Transcript No Slide Title

Biggest Pitfalls and Best Practices in EC
The Environment of
Care Chapter
Healthcare Engineering Consultants
The Survey Planning Session
What Should Be Included in the
Management Plans?
Healthcare Engineering Consultants
The Management Plans
Best Practices Include:
 Provide a description, not a rewrite of the program!
 Be consistent in format; place in a labeled, tabbed binder
 Include a list of applicable facilities to avoid multiple plans
 Describe how each “element of performance” is achieved
 Describe responsibilities from governing body to staff
 Include performance improvement and training information
 Reference applicable policies and procedures
 Review by the safety committee annually
*Note: Emergency Management requires an Emergency
Operations Plan (EOP), not a management plan
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Safety Management
Issue: Proactive Risk Assessments for Safety
Biggest Pitfall: Risk assessing regulatory issues
Best Practices:
1. Create a “HVA” for prioritizing safety risks (refer to sample chart)
2. Be sure to include areas with behavioral health patients
3. Prioritize the risks, from highest to lowest
4. Appoint a multi-disciplinary group of “stakeholders” to evaluate
changes necessary to minimize probability and impact
5. Seek approval for budget and recommended changes
6. Implement changes; track and document progress
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Documenting Risk Assessments
Global Risk Assessment Form
Department/ Area:_____________________________ Date: _____________ Completed by: _____________________
Risk Element Description
Occurrence Probability
(1-5)
Occurrence Impact
(1-5)
Total Impact Score
(Probability X Impact)
Notes: To use this form, list all of the possible risk elements associated with the department or area that may impact
patient or staff safety or result in damage to buildings or equipment. Using all available data sources, including experience
and previous history, insert numerical values for the probability and impact for each element. Calculate the total impact
score for each element, prioritize in descending numerical order and select a “cut-off” limit. For all scores above the “cutoff”, perform the six step risk assessment process.
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Example Global Safety Risk Assessment
Global Risk Assessment for Safety Management
Risk Element Description
Occurrence Probability (1-5)
Occurrence Impact (1-5)
Employee injuries
Ergonomic issues
Unauthorized staff appliances
Unauthorized smoking
Egress corridor clutter
Unlocked clean supply rooms
in inpatient areas
Improper storage
General housekeeping
Unlocked supply rooms in
outpatient clinics
Improperly stored cylinders
5
4
4
5
4
4
2
2
2
1
1
1
Total Impact Score
(Probability X Impact)
10
8
8
5
4
4
3
3
2
1
1
1
3
3
2
1
1
1
Note 1: This form is used to determine the possible impact to safety that may occur in the hospital resulting from a variety of
different risk elements. Each of the risk elements is prioritized based on the total impact score, starting with the highest score
obtained. Specific assessments are then performed for each risk element (starting with the highest impact score) to determine
actions that may be taken or processes that may be altered to reduce the overall risk to the hospital.
Note 2: The scoring is defined as follows:
Probability Score
1
2
3
4
5
Description
Impact Score
Very unlikely to ever occur
Unlikely to occur in one year
May occur in one year
Likely to occur in one year
Almost certain to occur within one year
1
2
3
4
5
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Description
No injury is likely to occur
Minor injury is likely to occur
Moderate injury is likely to occur
Serious injury is likely to occur
Death is likely to occur
Example Global Security Risk Assessment
Global Risk Assessment for Security Management
Risk Element Description
Occurrence Probability (1-5)
Occurrence Impact (1-5)
Infant abduction
Pediatric abduction
Assaultive behavior - ED
Assaultive behavior – mental
health unit
Theft – gift shop
Theft – pharmacy
Theft of hospital property
Theft from patients
Auto accidents on hospital
property
Trespassing
Auto vehicle break-in
Weapons brought onto
hospital property
Utility systems intentionally
turned off or damaged
Terrorist activity near or on
hospital property
Toxic gas introduced into
hospital air intakes
1
1
5
5
3
3
3
3
Total Impact Score
(Probability X Impact)
3
3
15
15
4
2
5
5
4
1
2
2
2
3
4
4
10
10
12
4
4
4
1
2
1
4
8
4
2
4
8
1
5
5
2
4
8
Note 1: This form is used to determine the possible impact to security that may occur in the hospital resulting from a variety of
different risk elements. Each of the risk elements is prioritized based on the total impact score, starting with the highest score
obtained. Specific assessments are then performed for each risk element (starting with the highest impact score) to determine
actions that may be taken or processes that may be altered to reduce the overall risk to the hospital.
1
Healthcare Engineering
Consultants
Example Behavioral Health Risk Assessment
Behavioral Health Area Risk Assessment Grid
Area of Evaluation: _______________________________
Component
Description
Electric/ other
cords
Electrical
receptacles
Patient beds
Impact
Probability
Patient
Impact
Staff
Impact
Date of Evaluation: _________________
Total
Impact Score
Revision
Recommended?
Door hinges
Hallway items,
wall coverings
Towel racks
Bathroom grab
bars
Bathroom
fixtures
Smoking
Fire alarm pull
boxes
Fire
extinguishers
Windows
Seclusion room
Washer/ dryer
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Page 1 of ____
Revision Description
Safety Management
Issue: How to enforce the smoking policy?
Biggest Pitfall: Impractical policy or non-compliance
Best Practice:
 Create a practical policy
 Incorporate smokeless tobacco and electronic cigarettes into
the policy
 Recognize the “citation priority”
 Monitor smoking compliance
 Provide realistic discipline for non-compliant staff, vendors
and contractors
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Security Management
Issue: Violence in the Workplace (JC PSG #45)
JC Recommended “Best Practice”
 Audit facility risk of violence
 Identify improvements in the violence protection program
 Provide extra security precautions in the ED
 Thoroughly pre-screen job applicants
 Work with HR to minimize chances of violent reactions
from employees who are disciplined or fired
 Provide staff training regarding potentially violent family
members
 Ensure violence response procedures are in place
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Security Management
Issue: Violence in the Workplace (continued)
JC Recommended “Best Practice”
 Encourage staff to report incidents of violent activity or
perceived threats of violence
 Educate supervisors to be aware of and thoroughly
investigate suspicious behavior, or threats
 Ensure counseling programs are in place for employees
who become victims of violent behavior or crime
 If violence occurs, respond accordingly:
1. Report the crime to law enforcement authorities
2. Recommend counseling for those affected
3. Take action to prevent future occurrence
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Hazardous Materials and Wastes
Issue: Minimizing Risks With Hazardous Energy
Best Practices:
 Provide clear signage for Zones 1 - 4 in MRI areas
 Ensure that emergency responders have been trained with regard to
entering MRI areas
 Verify that fire and other emergencies in the MRI area address
quenching the magnet (yes or no)
 Appoint a Laser Safety Officer (LSO) if lasers are used
 Create and follow all written safety guidelines for MRI’s and lasers
 Follow all arc flash protection/ PPE/ signage guidelines
 Continue to follow all safety procedures for ionizing radiation
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Hazardous Materials and Wastes
Issue: Proper Disposal of Hazardous Medications
Biggest Pitfall: Using sharps containers for hazardous medications
Best Practices:
 Meet federal RCRA (or possibly tougher state) regulations
 Be prepared for a visit from EPA, DOT or DEA
 Create RCRA “P”, “U” and “D” pharmaceutical inventories and use color-coded
labels to assist clinical staff in identification
 Create a separate waste stream for disposal of partially-used and unused
hazardous medications
 Supply color-coded collection containers with sponges in clinical units
 Track the manifest forms to verify proper incineration
 Check Federal Guidelines at:
www.whitehousedrugpolicy.gov/publications/pdf/prescrip_disposal.pdf
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Hazardous Materials and Wastes
Issue: Compressed Cylinder Storage
Code Requirements:
 Enclosures are not required for stored gases <300 cubic feet per smoke
compartment (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)
 FULL and EMPTY signage required for cylinders
 Storage requires stands, racks or fastening devices, such as chains
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Hazardous Materials and Wastes
Issue: Compressed Cylinder Storage
Interpretations:
 Requirements for stored gas only, not in-use tanks!
 In-use gas includes:
- Tanks on code carts
- Tanks on wheelchairs
- Tanks on gurneys
- 30-minute rule if patients are not present in wheelchairs, gurneys
 Empty tanks do not count toward the total (be careful of AHJ!)
 Use of fire-rated cabinets can be used on floors
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Hazardous Materials and Wastes
Issue: Alcohol-Based Hand Rub Units Requirements
Code Requirements:
 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 sprinkled
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
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Hazardous Materials and Wastes
Issue: Eyewashes and Showers
Biggest Pitfall: Failure to test eyewash according to policy
Best Practices:
 Use risk assessment to determine placement
 ANSI standards have not been officially adopted by the Joint Commission,
but JC can reference OSHA
 Tepid water between 60 and 100 degrees F will be expected
 Testing policy is required – specify test intervals (weekly for eyewash units,
monthly for showers recommended)
 Documentation of test results is required
 Differentiate between eyewash station and “first aid” station, such as
mounted bottles
Healthcare Engineering Consultants
Fire Prevention
Issue: Unobstructed access to exits
Biggest Pitfall: Believing that providing clear egress isn’t
required in a “business occupancy”
Code Requirement:
The 2011 “Fire Risk” standard (EC.02.03.01 - EP4), describes that the
“hospital must maintain free and unobstructed access to all exits”.
However, this requirement refers only to business occupancies, since
healthcare and ambulatory occupancy egress requirements are
specified in the Life Safety chapter
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Fire Prevention
Issue: Fire Drills
Biggest Pitfall: Missing specific fire drills required by AHJ
Best Practices:
 Consider healthcare facilities as “three shifts”, even if many clinical staff
work 12-hour shifts
 Clearly define specific fire response roles and responsibilities for all staff in
the hospital, including privileged physicians
 Perform and document at least one drill annually in the OR
 Use the fire drills as an opportunity to:
- document magnetic door releases for smoke and fire doors
- document the time from fire alarm initiation to receiving station
 Document the fire drill on a form with numerical values to track
improvement of staff response and knowledge over time
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Medical Equipment Management
Issue: Equipment Test Scoring
Biggest Pitfall: Not tracking PM completion rate
Code Requirements:
 100% PM completion for “life support” devices, based on “A” scoring
Note: JC considers defibrillators “life support” devices, even AED’s
 90% PM completion for “non-life support” devices (C)
 Determine test interval and procedures by “PM effectiveness” and
MTBF data (accepted now by CMS)
 Test tags with due dates are recommended, but not required! What
about Ongoing PM vs. initial test only?
 Flexible and rigid endoscopes are now required to be on the medical
equipment inventory for monitoring purposes
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Medical Equipment Management
Issue: Incoming Equipment Tests
Biggest Pitfall: Not performing incoming equipment
tests on patient-owned equipment
Code Requirements:
 Patient-owned equipment (NFPA 99, section 8.5.2.1.2.2)
Diagnostic and therapeutic (example: CPAP)
Personal use (iPods, smart phones, laptops, iPads)
 Rental devices
 Demo, loaner and trial equipment
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Utility Systems Management
Issue: Airborne Pathogens
Biggest Pitfall: No air exchange data in pharmacy or
clinical laboratory areas
Best Practice:
 Create an airborne pathogens policy that describes how often air
filters are changed, and air exchange and pressure relationships are
measured in operating rooms, delivery rooms, special procedure
rooms, patient isolation rooms, clinical laboratories, sterile supply
rooms and pharmacies
 Nominal test frequencies are annual, but can define other
Note: Refer to 2010 FGI document for requirements (new for 2011)
Note: “Grandfathering” permitted for air handlers
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Utility Systems Management
Issue: Temperature and Humidity in the
Operating Rooms
Code Requirements:
 NFPA 99, section 6.4.1.1 requires control of humidity >35%
 FGI 2010 Guidelines document lists control from 30% to 60% in
Table 7-1
 CMS requires humidity above 35%
 JC expects temperature and humidity monitoring/ documentation
 Policy is needed for monitoring and control range, including
clinical procedures when the actual readings are outside the range
 Changes to ASHRAE 170 (in FGI document) to lower humidity
level requirements to 20% have been approved by the Joint
Commission!
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Utility Systems Management
Issue: Utility System Test Scoring
Biggest Pitfall: PM not tracked for required categories
Best Practices:
 Create three different utility system inventory categories:
1. Critical utility life support
2. Critical utility infection control
3. Critical utility non-life support
 Track and maintain “on-time” PM completion rates for the
“critical life support” and “critical infection control” components
based on “A” scoring: 100%
 Track and maintain “on-time” PM completion rates for “critical
non-life support” components based on “C” scoring: 90%
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Functional Environment
Issue: The JC “General Duty Clause”
Biggest Pitfall: Surveyor interpretation
 Patient areas are safe, clean, free of odors and
suitable
 Lighting is suitable
 Ventilation, temperature and humidity are suitable
 Locks and restraints per regulation
 Emergency access for locked spaces is provided
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Functional Environment
Issue: Pre-Construction Risk Assessment (PCRA)
Biggest Pitfall: Only ICRA and ILSM are evaluated
Best Practice: Include all seven of the items listed
below in the PCRA evaluation
● Noise
● Emergency procedures
● Vibration
● Utility failures
● Air quality
● Interim life safety measures
● Infection control
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Infection Control Risk Assessment
(ICRA) – Best Practice Grid
Risk Criteria for Infection Control
Patient
Risk
Construction
Type
Type A
Type B
Type C
Type D
Group 1 (lowest)
I
II
II
III
Group 2 (medium)
I
II
III
IV
Group 3 (medium high)
II
III
III
IV
Group 4 (highest)
III
III
IV
IV
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Functional Environment
Issue: Documentation of PCRA
Best practices:
• Evaluate measures to reduce risk and minimize the
impact of the construction activities
• Perform daily monitoring in all construction areas
• Use a monitoring checklist
• Post required permits, such as hot work, ICRA,
above-the-ceiling work, ILSM, etc. on door entrance
to construction area
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Functional Environment
Issue: Pre-Construction Risk Assessment (PCRA)
Best Practice: Include PCRA changes during the project
Pre-Construction Risk Assessment Timeline Chart
Project number: __________________________
Date: _____________________
Completed by: ____________________________
PCRA Category
Week
1
Week
2
Week
3
Week
4
Week
5
Week
6
Week
7
Week
8
Noise
Vibration
Air Quality
Infection Control
Risk Assessment
(ICRA)
Interim Life Safety
Measures (ILSM)
Emergency
Procedures
Utility Failures
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Week
9
Week
10
Comments
Information Collection and Monitoring
What is the most effective
method to provide EC
monitoring and reporting?
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Measurement and Improvement
What Measurements are Required in 2011?
Patient and visitor injuries
Occupational illnesses and staff injuries
Incidents of damage to hospital or others property
Patient, staff or visitor security incidents
Hazmat spills and exposures
Fire safety management problems, deficiencies and failures
Medical equipment management problems, failures, and
user errors
Utility system management problems, failures and user
errors
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Monitoring Regulatory Requirements
Regulatory Compliance Dashboard
Description
General Reqs
SC Meetings
Dashboard Rpt
Leadership Rpt
Evaluations
Policy Review
Safety Mgmt
Hospital Surv
Clinic Surv
Security Mgmt
Alarm Tests
Abduction Drills
Hazmat Mgmt
Manifests
Haz Vapor Mon
Permits, Lic
Verify MSDS
Emer Mgmt
Hospital Drills
Clinic Drills
HVA
Fire Prev
Hosp Fire Drills
Clinic Drills
SOC Document
ILSM Measures
Extinguishers
Fire Det Dev
JAN
FEB
MAR
APR
MAY
JUN
X
X
JUL
AUG
X
X
X
SEP
OCT
X
X
NOV
DEC
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
N/A
N/A
N/A
N/A
X
X
X
X
X
X
X
X
X
X
X
A/R
X
A/R
X
X
A/R
X
A/R
X
A/R
X
X
A/R
X
A/R
X
A/R
X
X
Healthcare Engineering Consultants
Comments
Monitoring Regulatory Requirements
Regulatory Compliance Dashboard (continued)
Description
Fire Prev
Water Devices
Fire Pumps
Ver/Hor Doors
F/S Dampers
Med Equipmt
PM LS Eqmt
PM NLS Eqmt
Util Systems
PM LS Sys
PM NLS Sys
Em Gen Tests
Batt Light Test
Water Tests
HVAC Tests
MGAVS Tests
App Environ
PCRA
Miscellaneous
Eyewash units
Showers
JAN
N/A
FEB
N/A
MAR
N/A
APR
N/A
MAY
JUN
JUL
AUG
SEP
OCT
NOV
DEC
X
W
W
W
X
W
W
W
X
X
W
W
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
A/R
A/R
A/R
A/R
A/R
A/R
A/R
A/R
W
X
W
X
W
X
W
X
W
X
W
X
W
X
W
X
Comments
Key to dashboard symbols:
X – Indicates that action is required during the month indicated; W – Indicates that weekly action is required
A/R – Indicates that action is required when applicable
Key to colored boxes: Red boxes indicate non-compliance (tests were not performed); Yellow boxes indicate partial compliance
(tests have been delayed or not fully completed); Green boxes indicate full compliance (tests satisfactorily completed).
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Measurement and Improvement
What Performance Improvement Measures are Required
for each “EC” area?
 No longer any minimum number in 2011!
 Should be numerical
 No maximum number of numerical measures
 Should measure performance improvement
 Adopt goals, objectives and benchmarks
 At least one performance improvement initiative from
“EC” is required to be performed, documented and
reported to leadership annually
 Regular reporting and tracking of PI to the Safety
Committee
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Reporting of “EC” PI Indicators
Performance Improvement Dashboard
Description
of Measure
Safety
Management
Lost time
injuries
Security
Management
Internal theft
(equipment, $)
Hazmat
Management
Decrease in
RMW
Emergency
Management
Call-back
response rate
Fire
Prevention
Average fire
drill score
Medical
Equipment
Maint cost/
device/ month
Utility
Management
Priority I WO
response time
Benchmark
FY 2004
Objective
FY 2005
Jan
Feb
Mar
Apr
21/ year
<1.5 per
month
1
2
1
3
$ 25, 426 for
the year
<$ 2,000
per month
1,200
425
0
1,720
124,560# for
the year
< 9,500#
per month
9,245
9,386
9,142
9,524
68% within
20 minutes
75%
69%
73%
84%
81%
93
91
94
91
87 per drill
average
> 90 per
drill avg
$48.13 per
device/ mo
$45.00/
dev/ mo
53.14
47.86
58.22
39.78
3.2 days
< 3 days
3.1
3.1
2.9
3.0
May
Jun
Jul
Aug
Key to colored boxes:
Green boxes indicate data within the desired objective and an improvement trend
Yellow boxes indicate data at or slightly above the desired objective with no discernible trend
Red boxes indicate data above the desired objective and a negative trend
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Sep
Oct
Nov
Dec
Trend
Annual Evaluations
“Best Practice” Guidelines for the Evaluations
 Demonstrate that the program has improved
 Provide numerical data
 Demonstrate “effectiveness” rather than “busyness”
 Document evaluations for every “EC” area, including
Emergency Management
 Create the evaluations as soon as possible at the end of the
fiscal or calendar year
 Re-read the annual evaluations before the survey
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Annual Evaluations
The Annual Evaluations must include:
SCOPE - What is being evaluated?
OBJECTIVES - What are the numerical goals/
benchmarks?
PERFORMANCE - What does the data show?
EFFECTIVENESS - How does the performance
(data) compare to the objectives?
WHAT NEXT? - What objectives do we define for
next year, based on this year’s performance?
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Annual Evaluations
Best Practice: Each annual evaluation should
include a review of:
 The management plan
 Regulatory compliance
 Performance improvement
 Other issues to take credit for
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Annual Evaluations
Annual Effectiveness Evaluation Matrix
“EC” Area: ____________________
Calendar year: _________________
Management Plan
Regulatory
Compliance
Performance
Improvement
Other
Accomplishments
Scope
Objectives
Performance
Effectiveness
Objectives for Next
Year
Note: This matrix is not intended to be used for the actual annual evaluation format,
but provides a guide to what should be included in the evaluation
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The Safety Committee
Best Practices Include:
 Leadership representative (VP) present at every meeting
 Multi-disciplinary membership
 Attendance of standing members at least 70%
 Meet often enough to limit meeting time to 1 hour or less
 Document and distribute meeting minutes within two
weeks of the meeting and use the C-R-A-F format
 Use dashboards or spreadsheets to track regulatory and
performance improvement data
 Track the resolution of issues with a monitoring chart
 Use the meeting time to solve problems, not to review data
or information that does not require any action
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Safety Committee Issue Monitoring
Safety Committee Issue Monitoring Sheet
Issue
Number
10-17
10-23
10-26
11-01
11-02
11-03
11-04
11-05
11-06
11-07
11-08
11-09
11-10
11-11
Issue Description
Jan
Feb
Mar
Fire exit plans
Safety manual
In-services
Disaster reports
Recall sheet
Rear parking
OB project
Sharps in trash
Slick pavement
Snow removal
Telephone system.
Haz Com
Fire reports
Rehab door
F
F
T
P
P
P
P
P
F
C
F
F
T
T
F
F
P
P
P
C
Apr
May
Jun
Jul
Aug
F
R
R
F
V
R
C
C
F
P
P
P
Key to issue numbers: year of issue initiation followed by issue number in committee minutes
Key to action: P = problem initiated; F = follow-up; R = recommendation; T = tabled;
NA = no action; V = vote taken; C = complete
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Sep
Oct
Nov
Dec
Biggest Pitfalls and Best Practices in EC
Questions?
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