The Compliance Puzzle: Putting the Pieces Together A Guide to comply with JCAHO, EPA, OSHA, DOT, H2E and beyond. JCAHO EPA Attendees need: Working knowledge of JCAHO, EPA, OSHA and DOT regulations as they apply to hazardous materials and waste Laptop computer File is large so don’t want to overwhelm you. We are not going over environmental compliance, but a tool to walk you through the Environment of Care Standards. This guide to improving compliance with jcaho environment of care standards. Anyone doing this work knows there is a myriad of regulations we have to comply with and how does the jcaho inspector look for compliance with environmental regulations How do they overlap? How are they related to each other? The guide is to help make those connections and connect to the EOC Standards. Janet Brown, H2E Partner Program Mgr. Ph: 413/253-0254 E-mail: janet.brown@h2e-online.org www.h2e-online.org DOT/ OSHA

The Status of Environmental Compliance in Healthcare Today’s Objectives The Status of Environmental Compliance in Healthcare JCAHO Survey vs. EPA Inspections H2E JCAHO Environmental Compliance and Improvement Guide Status of environmental compliance today and what we have found in the past few years. We will talk about the differences and similarities between the EPA inspection and the JCAHO inspection process. While JCAHO may not focus on performance indicators, they can be folded inot an overall quality improvement initiative.

Rewriting all EOC Standards for 2009 Field Review JCAHO Update Rewriting all EOC Standards for 2009 Field Review Life Safety Chapter welcoming feedback right now. Emergency Management Standard will be pulled into its own chapter in 2008. So there will be 1. eoc, 2. emergency mgmt and 3. life safety Learn more at jointc.org

JCAHO Definition/Background The Joint Commission for the Accreditation of Healthcare Organizations Sets standards for care and quality improvement Minimum standards are set by Center Medicare and Medicaid Services (CMS) JCAHO accredited organizations meet and exceed CMS standards Other accreditation organizations E.g. Institute for Healthcare Improvement Also, state licensure Methodology Healthcare processes divided into areas, e.g. Environment of Care, Leadership, Treatment, Human Resources, Patient Rights Each area has a set of standards The standard is the “goal” “Rationale” explains why important to reach the goal. “Elements of Performance” are the steps necessary to reach the goal. This is just a background on what JCAHO is. The Methodology is broekn into environment of care, leadership, human resources, patient rights and have a set of standards within each one. The rationale explains why the goal is important. All of this information is on our main page of the tool on the H2E web site. “EP” That is the element of performance for each of the standards. JCAHO

Joint Commission http://www.jointcommission.org/ Top Stories Tell Us What You Think About The Proposed Standard Revisions to The Joint Commission’s Standards - Patient Rights

Joint Commission NEW!  Safe by Design Designing Safety in Health Care Facilities, Process, and Culture by John Reiling.   Learn the latest design trends and how they can enhance patient safety in health care environments.  Read about health care organizations that have succeeded in designing and constructing safe environments.  Discover the value of involving nurses, physicians, patients, and others in health care facility design.  http://www.jcrinc.com/26632/

Standards Improvement Initiative http://www.jointcommission.org/Standards/SII/ The Joint Commission has launched a Standards Improvement Initiative (SII) to: Clarify standards language Ensure that standards are program-specific Delete redundant or non-essential standards Consolidate similar standards As additional benefits to users, the manuals will be reorganized and the scoring and decision process will be refined. Improvements—both format and language edits—are targeted to go into effect January 2009 for the ambulatory, critical access hospital, home care, hospital, and office-based surgery programs. Beginning in 2008, The Joint Commission will seek feedback on standards for the behavioral health care, laboratory and long term care accreditation programs.  Questions can be sent to standardsimprovement@jointcommission.org.

JCAHO’s Environment of Care Goal: To provide a safe, functional, supportive and effective environment for patients, staff and others in the facility. This is crucial to providing quality patient care, achieving good outcomes and improving patient safety. Effective management of EC includes activities and processes for: Reduce & control environmental hazards and risks Prevent accidents and injuries Maintain safe conditions for patients, staff & visitors Maintain an environment that minimizes unnecessary environmental stresses for patients, staff and visitors*. *Crosswalk of 2003 Management of the Environment of Care Standards to 2004 Management of Environment of Care Standards for Hospitals, JCAHO, 2005.

JCR - www.jcrinc.com/26632/ The environment in which care is provided can make a difference Numerous studies demonstrate that factors in the physical and social environment can impact patients for better or worse.  Let JCR help you take a fresh look at your existing facility, or provide best practices in maintenance and design for a building prototype.  Our Environment of Care products and services provide organizations with the tools to build a safer environment for patients, staff, and visitors.

JCAHO “Performance Improvement*” Is a continuous process Involves measuring importance processes and services and identifying changes that enhance performance These changes are incorporated into new or existing processes Performance is monitored to ensure the improvements are sustained. *Crosswalk of 2003 Improving Organization Performance Standards for Hospitals to 2004 Improving Organization Performance Standards for Hospitals, JCAHO, 2005. Is a continuous process Involves measuring importance processes and services and identifying changes that enhance performance These changes are incorporated into new or existing processes Performance is monitored to ensure the improvements are sustained. *Crosswalk of 2003 Improving Organization Performance Standards for Hospitals to 2004 Improving Organization Performance Standards for Hospitals, JCAHO, 2005. If you are dong this work, make sure your work is demonstrated in your minutes for EOC Hazardous Material and Waste Management Plan.

Hospitals for a Healthy Environment Born out of a partnership between the US EPA, American Hospital Ass’n, American Nurses Ass’n and Healthcare without Harm, 1998. Provides assistance to healthcare industry Memorandum of Understanding setting goals for environmental improvement in healthcare Elimination of mercury Total waste reduction Minimize persistent, bioaccumulative pollutants such as dioxins, heavy metals and others. Awards program for facilities meeting and exceeding goals. H2E

JCAHO “Leadership” Leaders provide framework for planning, directing , coordinating, providing and improving care, treatment and services to respond to community and patient needs and improve healthcare outcomes. Effective leadership depends on: Governance Management-enables the hospital to fulfill its mission and meet/exceed its goals Planning Improving safety and quality of care Use of clinical practice guidelines Teaching and coaching staff. *Crosswalk of 2003 Leadership Standards for Hospitals to 2004 Leadership Standards for Hospitals, JCAHO, 2005.

Hazardous Materials If you were to pull down this tab, you would get a menu that looks like this. Hazardous materials definition. The material coming in, all the way til it is disposed, it is regulated by a variety of regulatory agencies. Hazardous materials is broken down into materials of concern, Managing Hazardous Materials, Pollution Prevention, Reduction of hazardous materials. If you reduce your hazardous materials, then you have less material that you have ot manage on site. Reduced liability, reduced paper work, reduced spill response, reduced tracking and reduced waste fees and reduced head ache. So identifying opportunities to detox at the point of purchase, the better.

Regulated Medical Waste Very draft page – changes will include more environmental pictures, etc. The objective of this page is one stop shopping for compliance, P2 and source reduction issues – overlap of RCRA, OSHA, JCAHO, DOT, etc… No federal standards for defining or managing RMW, but this is broken down state by state. The OSHA Blood borne pathogen standards does identify those items that are potentially infectious, including spill response. Some faciliites have used RMW reduction programs as a performance improvement plan.

JCAHO “Hazardous Materials and Waste” Materials whose handling, use and storage are guided or regulated by local, state or federal regulation* Examples EPA Chemicals & waste DOT Hazardous materials, including infectious agents transportation requirements OSHA Hazardous substances Blood borne pathogens Ionizing radiation, hazardous energy sources Nuclear Regulatory Commission Radioactives NIOSH Hazardous drugs State defined infectious waste *Crosswalk of 2003 Management of the Environment of Care Standards to 2004 Management of Environment of Care Standards for Hospitals, JCAHO, 2005.

10 Steps to Reducing RMW Sample Tools – 10 Step Guides http://www.h2e-online.org/pubs/tensteps/Rmw10steps.pdf Sample Tools – 10 Step Guides This is an example of one of the many tools available on the H2E Website. If you need to implement, enhance or demonstrate program implementation, this is all about our practical solution to step by step guidance of implementation of RMW programs.

Regulatory Compliance in Healthcare Healthcare has flown under the regulatory radar for years… Mid 1990’s EPA had focus on Colleges and Universities -- overlapped with university hospitals… What they found: 1 out of 2 hospitals has a penalty violation Compared to 1 out of 30 in general industry Health care has flown under the regulatory radar for quite some time and the EPA was focusing on industry. First there was a focus on colleges and unviersity and when they went into university hospitals, they were surprised by their findings and the recognition that hospitals and providers of care are generators of hazardous material and need to be watched closely to ensure proper managmeent of hazardous materials. 1 in 2 hospitals resulted in significant violations. 30% of industry was found to be out of compliance. Our communities may not think of us as Industry, but we are generators and users of hazardous materials and not always management materials appropriately.

“OUR TOXIC HOSPITALS” January 18, 2004 -- New York City hospitals are flouting environmental laws - spewing toxic fumes into the air and mishandling medical waste, The Post has learned. … recent violations by 10 private and public city hospitals, which led to fines as high as $500,000 for polluting. "With all we know about air pollution and its health effects, it's troubling that health-care institutions would be contributing to the problem," said a spokesman for the American Lung Association of New York State. The problem is so bad that the federal EPA began stepping up hospital inspections in 2002 because of "systemic problems" in meeting environmental codes. "We are focusing on them as an industry that needs extra attention," said EPA spokeswoman These are actual quotes from the New York Post. When the EPA issues violations, they also post them on their own website in a press release. So getting an environmental violation is not only about getting a fine and a violation, but negative press. Some hospitals, as a result, stepped up to the voluntary audit program. This was a way of working with the EPA and not gambling on the hopes that they wouldn’t show up.

EPA Enforcement - Top Ten Violations Hazardous materials and waste not identified (EC 3.10.2, 3, 5) Illegal disposal of waste (LD 1.30, EC 3.10.3) Waste not properly labeled (EC 3.10.3, 9) Staff not trained (EC 3.10.3, HR 2.20, HR 3.10) Appropriate authorities not notified (EC 3.10.2, 3, 7). Here are the top ten E PA violations since the hospital focus. These are mostly related to management of hazardous chemicals. So this is our way to overlap the environment of care standard with the EPA violation.

EPA Top Ten Violations (cont.) Manifest records lacking (EC 3.10.8) Hazardous waste containers not kept closed (EC 1.20.4, EC 3.10.3, HR 2.20, HR 3.10) Containers not inspected (EC.2.10.6, EC 3.10.3) Waste not stored to prevent leaks, spills or breakage (EC 3.10.3, 4, 6). Wastewater authorities not notified regarding sewer disposal of waste/permits not obtained (EC 3.10.3, 7)

Environmental Compliance Violations found in Region 2: Primarily NY and NJ EPA has sited hospitals that had just gone through the JCAHO and JCAHO found them to be fine, but the question was, how can they make it through an survey and not find the EPA violations?

What does that have to do with Joint Commission? Inspected hospitals expressed confusion that despite just “passing” JCAHO, they still had significant compliance violations under EPA Shouldn’t JCAHO have told us or cited us? It must not be that important since JCAHO didn’t survey on environmental compliance. Confusing maze of who regulates what. ? ?

Compliance… Is not optional… ‘Compliance’ is a term used for both JCAHO and other regulatory requirements -- JCAHO is typically reliant on other regulatory statutes for its elements of performance. BUT JCAHO Surveyors are not expected to be defacto inspectors for other regulatory agencies, like EPA JCAHO is not the EPA and we don’t expect them to have the focus that EPA has. But what can be expected from a JCAHO surveyor? Some that think they made it through JCAHO think they are good to go and don’t have a process in place to manage environmental programs. How do we make the connection between the importance of environmental compliance and jcaho preparedness? This cross walk is meant to do that. OSHA: Bloodborne Pathogens, HazCom RCRA EPCRA CAA CWA SPCC DOT HIPAA

Comprehensive Approach to ALL Compliance Issues While preparing for Joint Commission… incorporate environmental requirements. Use JCAHO’s emphasis on Environment of Care (EOC) and environmental requirements to leverage resource support for environmental compliance and pollution prevention programs. Use environmental programs as performance improvement initiatives for the Joint Commission. When you prepare for jcaho as a continuous quality improvement process, you should incorporate your environmental goals within that progress. If you don’t have the resources you need to get in compliance, then that goes the leadership standard. Tell them what resources you need – relate them to the JCAHO environmental standards.

How does the JCAHO Guide Work? JCAHO standards address an organization’s performance in key functional areas. Each standard is presented as a series of "Elements of Performance" (EP) -- expectations that establish the broad framework that JCAHO surveyors use to evaluate a facility's performance. Many of the environmentally relevant Elements of Performance fall under the Environment of Care (EC) standard, but others are included in the Human Resources (HR) and Leadership (LD) standards. The Guide relates each JCAHO Element of Performance to specific federal regulations, to help facilities be in compliance with both. How does the guide work? On the homepage it goes into all of this. The EOC, Human ResourcesStandard and Leadership standards are all addressed within this tool. This is what overlaps with environmental standards. The guide is meant to overlap jcaho and environmental best management practices. The tool or resources lets you know where you can go for more information to assist you with compliance.

Symbols in JCAHO Guide = Compliance = Environmental Improvement So it’s the compliance issue, the environmental benefit and where to go for more information. = Tools and Resources

ENVIRONMENTAL COMPLIANCE AND IMPROVEMENT GUIDE We want as many people to use this as possible so it can be a collaborative document used and shared among users. Some hospitals are using it to frame their environment of care standards and their training program. Can help identify the types of training information that is needed for all staffers. This is the table of contents. This is the tool where you will launch from to get most of the information that you need. This is tough to read but broken into EOC, Human Resources and Leadership. Each one of those categories is broken down into the standards within it. You can read the full text which is many pages of info for each standard with lots of details and explanations. The clip board version takes you to a check list so you could do a quick survey to check list what you need as evidence of compliance of performance improvement and then you can click to get more information and guidance on compliance. You can see what I mean when you get to the site and play around with it a bit. How does it work?

This is how you choose the standard you are interested in.

Choose a Standard. This describes the standard, the elements of performance and you can either click on the jcaho full text or the clip board with is the abbreviated version. The clip board versions are handy and then you can dig deeper for more information.

"Clip Board" Versions This is standard 3.10 clip board version for managing hazardous materials and waste risks. That’s a big element of performance. The goals are huge. This is a big standard. So clicking on the full text you will get a lot. This is petty much the full hazardous material and waste management program. Everything you do, pretty much falls into this area and is broken down more specifically in other standards.

Standards and Elements of Performance “Full” Versions – 3.10.3 Then we get into specific areas of concern with a long list of materials. Each one takes on a pattern so once you get the pattern down you can follow in that format.

Pollution Prevention Language Compliance Language When you click into the body of a full version you will see one section. This is on hazardous wastes. You have to have annual determination of hazardous generation status. This is a compliance issue. Those specific compliance citations are listed in blue. The specific CFR is listed there. The Pollution prevention language is next to the leaf. The other thing listed: The green links reference other standards where there is overlap. This is implementation and documentation. There are different ways to approach this section. If you click on a blue link that is a EPA reference, it takes you straight to that CFR for EPA. Pollution Prevention Language

Understand the Links Click on blue link: EPA Reference This is helpful and a real time saver to get you to where you need to go to learn more about the regulation.. Click on blue link: EPA Reference

Takes you straight to CFR citation for that requirement! This is the snap shop of the CFR for ePA.

Understand the Links Click on teal link: HERC Reference The teal references take you back to the H2E site where there might be a particular page for more information. Understanding your generator status – this will take you to the generator status page on the H2E Website This link takes you back to the H2E Page. Click on teal link: HERC Reference

Refers directly to other areas of the H2E website This is the H2E Website page on generator status page. Refers directly to other areas of the H2E website

Understand the Links Understanding the links. This reviews the colors again: jcaho reference is green, blue is epa and teal is h2e. Click the green link: JCAHO Reference (Topic Locator)

TOPIC LOCATOR The topic locator is where you might go to by subject or programmatic area, go down the long list and, let’s for example, focus on mercury. Under mercury you’ll see a bunch of green links. 310.1 is JCAHO standard. Inventory. There’s a code down at the bottom of this page which tells you what an inventory is. 310.2 – Element of performance that you have an inventory of hazardous materials. Implementation. This is the biggest place with references to mercury management. Under emergency – implementation plan for emergency response. Last a safety plan, EOC 1.10 A written management plan for environmental safety.

Leadership Standard: Compliance Counts Leaders provide framework for planning, directing , coordinating, providing and improving care, treatment and services to respond to community and patient needs and improve healthcare outcomes. Effective leadership depends on: Governance Management-enables the hospital to fulfill its mission and meet/exceed its goals Planning Improving safety and quality of care Use of clinical practice guidelines Teaching and coaching staff. Important to get the support we need to do this work through the leadership standard.

JCAHO Performance Improvement Write up Environmental Programs as Performance Improvement Initiatives H2E has sample write-ups for Performance Improvement Initiatives on: Regulated Medical Waste Reduction Mercury Elimination Glutaraldehyde Elimination Please let us know your experiences… Is a continuous process Involves measuring importance processes and services and identifying changes that enhance performance These changes are incorporated into new or existing processes Performance is monitored to ensure the improvements are sustained. *Crosswalk of 2003 Improving Organization Performance Standards for Hospitals to 2004 Improving Organization Performance Standards for Hospitals, JCAHO, 2005.

Evidence of Comprehensive Programs… Three lists … 1. Facility infrastructure that fundamentally addresses environmental compliance and improvement programs; 2. Current top compliance violation issues in healthcare; 3. Overall comprehensive environmental program management - priority issues. Evidence of comprehensive programs. Goes into a lot of details. Your surveyor probably won’t ask specifics regarding these questions but there are three different list of lists that might point to evidence of broad comprehensive programs. Infrastrucuter 0 do you have a structure in place to address environmental improvements? Top Ten compliance Issues - Make sure you have addressed the top ten compliance issues. 3. Overall environmental management program. Do you have a policy, do you have an environmental commitment statement, are you actively eliminating mercury.

Infrastructure Institutional Environment of Care Standard 3.10: The organization manages hazardous materials and waste risks e.g., comprehensive environmental management policy Leadership LD 1.20 - Staff resources - Is there enough staff and resources to appropriately manage and respond e.g., written commitment and policy from all levels within organization; includes roles of Safety Committee and staff HR Competencies 2.10, 2.20 - Staff appropriately respond Infrastructure – If you are looking at EC 3.1 – Your surveyor might ask you where your comprehensive management policy is. For leadership that you have staff resources. Is there enough staff resources to address environmental issues. Do you have a written commitment policy. This can be under leadership – that there is a commitment to environmental work. It starts at new employee orientation, annual training and how does traning respond to problem identification. This can demonstrate a program just frm checking on these few things.

Violations - Hazardous materials and waste not identified EC 3.10: The organization manages hazardous materials and waste risks (EP 3. Implementation) EC 3.10 EP 8 - Hazardous Waste Manifests - Manifest records lacking A RCRA hazardous waste determination has been made, and documented, for all solid waste that is generated. Manifest and other records are comprehensive and up-to-date. Staff shows core competency in proper management and minimization based on proper determination How to do it! --- JCAHO Guide and the HERC Hazardous Waste Determination Page 3.10 Implementation and organizational management. How do you do a determination. Is it made? Is it documented? Are the manifests up to date? Does staff have an understanding of the inventory? Does staff know how to find it?

Hazardous materials and waste not identified (EC 3.10 EP 3)

Comprehensive Programs Mercury Management, for example Surveyors might look for evidence of a Plan, an Inventory,  Implementation program and results including staff competency,   Emergency and Safety plan - spill policy and competency, Leadership - mercury elimination commitment statement MMMF Award How to do it! --- www.h2e-online.org

The Fit! EPA EPA H2E DOT OSHA JCAHO H2E Environmental regulations Waste, water, air, land DOT Hazardous materials in transportation OSHA Environment affects workers Hazardous materials/substances JCAHO Environment affects patients, visitors and healthcare staff H2E Goals for improving environmental performance in healthcare H2E JCAHO

Feedback on the Guide! Continuous Quality Improvement - it’s a work in progress… Is it useful? Is it confusing? Suggestions for additional tools and resources?

Summary JCAHO standards cover all environmental regulations H2E JCAHO guidance tool to assist with compliance and improvement Tool is free and online. Use is easy especially with practice. For comments or suggestions on the tool or training, contact Laura Brannen of H2E.

H2E JCAHO Guidance Introduction Table of Contents JCAHO standards http://www.h2e- online.org/regsandstandards/jcahointro.html

Where to Get More Information Laura Brannen, H2E Executive Director Laura.Brannen@H2E-online.org 603/795-9966 Catherine Zimmer, MnTAP zimme053@umn.edu 612/624-4635 www.mntap.umn.edu Hospitals for a Healthy Environment www.h2eonline.org

H2E Program Contacts Toll Free Hotline: 800-727-4179 E-mail: h2e@h2e-online.org www.h2e-online.org Cecilia DeLoach, State Partnership Programs Coordinator Cecilia.DeLoach@H2E-online.org 800-727-4179 Laura Brannen, Director Laura.Brannen@H2E-online.org 603-795-9966 Janet Brown, Partner Program Mgr. Janet.Brown@H2E-online.org 413/253-0254