© Copyright, The Joint Commission 2011 The Healthcare Environment George Mills, Sr. Engineer Standard Interpretation Group The Joint Commission

SIG Engineering © Copyright, The Joint Commission Risk Assessment  Use to evaluate any issue that lacks a clear decision  Educated guess that drives your assumptions  Clearly document the process  Determine when to re-assess the issue  Problem solving approach to determine appropriate response  Preventive strategies to address potential issues

SIG Engineering © Copyright, The Joint Commission Risk Assessment The hospital identifies safety and security risks associated with the environment of care. Risks are identified from internal sources such as ongoing monitoring of the environment, results of root cause analyses, results of annual proactive risk assessments of high-risk processes, and from credible external sources such as Sentinel Event Alerts. EC EP 1 The hospital takes action to minimize or eliminate identified safety and security risks in the physical environment. EC EP 3

SIG Engineering © Copyright, The Joint Commission Risk Assessment in the Healthcare Environment  Several tools exist to facilitate risk assessment in the Physical Environment  Environmental Tours  Observe the environment  Manage By Walking Around  Documentation  Inspect, Test & Maintain  Evaluate the effectiveness of the processes

SIG Engineering © Copyright, The Joint Commission Environmental Tours  Make sure that all areas of your organization are included:  Public waiting areas  Floor covering in safe/functional condition  Seating  Grounds, Sidewalks, Garages, Parking Lots  Egress to the “Public Way”  Elevators  Designated off-site locations

SIG Engineering © Copyright, The Joint Commission EC  EP 1: Interior spaces meet the needs of the individuals served for safety and suitability for the care, treatment or services provided.

SIG Engineering © Copyright, The Joint Commission Visual Observations  Evaluate typical processes  Include affected staff  Eliminating “work- around”  Eliminating hazards/safety issues  Proper storage of items  Supplies  Patient / Non-patient  Refrigerators  Medications, food, biohazards, supplies  Housekeeping carts & closet  Hand hygiene products  Alcohol gels, paper towels, gloves, etc.  Equipment

SIG Engineering © Copyright, The Joint Commission Visual Observations  Personal Space  Outside areas for use by individuals  Waiting & Reception areas  Restrooms are appropriate  Lighting is suitable for care, treatment, or services  Ventilation, temperature and humidity levels  Furnishings  Dining environment

SIG Engineering © Copyright, The Joint Commission Staff Interviews  Purpose:  Establish staff knowledge  Evaluate  Trend  Process:  Random selection  Evaluate against policy  Examples of processes evaluated:  Reporting patient and employee injury events  Referencing policies/procedures  Evacuation Plans  Labeling/reporting broken/non-functioning equipment  Role in Emergency Operations Plan

SIG Engineering © Copyright, The Joint Commission Summary  Make sure that all identified issues are followed up on in a timely matter  Close the loop  Utilize data collected as a performance improvement tool

© Copyright, The Joint Commission Questions?

SIG Engineering © Copyright, The Joint Commission SIG Engineers: George Mills, MBA, FASHE, CEM, CHFM, CHSP Senior Engineer SIG Michael Chisholm, CPE, CHFM Engineer SIG Anne Guglielmo, CFPS, LEED, A.P. Engineer SIG

SIG Engineering © Copyright, The Joint Commission The Joint Commission Disclaimer  These slides are current as of 2/17/2011. The Joint Commission reserves the right to change the content of the information, as appropriate.  These slides are only meant to be cue points, which were expounded upon verbally by the original presenter and are not meant to be comprehensive statements of standards interpretation or represent all the content of the presentation. Thus, care should be exercised in interpreting Joint Commission requirements based solely on the content of these slides.  These slides are copyrighted and may not be further used, shared or distributed without permission of the original presenter or The Joint Commission.