Environment of Care, Emergency Management & Life Safety Courtemanche & Associates Healthcare Synergists Environment of Care, Emergency Management & Life Safety Changing Expectations & Surveyor Approaches Marty Piepoli December 10, 2009 C&A Proprietary | www.courtemanche-assocs.com

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Courtemanche & Associates Healthcare Synergists Session Objectives At the conclusion of this session, learner will be able to: Describe the importance of assessing risk as it relates to Life Safety and Emergency Management preparation. Identify at least two challenging standards & potential solutions. Identify the impact of the disparity in findings for the Environment of Care regarding TJC and CMS surveys. www.courtemanche-assocs.com C&A Proprietary | www.courtemanche-assocs.com

Courtemanche & Associates Healthcare Synergists Glossary of Terms AIA – American Institute of Architects ASHE – American Society for Healthcare Engineering CMS – Centers for Medicare & Medicaid Services CoP – Conditions of Participation EC – Environment of Care EM – Emergency Management e-PFI – Electronic Plan for Improvement EPA – Environmental Protection Agency ESC – Evidence of Standards Compliance HAI – Healthcare Acquired Infections HAP – Hospital Accreditation Program www.courtemanche-assocs.com C&A Proprietary | www.courtemanche-assocs.com

Courtemanche & Associates Healthcare Synergists Glossary of Terms HCO – Healthcare Organization ICC – Incident Command Center ILSM – Interim Life Safety Measures LS – Life Safety LSC – Life Safety Code NFPA – National Fire Protection Agency OSHA – Occupational Safety Health Administration PARA – Pro-active Risk Assessment SA – State Agency TJC – The Joint Commission www.courtemanche-assocs.com C&A Proprietary | www.courtemanche-assocs.com

CMS Driving TJC Expectations Courtemanche & Associates Healthcare Synergists CMS Driving TJC Expectations www.courtemanche-assocs.com C&A Proprietary | www.courtemanche-assocs.com

CMS Deeming Application Courtemanche & Associates Healthcare Synergists CMS Deeming Application TJC-accredited hospitals = 4,153 82 percent of all hospitals participating in the Medicare program The CMS validation program assures accredited hospitals are in compliance with statutory requirements in 42 CFR Part 482 www.courtemanche-assocs.com C&A Proprietary | www.courtemanche-assocs.com

CMS Validation Surveys Courtemanche & Associates Healthcare Synergists CMS Validation Surveys FY 2007*, 4164 CMS surveys were performed 55 Look-back surveys were done (1.3%) 4,109 Allegation (complaint) surveys were completed (98.7%) Look-back surveys demonstrated: 55 of 1,451 (3.8%) hospitals surveyed by TJC in 2007 40% disparity rate between TJC and SA ability to detect CoP deficiencies 29% of the disparities relate to physical environment * CMS 2008 Annual Report to Congress, November 2008 www.courtemanche-assocs.com C&A Proprietary | www.courtemanche-assocs.com

By the Numbers – CMS Survey Activity Courtemanche & Associates Healthcare Synergists By the Numbers – CMS Survey Activity Increase in the disparity rate from 2006 (14.6%) In 2007, 73% of Physical Environment findings by TJC were not cited at the Condition Level Lack of detailed emphasis on the conditions of the physical plant/building safety www.courtemanche-assocs.com C&A Proprietary | www.courtemanche-assocs.com

Courtemanche & Associates Healthcare Synergists CMS/TJC Disparity With high disparity seen in the physical environment, TJC changes include: Completion of the Statement of Conditions by Qualified Personnel Set Minimum Standards for the Statement of Conditions/Plans for Improvement Submission of the Statement of Conditions and Plans for Improvement to TJC prior to survey Incorporating a Life Safety Surveyor into the process www.courtemanche-assocs.com C&A Proprietary | www.courtemanche-assocs.com

CMS Deeming Application Courtemanche & Associates Healthcare Synergists CMS Deeming Application Open dialogue between TJC & CMS Onsite visits Working through outstanding issues such as telemedicine, environment of care. Announcement in Federal Register November 27, 2009: approval of a deeming application from TJC for continued recognition as a national accreditation program for hospitals that request participation in the Medicare or Medicaid programs. Effective July 15, 2010 through July 15, 2014 www.courtemanche-assocs.com C&A Proprietary | www.courtemanche-assocs.com

Courtemanche & Associates Healthcare Synergists Top EC/EM/LS Findings 2009 www.courtemanche-assocs.com C&A Proprietary | www.courtemanche-assocs.com

Challenging Standards % Non-Compliance Courtemanche & Associates Healthcare Synergists 4/21/2017 Challenging Standards % Non-Compliance Standard 2008 (N=1427) 2009 (N=664) Issue EC.02.05.07 45% 43% Minimizing effects of fire, heat, smoke EC.02.03.05 26% 38% Maintaining fire safety equipment EC.02.06.01 3% 20% Maintaining a safe environment EC.02.05.09 16% Medical gas & vacuum systems EC.02.01.01 15% Safety and security risk assessment LS.02.01.10 LS.02.01.20 Maintaining egress LS.02.01.30 35% Maintaining building features from fire & smoke hazards www.courtemanche-assocs.com C&A Proprietary | www.courtemanche-assocs.com

EC.02.01.01 – Safety & Security Risks Courtemanche & Associates Healthcare Synergists EC.02.01.01 – Safety & Security Risks Findings: Identification of risks not evident – proactive risk assessment, etc. Secure areas accessible Strategies: EC or Safety Committee to charter and guide annual (more frequent as needed) risk assessment process; assure results & follow-up activities identified & implemented Implement secure access to high risk areas – i.e., pharmacy, mother/baby, hazardous storage rooms and assure staff adhere to security measures Change keypad codes regularly www.courtemanche-assocs.com C&A Proprietary | www.courtemanche-assocs.com

EC.02.03.05 – Maintaining Fire Equipment & Fire Safety Courtemanche & Associates Healthcare Synergists EC.02.03.05 – Maintaining Fire Equipment & Fire Safety Findings: Inspecting, testing, etc.: Fire alarms, sprinklers Fire extinguishers Tamper switches Strategies: Assure that vendor testing & maintenance documentation is maintained onsite Testing logs should include all required elements (i.e., tamper switches) Assure systems are fully functional and tied to local Fire Department www.courtemanche-assocs.com C&A Proprietary | www.courtemanche-assocs.com

Courtemanche & Associates Healthcare Synergists CMS Update – Dampers Option for Damper Testing Interval Hospitals permitted to apply the NFPA 6-year damper testing interval for fire and smoke dampers. Testing system must conform to the testing requirements under the 2007 edition of NFPA 80 and NFPA 105. At the time of a CMS onsite life-safety code survey, hospital must notify survey team it has elected to operate under this waiver. S&C-10-04-LSC 10/30/09 www.courtemanche-assocs.com C&A Proprietary | www.courtemanche-assocs.com

EC.02.05.07 – Inspect & Test Emergency Power Systems Courtemanche & Associates Healthcare Synergists EC.02.05.07 – Inspect & Test Emergency Power Systems Findings: Testing of battery powered lights, generators, automatic transfer switches Strategies: Assure that vendor testing & maintenance documentation is maintained onsite Testing logs should include all required elements (i.e., automatic transfer switches) Once issues are fixed, test the system again www.courtemanche-assocs.com C&A Proprietary | www.courtemanche-assocs.com

EC.02.05.09 – Inspect, Test & Maintain Medical Gas & Vacuum Courtemanche & Associates Healthcare Synergists EC.02.05.09 – Inspect, Test & Maintain Medical Gas & Vacuum Findings: Defined timeframes not met Shutoff valves not accessible or clearly labeled Strategies: Have testing and maintenance timeframes approved by EC or Safety Committee who will require status checks Assure shut-off valves are on an inventory, labeled and checked periodically www.courtemanche-assocs.com C&A Proprietary | www.courtemanche-assocs.com

EC.02.06.01 – Safe, Functional Environment Courtemanche & Associates Healthcare Synergists EC.02.06.01 – Safe, Functional Environment Findings: Furnishings & equipment not safe/in good repair Space inadequate for care Strategies: Conduct regular EC rounds (particularly behavioral health and pediatric areas) to identify hazardous (safety and infection control issues) equipment and furniture; then remove/repair Where space is an identified issue, document Leadership knowledge and understanding and future plans; if a Life Safety issue – place on e- PFI www.courtemanche-assocs.com C&A Proprietary | www.courtemanche-assocs.com

LS.02.01.10 – Minimize Fire, Smoke, Heat Effects Courtemanche & Associates Healthcare Synergists LS.02.01.10 – Minimize Fire, Smoke, Heat Effects Findings: Fire/Smoke door integrity Penetrations!!! Strategies: Use a building maintenance program to check doors regularly Institute an “above the ceiling” process to assure penetrations are filled when they happen “Red line” badges of vendors who work in the ceiling – so they can be easily identified www.courtemanche-assocs.com C&A Proprietary | www.courtemanche-assocs.com

LS.02.01.20 – Maintaining Egress Courtemanche & Associates Healthcare Synergists LS.02.01.20 – Maintaining Egress Findings: Hallway clutter Stairwell storage Exit signs not visible Strategies: “Garage” sale days – remove all broken, obsolete equipment Only what is in immediate use should be in halls Create docking areas for computers on wheels Use several vehicles for rounding – including Leadership Rounds www.courtemanche-assocs.com C&A Proprietary | www.courtemanche-assocs.com

LS.02.01.30 – Maintaining Buildings from Fire Hazards Courtemanche & Associates Healthcare Synergists LS.02.01.30 – Maintaining Buildings from Fire Hazards Findings: Issues in boiler rooms, flammable storage areas, labs, etc. Dampers inaccessible or inoperable Corridor door integrity Strategies: Assure these areas are secure from public access Clutter patrol! Engage folks from outside the area - you don’t see the cobwebs in your own home Evaluate dampers – identify those that are inaccessible or inoperable and fix them or place on the e-PFI www.courtemanche-assocs.com C&A Proprietary | www.courtemanche-assocs.com

LS Document Review and EC/EM Tracer Courtemanche & Associates Healthcare Synergists LS Document Review and EC/EM Tracer Document Review occurs the morning of Day 1 followed by building tour unless LSS arrives later. Provides additional observations for the surveyor directing the EC/EM tracer. The EC/EM session combined into one session in 2009. This session has three parts: EC Discussion EM Discussion EC Tracer www.courtemanche-assocs.com C&A Proprietary | www.courtemanche-assocs.com

Courtemanche & Associates Healthcare Synergists Getting Ready Know What Surveyors Review Annual evaluations of the Environment of Care (EC) management plans (EC.04.01.03) EC multidisciplinary team meeting minutes for the previous 12 months (EC.04.01.03) Hazard Vulnerability Analysis (EM.01.01.01) ILSM Policy (LS.01.02.01) www.courtemanche-assocs.com C&A Proprietary | www.courtemanche-assocs.com

Courtemanche & Associates Healthcare Synergists Getting Ready Know What Surveyors Review EC-related issues observed in previous survey activities by other survey team members Note identified risk points as possibilities for tracer observation www.courtemanche-assocs.com C&A Proprietary | www.courtemanche-assocs.com

What to Expect – Emergency Management Courtemanche & Associates Healthcare Synergists What to Expect – Emergency Management Surveyor Discussion Points Proactive Risk Assessment (HVA) Emergency Operations Plan Involvement of various organizational disciplines and the community Approaches for educating staff Organizational communication and notification plans www.courtemanche-assocs.com C&A Proprietary | www.courtemanche-assocs.com

Courtemanche & Associates Healthcare Synergists 4/21/2017 Surveyor Approaches 2009 www.courtemanche-assocs.com C&A Proprietary | www.courtemanche-assocs.com

Emergency Management Tracer Courtemanche & Associates Healthcare Synergists Emergency Management Tracer Selection Consider your top three vulnerabilities on your HVA Let’s consider recent concerns: Influx of H1N1 Miracle on the Hudson Floods in the Midwest Tornados everywhere! www.courtemanche-assocs.com C&A Proprietary | www.courtemanche-assocs.com

Courtemanche & Associates Healthcare Synergists Who, What and When Some Practical Tips Print out the standard survey agenda for your organization to see when the EC/EM tracer will be conducted. Check the backgrounds of your survey team Does the Life Safety Specialist come on the first day or later during the survey? www.courtemanche-assocs.com C&A Proprietary | www.courtemanche-assocs.com

Some Results from the Field Courtemanche & Associates Healthcare Synergists Some Results from the Field Example #1 Conducted by the physician Heavy focus on the specific items on the HVA Majority of discussion on the top 3 items Preparation to address these items Framework of mitigation, preparedness, response & recovery How the “Big 6” were addressed Chose to focus on Utilities Disruption of Water which was identified on proactive risk assessment related to planned well. www.courtemanche-assocs.com C&A Proprietary | www.courtemanche-assocs.com

Some Results from the Field Courtemanche & Associates Healthcare Synergists Some Results from the Field Example #2 Life Safety Specialist Arrived on day 3 of the 3.5 day survey. Conducted review of all of the EC Mgmt Plans and the EOP. In his review of the EC Management Plans, he tied in the Big 6 as they related to each of the plans. Very consultative and educational. www.courtemanche-assocs.com C&A Proprietary | www.courtemanche-assocs.com

Some Results from the Field Courtemanche & Associates Healthcare Synergists Some Results from the Field Example #3 Life Safety Specialist Arrived on day 4 of the 5 day survey. Conducted his review standard by standard from EC and EM. In his review of EM, focus was on the HVA methodology and sustainability. Emphasis on Communication, Assets and approach to drill critiques. www.courtemanche-assocs.com C&A Proprietary | www.courtemanche-assocs.com

Courtemanche & Associates Healthcare Synergists Surveyor Findings No specific scoring of the EM chapter thus far: only 3 direct impact EP’s in the EM chapter. EM.02.01.01 EP#8 In an actual emergency, the hospital implements its response procedures related to patient care, treatment, and services. EM.02.02.13/02.02.15 EP#5 that addresses volunteer disaster privileges to LIP and non- LIP volunteers. www.courtemanche-assocs.com C&A Proprietary | www.courtemanche-assocs.com

EM and Other Tracer Activity Courtemanche & Associates Healthcare Synergists EM and Other Tracer Activity Surge Capacity related to the Infection Control tracer. Availability of emergency medications in the medication management tracer. Patient Flow tracer/discussions in the ED related to Surge and same level of care. www.courtemanche-assocs.com C&A Proprietary | www.courtemanche-assocs.com

Use of Pro-active Risk Assessment in the Environment of Care Courtemanche & Associates Healthcare Synergists Use of Pro-active Risk Assessment in the Environment of Care www.courtemanche-assocs.com C&A Proprietary | www.courtemanche-assocs.com

Courtemanche & Associates Healthcare Synergists Risk Assessments Risk Assessment is a method for identification of potential harm to a patient population using quantifiable approaches. Objectively determining the potential for a negative outcome based on: Severity of outcome Frequency of event Likelihood of detection www.courtemanche-assocs.com C&A Proprietary | www.courtemanche-assocs.com

Proactive Risk Assessments Courtemanche & Associates Healthcare Synergists Proactive Risk Assessments To correct process issues or barriers and reduce the potential for experiencing adverse events To evaluate processes to see how they could fail To understand the potential impact of such a failure To identify components of the process that need improvement www.courtemanche-assocs.com C&A Proprietary | www.courtemanche-assocs.com

Courtemanche & Associates Healthcare Synergists Process Examples Clinical: Surgical Procedures Medication Administration Central Line Insertion Environmental and Other Non-Clinical: Maintenance of building fire prevention features Maintenance of medical gas systems www.courtemanche-assocs.com C&A Proprietary | www.courtemanche-assocs.com

Courtemanche & Associates Healthcare Synergists Select Process Map Process Identify Weaknesses Failure Effects Prioritize Conduct RCA Redesign Process Test Monitor Risk Assessment Cycle www.courtemanche-assocs.com C&A Proprietary | www.courtemanche-assocs.com

Courtemanche & Associates Healthcare Synergists Environmental Risks EC.01.01.01 The hospital works to assess and minimize risks in the environment of care. Can be managed by one or more individuals. Managing these risks through a systematic, proactive approach to evaluating potential harm and mitigating opportunities for harm is key. www.courtemanche-assocs.com C&A Proprietary | www.courtemanche-assocs.com

Courtemanche & Associates Healthcare Synergists Environmental Risks Potential for environmental risks Safety and security for people, equipment, and other material; The handling of hazardous materials and waste; Fire; The use of medical equipment; Utility systems. www.courtemanche-assocs.com C&A Proprietary | www.courtemanche-assocs.com

Courtemanche & Associates Healthcare Synergists Environmental Risks EC.02.06.05 - Experts, i.e., AIA, TJC, ASHE, recommend including at least the following in your pre-construction risk assessment Air quality requirements, Infection control, Utility requirements, Noise, Vibration, Other hazards Also refer to LS.01.02.01 related to interim life safety measures www.courtemanche-assocs.com C&A Proprietary | www.courtemanche-assocs.com

Courtemanche & Associates Healthcare Synergists Environmental Risks IC.01.03.01 EP#1Tells us that we should identify our risks for spread of infection by considering geographic location, community, and population served. EP#2 And always includes concerns related to the care, treatment, and services it provides for patients and the community. www.courtemanche-assocs.com C&A Proprietary | www.courtemanche-assocs.com

TJC – What to Expect in the Future Courtemanche & Associates Healthcare Synergists TJC – What to Expect in the Future www.courtemanche-assocs.com C&A Proprietary | www.courtemanche-assocs.com

TJC – Evolving to Drive Sustained Improvement Courtemanche & Associates Healthcare Synergists TJC – Evolving to Drive Sustained Improvement Standards & NPSGs focused on contributing to improved health outcomes. Attributes: Relates to quality & safety Has a positive impact on outcomes Has a ROI for safety & quality Can be measured or surveyed More in depth analysis of adverse events to identify sustainable improvement initiatives Improved internal operations - while maintaining integrity of survey process www.courtemanche-assocs.com C&A Proprietary | www.courtemanche-assocs.com

Courtemanche & Associates Healthcare Synergists Resources 2009 Comprehensive Accreditation Manual for Hospitals (CAMH): The Official Handbook. Published by: Joint Commission Resources, Inc., Oak Brook, IL. TJC Hospital Executive Briefings – September 2009. Presented by: Joint Commission Resources, Inc., Oak Brook, IL. CMS S&C-10-04-LSC. http://www.cms.hhs.gov /SurveyCertificationGenInfo/downloads/SCLet ter10_04.pdf. Published: October 30, 2009. Accessed: December 8, 2009. www.courtemanche-assocs.com C&A Proprietary | www.courtemanche-assocs.com

Courtemanche & Associates Healthcare Synergists Resources Environment of Care News, February 2009, Volume 12, Number 2. Published by: Joint Commission Resources, Inc., Oak Brook, IL. Environment of Care News, March 2009, Volume 12, Number 3. Published by: Joint Commission Resources, Inc., Oak Brook, IL. CMS 2008 Annual Report to Congress, November 2008. http://www.cms.hhs.gov/CFOReport/Downloa ds/2008_CMS_Financial_Report.pdf. Published: November 2009. Accessed: December 8, 2009. www.courtemanche-assocs.com C&A Proprietary | www.courtemanche-assocs.com

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