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2011 George Mills, Sr. Engineer Standard Interpretation Group The Joint Commission © Copyright, The Joint Commission The Healthcare Environment Risk Assessment clear decision Educated guess that drives your assumptions Clearly document the process Determine when to re-assess the issue Problem solving approach to determine appropriate response Preventive strategies to address potential issues SIG Engineering 2011 - 2 © Copyright, The Joint Commission Use to evaluate any issue that lacks a Risk Assessment The hospital takes action to minimize or eliminate identified safety and security risks in the physical environment. EC.02.01.01 EP 3 SIG Engineering 2011 - 3 © Copyright, The Joint Commission The hospital identifies safety and security risks associated with the environment of care. Risks are identified from internal sources such as ongoing monitoring of the environment, results of root cause analyses, results of annual proactive risk assessments of high-risk processes, and from credible external sources such as Sentinel Event Alerts. EC.02.01.01 EP 1 Risk Assessment in the Healthcare Environment assessment in the Physical Environment Environmental Tours Observe the environment Manage By Walking Around Documentation Inspect, Test & Maintain Evaluate the effectiveness of the processes SIG Engineering 2011 - 4 © Copyright, The Joint Commission Several tools exist to facilitate risk Environmental Tours are included: Public waiting areas Floor covering in safe/functional condition Seating Grounds, Sidewalks, Garages, Parking Lots Egress to the “Public Way” Elevators Designated off-site locations SIG Engineering 2011 - 5 © Copyright, The Joint Commission Make sure that all areas of your organization EC.02.06.01 EP 1: Interior spaces meet the SIG Engineering 2011 - 6 © Copyright, The Joint Commission needs of the individuals served for safety and suitability for the care, treatment or services provided. Visual Observations processes Include affected staff Eliminating “workaround” Eliminating hazards/safety issues Proper storage of items Supplies Refrigerators Medications, food, biohazards, supplies Housekeeping carts & closet Hand hygiene products Patient / Non-patient Alcohol gels, paper towels, gloves, etc. Equipment SIG Engineering 2011 - 7 © Copyright, The Joint Commission Evaluate typical Visual Observations Personal Space areas for use by individuals Waiting & Reception areas Restrooms are appropriate Lighting is suitable for care, treatment, or services Ventilation, temperature and humidity levels Furnishings Dining environment SIG Engineering 2011 - 8 © Copyright, The Joint Commission Outside Staff Interviews Establish staff knowledge Evaluate Trend Process: Random selection Evaluate against policy Examples of processes evaluated: Reporting patient and employee injury events Referencing policies/procedures Evacuation Plans Labeling/reporting broken/non-functioning equipment Role in Emergency Operations Plan SIG Engineering 2011 - 9 © Copyright, The Joint Commission Purpose: Summary Make sure that all identified issues are SIG Engineering 2011 - 10 © Copyright, The Joint Commission followed up on in a timely matter Close the loop Utilize data collected as a performance improvement tool © Copyright, The Joint Commission Questions? SIG Engineers: 630 792 5900 George Mills, MBA, FASHE, CEM, CHFM, CHSP Senior Engineer SIG Anne Guglielmo, CFPS, LEED, A.P. Engineer SIG SIG Engineering 2011 - 12 © Copyright, The Joint Commission Michael Chisholm, CPE, CHFM Engineer SIG The Joint Commission Disclaimer These slides are current as of 2/17/2011. The Joint Commission reserves the right to change the content of the information, as appropriate. These slides are only meant to be cue points, which These slides are copyrighted and may not be further used, shared or distributed without permission of the original presenter or The Joint Commission. SIG Engineering 2011 - 13 © Copyright, The Joint Commission were expounded upon verbally by the original presenter and are not meant to be comprehensive statements of standards interpretation or represent all the content of the presentation. Thus, care should be exercised in interpreting Joint Commission requirements based solely on the content of these slides.