Transcript Part 5 - Presentation - 2014 Physcial Environment Interview

Best Practices and Programs:
Getting Survey Ready
The Physical Environment
Interview Session
Healthcare Engineering Consultants
Preparing for the “PE” Interview
Facts About the Physical Environment Interview Session
 Is usually scheduled near the end of the survey for 2 to 3
hours
 Is likely to be conducted by the Life Safety Surveyor
 Is “discussion-oriented” – not much document review
 Hospital representatives from each of the “EC” and “EM”
areas should be present, and others such as infection control,
patient safety and administration, as desired
 The session will not include a tabletop simulation, but there
will be questions about Emergency Management
 Hospital staff should review the safety committee minutes
and the annual evaluations prior to the interview, since some
questions will be selected from these documents
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Preparing for the PE Interview
Have the Following Documents Available:
 Management plans and annual effectiveness evaluations
 Risk assessments for safety, security, behavioral health,
PCRA and ICRA; surveillance rounds reports
 Manifest forms for hazardous waste and results of toxic
waste gas exposure surveys
 Emergency operations plan (EOP), HVA, ICS org chart, job
action sheets, 96-hour utility and consumable timeline,
evaluations from emergency drills
 Fire drill reports and interim life safety documents
 PM data for medical equipment
 Waterborne and airborne policies and PM data for utility
systems
 “EC” reports to executive management/ governing body
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Assigning Responsibilities
“EC” Interview Responsibility Grid
“EC” Area
Primary
Spokesperson
Secondary
Spokesperson
Back-up
Spokesperson
Safety
Management
Security
Management
Hazardous
Materials
Emergency
Management
Fire
Prevention
Medical
Equipment
Utilities
Management
Appropriate
Environment
Healthcare Engineering Consultants
Comments
Preparing for the PE Interview
Prepare Answers to the Following Questions:
What is the biggest problem that you have for
_________________ ? (fill in EC area)
What is your greatest success regarding
_________________ ? (fill in EC area)
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Preparing for the PE Interview
Other Items to Remember about the PE Interview
 If the surveyor wants to be consultative, let them teach while you
listen!
 Don’t hesitate to explain “areas of excellence” about your program, if
the timing is appropriate
 Always let the “primary spokesperson” answer the question first –
never argue or disagree with each other in front of the surveyor!
 Don’t volunteer information that isn’t requested, unless it’s
guaranteed to provide positive information about your program
 Remember, you’re the expert – you know more about your program
then the surveyor ever will – but you must effectively communicate
 Be confident, but not arrogant
 If the surveyor decides to end the session early, say “thank you” –
don’t try to over-explain or extend the session!
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Safety Management
Issue: Proactive Risk Assessments for Safety
Achieving Compliance:
1. Create a “HVA” for prioritizing safety risks
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 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 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
Other Likely Safety-Related Questions
1. What have you done to minimize the safety risks that have been
identified and prioritized?
2. Explain the product recall process for durable equipment,
disposables, nutritionals and pharmaceuticals
3. How do you “aggregate” the recalled items and report to the
hospital safety committee?
4. How do you provide monitoring of “EC-related” issues, including
regulatory and performance items?
5. How do you provide orientation and ongoing “EC” training for all
staff?
6. How do you enforce the smoking policy (including electronic
cigarettes)?
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Measurement and Improvement
What Measurements are Required?
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 minimum number!
 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 is required
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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
Security Management
Issue: Proactive Security Risk Assessment
Achieving Compliance:
 Create a multi-disciplinary group to perform and document
the proactive security risk assessment, similar to what is
required for safety
 Use the numerical “HVA format” to easily prioritize the risks
 Evaluate necessary changes to minimize probability and
impact
 Obtain approval for the recommended changes
 Implement changes, and track and document progress
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Security Management
Issue: Security Sensitive Areas
Achieving Compliance:
 Clearly identify areas in the facility that are considered
“security sensitive”
 Expected areas include pharmacy, emergency
department, obstetrics and behavioral health
 Other areas might include information systems,
administration, intensive care units, etc.
 At least one infant abduction and active shooter drill is
expected annually
 A tabletop active shooter drill is acceptable
Healthcare Engineering Consultants
Security Management
Other Likely Security-Related Questions
1. What has been done to minimize the possibility of violence
in the workplace?
2. How are staff, patients, visitors and vendors and
contractors identified when in the hospital?
3. How do you track security-related incidents?
4. Have any security sentinel events occurred? What
measures did you take to prevent any recurrence?
5. Have you performed a risk assessment in areas where
behavioral health patients may be treated (including the
emergency department)?
6. How do you ensure security in the nuclear medicine “hot
lab”?
Healthcare Engineering Consultants
Hazardous Materials and Wastes
Issue: Hazardous Materials Inventory and SDS
Achieving Compliance:
 Create an electronic or “paper” inventory that includes a list of
hazardous materials used in the facility
 The SDS list is not sufficient – either average quantities “on hand” or
PAR reorder levels should be included on the list
 Safety Data Sheet (SDS) training for all facility staff was required to be
completed by December 1, 2013
 Distributors must not ship containers without a “Global Harmonization
System” (GHS) label after December 1, 2015
 Update workplace labeling and training program, as necessary, by
June 1, 2016
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Hazardous Materials and Wastes
Issue: Minimizing Risks With Hazardous Energy (R icon)
Achieving Compliance:
 Provide clear signage for Zones 1 - 4 in MRI areas
 Ensure that emergency responders (police and fire personnel) 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
Achieving Compliance:
 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 the following (even without patients!):
- Tanks on code carts
- Tanks on wheelchairs
- Tanks on gurneys
 Empty tanks do not count toward the total (be careful of AHJ!)
 Use of fire-rated cabinets can be used on floors
Note: Refer to the ASHE Monograph: Medical Gas Cylinder and Bulk Tank
Storage and the latest JC interpretations in “EC News”, February, 2014
issue
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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 (1 inch 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: 1.2 liters
- Maximum dispenser size per suite of rooms: 2.0 liters
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Hazardous Materials and Wastes
Issue: Eyewashes and Showers
Achieving Compliance:
 Use risk assessment to determine placement per OSHA guideline
 ANSI standards (ANSI Z358.1) have not been officially adopted by the
Joint Commission, but JC can reference OSHA
 Access within 55 feet, 10 seconds
 Tepid water between 60 and 100 degrees F will be expected
 Testing policy is required – specify test intervals (weekly flush for eyewash
units, monthly for showers recommended, annual inspection)
 Documentation of test results is required
 Differentiate between eyewash station and “first aid” station, such as
mounted bottles
 JC citation under EC.02.02.01, EP5 and Leadership (LD)!
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Hazardous Materials and Wastes
Issue: Hazardous Gases and Vapors
Achieving Compliance:
 Perform employee monitoring tests to determine exposure using dosimetry
badges or “real time” monitoring
 If the results are below the OSHA “action level”, monitoring can be
discontinued until the staff or process changes
 Toxic gases that are expected to be measured for staff exposure include:
1. Formaldehyde and xylene (clinical laboratory)
2. Glutaraldehyde (endoscopy and other equipment sterilization areas)
3. Nitrous oxide (as a “carrier gas” for anesthetic agents in the OR)
4. Ethylene oxide (central sterile supply)
5. Methyl-methacrylate (operating rooms and dental laboratories)
6. Collodion (sleep lab and EEG)
7. Smoke evacuators (used for control; no measurement required)
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Hazardous Materials and Wastes
Issue: Permits, Manifests and Labeling
Achieving Compliance:
 Have required permits for elevators, boilers, incinerators (if
applicable), emergency generators and other equipment as well as
hazardous material disposal permits available for review
 Be sure that manifest forms are tracked for receipt to verify proper
disposal and destruction
 Staff who have responsibilities for tracking the manifest forms have
received the required DOT training
 Ensure that a method (surveillance rounds and staff training) is in
place to verify that hazardous materials are properly labeled
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Hazardous Materials and Wastes
Other Likely Hazardous Materials Related Questions
1. Can you explain how you maintain an accurate hazardous materials
inventory?
2. Who is expected to respond to and clean up hazardous materials
spills?
3. Who is your laser safety officer? Do they have an appointment letter?
4. How is access to the “hot lab” provided to vendors who deliver
radioisotopes during “off-hours”?
5. How is personnel monitoring performed for employees who are
exposed to hazardous gases and vapors?
6. Who signs and tracks the manifest forms for medical, chemical and
pharmaceutical waste? Have they received DOT training?
7. Where do you find unlabeled containers during surveillance rounds?
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Fire Prevention
Issue: Unobstructed access to exits in business
occupancies
Code Requirement:
The “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
Achieving Compliance:
 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, MRI
and Hyperbaric areas and quarterly in the clinical laboratories
 Assess fire extinguisher type in specialized areas (OR, MRI, etc.)
 Remember that the requirement for business occupancies is one
drill per shift per year, and fire exit drills are expected (“defend-inplace” for healthcare occupancies)
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Fire Prevention
Issue: Fire Drills (continued)
Achieving Compliance:
 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
 Be aware of other AHJ requirements, such as additional drills in
OB/ GYN, long-term care, intensive care units and other specialized
areas
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Fire Prevention
Other Likely Fire Prevention Related Questions
1. Do you have a flame permit or procedure for using candles,
butane units or sterno containers?
2. Where are the fire listings kept for floor and wall coverings and
furniture?
3. How do you track the effectiveness of fire drills?
4. Who performs and documents fire drills in off-campus business
occupancy clinics?
5. How do you ensure that the required fire system tests are
performed “on schedule”, and that all of the identified deficiencies
are resolved in a timely manner?
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Medical Equipment Management
Issue: Incoming Equipment Tests
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
 New requirement for “visual only” checks for incoming
non-patient equipment (NFPA 99, 2012 edition)
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Medical Equipment Management
Issue: Equipment Test Procedures
Achieving Compliance:
 Joint Commission permits the hospital to determine medical
equipment test intervals and procedures, based on a documented risk
assessment, even if it does not match the manufacturer’s
recommendations
 CMS issued new guidance on December 13, 2013 which requires:
1. Maintenance must ensure an acceptable level of safety
2. A hospital may adjust maintenance, inspection and test frequency from
the manufacturer recommendations, based on a risk assessment, unless:
- Other laws (example: NRC) require specific maintenance
- The device is a medical laser
- New equipment does not have a sufficient maintenance history
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Medical Equipment Management
Issue: Alternate Equipment Maintenance (AEM) Program
Achieving Compliance:
 Create a AEM notebook that includes the following sections to show the Joint
Commission or CMS surveyor:
Tab 1: A copy of the Medical Equipment Management Plan that includes a
description of the AEM program
Tab 2: A copy of the risk assessment process that is used to identify which
devices considered “high risk” and “non-high risk”
Tab 3: A printed list of the AEM device inventory
Tab 4: A copy of the analysis used to determine changes to the test procedures
or intervals from the manufacturer recommendations
Tab 5: A list of the staff who are considered “qualified individuals” who can
perform the AEM analysis and determine changes to the AEM program
Note: This notebook is also recommended for the utility management program
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Medical Equipment Management
Issue: Equipment Test Scoring
Achieving Compliance:
 100% PM completion for “high risk” devices, based on “A” scoring
Note: JC considers defibrillators “life support” (and high risk) devices,
even AED’s
 90% PM completion for “non-high risk” devices (C)
 Determine test interval and procedures by “PM effectiveness” and
MTBF data (now accepted 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 an
equipment inventory for monitoring purposes
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Medical Equipment Management
Other Likely Medical Equipment Related Questions
1. How are you involved in purchasing decisions for medical
equipment?
2. Describe the risk assessment process that you use to create a
medical equipment inventory and determine test procedures and
test intervals
3. What is your role when an equipment-related incident occurs? Are
you involved in SMDA decisions?
4. Do clinical staff have written procedures in the event that life
support equipment fails when connected to a patient?
5. Are you involved in the hospital clinical alarm NPSG assessment?
6. Do you have competency documentation for non-OEM vendors who
service or test your medical equipment?
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Utility Systems Management
Issue: Waterborne Pathogens
Achieving Compliance:
Create a waterborne pathogens policy that describes the following
three issues:
 A risk assessment to determine which areas of the hospital have
patients with compromised immune systems
 What measures have been taken to minimize the growth of
waterborne pathogens (example: chemical treatment, copper/ silver
system, elimination of “dead legs”, removal of aerators, etc.)
 Procedures that are required in the event of a hospital-acquired
legionella case
Note 1: Ongoing testing for legionella is not required per CDC and JC
Note 2: Water features and fish tanks are not permitted in chemotherapy or
IV therapy areas (FGI, 2010 edition)
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Utility Systems Management
Issue: Airborne Pathogens
Achieving Compliance:
 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
 Be familiar with chapter 3 of AAMI standard ST-79
 Create and follow a humidity monitoring policy in critical areas
Note 1: Refer to 2010 FGI document for requirements
Note 2: “Grandfathering” normally permitted for existing air handlers
Note 3: Create a chart that shows the applicable codes for the air handlers
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Utility Systems Management
Issue: Temperature and Humidity in the Operating Rooms
Code Requirements:
 NFPA 99, 2005 edition, section 6.4.1.1 requires control of humidity >35%,
which CMS accepts, although the CMS “Categorical Waiver” permits 20%
 AAMI, JC and AORN have now adopted the level of 20% humidity
 FGI 2010 Guidelines document lists control from 30% to 60% in Table 7-1,
but changes to ASHRAE 170 have lowered the humidity level requirement to
20%, which has also been approved by the Joint Commission
 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 (consider separate “alert” and
“action” levels)
 Other areas in which temperature and humidity monitoring will be expected
includes central sterile supply and endoscopy (other areas possible with CMS)
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Utility Systems Management
Issue: Utility System Test Scoring
Achieving Compliance:
 Use a two-step process for the utility inventory:
1. Determine whether equipment is “critical” or “non-critical”
2. Create three different inventory categories from the “critical” list:
- Critical “high risk”
- Critical infection control
- Critical “non-high risk”
 Track and maintain “on-time” PM completion rates for the
“high risk” and “infection control” components based on “A”
scoring: 100%
 Track and maintain “on-time” PM completion rates for “nonhigh risk” components based on “C” scoring: 90%
Healthcare Engineering Consultants
Utility Systems Management
Other Likely Utility System Related Questions
1.
How is the “critical” and “non-critical” equipment separated in the utility
inventory?
2.
What methodology is used to determine which equipment and systems are
considered: a) critical “high risk”; b) critical infection control, and; 3) critical
“non-high risk”?
3.
How are the proper air exchange and pressure relationship measurements
obtained for critical areas in the hospital?
4.
Do clinical staff have written utility failure procedures available?
5.
Do maintenance and engineering staff have failure procedures available?
6.
How do you ensure the accuracy of the critical shut-off control labels?
7.
Do you have an “Interim Utility System Measures” (IUSM) procedure in
place? How do you document IUSM’s, when they are necessary?
Healthcare Engineering Consultants
Functional Environment
Issue: The Joint Commission “General Duty Clause”
Requirements:
 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
Note: This section is reserved for deficiencies that are not defined in other
areas of the standards manual or from referenced codes
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Best Practices and Programs for
Emergency Management in 2014
EMERGENCY
Strategies for the Emergency
Management Standards
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Emergency Management
 EM.01.01.01: Plans for managing emergencies, including HVA
EMERGENCY
 EM.02.01.01: Emergency operations plan (EOP) – R icon for ICS
 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 – R icon for credentials
 EM.02.02.15: Privileges to volunteer staff – R icon for credentials
 EM.03.01.01: Annual effectiveness review – LD review new for 2014
 EM.03.01.03: Regularly tests the emergency operations plan
 LD.04.01.05: Leadership identifies emergency responsibility – New for 2014
 LD.04.04.01: Leadership directs implementation – New for 2014
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Emergency Management
EMERGENCY
Issue: Emergency Management Committee
Achieving Compliance:
 Dedicated EM committee not required, but suggested
 Leadership and physicians should be committee members and
participate in planning
 The committee should perform the following functions:
- Review the HVA annually
- Plan for emergency drills
- Evaluate actual emergencies and drills
 Plan for other emergency activities
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Emergency Management
EMERGENCY
Issue: Hazard Vulnerability Analysis (HVA)
Achieving Compliance:
 A Hazard Vulnerability Analysis (HVA) must be performed and
documented for each geographically separate location
 The HVA should include a numerical score
 The hazards should be prioritized
 The HVA is used to define Mitigation and Preparedness
 The HVA can include a “disaster level” to determine how long the
resource timeline charts must be for specific emergencies
 The HVA must be reviewed and revised, as necessary, annually
Healthcare Engineering Consultants
Emergency Management
EMERGENCY
Hazard Vulnerability Analysis (HVA) for Emergency Management
Event Description
Occurrence
Probability (OP)
3
Human
Impact (HI)
3
Property
Impact (PI)
5
Operational
Impact (OI)
4
Total
Score (TS)
36
Procedure
Required?
Yes
Disaster
Level
1-2
Severe Thunderstorm
4
2
3
2
28
Yes
1
Severe Winter Storm
4
2
2
2
24
Yes
1-2-3
Severe Ice
4
2
3
3
32
Yes
1-2-3
Earthquake
3
1
3
2
18
No
N/A
Hurricane
0
4
4
4
0
No
N/A
Flooding
2
1
4
4
18
Yes
1-2
Pandemic
2
5
1
5
22
Yes
1-2-3
Hazmat Spill (internal)
3
3
2
3
24
Yes
1-2
Hazmat Spill (external)
2
2
1
3
12
Yes
1-2
Electrical Failure
4
1
1
5
28
Yes
1-2
Medical Gas Failure
2
4
1
5
20
Yes
1-2
Bomb Threat
2
4
4
4
24
Yes
1-2
Biological Terrorism
1
5
1
5
11
Yes
1-2-3
Nuclear Terrorism
1
5
5
5
15
No
N/A
Tornado
Healthcare Engineering Consultants
Emergency Management
EMERGENCY
Issue: Create an Emergency Operations Plan (EOP)
Achieving Compliance:
 Written EOP developed with participation by leadership and physicians
 EOP describes response procedures for HVA determined events
 EOP describes procedures for 96-hour community non-support
 EOP describes the recovery phase of disasters based on HVA
 EOP identifies the individual(s) who have the authority to activate the incident
command function and phases
 EOP includes descriptions of the six critical core areas: 1) communications; 2)
resources and assets; 3) safety and security; 4) staff roles; 5) utility management,
and; 6) patient management
 EOP must be reviewed and revised, as necessary, annually
Healthcare Engineering Consultants
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
Issue: 96-hour Timeline Charts
EMERGENCY
Achieving Compliance:
 Create color-coded timeline charts that 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” or “yellow” zones
 Create timeline charts for all of the Level 3 scenarios from the HVA; the
timeline can be evaluated based on the Level 3 duration (how many hours?)
Level 1: Supplies are available and are ordered and received
Level 2: Internal supply shortages or utility failures require partial or total patient evacuation
from the facility
Level 3: Shortages and/ or utilities are not sufficient to continue normal patient care,
although evacuation is not possible and outside assistance is not available
Healthcare Engineering Consultants
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
Based on the duration of the Level 3 scenario, the timeline
may only extend to 24 or 48 hours, rather than 96
24 hours
48 hours
Utility Failure Operational Impact Chart
Hours after utility failure
Normal power failure
0
8
16
24
32
40
48
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
Healthcare Engineering Consultants
56
64
72
80
88
96
Emergency Management
EMERGENCY
Issue: Emergency Communication Strategies
Achieving Compliance:
 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
Healthcare Engineering Consultants
Emergency Management
EMERGENCY
Issue: Emergency Communication Strategies
Achieving Compliance:
 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
Healthcare Engineering Consultants
Emergency Management
EMERGENCY
Issue: Safety and Security
Achieving Compliance:
 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
Issue: Staff Roles and Responsibilities
Achieving Compliance:
 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.)
 Make sure that decisions regarding staff and family support needs
(house and feed family and pets?) have been determined and are in
writing
Healthcare Engineering Consultants
Emergency Management
EMERGENCY
Issue: Utility Back-up Strategies
Achieving Compliance:
 Complete the utility timeline chart for the Level 3’s on the HVA
 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
Fuel – additional on-site storage
Healthcare Engineering Consultants
Emergency Management
EMERGENCY
Issue: Patient Management
Achieving Compliance:
 Identify which patients in the hospital are considered “vulnerable”
(neonatal intensive, pediatric, geriatric, dementia, behavioral health,
bariatric)
 Consider plans to move vulnerable patients vertically without elevators
 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
Issue: Privileges to LIP’s During Disasters (R icon)
Achieving Compliance:
 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
 Mentor must be provided to oversee LIP
 Hospital determines within 72 hours if privileges should continue
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Emergency Management
EMERGENCY
Issue: Privileges to Volunteer Practitioners During Disasters (R icon)
Achieving Compliance:
 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
 Mentor must be provided to oversee volunteer
 Hospital determines a method to evaluate performance and decide within 72
hours if responsibilities should continue
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Emergency Management
EMERGENCY
Issue: Emergency Drills
Achieving Compliance:
 Two drills per rolling 12-month period should be performed, based on the HVA
 At least one drill per 12 months for each business occupancy
 At least one “influx” drill for a disaster receiving station
 Community-wide and influx drills can be performed concurrently
 Don’t forget about patient “surge” drills (IC.01.06.01), infant/ pediatric
abduction drills (EC.02.01.01), and “active shooter” drills (EC.02.01.01)
 The community “non-support” and support drills can be a tabletop simulation
 Trained staff, including a physician and leadership, must evaluate the drill and
must document the six core areas in the evaluation
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Emergency Management
EMERGENCY
Issue: Emergency Drills (continued)
Achieving Compliance:
 To count, the drills and actual disasters must:
1) initiate the incident command system (ICS)
2) require additional internal or external resources, beyond what is normally
available
3) the drill or actual disaster must be documented and include an evaluation
of the six critical core areas
 Tabletop simulations are only permitted for the community and community
non-support drills
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Emergency Management
EMERGENCY
Issue: Leadership Standards Changes in 2014
Achieving Compliance:
 LD.04.01.05, EP 12: Leadership Assigns Responsibility
1) Individual appointed to have accountability for the EM program
2) Role addresses responsibilities other than incident commander role
 LD.04.04.01, EP25: Senior leadership directs implementation of emergency
management improvement in:
1) Annual planning review
2) Evaluation of all exercises and response to actual emergencies
3) Determination of priority of emergency management improvements
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Emergency Management
EMERGENCY
Other Likely Emergency Management Questions
1.
What are the “top three” vulnerabilities in your HVA?
2.
Explain the activation of your incident command system
3.
Where is your command center and is it equipped for emergency power,
communications and other needs?
4.
Do you have an emergency asset inventory list?
5.
Have you evaluated your ability to continue operations without outside
support up to 96 hours?
6.
Do you have an updated and accurate vendor and supplier list?
7.
Do you have agreements for alternative care sites?
8.
Explain the logistics involved in a patient evacuation
9.
Are you prepared for a mass decontamination event?
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Emergency Management
EMERGENCY
Other Likely Emergency Management Questions (cont’d)
9.
How would you control facility access in an emergency?
10. Will you provide accommodations for staff family members and pets in an
emergency?
11. What is your greatest utility vulnerability?
12. How would you transport and evacuate “vulnerable” patients in an
emergency? (bariatric, neonatal, behavioral health, dementia, etc.)
13. Do you have written policies that address emergency disaster privileges to
LIP’s and other clinical staff?
14. How often do you review the EOP, HVA and emergency supply inventory
documents?
15. How many drills have you performed during the past 12 months? Explain the
scenario and what you learned from the drill (or actual emergency)
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Emergency Management
EMERGENCY
Other Important Emergency Management Issues
1.
On February 28, 2014, CMS issued a “Revised Emergency Management
Checklist” for use by healthcare facilities
- The effective date is March 28, 2014
- Checklist address: www.cms.hhs.gov/SurveyCertEmergPrep/
2.
The new proposed rule from CMS for emergency management regulations
includes and requires:
- Emergency power for heating, cooling and waste management
- Personalized patient disaster plans for home health care
- Four hour emergency generator test annually rather than every three years
- Applies to hospitals, clinics, outpatient facilities, nursing homes, dialysis
centers, home health agencies, behavioral health and ambulatory centers
- Likely implementation date: April, 2017
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Best Practices and Programs
Questions?
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