Transcript No Slide Title

Part 7: Meeting the Standards Challenges
Strategies for the
Standards Challenges
Healthcare Engineering Consultants
Safety Management
Issue:
Proactive Risk Assessments for Safety
Tip for Compliance:
Think of risk assessments as simply
prioritizing potential problems
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Documenting Risk Assessments
Risk Assessment:
“Prioritization and management of
resources though an assessment of
probability and impact”
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Why Perform Risk Assessments?
Not enough time!
Not enough staff!
Not enough money!
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Calculating Risk Assessments
Risk =
Probability X Impact
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Global Risk Assessments
What’s a Global Risk
Assessment and What is
it’s Purpose?
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Performing a Global Risk Assessment
Step 1: Identify a “Global” Area to Assess
Step 2: Select a Team of Stakeholders
Step 3: Brainstorm and List the Risk Elements
Step 4: Assign Probability and Impact to the
Risk Elements
Step 5: Prioritize the Risk Elements
Step 6: Perform the Specific Risk Assessments
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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
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Specific Risk Assessments
What’s a Specific Risk
Assessment and What is
it’s Purpose?
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Performing a Specific Risk
Assessment
Step 1: Identify Issues and Select a Team
Step 2: Analyze Factors
Step 3: Make a Decision
Step 4: Document the Evaluation and Decision
Step 5: Make the Necessary Changes
Step 6: Monitor and Reassess
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Specific Risk Assessment Examples
Lock clean supply room doors?
Infant/ pediatric abduction measures
Safe environment for mental health
Medical equipment test tags
Utility system PM intervals
Security “sensitive areas”
Other?
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Understanding RCA’s and FMEA’s
What’s the Difference Between
an FMEA and an RCA?
Are They Both
Risk Assessments?
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Safety Management
Issue:
What about recurring operational
deficiencies?
Tip for Compliance:
You can’t improve what you can’t
measure!
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How Do We Solve This Problem?
Steps required to reduce operational deficiencies:
1. Determine how to measure the problem severity
2. Establish a numerical baseline score
3. Explain measurement system to area staff
4. Let staff determine an improvement goal
5. Re-measure scores at unscheduled times
6. Provide numerical feedback to staff
7. Celebrate achievement of goal
8. Continue measurement until the culture changes
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Solving the Hallway Clutter Problem
Step 1: Determine how to measure the
problem severity
Solution and Procedure: Assign points
to various types of egress corridor
deficiencies, based on severity of
violation
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Solving the Hallway Clutter Problem
Point Score Examples
Description of Deficiency
Point Score
(per occurrence)
Small medical device on wheels (NIBP unit),
against wall, charging, not blocking shut-offs
1
Equipment or furniture, not in use, one side of
corridor only, not blocking shut-off or fire alarm
3
Large furniture or equipment, on both sides of
corridor, not in use, not blocking shut-off/ alarm
5
Large furniture or equipment, in corridor, not in
use, blocking emergency shut-off or fire alarm
8
Large furniture or equipment, in corridor,
preventing fire or smoke door from closing
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10
Solving the Hallway Clutter Problem
Step 2a: Establish a numerical baseline
score for a specific hospital area (4 West)
Procedure: Use the point values for
deficiencies that have been assigned and
determine total scores by randomly
inspecting the area once per day for at
least one week
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Solving the Hallway Clutter Problem
Operational Deficiency Scorecard
Area: 4 West
Description of Deficiency
Reviewed By: GDS
Date: September 18, 2006
Points per Deficiency
Number of Deficiencies
Total Category Points
Chair blocking fire door
10
1
10
Gurney in corridor; blocking
alarm pull box, zone valve
Furniture, without wheels,
both sides of corridor
Items in corridor, with
wheels (IV, NIBP units)
8
1
8
5
2
10
1
5
6
Total Points:
34
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Solving the Hallway Clutter Problem
Point Score Results of Daily Inspections
Day
Mon.
Tues.
Wed.
Thurs.
Fri.
Points
34
27
39
42
28
Cum.
Average
34
32
33
36
34
This is the baseline
number for 4 West
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Solving the Hallway Clutter Problem
Graphical Results
70
60
50
40
30
20
10
0
Mon
Tues
Wed
Thurs
4 West Daily Data
Fri
Baseline
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Solving the Hallway Clutter Problem
Graphical Results
70
60
50
Daily Scores
New goal: 25 points
40
30
20
10
0
Mon
Tues
Wed
Thurs
4 West Daily Data
Fri
New Goal
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Safety Management
Issue:
How to solve the smoking dilemma?
Tips for Compliance:
 Create a practical policy
 Recognize the “citation priority”
 Monitor smoking compliance
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Smoking Monitoring
Summary of Smoking Violations
Location of Smoking Violation
Time of Observed Violation
Description of Violator
Area directly outside of Emergency
Center; “B-C” corridor area
Loading dock attached to “B” building
All shifts
Staff, patients, visitors
First and second shift
Staff, vendors
Loading dock attached to “D” building
First and second shift
Staff, vendors
Second level stairway exterior from “B”
building
Main entrance to “A” building (within 50
feet)
Second and third shift
Staff
First shift
Visitors and patients
Summary of Compliance Strategies






New anti-tobacco policy, effective 18 October, 2004
Smoking shelters are on order and will be installed in January, 2005 near the “A” building entrance
Current signage will be replaced with universal “No Smoking” signs in January, 2005
New protocols for staff discipline have been implemented with the new policy
Additional training for all staff regarding smoking policies has been provided
Smoking cessation classes for hospital staff have been implemented; all smokers are encouraged to participate
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Security Management
Issue: Security Responsibility Appointment
Tips for Compliance:
 Letter provided by leadership
 Identify security responsibility
 Include:
Coordination
Development and implementation
Monitoring
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Security Management
Issue: Security Risk Assessment
Tips for Compliance:
 Include security sensitive areas:
ED, OB/ Gyn, Pharmacy, Infectious waste
Other areas?
 Evaluate facility access control
 Provide training for staff in sensitive areas
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Security Management
Issue: Security “Special Cases”
Tips for Compliance: Consider the following –
 Use of firearms or other means of force
 Mental health areas

Medication and infectious waste security

Infant/ child abduction prevention and drills

Cell phones with cameras/ privacy issues

Access to unauthorized areas

Security in construction areas
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Hazardous Materials and Wastes
Issue: MSDS Sheets
Tips for Compliance:
 Ensure an accurate inventory
 Provide staff training
 Consider MSDS options:
Binder with data sheets
1-800 “Fax-on-Demand”
Internet or intranet access
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Hazardous Materials and Wastes
Issue: Chemical Waste Stream
Tips for Compliance:
 Ensure disposal procedures for:
Chemicals
Chemotherapeutics
Radioactive materials
Medical waste and sharps
Waste phamaceuticals
 Per applicable laws (OSHA, EPA, NRC, DOT)
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Hazardous Materials and Wastes
Issue: Compressed Cylinder Storage
Tips for Compliance:
 For stored gases <300 cubic feet in smoke compartment:
- Enclosures not required (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)
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Hazardous Materials and Wastes
Issue: Compressed Cylinder Storage
Tips for Compliance:
 Requirements for stored gas only, not in-use tanks!
 In-use gas includes:
- Tanks on code carts
- Tanks on wheelchairs
- Tanks on gurneys
 Empty tanks do not count toward the total
 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
Tips for Compliance:
 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
sprinklered 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
Tips for Compliance:
 Use risk assessment to determine placement
 ANSI standards have not been officially adopted by the
Joint Commission
 Testing policy is required – specify test intervals
 Documentation of test results is required
 Differentiate between eyewash station and “first aid”
station, such as mounted bottles
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Hazardous Materials and Wastes
Issue: Hazardous Vapor Monitoring
Tips for Compliance:
Clinical lab: formaldehyde and xylene
Central supply: ethylene oxide
OR’s: nitrous oxide, methyl-methacrylate
Respiratory: glutaraldehyde
Sleep lab: collodion
Monitor and document per OSHA requirements!
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Approved Changes for 2009
EMERGENCY
The organization of the standards :
 EM.01.01.01: Plans for managing emergencies
 EM.02.01.01: Develops an emergency operations plan
 EM.02.02.01: Establishes emergency communication strategies
 EM.02.02.03: Establishes strategies for managing resources
 EM.02.02.05: Establishes strategies for managing safety and security
 EM.02.02.07: Defines and manages staff roles and responsibilities
 EM.02.02.09: Identifies an alternative means for providing utilities
 EM.02.02.11: Identifies strategies for patient management
 EM.02.02.13: Privileges to LIP’s
 EM.02.02.15: Privileges to volunteer staff
 EM.03.01.01: Annual effectiveness review
 EM.03.01.03: Regularly tests the emergency operations plan
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Emergency Management
EMERGENCY
EM.01.01.01: The organization plans for managing the
consequences of emergencies
 Medical and clinical staff participate in planning
 A Hazard Vulnerability Analysis (HVA) is performed and documented
 The hazards are prioritized
 Communication of emergency plan with community responders
 Mitigation, Preparedness, Response, Recovery
 Assets and resources are inventoried and documented (CAP)
 Asset and resource inventories are monitored during emergencies
(CAP)
 The emergency management program is evaluated annually (S,O,P,E)
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Emergency Management
EMERGENCY
Tips for Compliance with EM.01.01.01:
 Appoint a physician and administrative representative to actively
participate on the emergency management planning committee
 Perform and document the Hazard Vulnerability Analysis (HVA) for all
geographically separate facilities – review annually!
 Be ready to describe the Mitigation, Preparedness, Response and
Recovery procedures in the EOP
 Ensure that emergency resources are inventoried (PPE, utility and
medical supplies and pharmaceuticals) and monitored
 Evaluate the emergency management program annually (S,O,P,E)
and report the results to the safety committee
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Emergency Management
EMERGENCY
EM.02.01.01: The organization develops and maintains
an Emergency Operations Plan (EOP)
 Written EOP includes an “all hazards” command structure
 An incident command structure (ICS) is established and is consistent
with the community plan
 The ICS identifies a reporting structure
 Activation of ICS is identified
 Activation of ICS phases is identified
 The EOP identifies the organization response when community nonsupport may occur for up to 96 hours (CAP)
 Alternative care sites are identified
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Emergency Management
EMERGENCY
Tips for Compliance with EM.02.01.01
 Create a written emergency operations plan (EOP) that describes the
incident command structure and process that is in use (HICS 4?) as well
as how ICS integrates into the six critical core areas:
1. Emergency communications
2. Resources and assets
3. Safety and security
4. Staff roles and responsibilities
5. Management of utilities
6. Clinical and support activities
 The EOP can either describe the ICS and core area integration in
detail or reference existing documents
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Emergency Management
EMERGENCY
HICS Organizational Chart
Incident
Commander
Operations
Section Chief
Public Info
Officer
Safety
Officer
Liaison
Officer
Med/ Tech
Specialist(s)
Planning
Section Chief
Logistics
Section Chief
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Finance/ Admin
Section Chief
Emergency Management
EMERGENCY
Tips for Compliance with EM.02.01.01
 Create two color-coded timeline charts the indicate how long utilities
will be operational and how long consumable supplies will be available in
the event of an emergency in which no re-supply is possible
 Ensure that decisions are made to determine whether any utility or
supply changes will be implemented to extend “green zones”
 Create two 96-hour plans that assume the following scenarios:
PLAN A: Supplies are available and are ordered and received
PLAN B: Internal supply shortages or utility failures require partial or
total patient evacuation
PLAN C: Shortages and/ or utilities are not sufficient to continue
normal patient care, although evacuation is not possible
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Emergency Management
EMERGENCY
Critical Utilities and Supplies Timeline
 Assume external help is not available
 Create timeline for utilities and critical
supplies, such as food and medications
 Determine time-dependent status:
- Green: Continue all services as usual
- Yellow: Transition to conservation mode
- Red: Discontinue patient treatment, evacuate
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Emergency Management
EMERGENCY
Utility Failure Operational Impact Chart
Hours after utility failure
Normal power failure
0
8
16
24
32
40
48
56
Emergency power failure
Water pressure low
Entire loss of water pressure
Loss of steam generation (winter)
Loss of steam generation (summer)
Loss of natural gas
Loss of propane
Chiller failure (winter)
Chiller failure (summer)
Major air handler failure
Failure of sewage system
Sump pump failure
Loss of bulk oxygen
Loss of medical air
Loss of bulk nitrous oxide
Loss of medical vacuum
Computer server failure
Telephone switch failure
Failure of elevators
Pneumatic tube system failure
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64
72
80
88
96
Emergency Management
EMERGENCY
Consumable Supply Operational Impact Chart
Hours after emergency occurs
Fuel oil (winter)
0
8
16
24
32
40
48
56
Fuel oil (summer)
Gasoline
Propane fuel
Natural gas
Potable water
Non-potable water
Oxygen
Medical air
Nitrous Oxide
Nitrogen
Nutrition supplies
Pharmaceutical supplies
IV solutions
Pharmaceutical medications
General patient supplies
Surgical supplies
Environmental cleaning supplies
Central sterile supplies
General office supplies
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64
72
80
88
96
Emergency Management
EMERGENCY
EM.02.02.01: The organization establishes emergency
communications strategies
 Staff notification procedures are created
 Provisions for ongoing staff communication during the emergency
 Process to notify external authorities
 Communication with patients and their families
 Communication with the community and media
 Communication with vendors and suppliers (CAP)
 Sharing information with other health care providers
 Providing information about patients to third-parties (FEMA, CDC, etc.)
 Communication with alternative care sites
 Establishment of back-up communication systems and technologies
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Emergency Management
EMERGENCY
Tips for Compliance with EM.02.02.01
 Create notification charts with phone numbers, email addresses, etc.
 Include for staff, external authorities, community, media, vendors
 Determine what information will be shared with other health care
providers in the area
 Ensure that liaisons are established with government agencies
 Verify that MOU’s for alternative care sites are updated
 Establish and check operation of back-up communication systems,
such as the internet, cell phones, two-way radios, emergency land lines,
and amateur radio operators
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Emergency Management
EMERGENCY
EM.02.02.03: The organization establishes strategies for managing
resources and assets during emergencies
 Plans for obtaining medications and non-clinical supplies
 Replenishing medical supplies and equipment during the emergency
 Replenishing pharmaceutical supplies
 Replenishing non-medical supplies (food, water, fuel, linens, etc.)
 Managing staff and family support activities
 Sharing of resources with other health care organizations in and outside of the
local community (CAP)
 Horizontal, vertical and total evacuation (CAP), including transportation of
patients, medications, equipment, staff and medical record information
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Emergency Management
EMERGENCY
Tips for Complying with EM.02.02.03
 Plans should be in place to stockpile and reorder critical clinical and
non-clinical supplies
 Written procedures should describe how the needs of staff and
families of staff will be met during an emergency
 A plan to share community resources and assets should be in place
 A practical patient evacuation plan that includes horizontal and vertical
movement within the facility as well as partial or total evacuation outside
of the facility is required
 Logistics for evacuation should include: 1) transportation; 2) staffing;
3) medications; 4) equipment, and; 5) the medical record
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Emergency Management
EMERGENCY
EM.02.02.05: The organization establishes strategies for managing
safety and security during emergencies
 Internal safety and security measures are established
 Role of community security agencies is established with the healthcare
organization and means of coordination is identified (CAP)
 Processes for handling hazardous materials and waste are developed (CAP)
 Plans are developed for radioactive, biological, chemical decontamination
 Patients susceptible to wandering are identified (CAP)
 Access into and out of the facility are controlled
 Movement of staff and patients is controlled within the facility
 Traffic accessing the facility is controlled
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Emergency Management
EMERGENCY
Tips for Complying with EM.02.02.05
 Security staffing plans during emergencies must be established
 Expectations with outside police agencies should be identified
 Plans to dispose of infectious and hazardous waste must be created
 Procedures to treat contaminated patients must be written
(radioactive, biological and chemical)
 Methods to lock down the facility to prevent entry must be provided
 Methods to minimize staff and patients from leaving the facility must
be planned
 Plans must be in place to control traffic accessing the facility
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Emergency Management
EMERGENCY
EM.02.02.07: The organization defines and manages staff
roles and responsibilities
 Staff roles and responsibilities are defined for the critical areas
(communications, resources and assets, safety and security, utilities,
clinical activities)
 Staff are trained relative to their responsibilities (CAP)
 Roles of LIP’s are specifically defined (CAP)
 Care providers and command center staff are identified (ID badges,
vests, caps, etc.)
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Emergency Management
EMERGENCY
Tips for Complying with EM.02.02.07
Review and update as necessary, the ICS organizational chart and job
action sheets (check after each drill)
 Ensure that hospital staff have participated in NIMS training
 Discuss emergency expectations with the independent physicians
who have privileges at the hospital
 Select the primary and back-up command center locations
 Have a method to identify incident command staff (ID badges, vests,
caps, etc.)
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Emergency Management
EMERGENCY
EM.02.02.09: The organization establishes strategies for
managing utilities during emergencies, such as:
 Electricity
 Potable and non-potable water
 Fuel for building operations or transport vehicles (CAP)
 Other essential utility needs, such as:
- HVAC equipment
- Medical gas and vacuum systems
- Fire systems
- Sewer
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Emergency Management
EMERGENCY
Tips for Complying with EM.02.02.09
 Complete the utility 96-hour timeline chart
 Determine which utilities require additional supplies, especially water
and fuel
 Determine the feasibility of redundant systems or supplies
Examples: Water – on-site well, water tower or nearby lake
Electricity – additional generators installed
Boilers – portable boiler “on a truck”
Medical gas – low pressure external connection, manifold
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Emergency Management
EMERGENCY
EM.02.02.11: The organization establishes strategies for managing
clinical and support activities during emergencies, including:
 Patient scheduling, triage, assessment, treatment admission, transfer,
discharge and evacuation
 Clinical services for vulnerable patients, such as: pediatric, geriatric,
disabled or serious chronic conditions or addictions
 Personal hygiene and sanitation
 Mental health needs (CAP)
 Mortuary services (CAP)
 Tracking and documenting patient information (CAP)
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Emergency Management
EMERGENCY
Tips for Complying with EM.02.02.11
 Identify which patients in the hospital are considered “vulnerable”
(neonatal intensive, pediatric, geriatric, dementia, behavioral health)
 Plan for patient and staff hygiene and sanitation without water or sewer
 Determine mortuary needs in the event of a pandemic
 Evaluate back-up methods to track patient information in the event that
the electronic information system fails
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Emergency Management
EMERGENCY
EM.02.02.13: During disasters, the organization may grant privileges
to licensed independent practitioners
 Privileges granted only when EOP has been activated
 Medical staff bylaws indicate to who and how to grant privileges, and
policies will indicate how performance will be evaluated
 Minimum privileging requirements include:
1. Current picture ID and license to practice
2. Must be a member of a recognized disaster response group
3. Proof of government authority to provide services during a disaster
 Hospital determines within 72 hours if privileges should continue
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Emergency Management
EMERGENCY
EM.02.02.15: During disasters, the organization may assign disaster
responsibilities to volunteer practitioners
 Hospital assigns responsibilities only when EOP has been activated
 Hospital identifies in writing who is eligible and how to assign disaster
responsibilities to non-LIP’s
 Minimum requirements to assist during disasters include:
1. Current picture ID and license to practice professional specialty
2. Must be a member of a recognized disaster response group
3. Confirmation by hospital staff the individual is qualified
 Hospital determines a method to evaluate performance and decide
within 72 hours if responsibilities should continue
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Emergency Management
EMERGENCY
EM.03.01.01: The organization evaluates the effectiveness of its
emergency management planning activities
 The Hazard Vulnerability Analysis (HVA) is evaluated annually to
determine if revisions are necessary
 The Emergency Operations Plan (EOP) is evaluated annually with
regard to the Scope, Objectives, Performance and Effectiveness of
the program
 The hospital conducts an annual review of the inventory process with
regard to emergency supplies, and documents the results
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Emergency Management
EMERGENCY
EM.03.01.03: The organization regularly tests its emergency
operation plan
 Twice over 12 months, either as a drill or actual emergency
 Once per year in a business occupancy
 One “influx of patient” drill per year
 One escalation per year to test community “non-support”
 One “community-wide” drill per year
 Drills are realistic and based on the HVA
 A dedicated, trained individual must evaluate the drill
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Emergency Management
EMERGENCY
EM.03.01.03: The organization regularly tests its emergency
operation plan (continued)
 The six critical areas are monitored: 1) Communication; 2) Resource
mobilization; 3) Safety and security; 4) Staff roles and responsibilities; 5)
Utility systems, and; 6) Patient clinical and support activities
 Exercises are critiqued with a multi-disciplinary group, including
leadership, physician and support staff and evaluate deficiencies
 The operations plan is revised based on the drill findings
 Subsequent exercises evaluate the improvements to the EOP
 Drill evaluations are reported to the hospital safety committee
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Emergency Management
EMERGENCY
Tips for Compliance with EM.03.01.03
 Two drills per rolling 12-month period should be performed, based on
the HVA
 At least one drill per 12 months in a business occupancy
 At least one “influx” drill for a disaster receiving station
 Community-wide and influx drills can be performed concurrently
 The community 96-hour “non-support” drill can be a tabletop
 Trained staff, including a physician and leadership, must evaluate the
drill and must document the six core areas in the evaluation
 Infant abduction (EC.2.10) and patient surge (IC.6.10) drills are highly
recommended
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Fire Prevention
Issue: Fire Drills
Tips for Compliance:
 Healthcare and ambulatory:
1 drill per shift per quarter
 Business occupancy:
1 drill per shift per year
 Drill monitoring as defined in the plan
 Evaluate effectiveness annually in written report
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Fire Prevention
Issue: Interim Life Safety Measures
Tips for Compliance:
 A policy must describe the program
 Document whether ILSM is or is not required
 Determine ILSM applicability for PFI’s!
 Document which measures are applicable
 Document required inspections
 Failure to meet ILSM provisions: CON04!
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Medical Equipment Management
Issue: Equipment Test Scoring
Tips for Compliance:
 100% PM completion for “life support” devices,
based on scoring (A)
 90% PM completion for “non-life support”
devices (C)
 Determine test interval by “PM effectiveness”
and MTBF data
 Test tags with due dates recommended, but not
required! What about Ongoing PM vs. initial test
only?
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Medical Equipment Management
Issue: Other Medical Equipment Issues
Tips for Compliance:
 Patient-owned equipment
Diagnostic and therapeutic (example: CPAP)
Personal use (iPods, cell phones, blackberries)
 Rental devices
 Demo, loaner and trial equipment
 Radio-frequency interference
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Utility Systems Management
Issue: Waterborne Pathogens
Tips for Compliance:
Waterborne pathogens policy must include:
1. Patient risk assessment for pathogen
vulnerability
2. Operational description of measures to reduce
waterborne pathogens
3. Remediation procedures if hospital-acquired
waterborne infection is determined
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Utility Systems Management
Issue: Airborne Pathogens
Tips for Compliance:
An airborne pathogens policy must exist that
describes:
Air filter maintenance, room air exchange rate and
pressure relationships for operating rooms, delivery
rooms, special procedure rooms, patient isolation rooms,
clinical laboratories, sterile supply rooms and pharmacies
Note: Refer to AIA document for requirements
Note: “Grandfathering” permitted for air handlers
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Utility Systems Management
Issue: Utility System Test Scoring
Tips for Compliance:
 All devices included in the utility systems
management program must be at least initially tested
 Expected PM completion rate for “critical life
support” and “critical infection control” components
based on “A” scoring: 100%
 Expected PM completion rate for “critical non-life
support” components based on “C” scoring: 90%
 “Non-critical” components are not scored
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Appropriate Environment
Issue: The “General Duty Clause”
Tips for Compliance:
 Patient areas are safe, clean, comfortable
 Lighting is suitable
 Ventilation provides for acceptable temperature
 Locks and restraints per regulation
 Emergency access for locked spaces
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Appropriate Environment
Issue: New Construction
Tips for Compliance:

AIA document, 2001 edition (2006 soon?)
 Applicable federal, state or local
guidelines
 Equivalent design criteria
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Appropriate Environment
Issue: Pre-Construction Risk Assessment (PCRA)
Tips for Compliance: Include all of the items listed
below in the PCRA evaluation
Noise
Vibration
Air quality
Infection control
Emergency procedures
Utility failures
Interim life safety measures
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Infection Control Risk Assessment
(ICRA)
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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Appropriate Environment
Issue: Ongoing Monitoring
Tips for Compliance:
• Controls include measures to reduce risk and
minimize the impact of the construction activities
• Daily monitoring checklist is recommended
• Consider posting required PCRA permits, such as
hot work, ICRA, above-the-ceiling work, etc. on door
entrance to construction area
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