Transcript ASHE 7 07 Emerg Mgmt

2011
George Mills, Sr. Engineer
Standard Interpretation Group
The Joint Commission
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The Healthcare Environment
Risk Assessment
clear decision
 Educated guess that drives your
assumptions
 Clearly document the process
 Determine when to re-assess the issue
 Problem solving approach to determine
appropriate response
 Preventive strategies to address
potential issues
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 Use to evaluate any issue that lacks a
Risk Assessment
The hospital takes action to minimize or eliminate
identified safety and security risks in the
physical environment.
EC.02.01.01 EP 3
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The hospital identifies safety and security risks
associated with the environment of care. Risks
are identified from internal sources such as
ongoing monitoring of the environment, results
of root cause analyses, results of annual
proactive risk assessments of high-risk
processes, and from credible external sources
such as Sentinel Event Alerts.
EC.02.01.01 EP 1
Risk Assessment in the
Healthcare Environment
assessment in the Physical Environment
 Environmental Tours
 Observe the environment
 Manage By Walking Around
 Documentation
 Inspect, Test & Maintain
 Evaluate the effectiveness of the
processes
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 Several tools exist to facilitate risk
Environmental Tours
are included:
 Public waiting areas
 Floor covering in safe/functional condition
 Seating
 Grounds, Sidewalks, Garages, Parking Lots
 Egress to the “Public Way”
 Elevators
 Designated off-site locations
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 Make sure that all areas of your organization
EC.02.06.01
 EP 1: Interior spaces meet the
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needs of the individuals served for
safety and suitability for the care,
treatment or services provided.
Visual Observations
processes



Include affected staff
Eliminating “workaround”
Eliminating
hazards/safety issues
 Proper storage of items

Supplies


Refrigerators



Medications, food,
biohazards, supplies
Housekeeping carts &
closet
Hand hygiene products


Patient / Non-patient
Alcohol gels, paper
towels, gloves, etc.
Equipment
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 Evaluate typical
Visual Observations
 Personal Space
areas for use by individuals
 Waiting & Reception areas
 Restrooms are appropriate
 Lighting is suitable for care, treatment, or
services
 Ventilation, temperature and humidity levels
 Furnishings
 Dining environment
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 Outside
Staff Interviews
 Establish
staff
knowledge
 Evaluate
 Trend
 Process:
 Random selection
 Evaluate against
policy
 Examples of processes
evaluated:
 Reporting patient and
employee injury events
 Referencing
policies/procedures
 Evacuation Plans
 Labeling/reporting
broken/non-functioning
equipment
 Role in Emergency
Operations Plan
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 Purpose:
Summary
 Make sure that all identified issues are
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followed up on in a timely matter
 Close the loop
 Utilize data collected as a performance
improvement tool
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Questions?
SIG Engineers: 630 792 5900
George Mills, MBA, FASHE, CEM, CHFM, CHSP
Senior Engineer
SIG
Anne Guglielmo, CFPS, LEED, A.P.
Engineer
SIG
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Michael Chisholm, CPE, CHFM
Engineer
SIG
The Joint Commission
Disclaimer
 These slides are current as of 2/17/2011. 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
 These slides are copyrighted and may not be further
used, shared or distributed without permission of the
original presenter or The Joint Commission.
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were expounded 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.