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Changes to the 2011 Standards
What’s New?
Healthcare Engineering Consultants
Safety Management
Issue: Joint Commission Sentinel Event Alert
#46 – Suicide Prevention (issued 11/17/2010)
What’s New?
 Focuses attention on areas outside behavioral
health
 Risk assessment recommended
 Consider ED, medical/ surgical units, outpatient
counseling areas
 Patient screening, monitoring and staff training
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Security Management
Issue: Joint Commission Sentinel Event Alert
#45 - Violence in the Healthcare Setting
What’s New?
 Audit the risk of violence in your facility
 Evaluate violence prevention program
 Discuss issues with HR department
 Provide appropriate staff training
 Ensure practical response procedures are in place
 Provide counseling and other services, as required
 Report violent acts to local authorities
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Hazardous Materials and Wastes
Issue: Proper disposal of partially used hazardous
medications
What’s New?
 P, U and D-listed medications must be identified
 A separate waste stream must be provided
 Staff must be trained to identify and properly dispose of
partially used medications in specific containers
 Waste medications must be incinerated by licensed
contractor
 Compliance with EPA, DOT and DEA is required
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Fire Prevention
Issue: Changes in test frequencies for fire
devices (EC.02.03.05, EP2)
What’s New?
Effective July 1, 2011, the Joint Commission will
require quarterly rather than semi-annual tests for
valve tamper and water-flow devices.
Note 1: References NFPA 25, 1998 edition, section 2-3.3 and NFPA
72, 1999 edition, table 7-3.2
Note 2: Published in the January 12, 2011 edition of Joint
Commission Online
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Fire Prevention
Issue: Changes in documentation requirements for fire alarm and
water-based fire protection systems (EC.02.03.05, EP25 – new!)
What’s New?
Effective July 1, 2011, the Joint Commission will require the
following documentation for fire system tests:
1. Name, date and required test frequency of the activity
2. Name and contact information of the person who performed the tests
3. NFPA reference for the test
4. Test result (pass or fail)
Note: Published in the January 12, 2011 edition of Joint Commission
Online
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Medical Equipment Management
Issue: Inventory of Endoscopes
What’s New?
 Flexible and rigid endoscopes must be included on the medical
equipment inventory
 The Biomedical Engineering Department is not required to repair or
service the endoscopes, but must monitor the service and repair
 Reusable medical equipment and proper cleaning of devices is a
“focus area” for 2011
Note: Announced by George Mills at the 2010 AAMI Annual Conference and
published in the August, 2010 and January 2011 issues of AAMI News
Healthcare Engineering Consultants
Medical Equipment Management
Issue: CMS Accepts Alternatives to
Manufacturer Maintenance Recommendations
What’s New?
 Previous disparity between CMS and the Joint Commission
regarding PM procedures has been eliminated
 Renewed focus on the following criteria for maintenance:
1. Manufacturer’s recommendations
2. Risk levels associated with equipment
3. Hospital experience with the equipment
Note: Published in the December, 2010 issue of Joint Commission Perspectives
and the January, 2011 issue of EC News
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Utility Systems Management
Issue: Humidity Monitoring in the OR’s
What’s New?
1. The Joint Commission has adopted the 2010 FGI Guidelines
document that references the new ANSI/ ASHE/ ASHRAE 170
standard for ventilation
2. The Guidelines document references humidity levels of 20% - 60%
3. CMS still references NFPA 99, section 5-4.1.1, which specifies a
minimum humidity level of 35%
4. The Joint Commission/ CMS disparity still exists
Note: Refer to 2010 FGI document for specific requirements
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Functional Environment
Issue: New 2010 FGI Document Referenced (EC.02.06.05, EP 1)
What’s New?
 2010 FGI document now referenced by the Joint Commission
 Applies to new, altered or renovated space after 1/1/2011
 Major changes in the 2010 edition include:
- Acoustics, patient handling and bariatric accommodations
- Cancer treatment and IV therapy services
- Telecommunications areas, wayfinding and patient safety
assessments
- Freestanding cancer treatment and outpatient rehab. facilities
- Incorporates ANSI/ ASHE/ ASHRE Standard 170 for ventilation
Healthcare Engineering Consultants
Changes to the 2011 Standards
Questions?
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