Transcript Organization of the 2005 Accreditation Manual

Changes and Challenges
for “EC” in 2009
Joint Commission
Presented by:
Gary D. Slack, PE, CCE
Healthcare Engineering Consultants
Part 1: Meeting the Challenges of the Survey
Process and New Changes for 2009
Understanding the
Survey Process
Healthcare Engineering Consultants
The Survey Process in 2009
Typical Surveys Include:
 Two to five days “on-site”
 Two, three or more surveyors (usually nurses
and physicians - includes a “Life Safety Specialist”
for all hospitals in 2008; two LSS surveyor days
for >750K sq ft, three for >1.3 million sq ft
 Review of documents (survey planning meeting)
 Life safety-focused facility tour
 “EC” interview includes tabletop simulation
 Questions to staff based on tracer methodology
 Summary conference to present tentative findings
Healthcare Engineering Consultants
The Unannounced Survey Challenge
Unannounced Surveys will Occur:
 Between January 1 and December 31, three years
after the last scheduled survey (during 2008)
 Between 18 and 39 months from the date of the first
unannounced survey (2009 forward)
 The timing of all surveys after the first unannounced
survey will be based on Priority Focus Process (PFP)
data (poor S3 scores lead to earlier survey?)
Note 1: All new applicants for the accreditation process as well
as changes to a new classification (example: critical access
designation) have unscheduled surveys
Note 2: Exceptions to unannounced surveys occur with the
Bureau of Prisons or certain DOD facilities
Healthcare Engineering Consultants
The Unannounced Survey Challenge
Surveys Can Also Occur Due To:
 One year follow-up survey for newly accredited
organizations that provide high risk or critical services
 Random off-cycle validation survey (5% pool,
discontinued at end of 2008)
 Random unannounced validation surveys to verify
“evidence of standards compliance” (ESC)
 Sentinel event follow-up
 Adverse media coverage of specific issue
 Complaint from the public
 Any other time that the JC decides it’s appropriate!
Healthcare Engineering Consultants
Meeting the Scoring Challenges
Understanding Scoring
Decisions and Defining
Low-Scoring Areas
Healthcare Engineering Consultants
“EC”-Related Scoring Rules for 2008
 Preliminary Denial of Accreditation (PDA)
PDA01 - Immediate threat to health or safety
PDA03 - Falsification of documentation
PDA06 - Non-compliant standards 3 standard
deviations above the mean (14 or 18 RFI’s)
 Conditional Accreditation (CON)
CON01 - Non-compliant standards count 1.5 standard
deviations above the mean (10 or 14 RFI’s)
CON03 - Failure to clear repeat non-compliant
standards
CON04 - Delayed PFI or no ILSM implementation or
enforcement when required
Healthcare Engineering Consultants
Joint Commission Scoring Decisions
Accreditation Thresholds for 2008
 Conditional Accreditation (CA)
10 or more non-compliant standards (< 100 ADC)
14 or more non-compliant standards (>100 ADC)
(change from 13 in 2007)
 Preliminary Denial of Accreditation (DOA)
14 or more non-compliant standards (<100 ADC)
18 or more non-compliant standards (>100 ADC)
(change from 17 in 2007)
 “CALS” threshold for DOA is 16 and 20 for small and
large hospitals, respectively
Healthcare Engineering Consultants
Lowest Scoring JC Areas
Percent Scored Not Compliant for Hospitals
MM.2.20 (43%) – Proper and safe medication storage
PSG 2C (36%) – Timeliness of critical test results
PSG 2B (29%) – Standardized list of abbreviations
Will likely
Move up
In 2008
EC.5.20 (27%) – Compliance with the Life Safety Code
IM.6.10 (24%) – Complete and accurate medical record
Universal Protocol 1: 2C (23%) – Conduct a “time out” before
starting a procedure
Healthcare Engineering Consultants
Lowest Scoring JC “EC” Areas
“EC” Standards Scored Not Compliant
for Other Facilities
EC.5.20 – Life Safety Code compliance
EC.4.10 – Emergency management
EC.9.10 – Conditions monitored in the environment
EC.6.20 – Equipment is maintained, inspected and
tested
Healthcare Engineering Consultants
Joint Commission Standards Scoring
“A” Scores: High priority, One and Done!
Safety Management Scoring Sheet
Example: EC1.10, EP 2
Safety officer appointment
You either have the letter or
you don’t – Compliant or
non-compliant, no partial
credit!
JCAHO
Standard
EC.1.10
1
2
3
4
5
6
8
9
EC.1.20
1
2
3
EC.1.30
1
2
3
4
5
6
7
Element of Performance
Safety Risk Management
Management Plan
Safety leadership appointment
Intervention authority
Proactive risk assessments
Procedures based on risk
Safety policy review
Safety recall process
Grounds and equipment
Maintains Safe Environment
Environmental tours
Patient areas
Non-patient areas
Smoking Policy
Policy in buildings
Outpatient/ youth prohibition
Exceptions to policy
Building requirements
Smoking cessation education
Compliance monitoring
Strategies for violations
Scoring Measure of Current
Category Success
Score
B
A
A
B
C
C
B
B
B
C
C
B
B
B
C
C
B
B
Healthcare Engineering Consultants
M
M
M
M
M
M
Joint Commission Standards Scoring
“B” Scores: Process, surveyor Discretion
Safety Management Scoring Sheet
Example: EC1.10, EP 3
Proactive risk assessment
Can be fully, partially or
non-compliant
Note: All of the “B” scores
will be deleted in 2009
JCAHO
Standard
EC.1.10
1
2
3
4
5
6
8
9
EC.1.20
1
2
3
EC.1.30
1
2
3
4
5
6
7
Element of Performance
Safety Risk Management
Management Plan
Safety leadership appointment
Intervention authority
Proactive risk assessments
Procedures based on risk
Safety policy review
Safety recall process
Grounds and equipment
Maintains Safe Environment
Environmental tours
Patient areas
Non-patient areas
Smoking Policy
Policy in buildings
Outpatient/ youth prohibition
Exceptions to policy
Building requirements
Smoking cessation education
Compliance monitoring
Strategies for violations
Scoring Measure of Current
Category Success
Score
B
A
A
B
C
C
B
B
B
C
C
B
B
B
C
C
B
B
Healthcare Engineering Consultants
M
M
M
M
M
M
Joint Commission Standards Scoring
“C” Scores: Three strikes and you’re out!
Fire Prevention Scoring Sheet
Example: EC5.40, EP 12
Portable fire extinguishers
Three missed monthly
checks (aggregated) is an
RFI!
JCAHO
Standard
EC.5.10
1
2
3
4
5
EC.5.20
1
2
5
6
EC.5.30
1
2
4
5
6
7
8
EC.5.40
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
Element of Performance
Fire Safety Management
Management plan
Proactive fire protection
Fire system testing program
Fire response plan
Acquisitions, decoration policy
Life Safety Code Compliance
NFPA 101 compliance
e-SOC completion
Sufficient PFI progress
SOC responsibility assignment
Fire Drills
Quarterly/ shift hospital drills
Annual/ shift clinic drills
Unannounced drills
Staff drill participation
Drill critique
Annual response evaluation
Staff knowledge during drills
Fire Component Tests
Supervisory/ tamper switches
Alarm notification devices
Off-premises trans. eqmt.
Fire pumps
Water tank level alarms
Water tank level alarms (cold)
Main drain tests
Fire department connections
Fire pumps
Kitchen systems
Gaseous extinguishing systems
Portable fire extinguishers
Occupant hoses
Smoke/ fire dampers
HVAC smoke detectors
Horizontal/ vertical fire doors
Scoring
Category
Measure of
Success
B
B
B
B
B
B
A
A
B
C
A
C
B
B
A
B
M
C
C
A
C
C
C
C
C
A
A
C
C
C
C
A
C
M
M
Healthcare Engineering Consultants
M
M
M
M
M
M
M
M
M
M
M
Current
Score
Special Scoring for SOC Deficiencies
During the Facility Tour
 “X” is considered a minor deficiency Example: a fire door
does not latch properly (item 1C3) – Score 1 point
 “Y” is considered a midrange deficiency Example: the
same fire door above is missing hardware (item 1C2) –
Score 2 points
 “Z” is considered a major deficiency Example: the building
is not of an allowable type of construction (item 1A1) or each
floor does not have at least two approved exits (item 5A) –
Score 4 points
Note 1: Use the scoring grid and key to determine the X, Y and Z
scores; 1-5 total score is partial compliance; 6 or greater is noncompliance, or a “Z” score!
Note 2: Implementation of an “effective” Building Maintenance
Program (BMP) “caps” each item at 1 point
Healthcare Engineering Consultants
Scoring Changes for 2009
 Scoring in the new Life Safety chapter will be the same as
the rest of the scoring (no longer any “X”, “Y” or “Z” scores)
 “A’s” and “C’s” will remain, “B” scores will be eliminated
 Four new levels of scoring risk (surveyor discretion):
1. Immediate Threat to Life: results in preliminary DOA
until follow-up evidence of compliance demonstrated
2. Situation Decision: results in preliminary DOA or CA
3. Immediate Impact Requirements: immediate care
impact; must submit ESC within 45 days
4. Less Immediate Impact: no immediate risk; ESC
submission within 60 days
Healthcare Engineering Consultants
Challenges for 2008 and 2009
Changes and Focus
Areas in 2008 and 2009
Healthcare Engineering Consultants
“EC”-Related Patient Safety Goals for 2008
For Ambulatory, Behavioral Health, Home
Care and Hospital Facilities
Add Goal #13: Encourage patient’s active
involvement in their own care as a patient safety
strategy (define and communicate the means for
patients and families to report safety concerns)
Add Goal #15: The organization identifies safety
risks inherent in its patient population (identify suicide
risk – relates to patients being treated for emotional
and behavioral disorders)
Note: This applies to all areas of the hospital!
Healthcare Engineering Consultants
Other “EC” Changes for 2008
 Smoke and fire dampers in hospitals can be
tested every six rather than every four years
 All hospitals, regardless of size, will have a Life
Safety Specialist for at least one day during the
survey
 Sentinel Event Alert #38 (MRI safety) must be
reviewed and appropriate action taken
 Behavioral health environmental risk
assessments must be documented
Healthcare Engineering Consultants
EC-Related Priority Focus Areas
(PFA’s) for 2009
 Equipment Use
 Infection Control
 Information Management
 Organizational Structure
 Orientation and Training
 Patient Safety
 Physical Environment
 Staffing
Healthcare Engineering Consultants
The 2009 Joint Commission Manual
 The entire Joint Commission manual will be
rewritten in 2009
 The Environment of Care chapter in 2008 will be
split into three chapters in 2009:
1. Environment of Care (EC)
2. Emergency Management (EM)
3. Life Safety, including the Statement of
Conditions (SOC) document (LS)
Healthcare Engineering Consultants
The 2009 EC Chapter
What will be the major EC changes?
 Mostly editorial changes
 Emergency management and life safety (not fire
safety) will have their own chapters
 Staff competency (including for clinical staff) will
be returned to the EC chapter
 Safety and security may be combined into one
standard
 An entirely new numbering system will be used
Healthcare Engineering Consultants
Numbering the EC Standards
 EC.01.01.01 – Management Plan Requirements
 EC.02.01.01 – Safety and Security
 EC.02.02.01 – Hazardous Materials and Wastes
 EC.02.03.01 – Fire Safety
 EC.02.04.01 – Medical Equipment
 EC.02.05.01 – Utilities Management
 EC.02.06.01 – Functional Environment
 EC.03.01.01 – Staff and LIP Training
 EC.04.01.01 – Monitoring and Improvement
Healthcare Engineering Consultants
Major Revisions to the EC Standards
EC.01.01.01 – The organization plans activities to
minimize risks in the Environment of Care
 Safety officer appointment with intervention authority
 Management plans for:
1. Safety
2. Security
3. Hazardous materials and wastes
4. Fire safety
5. Medical equipment
6. Utility systems
Healthcare Engineering Consultants
Major Revisions to the EC Standards
EC.02.01.01 – The organization manages safety
and security risks
 Identification of potential safety and security risks
 Action taken to minimize risks
 Maintenance of grounds and equipment
 Identifies staff, patients and others entering the facility
 Access control to and from security sensitive areas
 Identifies and implements procedures for security incidents
 The organization responds to product recalls/ notices
Healthcare Engineering Consultants
Major Revisions to the EC Standards
EC.02.01.03 – The organization prohibits smoking
except in specific circumstances
 Written smoking policy required
 Designates smoking areas that are environmentally
separate from care and service areas
 Action is taken to ensure compliance with the policy
Note: Smoking requirements for patients will be moved to
the “Provision of Care” (PC) chapter
Healthcare Engineering Consultants
Major Revisions to the EC Standards
EC.02.02.01 – The organization manages risks
related to hazardous materials and wastes
 Maintenance of hazmat inventory (Ref. CFR, IC,and MM)
 Procedures to minimize risk for hazardous chemicals,
radioactive materials, hazardous energy sources (radiation
and lasers) and hazardous gases and vapors
 Monitoring of exposure to hazardous gases and vapors
 Permits, licenses, manifests and MSDS sheets maintained
 Hazardous materials are properly labeled
 Procedures exist for PPE and spill responses
 Infectious waste management moved to IC chapter
 Proper disposal of hazardous medications
Healthcare Engineering Consultants
Major Revisions to the EC Standards
EC.02.03.01 – The organization manages fire
risks (includes fire policies and fire responsibilities)
EC.02.03.03 – The organization conducts fire
drills (includes conducting and evaluating drills)
EC.02.03.05 – The organization maintains fire
safety equipment and fire safety building features
(same fire system tests are required)
Note: The requirement for the implementation of interim life
safety measures has been moved to the new LS chapter
Healthcare Engineering Consultants
Major Revisions to the EC Standards
EC.02.04.01 – The organization manages medical
equipment risks
(includes policies for acquisition, including input from users,
equipment inventory, maintenance strategies, test intervals,
hazard notices, SMDA reports and equipment failures,
including clinical interventions)
EC.02.04.03 – The organization inspects,
maintains and tests medical equipment
(includes tests before initial use, ongoing testing for life
support equipment, non-life support equipment, sterilizers
and dialysis equipment, including water testing)
Healthcare Engineering Consultants
Major Revisions to the EC Standards
EC.02.05.01 – The organization manages risks
associated with its utility systems
(includes systems to meet patient needs, system inventory,
maintenance strategies, test intervals, water and airborne
pathogen policies, utility diagrams, labeling, and failure
procedures that include clinical interventions and obtaining
repair services)
EC.02.05.03 – The organization possesses a
reliable emergency electrical power source
(defines equipment and systems that are required to be
connected by the Life Safety Code and the National
Electrical Code)
Healthcare Engineering Consultants
Major Revisions to the EC Standards
EC.02.05.05 – The organization inspects, tests
and maintains utility systems
(requires initial testing of all utility systems and equipment
and also requires a defined maintenance program for life
support, infection control and non-life support utility systems)
EC.02.05.07 – The organization inspects, tests
and maintains emergency power systems
(requires monthly and annual battery light testing or battery
replacement with 10% random sample test, tests for SEPSS
systems, weekly, monthly and trienniel generator tests,
monthly transfer switch tests and annual load bank tests,
when required)
Healthcare Engineering Consultants
Major Revisions to the EC Standards
EC.02.05.09 – The organization inspects, tests
and maintains medical gas and vacuum systems
1. Requires inspecting, testing and maintenance of master
signal panels, area alarms, automatic pressure switches,
shutoff valves, flexible connectors and outlets at intervals
defined by the organization
2. Requires certification after installation or modification of
the system and purity, proper gas and proper pressure after
repair
3. Requires accessibility and labeling of main supply and
area shut-off valves
Healthcare Engineering Consultants
Major Revisions to the EC Standards
EC.02.06.01 – The organization manages and
maintains a safe, functional environment
(requires appropriate space and storage needs, suitable
outdoors area, appropriate lighting and ventilation, clean and
odor-free areas, emergency access to locked areas and
maintenance of furnishings and equipment)
EC.02.06.05 – The organization manages its
environment during demolition, renovation, or new
construction to reduce risk to those in the
organization
(requires adherence to AIA or other criteria, documentation of
a pre-construction risk assessment (PCRA) and action based
on the PCRA)
Healthcare Engineering Consultants
Major Revisions to the EC Standards
EC.03.01.01 – Staff and licensed independent
practitioners are familiar with their roles and
responsibilities relative to the environment of care
1. Staff and licensed independent practitioners can describe
or demonstrate methods for eliminating and minimizing
physical risks in the environment of care
2. Staff and licensed independent practitioners can describe
or demonstrate actions to take in the event of an
environment of care incident
3. Staff and licensed independent practitioners can describe
or demonstrate how to report environment of care risks
Note: This is a new standard for 2009; also HR reference
Healthcare Engineering Consultants
Major Revisions to the EC Standards
EC.04.01.01 – The organization collects
information to monitor conditions in the
environment
Requires a process to monitor performance in managing EC
risks and for investigating and reporting patient and staff
injuries; property damage; security incidents; hazardous
materials spills and exposures; fire safety problems,
deficiencies and failures; medical equipment problems,
failures and user errors, and; utility system problems, failures
and user errors. Semi-annual environmental tours in patient
areas and annual tours in non-patient areas are conducted
and an annual evaluation of each EC management plan is
documented.
Note: Requirement for specific PI measures eliminated!
Healthcare Engineering Consultants
Major Revisions to the EC Standards
EC.04.01.03 – The organization analyzes identified
environment of care issues and develops
recommendations for improving them
1. A multi-disciplinary improvement (MIT) team is required to
analyze EC issues
2. The analysis results in recommendations for improvement
3. The MIT recommends one or more EC performance
improvement activities to executive management
EC.04.01.05 – The organization uses the results of
the analysis to improve its environment
Action is taken on identified recommendations for
improvement in the environment of care
Healthcare Engineering Consultants
Contents of the 2009 Life Safety Chapter
LS.01.01.01 – Completion of the Statement of Conditions
LS.01.02.01 – Implementation of interim life safety measures
LS.02.01.10 – Building fire protection features
LS.02.01.20 – Integrity of the means of egress
LS.02.01.30 – Building features are maintained
LS.02.01.34 – Maintenance of fire alarm systems
LS.02.01. 35 – Maintenance of extinguishing systems
LS.02.01.40 – Special features for fire protection
LS.02.01.50 – Maintenance of building service systems
LS.02.01.70 – Operating features
LS.03.01.10 through LS.03.01.70 – Ambulatory health care
Healthcare Engineering Consultants
Impact of the 2009 Life Safety Chapter
 Individual chapter will focus attention on Life Safety
 Notes include a PFI “trigger” of 45 days from the DRAFT
 Parallels requirements in the 2000 Life Safety Code
 Standards can be used for the Life Safety Assessment
 Eliminates the “cap” on the Building Maintenance Program
 Notes include a maximum 6 month PFI completion time
from the DRAFT
 Permits some requirements in the 2006 edition of NFPA
101 (6” corridor wall protrusion)
 Also includes references to NFPA 10, 13, 18, 25, 72, 82,
96 and 99 and all other provisions of NFPA 101!
 Covers hospital and ambulatory occupancies
Healthcare Engineering Consultants
Contents of the 2009 Emergency
Management (EM) Chapter
EM.01.01.01 – Planning activities: HVA, M-P-R-R and ICS
EM.02.01.01 – Creation of the EOP
EM.02.02.01 – Emergency communications
EM.02.02.03 – Resource and asset management
EM.02.02.05 – Security and safety
EM.02.02.07 – Management of staff
EM.02.02.09 – Management of utilities
EM.02.02.11 – Patient management
EM.02.02.13 – Emergency privileges to LIP’s
EM.02.02.15 – Disaster responsibilities to volunteers
EM.03.01.01 – Evaluation of program effectiveness
EM.03.01.03 – EOP evaluation using drills
Healthcare Engineering Consultants
Organizational Function Overview
 Human Resources (HR)
Staff training, competency and performance
 Leadership (LD)
Compliance, resources, patient safety, oversight of
contracts/ services
 Performance Improvement (PI)
Data collection, aggregation, analysis , action
 Information Management (IM)
Data collection, aggregation, security
 Infection Control (IC)
Measurement and reduction of infections
Healthcare Engineering Consultants
Organizational Function Overview
Questions?
Healthcare Engineering Consultants