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 Healthcare Engineering Consultants Understanding the Survey Process

The Survey Process in 2009 Healthcare Engineering Consultants 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 Healthcare Engineering Consultants 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 Healthcare Engineering Consultants 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 Healthcare Engineering Consultants Understanding Scoring Decisions and Defining Low-Scoring Areas

“EC”-Related Scoring Rules for 2008 Healthcare Engineering Consultants  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 Healthcare Engineering Consultants 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 Healthcare Engineering Consultants 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 Healthcare Engineering Consultants “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 Healthcare Engineering Consultants “A” Scores: High priority, One and Done! Example: EC1.10, EP 2 Safety officer appointment You either have the letter or you don’t – Compliant or non-compliant, no partial credit!

Joint Commission Standards Scoring Healthcare Engineering Consultants “B” Scores: Process, surveyor Discretion Example: EC1.10, EP 3 Proactive risk assessment Can be fully, partially or non-compliant Note: All of the “B” scores will be deleted in 2009

Joint Commission Standards Scoring Healthcare Engineering Consultants “C” Scores: Three strikes and you’re out! Example: EC5.40, EP 12 Portable fire extinguishers Three missed monthly checks (aggregated) is an RFI!

Special Scoring for SOC Deficiencies During the Facility Tour Healthcare Engineering Consultants  “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 Healthcare Engineering Consultants  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 Healthcare Engineering Consultants Changes and Focus Areas in 2008 and 2009

“EC”-Related Patient Safety Goals for 2008 Healthcare Engineering Consultants 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 Healthcare Engineering Consultants  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 Healthcare Engineering Consultants  Equipment Use  Infection Control  Information Management  Organizational Structure  Orientation and Training  Patient Safety  Physical Environment  Staffing

The 2009 Joint Commission Manual Healthcare Engineering Consultants 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 Healthcare Engineering Consultants 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 Healthcare Engineering Consultants  EC – Management Plan Requirements  EC – Safety and Security  EC – Hazardous Materials and Wastes  EC – Fire Safety  EC – Medical Equipment  EC – Utilities Management  EC – Functional Environment  EC – Staff and LIP Training  EC – Monitoring and Improvement

Major Revisions to the EC Standards Healthcare Engineering Consultants EC – 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

Major Revisions to the EC Standards Healthcare Engineering Consultants EC – 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

Major Revisions to the EC Standards Healthcare Engineering Consultants EC – 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

Major Revisions to the EC Standards Healthcare Engineering Consultants EC – 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

Major Revisions to the EC Standards Healthcare Engineering Consultants EC – The organization manages fire risks (includes fire policies and fire responsibilities) EC – The organization conducts fire drills (includes conducting and evaluating drills) EC – 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

Major Revisions to the EC Standards Healthcare Engineering Consultants EC – 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 – 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)

Major Revisions to the EC Standards Healthcare Engineering Consultants EC – 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 – 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)

Major Revisions to the EC Standards Healthcare Engineering Consultants EC – 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 – 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)

Major Revisions to the EC Standards Healthcare Engineering Consultants EC – 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

Major Revisions to the EC Standards Healthcare Engineering Consultants EC – 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 – 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)

Major Revisions to the EC Standards Healthcare Engineering Consultants EC – 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

Major Revisions to the EC Standards Healthcare Engineering Consultants EC – 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!

Major Revisions to the EC Standards Healthcare Engineering Consultants EC – 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 – 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 Healthcare Engineering Consultants LS – Completion of the Statement of Conditions LS – Implementation of interim life safety measures LS – Building fire protection features LS – Integrity of the means of egress LS – Building features are maintained LS – Maintenance of fire alarm systems LS – Maintenance of extinguishing systems LS – Special features for fire protection LS – Maintenance of building service systems LS – Operating features LS through LS – Ambulatory health care

Impact of the 2009 Life Safety Chapter Healthcare Engineering Consultants  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 Healthcare Engineering Consultants EM – Planning activities: HVA, M-P-R-R and ICS EM – Creation of the EOP EM – Emergency communications EM – Resource and asset management EM – Security and safety EM – Management of staff EM – Management of utilities EM – Patient management EM – Emergency privileges to LIP’s EM – Disaster responsibilities to volunteers EM – Evaluation of program effectiveness EM – EOP evaluation using drills

Organizational Function Overview Healthcare Engineering Consultants  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 Healthcare Engineering Consultants Questions?