement measures to monitor Environment of Care and Life Safety contracts Require that Senior Leaders received regular updates on Environment of Care and Life Safety Compliance Issues Involve facilities management staff and clinical staff in EC Tours/Rounds Use building equipment life cycle data to support requests for funding to replace/update old equipment Implement an “above the ceiling” permit policy Facilitate collaboration, and clarify responsibilities, between clinical staff and facilities management staff Engineering Department 2015- 71

© Copyright, The Joint Commission

Hospitals should:

Action Plan: JCPEP Joint Commission Physical Environment Portal instances of non-compliance with the top eight EC/LS standards.  Target Audiences:  Hospital Leaders  Facilities Managers  Clinicians  Quality Coordinator/Leaders  Available on the Joint Commission website; links to the ASHE website Engineering Department 2015- 72

© Copyright, The Joint Commission

 Purpose: Provide guidance and education to reduce

Action Plan 



  

Provided at no cost  Joint Commission Home Page, TOPICS  www.jointcommission/JCPEP Limited to compliance strategies for the eight EC/LS standards that are most frequently cited as noncompliant Videos and pictures to illustrate compliance Articles, customer strategies, surveyor insights Fireside Chats  Two for each of the eight standards  Conducted every month Engineering Department 2015- 73

© Copyright, The Joint Commission

 JCPEP Content:

Engineering Department 2015- 74

© Copyright, The Joint Commission

Page 1 of 2

Engineering Department 2015- 75

© Copyright, The Joint Commission

Page 2 of 2

Engineering Department 2015- 76

© Copyright, The Joint Commission

Page 1 of 1

Engineering Department 2015- 77

© Copyright, The Joint Commission

Page 1 of 2

Engineering Department 2015- 78

© Copyright, The Joint Commission

Page 2 of 2

Engineering Department 2015- 79

© Copyright, The Joint Commission

Page 1 of 3

Page 2 of 3

Engineering Department 2015- 80

© Copyright, The Joint Commission

ASHE Focus on Compliance

Engineering Department 2015- 81

© Copyright, The Joint Commission

Page 3 of 3

Department of Engineering 630 792 5900 George Mills, MBA, FASHE, CEM, CHFM, CHSP, Green Belt Director

Andrea Browne, PhD., DABR Medical Physicist

Anne Guglielmo, CFPS, LEED, A.P., CHFM, CHSP Engineer

John Maurer, CHFM, CHSP, SASHE Kathy Tolomeo, CHEM, CHSP Engineer

James Woodson, P.E., CHFM Engineer Engineering Department 2015- 82

© Copyright, The Joint Commission

Engineer

The Joint Commission Disclaimer  These slides are current as of 9/14/2015. 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

 These slides are copyrighted and may not be further used, shared or

distributed without permission of the original presenter or The Joint Commission.

Engineering Department 2015- 83

© Copyright, The Joint Commission

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.

Loading...

The Joint Commission - MHCEA

2015 George Mills, Director Engineering Department The Joint Commission © Copyright, The Joint Commission Challenging Standards & Updates Perform...

3MB Sizes 30 Downloads 12 Views

Recommend Documents

Joint Commission and CMS Crosswalk - Joint Commission International
Jan 1, 2016 - No part of this publication may be reproduced in any form or by any means without written permission .....

Certification Handbook - Joint Commission
This comprehensive evaluation is what makes. Joint Commission certification the “Gold Seal of ApprovalTM”. Health Ca

FAQ's | Joint Commission International
WHO and CDC guidelines address hand hygiene when a health care worker touches a patient or the health care environment a

leadership in - Joint Commission
and regulations that are adopted by the medical staff and approved by the ..... “element(s) of performance” (that ar

¡Hable! - Joint Commission
Academy of Breastfeeding Medicine www.bfmed.org. American Academy of Pediatrics www.aap.org. Association of Women's Heal

Joint Commission Readiness Meeting - BidNet
DLAR = Department for Laboratory Animal Research ... UKHC = University of Kentucky Health Care (This includes all medica

UHFE10_body_HFE_Part I_final - Joint Commission Resources
because of poor layout, small font size, too many instructions, or the use of ... A staff shortage may have increased th

Medication Management Standards - Joint Commission
Dec 17, 2013 - Revisions to the Medication Management Standards Regarding. Sample Medications. APPLICABLE TO .... receip

Accreditation Patient safety - Joint Commission
Aug 20, 2014 - also refer to the Facility Guidelines Institute's (FGI's) Guidelines for Design and Construction of Healt

CVC Maintenance Bundles - Joint Commission
Nov 20, 2013 - place.2. Many of the evidence-based practices used for the insertion of CVCs are also important in the ca