Download The Joint Commission`s Environment of Care Update 2009

The Joint Commission®’s
Environment of Care® Update 2009
William M. Wagner, ScD CHCM CHSP CHEP
Vice President-Education, Research & Development
Safety Management Services, Inc.
September 22, 2009
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Goals
• Review the New Physical Environment
• Discuss Revised Scoring Process
• Identify Tracer Activities & Survey
Methods
• Analyze Impact on Environmental
Services
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Changes in 2009
y EC Standards re-numbered, some EP
numbers “omitted” in Standards
y Safety & Security combined
y Life Safety Code (EC.5.20) removed from EC
y Emergency Management (4.11-.20) removed
y Infectious waste management moved to IC??
y Training component (HR) reintroduced to EC
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
The New Physical Environment
Environment of Care
y
y
y
y
y
Safety & Security
Hazardous Materials & Waste
Fire Safety
Medical Equipment
Utility Systems
Life Safety
y
Life Safety Code©, ILSM, eSOC™
eSOC
Emergency Management
y
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
EOP & Testing Response
Scoring
Process
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Criticality Categories
The “criticality” for scoring EP’s fall into
the following four categories:
y
y
y
y
Immediate Threat to Life
Situational Decision Rules
Direct Impact Requirements
Indirect Impact Requirements
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Criticality Categories
Examples: “Immediate Threat”
y Inoperable fire alarm
y Adult-strength medications on pediatric
crash cart
y Lack of master alarms for medical gas
systems
y Patients with known antibodies received
transfusions without the units being typed
for the corresponding antigens
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Criticality Categories
Examples: “Situational Decision Rule”
y
y
y
Evidence of an unlicensed facility
Unlicensed individual who requires a
license
Failure to implement corrective action in
response to identified Life Safety Code®
deficiencies
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Criticality Categories
Examples: “Direct Impact Requirements”
(Five in Hazardous materials & waste standard)
y EC.02.02.01, EP 4: The hospital implements its
procedures in response to hazardous material & waste
spills or exposures.
y EC.02.02.01, EP 6: The hospital minimizes risks
associated with the selection, handling, storing,
transporting, using & disposing radioactive materials
y EC.02.02.01, EP 10: The hospital monitors levels of
hazardous gases & vapors to determine that they are in
safe range.
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Criticality Categories
Examples: “Indirect Impact Requirements”
y
Leadership—Standard LD.01.04.01, EP 11: When
the chief executive is absent from the hospital, a
qualified individual is designated to perform the
duties of this position.
y
Environment of Care—EC.02.02.01, EP 11: For
managing hazardous materials & waste, the
hospitals has permits, licenses, manifests, &
material safety data sheets.
y
Infection Control—IC.01.01.01, EP 1: The hospital
identifies the individual(s) with clinical authority over
the infection prevention & control program.
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Scoring Process
y Standards are not scored as
either:
y Compliant
y Not Compliant
y Only specific EPs count toward
accreditations (i. e., Direct
Impact)
y No supplemental citations
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Scoring Process
y Elements of Performance (EP) are
scored as:
y 0 = Insufficient Compliance
y 1 = Partial Compliance
y 2 = Satisfactory Compliance
y Each non-compliant EP results in RFI
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
EP Categories
y “A”
y Either exist or do not exist,
y Scored either “0” or “2”
y “C”
y Scored “2” if there is one or no occurrences of
noncompliance
y Scored “1” if there are two occurrences of
noncompliance
y Scored “0” if there are three or more occurrences
of noncompliance
y “B” are no longer!
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Scoring Icons
•
Requirement for documentation is mandatory.
•
The “situational decision” rules apply.
•
The “direct impact requirements” rules apply.
The following icons remain:
– A: category A requirements
– C: category C requirements
•
•
Measure of Success (MOS) is needed.
The Self-assessment Grid;
– “0” =insufficient compliance, “1”= partial compliance,
“2” =satisfactory compliance, and “N/A” = the
requirement is not applicable.
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Tracer
Activities
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Tracer Activities
y Occurs 10-15 times per/survey
y Movement of patient or event throughout the
system
y Each involves “mini EC” building tours
y Surveyors can make a list of potential EC
issues
y Need to practice EC tracers
y Examples…
y
y
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Hazmat - chemical delivery or waste disposal
Utility System – water shutdown
Tracer Activities
y Hazmat Tracer
– Spill clean-up
– Waste disposal “cradle to grave”
– Chemical delivery
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Tracer Activities
• Common elements
– Evaluate:
•
•
•
•
Personnel response
Staff knowledge
Appropriate equipment
Available documentation
– Train:
• Rapid response to questions
• Utilization of appropriate equipment
• Location of specific procedures or
data
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Tracer Activities
• People Tracer
– Ask questions about policy or
procedure
• Location of MSDS
• Precautions & procedures for spill clean-up
• Notification of appropriate personnel
• Process Tracer
– Follow procedures or directions
• Find proper PPE
• Get appropriate spill kit
• Apply spill kit once located
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Tracer Training
•
•
•
•
•
Objective of the tracer
Equipment to remediate a situation
Location of information or equipment
Resources to assist effort
Procedure to follow
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Survey
Method
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Preparing for Survey
Initial documentation needed:
•
•
•
•
•
Management Plans for current year
Annual Evaluations for previous year
Management Plan for previous year
Performance Measures for past &
current years
Committee Minutes for current year
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Survey Focus
•
•
•
•
Staff knowledge
Staff behavior
Environmental conditions
Quality of programs
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Survey Activities
•
•
•
•
•
Life Safety Code survey
EC document review
EC interview with Committee
Building tours & tracers
Emergency management scenario
–
Order of activities may vary depending on
surveyor
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Decision Process
• Survey information gathered
• PPR
• Tracers & observations
• Onsite objections raised
• Discrepancies raised during survey
• Surveyor analysis
• Aggregation of data
• Application of decision rules
• Decision provided
• Appeal received
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Survey Response
• 10-day “opportunity to clarify” findings
– Evidence submitted that were not available
at survey
• Evidence of Standards Compliance
submission for PFI’s
• No supplemental findings
• Each findings will need an ESC & RFI
• Begin developing response immediately
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Survey Response
Response time*:
• Direct Impact Requirement = 45 days
• Indirect Impact Requirement = 60 days
*If organization uses the 10-day time frame
“opportunity to clarify,” it is subtracted from the
above time limits.
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Physical Environment
Mastering
the
Environment of Care
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
wxw1
Slide 29
wxw1
William Wagner, 9/9/2008
Four Groups of EC Standards
• Planning- EC.01.01.01
– Management Plans
• Implementing- EC.02.01.01-02.06.05
– Safety/Security, HazMat, Fire Safety, Medical
Equipment, Utility Systems
• Staff Competency-EC.03.01.01
– Roles & Responsibilities of Staff/LIP
• Monitoring & Improving- EC.04.01.01-.05
– Evaluation & Analysis
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Planning
Managing Risks
EC.01.01.01
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Managing Risks
EC.01.01.01
EP 1- Leaders identifies individual(s) to:
•
•
•
•
Manage risk,
Coordinate risk reduction activities
Collect deficiency information
Disseminate summary information
- Letter identifying the individual (s) (e.g.,
Safety Officer, Director of Security)
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Managing Risks
EC.01.01.01
EP 2 - Leaders identify individual(s):
– Intervene immediately threats to:
• Life
• Health
– Intervene immediately threats to:
• Damage equipment or buildings
– Letter identifying the individual(s) (e. g.,
Nursing Supervisor, Administrator on Call,
Executive VP, Safety Officer)
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Managing Risks
EC.01.01.01
EP 3-8: Management Plans
• Safety (EC.02.01.01)
• Security (EC.02.01.01)
• Hazardous Materials & Waste
(EC.02.02.01)
• Fire Safety (EC.02.03.01)
• Medical Equipment (EC.02.04.01)
• Utility Systems (EC.02.05.01)
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Safety & Security Risks
EC.02.01.01
EP 1- Identifies safety & security risks
●
●
●
●
●
Proactive risk assessment
Ongoing program monitoring
Root cause analyses
Sentinel event alert monitoring
Hospital-wide high risk assessment*
(one every 18 months LD.04.04.05)
*Does not need to be in the Environment of Care
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Hospital-Wide Risk Assessment for Safety and Security
Conducted by:
Date:
Dept
Safety Risk Elements
Security Risk Elements
List of Areas
Blood,
body fluids
Slips and
Fails
Ergonomics
Lifting
Objects
Lifting
Patient
Workplace
Violence
Security
Assaults
Combative
Patient
Infant
Abduction
Theft
3rd Surgical
3, E, P
2
2
2
2
1
1
2
1
1
8th Medical
2
2
1
1
4, T, E
3, T. P, E
1
2
0
2
Ultrasound
Wound
Care/ OP
Specialty
Risk Value
0
1
2
3
4
Risk Rating
Criteria
No risk
Minimal risk
Moderate risk
Significant risk
Significant risk with history of occurrence
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Corrective Action
Implementation
C = Change procedure
T = Training
P = Policy or procedure
E = Equipment or PPE
O= Other
Safety & Security Risks
EC.02.01.01
EP 3- Takes action to minimize or
eliminate identified risks*
•
•
•
•
Equipment
Procedures
Training
Process Changes
*Document action taken
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Safety & Security Risks
EC.02.01.01
EP 5- Maintains all grounds &
equipment
y
y
y
y
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Identify responsible parties
Document inspections
Track corrective actions
Included in Environmental Tours
Safety & Security Risks
EC.02.01.01
EP 7- Identifies individuals entering the
facility
• Department responsible for issuing
identification badges & bands (Security,
Nursing, Nursery)
• Ramification for not wearing identification
• Samples of current badges for patient staff
& visitors, including vendors & contractors
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Sample of ID Badge
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Safety & Security Risks
EP 9- Written security incident procedures,
including an infant or pediatric abduction.
• Procedure on infant or pediatric abductionCode Pink
• Table of contents of security policies
• List of departmental security policies
• Documentation of triennial review??
<<Look in leadership standard>>
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Safety & Security Risks
EC.02.01.01
EP 10- Follows security incident
procedures
y
y
y
y
y
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Respond
Investigate
File Security Incident Report
Review & evaluation
Take corrective action
Safety & Security Risks
EC.02.01.01
EP 11- Responds to product notices &
recalls
• Respond to all types of items
-
Medical Equipment
Consumer Products
Foods
• Identify responsible parties
-
Materials Management
Safety Officer
Risk Management
• Document actions taken
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Implementing
Managing Hazardous
Materials & Waste
Risks
EC.02.02.01
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Hazardous Materials & Waste
EC.02.02.01
•
•
•
•
Hazardous chemicals
Radioactive material
Hazardous energy sources
Hazardous medications
(Chemotherapeutics)
• Gases & vapors
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Hazardous Materials & Waste
EC.02.02.01
EP 1- Maintains written & current inventory of
hazardous materials & waste
•
•
•
•
Materials & waste that are used, stored,
& generated
Addressed by law or regulation
Identify locations through risk
assessment
Document current hazard information (i.
e., MSDS, etc.) for material on inventory
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Hazardous Materials & Waste Inventory
DEPARTMENT
Admission
Emergency Room
Engineering Department
Laboratory
Pharmacy
3 Floor
4 Floor
5 Floor
Kitchen
Nuclear Medicine
Endoscopy
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
RESPONSIBLE
PERSON
PHONE
NUMBER
DATE OF
INVENTORY
INVENTORY
LOCATION
5555
8/10/08
Nursing station
N/A
John Doe
Hazardous Materials & Waste
EC.02.02.01
EP 3-4: Written procedures to
implement in response to spills or
exposures
•
•
•
Remediation precautions
PPE procedures
Incident reports
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Hazardous Materials & Waste
EC.02.02.01
EP 5-Process for selecting, handling,
storing, transporting, using & disposing
of:
Hazardous chemicals
•
•
•
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Laboratory chemicals
Oils, fuels, grease, cleaning agents
ABHR
GENERAL HOSPITAL
Chemical Safety
Manual
Safe handling of hazardous
chemicals
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Hazardous Materials & Waste
EC.02.02.01
EP 6-Process for selecting, handling, storing,
transporting, using & disposing of:
Radioactive materials
•
•
•
Nuclear medicine
Laboratory
Cancer therapy
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
GENERAL HOSPITAL
Radiation Safety
Manual
Safe Handling of Radioactive
Materials
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Hazardous Materials & Waste
EC.02.02.01
EP 7-Process for selecting &
using:
Hazardous energy sources
y
y
y
Ionizing radiation (X-Ray)
Non-Ionizing (Microwave, MRI)
Lasers
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Hazardous Materials & Waste
EC.02.02.01
EP 8- Process for disposing of:
Hazardous medications
y Anti-neoplastic cytotoxic
y Anesthetic agents
y Anti-viral agents
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Hazardous Materials & Waste
EC.02.02.01
EP 9- Process for selecting, handling,
storing, transporting, using &
disposing of:
Hazardous gases & vapors
•
•
•
•
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Anesthesia gases
Formaldehyde
Ethylene oxide
Vapors from cauterizing
Hazardous Materials & Waste
EC.02.02.01
EP 10-Process for monitoring:
Hazardous gases & vapors
• Identify areas with gases or vapors
• Document testing with vendor & date
• Document follow-up on deficiencies
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Hazardous Materials & Waste
EC.02.02.01
EP 11- Maintaining documentation, such as
permits, licenses, manifests, & material
safety data sheets (MSDS)
y
y
y
y
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
List of permits & licenses
Expiration dates
Manifests to document “Cradle to Grave”
disposal
Documentation of material safety data
sheets
Licenses & Permits
Type of Hazardous Material
(Chemical, biohazard us, radioactive)
Purpose of Permit
(Procurement or Waste
Disposal)
Issuing Authority
(local, state, federal)
Permit or
License
Number
Renewal Date
Chemicals
Ordering &
disposal
DHEC
2222222
08-12-10
Radioactive
Ordering
NRC
A343434
01-3-12
Bio-hazardous
Disposal
DHEC, Steri
SC4454
01-06-09
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Hazardous Materials & Waste
EC.02.02.01
EP 12-Properly labeling hazardous materials
& waste
y
y
y
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
OSHA Bloodborne Pathogens
OSHA Hazard Communication
NFPA Label Criteria
Warning Labels
HOW TO IDENTIFY HAZARDS?
• NAME OF MATERIAL
• TYPE OF MATERIAL OR WASTE
• HAZARD RATING ON LABEL
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Goals Revisited
• Review the New Physical Environment
–
Environment of Care still key part
• Discuss Revised Scoring Process
–
Focus on Direct Impact EPs
• Identify Tracer Activities and Survey Methods
–
Practice Makes Perfect
• Analyze Impact on Environmental Services
–
Responsibility remains everywhere
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Questions
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV