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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