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ENVIRONMENT OF CARE INTERVIEW QUESTIONS
The Survey Team Process
The following questions relate to each of the "Environment of Care" sections listed below.
The "EC" interview session will be scheduled as a three-part review which includes the
discussion, observation and conclusion phases. Other questions may also occur at any
time when the surveyors determine that tracer methodology sessions have uncovered
“EC” issues related to the patient treatment process. During the scheduled interview
session, staff who have responsibilities related to the "Environment of Care" should be
present. Relevant policies, procedures, and written supporting documents that indicate
compliance with the required standards must be available and well-organized so that they
can be explained to the surveyor, if requested.
During the discussion portion of the “EC” interview, also be prepared to describe how a
risk assessment process is used and documented and how each “EC” program
component (safety, security, hazardous materials, etc.) meets each of the risk cycle
components – Plan, Teach, Implement, Monitor, Respond and Improve.
Finally, identify who will participate in the "EC" interview and who will be the primary and
secondary spokespersons for each "EC" area (safety, security, etc.). This will minimize
confusion during the actual interview sessions.
The Assessment Questions – Safety Management
1. Has a management plan been written using a consistent format, that describes all of
the required processes to effectively manage the safety environment for patients, staff
and visitors? (EC.1.10)
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
2. Have proactive risk assessments (example: FMEA’s) been conducted and
documented for safety-related issues that may impact the environment of care, but are
not specifically defined in the standards? (EC.1.10)
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
3. Have the results of these risk assessments been used to modify the safety
management program to minimize risks to patients, staff and visitors?
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Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
4. Is there an incident reporting system that documents incidents that may occur to
patients, staff or visitors and also ensures that product recalls are reviewed and acted
upon? (EC.1.10)
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
5. Is there a hazard surveillance program that reviews and documents the environment at
least twice annually in patient care areas and annually in non-patient areas to identify
unsafe hazards and practices in the environment? (EC.1.20)
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
6. Does the hazard surveillance program also include documented rounds for the
satellite (off-site) outpatient clinics? (EC.1.20)
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
7. Are all “EC”-related policies reviewed and revised, as necessary, but at least every
three years? (EC.1.10)
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
8. Is there an individual who has been appointed to oversee and coordinate the safety
management program for the facility (safety officer) and does this individual have a
letter signed by the Chief Executive Officer that permits intervention in the event of a
situation that could threaten life or health or damage property?
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
9. Is there a policy that describes how the exterior grounds are maintained? (EC.1.10)
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Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
10. Does the organization have a written “No Smoking” policy and is it enforced for
patients, staff and visitors? (EC.1.30)
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
11. Does the organization monitor compliance with the smoking policy and develop
strategies to reduce violations to the policy? (EC.1.30)
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
12. Is there a required safety orientation and annual training program for all staff,
including physicians and volunteers? Is there also a method to assess knowledge
after the training has occurred? (HR.2.20)
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
The Assessment Questions – Security Management
1. Has a management plan been written using a consistent format, that describes all of
the required processes to effectively manage security for patients, staff and visitors?
(EC.2.10)
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
2. Has an individual or organization been identified by leadership, in writing, to coordinate
the security management program? (EC.2.10)
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
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3. Have proactive risk assessments been conducted and documented for security-related
issues that may impact the environment of care, but are not specifically defined in the
standards? (EC.2.10)
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
4. Have the results of these risk assessments been used to modify the security
management program to minimize risks to patients, staff and visitors?
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
5. Is there a method in place to document and evaluate security issues and incidents that
occur? (EC.2.10)
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
6. Does the organization have a policy that describes how patients, staff and visitors
are identified? (EC.2.10)
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
7. Have “security sensitive areas” been evaluated and identified in a policy, do these
areas have controlled access and have staff in those areas been trained relative to the
possible dangers, especially in the pharmacy, emergency department and OB/Gyn
areas? (EC.2.10)
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
8. Do written policies exist for the following issues: VIP’s (patients and visitors), media
relations, parking and civil disturbances? (EC.2.10)
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
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9. Is access to the emergency department maintained at all times for emergency
vehicles? (EC.2.10)
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
10. Has the organization identified and implemented emergency procedures related to the
possibility of infant or pediatric abduction?
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
The Assessment Questions – Hazardous Materials
1. Has a management plan been written using a consistent format, that describes all of
the required processes to effectively manage the safety environment for patients, staff
and visitors? (EC.3.10)
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
2. Are there current policies that address the “cradle-to-grave” treatment of all types of
hazardous materials (infectious medical waste and sharps, chemical, radioactive and
chemotherapeutic) that are used in the organization? (EC.3.10)
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
3. Has a method been approved by the organization that is used to identify and
classify hazardous materials, and to create an inventory list that is consistent with
applicable local, regional and federal regulations, such as OSHA, the NRC and EPA?
(EC.3.10)
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
4. Are hazardous materials stored in locked areas that are accessible to authorized staff
only and are the storage areas approved for the materials? (EC.3.10)
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Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
5. Does a policy exist that clearly describes how hazardous waste spills are reported,
cleaned up and documented? Are all staff trained to understand these procedures?
(EC.3.10)
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
6. Is there a program in place to monitor personnel exposure to the following hazardous
Vapors, as applicable: formalin, xylene, nitrous oxide, glutaraldehyde, ethylene oxide,
methyl-methacrylate and collodion? (EC.3.10)
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
7. Has an individual been assigned to apply for and maintain required permits and
licenses and to ensure that the required material safety data sheets are accurate and
readily available to all staff? (EC.3.10)
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
8. Are manifest forms for chemical and infectious wastes checked to ensure that they are
received on a timely basis? (EC.3.10)
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
9. Are all hazardous chemicals properly labeled, especially for those that are placed into
a container that is not the original one? (EC.3.10)
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
10. Are hazardous materials and wastes effectively separated from other areas of the
facility during storage and processing?
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Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
The Assessment Questions – Emergency Management
1. Has a management plan been written using a consistent format, that describes all of
the required processes for emergency management and how to implement the
procedures, when appropriate? Has the plan been written with participation from
medical staff and executive management? (EC.4.10)
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
2. Has a vulnerability analysis been performed and documented to determine which
disasters are likely to occur and which one will have a significant impact on the
organization? Has this analysis been reviewed and approved by the safety committee?
Has the analysis been used to determine which procedures will be included in the
disaster manual? (EC.4.10)
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
3. Has the organization established disaster priorities resulting from the hazard
vulnerability analysis in conjunction with the community? Has the organization also
discussed it’s role with the community related to emergency management and created
a command structure for disaster implementation that is consistent with the command
structure used by the community? (EC.4.10)
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
4. Have the procedures for the four phases of emergency management (mitigation,
preparedness, response and recovery) been included in the disaster manual for each
priority emergency? Do they include a procedure for initiating the plan phases and do
they specify who is responsible for the initiation? (EC.4.10)
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
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5. Is an incident command system that is compatible with the community been written
into the disaster manual? Does it include an organizational chart with identified
hospital staff, job action sheets and a method to initiate the system? (EC.4.10)
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
6. Is there a practical total facility evacuation plan that has been written in the event that
the facility must be evacuated? Does the plan include a discussion of the logistics
involved, such as patient records, medications, equipment, staffing, transportation, and
an identified alternate site(s)etc.? (EC.4.10)
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
7. Does the plan describe how internal staff and external authorities will be notified
during an emergency, and how the staff will be assigned? (EC.4.10)
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
8. Does the plan also include for the management of discontinuation of patient services,
support activities for staff and their families, logistics for critical supplies, security and
media communication? (EC.4.10)
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
9. Is there a written process in place to identify care providers and other personnel during
emergencies, such as volunteer physicians and nurses? (EC.4.10)
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
10. Have processes been put into place to share information with other healthcare
providers regarding command structures, names and contact information of command
staff, available resources and assets and methods to identify patients who are
transported from different facilities? (EC.4.10)
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Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
11. Have failure plans and back-up procedures been written for the loss of utilities,
including communication systems, electricity, water, fuel, medical gas and vacuum,
heating and cooling, ventilation and sewer? (EC.4.10)
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
12. Is there a written plan with appropriate equipment to treat patients who have been
Chemically, radioactively or biologically contaminated? (EC.4.10)
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
13. Is there also a written plan for the medical center and community to effectively
respond to a terrorist action? Have appropriate staff been trained to respond to such
an emergency? (EC.4.10)
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
14. Have at least two emergency disaster drills been simulated (or have been actual
disasters) during the past 12 months, and have they been at least 4 to 8 months
apart? Have the drills been documented and evaluated? Has at least one of the drills
been an external disaster and community drill? (EC.4.20)
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
15. Has there been at least one emergency preparedness drill conducted and evaluated at
each of the outpatient satellite business occupancy clinics during the past year?
(EC.4.20)
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
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The Assessment Questions – Fire Prevention
1. Has a management plan been written using a consistent format, that describes all of
the required processes to effectively manage fire safety for patients, staff and visitors?
(EC.5.10)
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
2. Is there a written fire plan that describes emergency procedures in the event of a fire
emergency? Does the plan include department-specific procedures for staff,
independent physicians (LIP’s) and volunteers who are at and away from the point of
origin of a fire and for horizontal, vertical and total facility evacuation? (EC.5.10)
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
3. Have all of the fire alarm and extinguishing system components been tested and
documented as required by the NFPA documents listed below? Are the results
maintained in a manner that permits easy retrieval? (EC.5.40)
Required Test
Supervisory signal devices
Valve tamper switches
Detectors and alarms
Notification devices
Fire department notification
Fire pumps
Water tank level alarms
Level alarms (cold weather)
Main drain riser tests
Fire department connections
Fire pumps
Automatic kitchen systems
Gaseous exting. Systems
Portable extinguishers
Occupant hoses
Fire and smoke dampers
Smoke shut-down devices
Sliding/ rolling fire doors
Test Frequency
Quarterly
Semi-annually
Annually
Annually
Quarterly
Weekly, no flow
Semi-annually
Monthly
Annually
Quarterly
Annually, discharge flow
Semi-annually
Annually
Monthly, annually
Install, 5 yrs; hydro, 3 yrs
Every 4 years
Annually
Annually
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Reference
NFPA 72, current edition
NFPA 72, current edition
NFPA 72, current edition
NFPA 72, current edition
NFPA 72, current edition
NFPA 25, current edition
NFPA 25, current edition
NFPA 25, current edition
NFPA 25, current edition
NFPA 25, current edition
NFPA 25, current edition
NFPA 25, current edition
NFPA 25, current edition
NFPA 10, current edition
NFPA 1962, current edition
NFPA 90A, current edition
NFPA 90A, current edition
NFPA 80, current edition
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
4. Is there a policy that describes what is required for floor and wall covering fire listings
and what is permitted regarding fire ratings for purchased furnishings? Is there a
holiday decorations policy that clearly describes which decorations are permitted?
(EC.5.10)
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
5. Is the “Statement of Conditions” document current and does it accurately reflect the
compliance with the 2000 Life Safety Code for all required healthcare and ambulatory
facilities? Have all of the required portions of the document been completed (BBI,
compartmentation drawings, LSA, PFI? Have all of the deficiencies noted in the “PFI”
document that was reviewed and signed by the surveyor been corrected within the
obligated time frame? If not, has a delay request letter been sent to the Joint
Commission for new date approval? (EC.5.20)
Note: Failure to meet the PFI deadline requirements can result in CONDITIONAL
ACCREDITATION.
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
6. Has a building maintenance program been implemented to determine whether the
operational life safety items in the facilities (exit lights; fire, smoke and corridor doors;
barrier penetrations, etc.) function as they are intended? Is the effectiveness of the
program measured? (EC.5.20)
Note: This is a voluntary requirement.
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
7. Do record drawings exist that accurately depict the facility smoke, fire and building
compartmentation? (EC.5.20)
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
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8. Have fire drills been conducted and documented on every shift, during every quarter
for every building that is classified as either healthcare or ambulatory? Have drills been
conducted and documented at least annually per shift for all business occupancies
where patients are examined or treated? Were the drills evaluated for staff response
and did the evaluation include the following required items: 1) use of fire alarm
components; 2) audibility of alarms; 3) containment of smoke and fire; 4) preparation
for horizontal or vertical evacuation; 5) use of extinguishing equipment, and; 6) other
specific fire-response duties? (EC.5.30)
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
9. Is there a policy that describes how interim life safety measures are determined,
evaluated, implemented and documented, when required? Are forms used to
document the evaluation of the need for interim measures as well as which measures
apply and whether the interim measures have been implemented as determined
through an inspection process? (EC.5.50)
Note: Failure to implement or document required interim life safety measures can
result in CONDITIONAL ACCREDITATION!
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
The Assessment Questions – Medical Equipment
1. Has a management plan been written using a consistent format, that describes all of
the required processes to effectively manage the safe and reliable operation of medical
equipment? (EC.6.10)
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
2. Does a policy exist that describes the process used to select and acquire medical
equipment? (EC.6.10)
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
3. Is there a criteria evaluation used to determine which patient medical equipment is
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included in the management program? (EC.6.10)
Note: If a criteria evaluation is not used, then all medical equipment must be included
in the program.
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
4. Is there a process to aggregate, evaluate and take necessary action for all medical
equipment hazard recalls and FDA reports that may be required under the SMDA act?
(EC.6.10)
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
5. Are there procedures to report and document equipment-related incident reports that
may occur? Do the procedures also include emergency actions such as equipment
failure, and access to back-up equipment and repair services? (EC.6.10)
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
6. Are the clinical users of medical equipment able to easily determine, such as through
the use of tags affixed to the equipment, when the devices have been tested and when
they are due to be tested again? (HR.2.20)
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
7. Do the equipment maintainers (in-house biomedical technician staff and outside
contractors and vendors who are not the OEM) have documented competency
assessments performed on a periodic basis? (HR.3.10)
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
8. Does an accurate, aggregated inventory exist for all devices that are included in the
medical equipment management program, regardless of ownership and test/ repair
responsibilities? Does this inventory clearly indicate life support and non-life support
equipment? (EC.6.20)
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Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
9. Is all equipment that is included in the medical equipment program tested for safety
and performance prior to use?
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
10. Is routine, scheduled preventive maintenance performed on life support and non-life
support equipment that is consistent with maintenance strategies that have been
established based upon equipment risks, manufacturer recommendations and
historical data and are the test results documented? Have preventive maintenance
“on-time” completion rates been established for the life support and non-life support
equipment? (EC.6.20)
Note: It is expected that the PM completion rates for life support equipment will be at
100% and for the non-life support equipment at least 90%.
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
11. Are the results of sterilizer preventive maintenance and repairs maintained?
(EC.6.20)
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
12. Are the results of dialysis chemical and biological water tests documented and
reported to infection control and the safety committee, when required? (EC.6.20)
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
The Assessment Questions – Utility Systems
1. Has a management plan been written using a consistent format, that describes all of
the required processes to effectively manage the safe, effective and reliable operation
of utility systems? (EC.7.10)
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Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
2. Is there a criteria evaluation used to determine which utility systems are included
in the management program? (EC.7.10)
Note: If a criteria evaluation is not used, then all utility equipment and systems must
be included in the program.
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
3. Have utility systems been designed and installed that meet the patient care and
operational needs of the organization? (EC.7.10)
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
4. Are there written test procedures, that include acceptable parameters and test
intervals, for all of the utility systems and equipment included in the program?
(EC.7.10)
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
5. Are there written procedures that describe actions that are required when utility
systems malfunction, that include clinical interventions, alternate utility sources, valve
closure responsibility and methods to obtain repair services? (EC.7.10)
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
6. Are one-line diagrams provided for the utility systems and Is accurate labeling provided
for the following: 1) medical gas and vacuum shut-off valves; 2) electrical breaker
panels; 3) utility isolation and shut-off valves? (EC.7.10)
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
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7. Is there a policy that describes methods to minimize the possibility of water-borne
pathogens that includes the following sections: 1) an infection control risk assessment
that identifies which areas of the medical center house patients with compromised
immune system function; 2) operational actions that are taken to minimize the growth
of water-borne pathogens, such as legionella (water temperature, chemical treatment,
ion-transfer systems, elimination of “dead” water legs, aerosol removal, shower head
replacement, etc.); 3) a description of remediation actions taken in the event that a case
of hospital-acquired legionella is verified? Are the procedures as defined in the policy
implemented? (EC.7.10)
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
8. Is there a policy that describes how air filtration, air exchange and pressure
relationships are maintained and tested in the following areas: operating rooms, special
procedure rooms, delivery rooms, negative isolation rooms, protective isolation rooms,
clinical laboratories, pharmacies and sterile supply areas? Are these tests performed
and documented on a periodic basis? (EC.1.7)
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
9. Are emergency power generators installed that meet the requirements of NFPA 99,
101 and 110 with regard to life safety and critical branch circuits? (EC.7.20)
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
10. Does an accurate, aggregated inventory exist for all devices that are included in the
utility equipment management program, regardless of ownership and test/ repair
responsibilities? (EC.7.30)
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
11. Is all critical equipment that is included in the utility management program tested for
safety and performance prior to use?
Compliance: Satisfactory 
Partial 
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Unsatisfactory 
Action Required:_________________________________________________________
12. Is routine, scheduled preventive maintenance performed on the critical components of
life support utility systems that is consistent with maintenance strategies that have
been established based upon equipment risks, manufacturer recommendations and
historical data and are the test results documented? (EC.7.30)
Note: Expected PM completion rates for the life support components is 100%.
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
13. Is routine, scheduled preventive maintenance performed on the critical components of
infection control utility systems for high-risk patients that is consistent with
maintenance strategies that have been established based upon equipment risks,
manufacturer recommendations and historical data and are the test results
documented? (EC.7.30)
Note: Expected PM completion rates for the infection control components is 100%.
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
14. Is routine, scheduled preventive maintenance performed on critical components of
non-life support utility systems that is included in the management program and is it
consistent with maintenance strategies that have been established based upon
equipment risks, manufacturer recommendations and historical data? Are the test
results documented? (EC.7.30)
Note: Expected PM completion rates for the non-life support components is 90%.
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
15. Are the generators visually inspected on a weekly basis and tested under loaded
conditions monthly (20 to 40 days apart) for at least 30 minutes and under at least
30% of the nameplate load? Are the tests documented and do they include tests for
every transfer switch each month? (EC.7.40)
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
16. Are battery-powered egress lights in the healthcare facilities and satellite outpatient
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clinics tested monthly for 30 seconds and is an annual 1.5 hour discharge test
performed and documented? (EC.7.40) Note: If annual discharge tests are not
performed, are the batteries changed in each unit on an annual basis?
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
17. If a Level I UPS system is installed (malfunction may severely jeopardize the life and
safety of occupants), is it maintained according to the requirements in NFPA 111,
which requires a quarterly functional test and annual test at full load? (JCAHO
requires the test at 60% of full load) (EC.7.40)
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
18. Is there a documented preventive maintenance program for the medical gas and
vacuum systems used in the healthcare facilities? Does it include preventive
maintenance for the system source valves, zone valves, outlets, alarms, pressure
switches, flexible connectors and other identified components in accordance with the
manufacturer recommendations and prudent engineering practice? (EC.7.50)
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
19. Is the medical gas and vacuum system tested when new systems are installed or
when existing systems are modified or repaired to ensure that the connections,
pressures and purity of the gases is acceptable? Is the purity of the piped medical
gases, including oxygen, nitrous oxide and medical air verified on a periodic basis to
ensure that it is in compliance with the USP and FDA requirements? (EC.7.50)
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
20. Do the utility system maintainers (in-house staff and outside contractors and vendors)
have documented competency assessments performed on a periodic basis if they test
or maintain utility systems that might impact the clinical environment? (HR.3.10)
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
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The Assessment Questions – Appropriate Environment
1. Are interior spaces for patients appropriate to their care and needs? Do they include
closet and drawer space for their personal property? For care longer than 30 days,
does the setting provide for socialization and does it accommodate special equipment,
such as that required for rehabilitation? (EC.8.10)
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
2. Are areas used by the patients safe, clean, functional and comfortable, and provide for
suitable lighting and ventilation? Are door locks and restraints that are used consistent
with the patients needs, policies and applicable regulations? (EC.8.10)
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
3. Prior to new construction projects, are applicable local, state and federal guidelines
and regulations used as a guide? Is a “Pre-Construction Risk Assessment” performed
and documented? Does the assessment include an evaluation for the impact of
infection control, noise, vibration, air quality, utility failures, emergencies and interim
life safety measures on the physical and patient environment? (EC.8.30)
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
The Assessment Questions – Measurement and Improvement
1. Does the organization measure and report the following indicator data: (EC.9.10)
a. patient injuries and property damage
b. staff illness and injuries
c. security incidents involving patients, staff or visitors
d. hazardous material spills, exposures and incidents
e. fire-safety-related problems, deficiencies, and failures
f. equipment problems, failures and user errors
g. utility systems problems, failures and user errors
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
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2. Has an individual (safety officer) been appointed by the Chief Executive Officer of the
medical center to monitor and evaluate the organization’s environment of care and
coordinate the following tasks:
a. collect information about deficiencies and opportunities for improvement in the
environment of care;
b. collect information related to hazard recalls;
c. prepare summaries of “EC”-related deficiencies, problems, failures and user
errors;
d. prepare summaries of performance improvement activities;
e. participate in incident reporting, hazard surveillance and policy and procedure
development.
(EC.9.10)
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
3. Is there a process that is used to monitor on an ongoing basis risks that are
encountered in the environment of care, and are the management plans evaluated
annually and changed as required based upon these risk assessments? (EC.9.10)
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
4. Have effectiveness evaluations been written for each of the seven “EC” areas on at
least an annual basis? Have they been approved by the safety committee and reported
to top management and the governing body? Does each evaluation specifically
discuss the Scope, Objectives, Performance and Effectiveness of each plan and
performance element? (EC.9.10)
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
5. Are issues in the environment of care that impact patient safety reported to the patient
safety representative and integrated into the patient safety program? Similarly, are
patient safety issues that affect the environment of care communicated to the safety
officer and safety committee? (EC.9.10)
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
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6. Is there a multi-disciplinary committee (safety) that meets on a prescribed basis (at
least every other month, unless otherwise determined by experience and approved by
the committee), to review, discuss, analyze, resolve and document environment of
care issues? (EC.9.20)
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
7. Does the committee membership include a chair (usually the administrative
representative), the safety officer, representatives from each of the “EC” areas (safety,
security, hazmat, etc.), clinical representative, support services representative and the
following additional representatives, either as standing members or invited guests:
performance improvement, infection control, patient safety, employee health, satellite
clinics, risk manager, radiation safety officer and laser safety officer? (EC.9.20)
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
8. Has at least one non-regulatory, numerical, performance measure been selected for
each of the seven “EC” areas? Have goals, benchmarks and thresholds, as applicable,
been selected for comparative purposes? Are the measures aggregated and reported
to the safety committee on an ongoing basis? (EC.9.20)
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
9. Has at least one performance improvement initiative that occurred during the previous
year been presented to top management for further action? (EC.9.20, PI)
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
10. Are summaries of the safety committee actions reported to the executive leadership
and ultimately the medical center governing body on a periodic (at least quarterly)
basis? (EC.9.20, LD)
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
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11. Are “EC” issues that impact patient safety and the clinical environment communicated
to the patient safety representative and executive leadership, when applicable?
(EC.9.20, LD)
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
12. Are measurements of regulatory requirements and performance improvement issues
monitored by the safety committee and reported periodically to executive leadership
and as applicable, the patient safety program? (EC.9.30, LD)
Compliance: Satisfactory 
Partial 
Unsatisfactory 
Action Required:_________________________________________________________
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