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Changes to the 2011 Standards What’s New? Healthcare Engineering Consultants Safety Management Issue: Joint Commission Sentinel Event Alert #46 – Suicide Prevention (issued 11/17/2010) What’s New? Focuses attention on areas outside behavioral health Risk assessment recommended Consider ED, medical/ surgical units, outpatient counseling areas Patient screening, monitoring and staff training Healthcare Engineering Consultants Security Management Issue: Joint Commission Sentinel Event Alert #45 - Violence in the Healthcare Setting What’s New? Audit the risk of violence in your facility Evaluate violence prevention program Discuss issues with HR department Provide appropriate staff training Ensure practical response procedures are in place Provide counseling and other services, as required Report violent acts to local authorities Healthcare Engineering Consultants Hazardous Materials and Wastes Issue: Proper disposal of partially used hazardous medications What’s New? P, U and D-listed medications must be identified A separate waste stream must be provided Staff must be trained to identify and properly dispose of partially used medications in specific containers Waste medications must be incinerated by licensed contractor Compliance with EPA, DOT and DEA is required Healthcare Engineering Consultants Fire Prevention Issue: Changes in test frequencies for fire devices (EC.02.03.05, EP2) What’s New? Effective July 1, 2011, the Joint Commission will require quarterly rather than semi-annual tests for valve tamper and water-flow devices. Note 1: References NFPA 25, 1998 edition, section 2-3.3 and NFPA 72, 1999 edition, table 7-3.2 Note 2: Published in the January 12, 2011 edition of Joint Commission Online Healthcare Engineering Consultants Fire Prevention Issue: Changes in documentation requirements for fire alarm and water-based fire protection systems (EC.02.03.05, EP25 – new!) What’s New? Effective July 1, 2011, the Joint Commission will require the following documentation for fire system tests: 1. Name, date and required test frequency of the activity 2. Name and contact information of the person who performed the tests 3. NFPA reference for the test 4. Test result (pass or fail) Note: Published in the January 12, 2011 edition of Joint Commission Online Healthcare Engineering Consultants Medical Equipment Management Issue: Inventory of Endoscopes What’s New? Flexible and rigid endoscopes must be included on the medical equipment inventory The Biomedical Engineering Department is not required to repair or service the endoscopes, but must monitor the service and repair Reusable medical equipment and proper cleaning of devices is a “focus area” for 2011 Note: Announced by George Mills at the 2010 AAMI Annual Conference and published in the August, 2010 and January 2011 issues of AAMI News Healthcare Engineering Consultants Medical Equipment Management Issue: CMS Accepts Alternatives to Manufacturer Maintenance Recommendations What’s New? Previous disparity between CMS and the Joint Commission regarding PM procedures has been eliminated Renewed focus on the following criteria for maintenance: 1. Manufacturer’s recommendations 2. Risk levels associated with equipment 3. Hospital experience with the equipment Note: Published in the December, 2010 issue of Joint Commission Perspectives and the January, 2011 issue of EC News Healthcare Engineering Consultants Utility Systems Management Issue: Humidity Monitoring in the OR’s What’s New? 1. The Joint Commission has adopted the 2010 FGI Guidelines document that references the new ANSI/ ASHE/ ASHRAE 170 standard for ventilation 2. The Guidelines document references humidity levels of 20% - 60% 3. CMS still references NFPA 99, section 5-4.1.1, which specifies a minimum humidity level of 35% 4. The Joint Commission/ CMS disparity still exists Note: Refer to 2010 FGI document for specific requirements Healthcare Engineering Consultants Functional Environment Issue: New 2010 FGI Document Referenced (EC.02.06.05, EP 1) What’s New? 2010 FGI document now referenced by the Joint Commission Applies to new, altered or renovated space after 1/1/2011 Major changes in the 2010 edition include: - Acoustics, patient handling and bariatric accommodations - Cancer treatment and IV therapy services - Telecommunications areas, wayfinding and patient safety assessments - Freestanding cancer treatment and outpatient rehab. facilities - Incorporates ANSI/ ASHE/ ASHRE Standard 170 for ventilation Healthcare Engineering Consultants Changes to the 2011 Standards Questions? Healthcare Engineering Consultants
