changes and challenges for “ec” in 2009

Changes and Challenges

for “EC” in 2009

Presented by:

Gary D. Slack, PE, CCE

Healthcare Engineering Consultants

Joint Commission

Part 1: Meeting the Challenges of the Survey Process and New Changes for 2009


Understanding the Survey Process

The Survey Process in 2009


Typical Surveys Include:

Two to five days “on-site”

Two, three or more surveyors (usually nurses

and physicians - includes a “Life Safety Specialist”

for all hospitals in 2008; two LSS surveyor days

for >750K sq ft, three for >1.3 million sq ft

Review of documents (survey planning meeting)

Life safety-focused facility tour

“EC” interview includes tabletop simulation

Questions to staff based on tracer methodology

Summary conference to present tentative findings

The Unannounced Survey Challenge


Unannounced Surveys will Occur:

Between January 1 and December 31, three years after the last scheduled survey (during 2008)

Between 18 and 39 months from the date of the first unannounced survey (2009 forward)

The timing of all surveys after the first unannounced survey will be based on Priority Focus Process (PFP) data (poor S3 scores lead to earlier survey?)

Note 1: All new applicants for the accreditation process as well as changes to a new classification (example: critical access designation) have unscheduled surveys

Note 2: Exceptions to unannounced surveys occur with the Bureau of Prisons or certain DOD facilities

The Unannounced Survey Challenge


Surveys Can Also Occur Due To:

One year follow-up survey for newly accredited organizations that provide high risk or critical services

Random off-cycle validation survey (5% pool, discontinued at end of 2008)

Random unannounced validation surveys to verify “evidence of standards compliance” (ESC)

Sentinel event follow-up

Adverse media coverage of specific issue

Complaint from the public

Any other time that the JC decides it’s appropriate!

Meeting the Scoring Challenges


Understanding Scoring Decisions and Defining

Low-Scoring Areas

“EC”-Related Scoring Rules for 2008


Preliminary Denial of Accreditation (PDA)

PDA01 - Immediate threat to health or safety

PDA03 - Falsification of documentation

PDA06 - Non-compliant standards 3 standard

deviations above the mean (14 or 18 RFI’s)

Conditional Accreditation (CON)

CON01 - Non-compliant standards count 1.5 standard

deviations above the mean (10 or 14 RFI’s)

CON03 - Failure to clear repeat non-compliant

standards

CON04 - Delayed PFI or no ILSM implementation or

enforcement when required

Joint Commission Scoring Decisions


Accreditation Thresholds for 2008

Conditional Accreditation (CA)

10 or more non-compliant standards (< 100 ADC)

14 or more non-compliant standards (>100 ADC)

(change from 13 in 2007)

Preliminary Denial of Accreditation (DOA)

14 or more non-compliant standards (<100 ADC)

18 or more non-compliant standards (>100 ADC)

(change from 17 in 2007)

“CALS” threshold for DOA is 16 and 20 for small and

large hospitals, respectively

Lowest Scoring JC Areas


Percent Scored Not Compliant for Hospitals

MM.2.20 (43%) – Proper and safe medication storage

PSG 2C (36%) – Timeliness of critical test results

PSG 2B (29%) – Standardized list of abbreviations

EC.5.20 (27%) – Compliance with the Life Safety Code

IM.6.10 (24%) – Complete and accurate medical record

Universal Protocol 1: 2C (23%) – Conduct a “time out” before starting a procedure

Will likely

Move up

In 2008

Lowest Scoring JC “EC” Areas


“EC” Standards Scored Not Compliant for Other Facilities

EC.5.20 – Life Safety Code compliance

EC.4.10 – Emergency management

EC.9.10 – Conditions monitored in the environment

EC.6.20 – Equipment is maintained, inspected and

tested

Joint Commission Standards Scoring


“A” Scores: High priority, One and Done!

Safety Management Scoring Sheet

JCAHO Standard

Element of Performance Scoring Category

Measure of Success

Current Score

EC.1.10 Safety Risk Management 1 Management Plan B 2 Safety leadership appointment A 3 Intervention authority A 4 Proactive risk assessments B 5 Procedures based on risk C M 6 Safety policy review C M 8 Safety recall process B 9 Grounds and equipment B EC.1.20 Maintains Safe Environment 1 Environmental tours B 2 Patient areas C M 3 Non-patient areas C M EC.1.30 Smoking Policy 1 Policy in buildings B 2 Outpatient/ youth prohibition B 3 Exceptions to policy B 4 Building requirements C M 5 Smoking cessation education C M 6 Compliance monitoring B 7 Strategies for violations B

Example: EC1.10, EP 2

Safety officer appointment

You either have the letter or you don’t – Compliant or non-compliant, no partial credit!



“B” Scores: Process, surveyor Discretion

Safety Management Scoring Sheet

JCAHO Standard


Measure of Success

Current Score

EC.1.10 Safety Risk Management 1 Management Plan B 2 Safety leadership appointment A 3 Intervention authority A 4 Proactive risk assessments B 5 Procedures based on risk C M 6 Safety policy review C M 8 Safety recall process B 9 Grounds and equipment B EC.1.20 Maintains Safe Environment 1 Environmental tours B 2 Patient areas C M 3 Non-patient areas C M EC.1.30 Smoking Policy 1 Policy in buildings B 2 Outpatient/ youth prohibition B 3 Exceptions to policy B 4 Building requirements C M 5 Smoking cessation education C M 6 Compliance monitoring B 7 Strategies for violations B


Proactive risk assessment

Can be fully, partially or non-compliant

Note: All of the “B” scores will be deleted in 2009



“C” Scores: Three strikes and you’re out!


Portable fire extinguishers

Three missed monthly checks (aggregated) is an RFI!

Fire Prevention Scoring Sheet

JCAHO Standard


Measure of Success

Current Score

EC.5.10 Fire Safety Management 1 Management plan B 2 Proactive fire protection B 3 Fire system testing program B 4 Fire response plan B 5 Acquisitions, decoration policy B EC.5.20 Life Safety Code Compliance 1 NFPA 101 compliance B 2 e-SOC completion A 5 Sufficient PFI progress A 6 SOC responsibility assignment B EC.5.30 Fire Drills 1 Quarterly/ shift hospital drills C M 2 Annual/ shift clinic drills A 4 Unannounced drills C M 5 Staff drill participation B 6 Drill critique B 7 Annual response evaluation A 8 Staff knowledge during drills B EC.5.40 Fire Component Tests 1 Supervisory/ tamper switches C M 2 Alarm notification devices C M 3 Off-premises trans. eqmt. A 4 Fire pumps C M 5 Water tank level alarms C M 6 Water tank level alarms (cold) C M 7 Main drain tests C M 8 Fire department connections C M 9 Fire pumps A 10 Kitchen systems A 11 Gaseous extinguishing systems C M 12 Portable fire extinguishers C M 13 Occupant hoses C M 14 Smoke/ fire dampers C M 15 HVAC smoke detectors A 16 Horizontal/ vertical fire doors C M

Special Scoring for SOC Deficiencies During the Facility Tour


“X” is considered a minor deficiency Example: a fire door does not latch properly (item 1C3) – Score 1 point

“Y” is considered a midrange deficiency Example: the same fire door above is missing hardware (item 1C2) – Score 2 points

“Z” is considered a major deficiency Example: the building is not of an allowable type of construction (item 1A1) or each floor does not have at least two approved exits (item 5A) – Score 4 points

Note 1: Use the scoring grid and key to determine the X, Y and Z scores; 1-5 total score is partial compliance; 6 or greater is non-compliance, or a “Z” score!

Note 2: Implementation of an “effective” Building Maintenance Program (BMP) “caps” each item at 1 point

Scoring Changes for 2009


Scoring in the new Life Safety chapter will be the same as the rest of the scoring (no longer any “X”, “Y” or “Z” scores)

“A’s” and “C’s” will remain, “B” scores will be eliminated

Four new levels of scoring risk (surveyor discretion):

1. Immediate Threat to Life: results in preliminary DOA

until follow-up evidence of compliance demonstrated

2. Situation Decision: results in preliminary DOA or CA

3. Immediate Impact Requirements: immediate care

impact; must submit ESC within 45 days

4. Less Immediate Impact: no immediate risk; ESC

submission within 60 days

Challenges for 2008 and 2009


Changes and Focus Areas in 2008 and 2009

“EC”-Related Patient Safety Goals for 2008


For Ambulatory, Behavioral Health, Home Care and Hospital Facilities

Add Goal #13: Encourage patient’s active involvement in their own care as a patient safety strategy (define and communicate the means for patients and families to report safety concerns)

Add Goal #15: The organization identifies safety risks inherent in its patient population (identify suicide risk – relates to patients being treated for emotional and behavioral disorders)

Note: This applies to all areas of the hospital!

Other “EC” Changes for 2008


Smoke and fire dampers in hospitals can be tested every six rather than every four years

All hospitals, regardless of size, will have a Life Safety Specialist for at least one day during the survey

Sentinel Event Alert #38 (MRI safety) must be reviewed and appropriate action taken

Behavioral health environmental risk assessments must be documented

EC-Related Priority Focus Areas (PFA’s) for 2009


Equipment Use

Infection Control

Information Management

Organizational Structure

Orientation and Training

Patient Safety

Physical Environment

Staffing

The 2009 Joint Commission Manual


The entire Joint Commission manual will be rewritten in 2009

The Environment of Care chapter in 2008 will be split into three chapters in 2009:

1. Environment of Care (EC)

2. Emergency Management (EM)

3. Life Safety, including the Statement of

Conditions (SOC) document (LS)

The 2009 EC Chapter


What will be the major EC changes?

Mostly editorial changes

Emergency management and life safety (not fire safety) will have their own chapters

Staff competency (including for clinical staff) will be returned to the EC chapter

Safety and security may be combined into one standard

An entirely new numbering system will be used

Numbering the EC Standards


EC.01.01.01 – Management Plan Requirements

EC.02.01.01 – Safety and Security

EC.02.02.01 – Hazardous Materials and Wastes

EC.02.03.01 – Fire Safety

EC.02.04.01 – Medical Equipment

EC.02.05.01 – Utilities Management

EC.02.06.01 – Functional Environment

EC.03.01.01 – Staff and LIP Training

EC.04.01.01 – Monitoring and Improvement

Major Revisions to the EC Standards


EC.01.01.01 – The organization plans activities to minimize risks in the Environment of Care

Safety officer appointment with intervention authority

Management plans for:

1. Safety

2. Security

3. Hazardous materials and wastes

4. Fire safety

5. Medical equipment

6. Utility systems



EC.02.01.01 – The organization manages safety and security risks

Identification of potential safety and security risks

Action taken to minimize risks

Maintenance of grounds and equipment

Identifies staff, patients and others entering the facility

Access control to and from security sensitive areas

Identifies and implements procedures for security incidents

The organization responds to product recalls/ notices



EC.02.01.03 – The organization prohibits smoking except in specific circumstances

Written smoking policy required

Designates smoking areas that are environmentally

separate from care and service areas

Action is taken to ensure compliance with the policy

Note: Smoking requirements for patients will be moved to

the “Provision of Care” (PC) chapter



EC.02.02.01 – The organization manages risks related to hazardous materials and wastes

Maintenance of hazmat inventory (Ref. CFR, IC,and MM)

Procedures to minimize risk for hazardous chemicals, radioactive materials, hazardous energy sources (radiation and lasers) and hazardous gases and vapors

Monitoring of exposure to hazardous gases and vapors

Permits, licenses, manifests and MSDS sheets maintained

Hazardous materials are properly labeled

Procedures exist for PPE and spill responses

Infectious waste management moved to IC chapter

Proper disposal of hazardous medications



EC.02.03.01 – The organization manages fire risks (includes fire policies and fire responsibilities)

EC.02.03.03 – The organization conducts fire drills (includes conducting and evaluating drills)

EC.02.03.05 – The organization maintains fire safety equipment and fire safety building features (same fire system tests are required)

Note: The requirement for the implementation of interim life safety measures has been moved to the new LS chapter



EC.02.04.01 – The organization manages medical equipment risks (includes policies for acquisition, including input from users, equipment inventory, maintenance strategies, test intervals, hazard notices, SMDA reports and equipment failures, including clinical interventions)

EC.02.04.03 – The organization inspects, maintains and tests medical equipment (includes tests before initial use, ongoing testing for life support equipment, non-life support equipment, sterilizers

and dialysis equipment, including water testing)



EC.02.05.01 – The organization manages risks associated with its utility systems (includes systems to meet patient needs, system inventory, maintenance strategies, test intervals, water and airborne pathogen policies, utility diagrams, labeling, and failure procedures that include clinical interventions and obtaining repair services)

EC.02.05.03 – The organization possesses a reliable emergency electrical power source (defines equipment and systems that are required to be connected by the Life Safety Code and the National

Electrical Code)



EC.02.05.05 – The organization inspects, tests and maintains utility systems (requires initial testing of all utility systems and equipment and also requires a defined maintenance program for life support, infection control and non-life support utility systems)

EC.02.05.07 – The organization inspects, tests and maintains emergency power systems (requires monthly and annual battery light testing or battery replacement with 10% random sample test, tests for SEPSS systems, weekly, monthly and trienniel generator tests, monthly transfer switch tests and annual load bank

tests, when required)



EC.02.05.09 – The organization inspects, tests and maintains medical gas and vacuum systems

1. Requires inspecting, testing and maintenance of master signal panels, area alarms, automatic pressure switches, shutoff valves, flexible connectors and outlets at intervals defined by the organization

2. Requires certification after installation or modification of the system and purity, proper gas and proper pressure after repair

3. Requires accessibility and labeling of main supply and area shut-off valves



EC.02.06.01 – The organization manages and maintains a safe, functional environment (requires appropriate space and storage needs, suitable outdoors area, appropriate lighting and ventilation, clean and odor-free areas, emergency access to locked areas and maintenance of furnishings and equipment)

EC.02.06.05 – The organization manages its environment during demolition, renovation, or new construction to reduce risk to those in the organization (requires adherence to AIA or other criteria, documentation of a pre-construction risk assessment (PCRA) and action

based on the PCRA)



EC.03.01.01 – Staff and licensed independent practitioners are familiar with their roles and responsibilities relative to the environment of care

1. Staff and licensed independent practitioners can describe or demonstrate methods for eliminating and minimizing physical risks in the environment of care

2. Staff and licensed independent practitioners can describe or demonstrate actions to take in the event of an

environment of care incident

3. Staff and licensed independent practitioners can describe or demonstrate how to report environment of care risks

Note: This is a new standard for 2009; also HR reference



EC.04.01.01 – The organization collects information to monitor conditions in the environment

Requires a process to monitor performance in managing EC risks and for investigating and reporting patient and staff injuries; property damage; security incidents; hazardous materials spills and exposures; fire safety problems, deficiencies and failures; medical equipment problems, failures and user errors, and; utility system problems, failures and user errors. Semi-annual environmental tours in patient areas and annual tours in non-patient areas are conducted and an annual evaluation of each EC management plan is documented.

Note: Requirement for specific PI measures eliminated!



EC.04.01.03 – The organization analyzes identified environment of care issues and develops recommendations for improving them

1. A multi-disciplinary improvement (MIT) team is required to analyze EC issues

2. The analysis results in recommendations for improvement

3. The MIT recommends one or more EC performance improvement activities to executive management

EC.04.01.05 – The organization uses the results of the analysis to improve its environment

Action is taken on identified recommendations for

improvement in the environment of care

Contents of the 2009 Life Safety Chapter


LS.01.01.01 – Completion of the Statement of Conditions

LS.01.02.01 – Implementation of interim life safety measures

LS.02.01.10 – Building fire protection features

LS.02.01.20 – Integrity of the means of egress

LS.02.01.30 – Building features are maintained

LS.02.01.34 – Maintenance of fire alarm systems

LS.02.01. 35 – Maintenance of extinguishing systems

LS.02.01.40 – Special features for fire protection

LS.02.01.50 – Maintenance of building service systems

LS.02.01.70 – Operating features

LS.03.01.10 through LS.03.01.70 – Ambulatory health care

Impact of the 2009 Life Safety Chapter


Individual chapter will focus attention on Life Safety

Notes include a PFI “trigger” of 45 days from the DRAFT

Parallels requirements in the 2000 Life Safety Code

Standards can be used for the Life Safety Assessment

Eliminates the “cap” on the Building Maintenance Program

Notes include a maximum 6 month PFI completion time from the DRAFT

Permits some requirements in the 2006 edition of NFPA 101 (6” corridor wall protrusion)

Also includes references to NFPA 10, 13, 18, 25, 72, 82, 96 and 99 and all other provisions of NFPA 101!

Covers hospital and ambulatory occupancies

Contents of the 2009 Emergency Management (EM) Chapter


EM.01.01.01 – Planning activities: HVA, M-P-R-R and ICS

EM.02.01.01 – Creation of the EOP

EM.02.02.01 – Emergency communications

EM.02.02.03 – Resource and asset management

EM.02.02.05 – Security and safety

EM.02.02.07 – Management of staff

EM.02.02.09 – Management of utilities

EM.02.02.11 – Patient management

EM.02.02.13 – Emergency privileges to LIP’s

EM.02.02.15 – Disaster responsibilities to volunteers

EM.03.01.01 – Evaluation of program effectiveness

EM.03.01.03 – EOP evaluation using drills

Organizational Function Overview


Human Resources (HR)

Staff training, competency and performance

Leadership (LD)

Compliance, resources, patient safety, oversight of

contracts/ services

Performance Improvement (PI)

Data collection, aggregation, analysis , action

Information Management (IM)

Data collection, aggregation, security

Infection Control (IC)

Measurement and reduction of infections

Organizational Function Overview


Questions?

changes and challenges for “ec” in 2009

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