biggest pitfalls and best practices in ec

Biggest Pitfalls and Best Practices in EC

Healthcare Engineering Consultants

The Environment of Care Chapter

The Survey Planning Session


What Should Be Included in the

Management Plans?

The Management Plans


Best Practices Include:

Provide a description, not a rewrite of the program!

Be consistent in format; place in a labeled, tabbed binder

Include a list of applicable facilities to avoid multiple plans

Describe how each “element of performance” is achieved

Describe responsibilities from governing body to staff

Include performance improvement and training information

Reference applicable policies and procedures

Review by the safety committee annually

*Note: Emergency Management requires an Emergency Operations Plan (EOP), not a management plan

Safety Management


Issue: Proactive Risk Assessments for Safety

Biggest Pitfall: Risk assessing regulatory issues

Best Practices: 1. Create a “HVA” for prioritizing safety risks (refer to sample chart)

2. Be sure to include areas with behavioral health patients

3. Prioritize the risks, from highest to lowest

4. Appoint a multi-disciplinary group of “stakeholders” to evaluate changes necessary to minimize probability and impact

5. Seek approval for budget and recommended changes

6. Implement changes; track and document progress

Documenting Risk Assessments


Global Risk Assessment Form

Department/ Area:_____________________________ Date: _____________ Completed by: _____________________

Risk Element Description Occurrence Probability(1-5)

Occurrence Impact(1-5)

Total Impact Score(Probability X Impact)

Notes: To use this form, list all of the possible risk elements associated with the department or area that may impactpatient or staff safety or result in damage to buildings or equipment. Using all available data sources, including experienceand previous history, insert numerical values for the probability and impact for each element. Calculate the total impactscore for each element, prioritize in descending numerical order and select a “cut-off” limit. For all scores above the “cut-off”, perform the six step risk assessment process.

Example Global Safety Risk Assessment


Global Risk Assessment for Safety Management

Risk Element Description Occurrence Probability (1-5) Occurrence Impact (1-5) Total Impact Score(Probability X Impact)

Employee injuries 5 2 10Ergonomic issues 4 2 8Unauthorized staff appliances 4 2 8Unauthorized smoking 5 1 5Egress corridor clutter 4 1 4Unlocked clean supply roomsin inpatient areas

4 1 4

Improper storage 3 1 3General housekeeping 3 1 3Unlocked supply rooms inoutpatient clinics

2 1 2

Improperly stored cylinders 1 1 1

Note 1: This form is used to determine the possible impact to safety that may occur in the hospital resulting from a variety ofdifferent risk elements. Each of the risk elements is prioritized based on the total impact score, starting with the highest scoreobtained. Specific assessments are then performed for each risk element (starting with the highest impact score) to determineactions that may be taken or processes that may be altered to reduce the overall risk to the hospital.

Note 2: The scoring is defined as follows:

Probability Score Description Impact Score Description

1 Very unlikely to ever occur 1 No injury is likely to occur 2 Unlikely to occur in one year 2 Minor injury is likely to occur 3 May occur in one year 3 Moderate injury is likely to occur 4 Likely to occur in one year 4 Serious injury is likely to occur 5 Almost certain to occur within one year 5 Death is likely to occur

Example Global Security Risk Assessment


Global Risk Assessment for Security Management

Risk Element Description Occurrence Probability (1-5) Occurrence Impact (1-5) Total Impact Score(Probability X Impact)

Infant abduction 1 3 3Pediatric abduction 1 3 3Assaultive behavior - ED 5 3 15Assaultive behavior – mentalhealth unit

5 3 15

Theft – gift shop 4 1 4Theft – pharmacy 2 2 4Theft of hospital property 5 2 10Theft from patients 5 2 10Auto accidents on hospitalproperty

4 3 12

Trespassing 4 1 4Auto vehicle break-in 4 2 8Weapons brought ontohospital property

4 1 4

Utility systems intentionallyturned off or damaged

2 4 8

Terrorist activity near or onhospital property

1 5 5

Toxic gas introduced intohospital air intakes

2 4 8

Note 1: This form is used to determine the possible impact to security that may occur in the hospital resulting from a variety ofdifferent risk elements. Each of the risk elements is prioritized based on the total impact score, starting with the highest scoreobtained. Specific assessments are then performed for each risk element (starting with the highest impact score) to determineactions that may be taken or processes that may be altered to reduce the overall risk to the hospital.

1

Example Behavioral Health Risk Assessment


Behavioral Health Area Risk Assessment Grid

Area of Evaluation: _______________________________ Date of Evaluation: _________________ Page 1 of ____

Component Description

Impact Probability

Patient Impact

Staff Impact

Total Impact Score

Revision Recommended?

Revision Description

Electric/ other cords

Electrical receptacles

Patient beds

Door hinges

Hallway items, wall coverings

Towel racks

Bathroom grab bars

Bathroom fixtures

Smoking

Fire alarm pull boxes

Fire extinguishers

Windows

Seclusion room

Washer/ dryer

Safety Management


Issue: How to enforce the smoking policy?

Biggest Pitfall: Impractical policy or non-compliance

Best Practice: Create a practical policy

Incorporate smokeless tobacco and electronic cigarettes into the policy

Recognize the “citation priority”

Monitor smoking compliance

Provide realistic discipline for non-compliant staff, vendors and contractors

Security Management


Issue: Violence in the Workplace (JC PSG #45)

JC Recommended “Best Practice”

Audit facility risk of violence

Identify improvements in the violence protection program

Provide extra security precautions in the ED

Thoroughly pre-screen job applicants

Work with HR to minimize chances of violent reactions from employees who are disciplined or fired

Provide staff training regarding potentially violent family members

Ensure violence response procedures are in place

Security Management


Issue: Violence in the Workplace (continued)

JC Recommended “Best Practice”

Encourage staff to report incidents of violent activity or perceived threats of violence

Educate supervisors to be aware of and thoroughly investigate suspicious behavior, or threats

Ensure counseling programs are in place for employees who become victims of violent behavior or crime

If violence occurs, respond accordingly:

1. Report the crime to law enforcement authorities

2. Recommend counseling for those affected

3. Take action to prevent future occurrence

Hazardous Materials and Wastes


Issue: Minimizing Risks With Hazardous Energy

Best Practices:

Provide clear signage for Zones 1 - 4 in MRI areas

Ensure that emergency responders have been trained with regard to entering MRI areas

Verify that fire and other emergencies in the MRI area address quenching the magnet (yes or no)

Appoint a Laser Safety Officer (LSO) if lasers are used

Create and follow all written safety guidelines for MRI’s and lasers

Follow all arc flash protection/ PPE/ signage guidelines

Continue to follow all safety procedures for ionizing radiation



Issue: Proper Disposal of Hazardous Medications

Biggest Pitfall: Using sharps containers for hazardous medications

Best Practices:

Meet federal RCRA (or possibly tougher state) regulations

Be prepared for a visit from EPA, DOT or DEA

Create RCRA “P”, “U” and “D” pharmaceutical inventories and use color-coded labels to assist clinical staff in identification

Create a separate waste stream for disposal of partially-used and unused hazardous medications

Supply color-coded collection containers with sponges in clinical units

Track the manifest forms to verify proper incineration

Check Federal Guidelines at:

www.whitehousedrugpolicy.gov/publications/pdf/prescrip_disposal.pdf



Issue: Compressed Cylinder Storage

Code Requirements:

Enclosures are not required for stored gases <300 cubic feet per smoke compartment (NFPA 99, section 9.4.3)

For stored gases >300 but <3,000 cubic feet:

- Outdoors: enclosed space with doors or gates (9.4.2.1)

- Indoors: an enclosure with minimum ½ hour protection (9.4.2.3)

For stored gases >3,000 cubic feet:

- Walls, floors, ceilings, doors at least 1-hour rated (5.1.3.3.2)

- Racks, chains or fastenings to secure all cylinders (5.1.3.3.2)

- Continuous powered ventilation within 1 foot of floor (5.1.3.3.3)

FULL and EMPTY signage required for cylinders

Storage requires stands, racks or fastening devices, such as chains



Issue: Compressed Cylinder Storage

Interpretations:

Requirements for stored gas only, not in-use tanks!

In-use gas includes:

- Tanks on code carts

- Tanks on wheelchairs

- Tanks on gurneys

- 30-minute rule if patients are not present in wheelchairs, gurneys

Empty tanks do not count toward the total (be careful of AHJ!)

Use of fire-rated cabinets can be used on floors



Issue: Alcohol-Based Hand Rub Units Requirements

Code Requirements:

Patient safety goal 7 requires CDC compliance with Category I recommendations, suggests Category II compliance!

When no soiling is present, ABHR units are recommended (Cat I)

ABHR is permitted in a corridor at least 6 feet in width, at least 4 feet apart, and not directly over electrical outlets (6 inches from dispenser)

ABHR dispensers can be used over carpeted surfaces only in sprinkled smoke compartments!

ABHR permissible volumes:

- 10 gallons in dispensers/ 5 gallons in storage per smoke compartment

- Maximum individual dispenser capacity: .3 gallons

- Maximum dispenser size per suite of rooms: .5 gallons



Issue: Eyewashes and Showers

Biggest Pitfall: Failure to test eyewash according to policy

Best Practices:

Use risk assessment to determine placement

ANSI standards have not been officially adopted by the Joint Commission, but JC can reference OSHA

Tepid water between 60 and 100 degrees F will be expected

Testing policy is required – specify test intervals (weekly for eyewash units, monthly for showers recommended)

Documentation of test results is required

Differentiate between eyewash station and “first aid” station, such as mounted bottles

Fire Prevention


Issue: Unobstructed access to exits

Biggest Pitfall: Believing that providing clear egress isn’t required in a “business occupancy”

Code Requirement:

The 2011 “Fire Risk” standard (EC.02.03.01 - EP4), describes that the “hospital must maintain free and unobstructed access to all exits”. However, this requirement refers only to business occupancies, since healthcare and ambulatory occupancy egress requirements are

specified in the Life Safety chapter

Fire Prevention


Issue: Fire Drills

Biggest Pitfall: Missing specific fire drills required by AHJ

Best Practices:

Consider healthcare facilities as “three shifts”, even if many clinical staff work 12-hour shifts

Clearly define specific fire response roles and responsibilities for all staff in the hospital, including privileged physicians

Perform and document at least one drill annually in the OR

Use the fire drills as an opportunity to:

- document magnetic door releases for smoke and fire doors

- document the time from fire alarm initiation to receiving station

Document the fire drill on a form with numerical values to track improvement of staff response and knowledge over time

Medical Equipment Management


Issue: Equipment Test Scoring

Biggest Pitfall: Not tracking PM completion rate

Code Requirements:

100% PM completion for “life support” devices, based on “A” scoring

Note: JC considers defibrillators “life support” devices, even AED’s

90% PM completion for “non-life support” devices (C)

Determine test interval and procedures by “PM effectiveness” and MTBF data (accepted now by CMS)

Test tags with due dates are recommended, but not required! What about Ongoing PM vs. initial test only?

Flexible and rigid endoscopes are now required to be on the medical equipment inventory for monitoring purposes

Medical Equipment Management


Issue: Incoming Equipment Tests

Biggest Pitfall: Not performing incoming equipment tests on patient-owned equipment

Code Requirements:

Patient-owned equipment (NFPA 99, section 8.5.2.1.2.2)

Diagnostic and therapeutic (example: CPAP)

Personal use (iPods, smart phones, laptops, iPads)

Rental devices

Demo, loaner and trial equipment

Utility Systems Management


Issue: Airborne Pathogens

Biggest Pitfall: No air exchange data in pharmacy or clinical laboratory areas

Best Practice:

Create an airborne pathogens policy that describes how often air filters are changed, and air exchange and pressure relationships are measured in operating rooms, delivery rooms, special procedure rooms, patient isolation rooms, clinical laboratories, sterile supply rooms and pharmacies

Nominal test frequencies are annual, but can define other

Note: Refer to 2010 FGI document for requirements (new for 2011)

Note: “Grandfathering” permitted for air handlers



Issue: Temperature and Humidity in the Operating Rooms Code Requirements: NFPA 99, section 6.4.1.1 requires control of humidity >35%

FGI 2010 Guidelines document lists control from 30% to 60% in Table 7-1

CMS requires humidity above 35%

JC expects temperature and humidity monitoring/ documentation

Policy is needed for monitoring and control range, including clinical procedures when the actual readings are outside the range

Changes to ASHRAE 170 (in FGI document) to lower humidity level requirements to 20% have been approved by the Joint Commission!



Issue: Utility System Test Scoring

Biggest Pitfall: PM not tracked for required categories

Best Practices:

Create three different utility system inventory categories:

1. Critical utility life support

2. Critical utility infection control

3. Critical utility non-life support

Track and maintain “on-time” PM completion rates for the “critical life support” and “critical infection control” components based on “A” scoring: 100%

Track and maintain “on-time” PM completion rates for “critical non-life support” components based on “C” scoring: 90%

Functional Environment


Issue: The JC “General Duty Clause”

Biggest Pitfall: Surveyor interpretation

Patient areas are safe, clean, free of odors and

suitable

Lighting is suitable

Ventilation, temperature and humidity are suitable

Locks and restraints per regulation

Emergency access for locked spaces is provided



Issue: Pre-Construction Risk Assessment (PCRA)

Biggest Pitfall: Only ICRA and ILSM are evaluated

Best Practice: Include all seven of the items listed below in the PCRA evaluation

● Noise ● Emergency procedures

● Vibration ● Utility failures

● Air quality ● Interim life safety measures

● Infection control

Infection Control Risk Assessment (ICRA) – Best Practice Grid


Risk Criteria for Infection Control

Type A Type B Type C Type D

Group 1 (lowest) I II II III

Group 2 (medium) I II III IV

Group 3 (medium high) II III III IV

Group 4 (highest)

III

III IV IV

Construction TypePatient

Risk



Issue: Documentation of PCRA

Best practices:

• Evaluate measures to reduce risk and minimize the impact of the construction activities

• Perform daily monitoring in all construction areas

• Use a monitoring checklist

• Post required permits, such as hot work, ICRA, above-the-ceiling work, ILSM, etc. on door entrance to construction area



Issue: Pre-Construction Risk Assessment (PCRA)

Best Practice: Include PCRA changes during the project

Pre-Construction Risk Assessment Timeline Chart

Project number: __________________________ Date: _____________________ Completed by: ____________________________

PCRA Category

Week 1

Week 2

Week 3

Week 4

Week 5

Week 6

Week 7

Week 8

Week 9

Week 10

Comments

Noise

Vibration

Air Quality

Infection Control Risk Assessment (ICRA)

Interim Life Safety Measures (ILSM)

Emergency Procedures

Utility Failures

Information Collection and Monitoring


What is the most effective method to provide EC

monitoring and reporting?

Measurement and Improvement

What Measurements are Required in 2011?

Patient and visitor injuries

Occupational illnesses and staff injuries

Incidents of damage to hospital or others property

Patient, staff or visitor security incidents

Hazmat spills and exposures

Fire safety management problems, deficiencies and failures

Medical equipment management problems, failures, and user errors

Utility system management problems, failures and user

errors Healthcare Engineering Consultants

Monitoring Regulatory Requirements


Regulatory Compliance Dashboard

Description JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC Comments General Reqs SC Meetings X X X X Dashboard Rpt X X X X Leadership Rpt X X Evaluations X Policy Review X Safety Mgmt Hospital Surv X Clinic Surv X Security Mgmt Alarm Tests X X X X X X X X Abduction Drills X X Hazmat Mgmt Manifests X X X X X X X X Haz Vapor Mon X X X Permits, Lic X Verify MSDS X Emer Mgmt Hospital Drills X Clinic Drills HVA Fire Prev Hosp Fire Drills X X X X X X X X Clinic Drills X X X SOC Document ILSM Measures N/A N/A N/A N/A A/R A/R A/R A/R A/R A/R A/R A/R Extinguishers X X X X X X X X Fire Det Dev X X X

Monitoring Regulatory Requirements


Regulatory Compliance Dashboard (continued)

Description JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC Comments Fire Prev Water Devices X X X Fire Pumps W W W W W W W W Ver/Hor Doors X F/S Dampers Med Equipmt PM LS Eqmt X X X X X X X X PM NLS Eqmt X X X X X X X X Util Systems PM LS Sys X X X X X X X X PM NLS Sys X X X X X X X X Em Gen Tests X X X X X X X X Batt Light Test X X X X X X X X Water Tests X X X HVAC Tests X X X MGAVS Tests X X X X X X X X App Environ PCRA N/A N/A N/A N/A A/R A/R A/R A/R A/R A/R A/R A/R Miscellaneous Eyewash units W W W W W W W W Showers X X X X X X X X

Key to dashboard symbols: X – Indicates that action is required during the month indicated; W – Indicates that weekly action is required A/R – Indicates that action is required when applicable Key to colored boxes: Red boxes indicate non-compliance (tests were not performed); Yellow boxes indicate partial compliance (tests have been delayed or not fully completed); Green boxes indicate full compliance (tests satisfactorily completed).

Measurement and Improvement

What Performance Improvement Measures are Required for each “EC” area?

No longer any minimum number in 2011!

Should be numerical

No maximum number of numerical measures

Should measure performance improvement

Adopt goals, objectives and benchmarks

At least one performance improvement initiative from “EC” is required to be performed, documented and reported to leadership annually

Regular reporting and tracking of PI to the Safety Committee


Reporting of “EC” PI Indicators


Performance Improvement Dashboard

Description of Measure

Benchmark FY 2004

Objective FY 2005

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Trend

Safety Management

Lost time injuries

21/ year <1.5 per month

1 2 1 3

Security Management

Internal theft (equipment, $)

$ 25, 426 for the year

<$ 2,000 per month

1,200 425 0 1,720

Hazmat Management

Decrease in RMW

124,560# for the year

< 9,500# per month

9,245 9,386 9,142 9,524

Emergency Management

Call-back response rate

68% within 20 minutes

75% 69% 73% 84% 81%

Fire Prevention

Average fire drill score

87 per drill average

> 90 per drill avg

93 91 94 91

Medical Equipment

Maint cost/ device/ month

$48.13 per device/ mo

$45.00/ dev/ mo

53.14 47.86 58.22 39.78

Utility Management

Priority I WO response time

3.2 days < 3 days 3.1 3.1 2.9 3.0

Key to colored boxes: Green boxes indicate data within the desired objective and an improvement trend Yellow boxes indicate data at or slightly above the desired objective with no discernible trend Red boxes indicate data above the desired objective and a negative trend

Annual Evaluations

“Best Practice” Guidelines for the Evaluations

Demonstrate that the program has improved

Provide numerical data

Demonstrate “effectiveness” rather than “busyness”

Document evaluations for every “EC” area, including Emergency Management

Create the evaluations as soon as possible at the end of the fiscal or calendar year

Re-read the annual evaluations before the survey


Annual Evaluations

The Annual Evaluations must include:

SCOPE - What is being evaluated?

OBJECTIVES - What are the numerical goals/ benchmarks?

PERFORMANCE - What does the data show?

EFFECTIVENESS - How does the performance (data) compare to the objectives?

WHAT NEXT? - What objectives do we define for next year, based on this year’s performance?


Annual Evaluations

Best Practice: Each annual evaluation should include a review of:

The management plan

Regulatory compliance

Performance improvement

Other issues to take credit for


Annual Evaluations


Annual Effectiveness Evaluation Matrix

“EC” Area: ____________________

Calendar year: _________________

Management Plan RegulatoryCompliance

PerformanceImprovement

OtherAccomplishments

Scope

Objectives

Performance

Effectiveness

Objectives for NextYear

Note: This matrix is not intended to be used for the actual annual evaluation format, but provides a guide to what should be included in the evaluation

The Safety Committee


Best Practices Include:

Leadership representative (VP) present at every meeting

Multi-disciplinary membership

Attendance of standing members at least 70%

Meet often enough to limit meeting time to 1 hour or less

Document and distribute meeting minutes within two weeks of the meeting and use the C-R-A-F format

Use dashboards or spreadsheets to track regulatory and performance improvement data

Track the resolution of issues with a monitoring chart

Use the meeting time to solve problems, not to review data or information that does not require any action

Safety Committee Issue Monitoring


Safety Committee Issue Monitoring Sheet

Issue Number

Issue Description Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

10-17 10-23 10-26 11-01 11-02 11-03 11-04 11-05 11-06 11-07 11-08 11-09 11-10 11-11

Fire exit plans Safety manual In-services Disaster reports Recall sheet Rear parking OB project Sharps in trash Slick pavement Snow removal Telephone system. Haz Com Fire reports Rehab door

F F T P P P P P

F C F F T T F F P P P

C

F R R F V R C C F P P P

Key to issue numbers: year of issue initiation followed by issue number in committee minutes Key to action: P = problem initiated; F = follow-up; R = recommendation; T = tabled; NA = no action; V = vote taken; C = complete

Biggest Pitfalls and Best Practices in EC

Questions?


biggest pitfalls and best practices in ec

Documents

overall risk

possible risk elements

proactive risk assessments

staff safety

highest impact score

possible impact

safety committee

step risk assessment