1. 2009 The Physical Environment Overview Environment of Care Emergency Management Life Safety Chapter
George Mills, Sr. Engineer
Standard Interpretation Group
The Joint Commission

2. Standards Improvement Initiative (SII)
Overview
Standards Improvement Initiative (SII)

3. Standards Improvement Initiative
The Standards Improvement Initiative (SII) did not create any new requirements
Replaced bulleted lists with expanded Elements of Performance
Enhance clarity and objectivity of standards and EPs
3 chapters of the Physical Environment:
Management of the Environment of Care
Emergency Management Chapter
Life Safety Chapter
Management of these chapters is up to the organization

4. Standards Improvement Initiative
Improved language
No more ‘hard to measure’ words like “appropriate”
Improved structure of the manual
Hard copy (6 x 9)
Electronic (CD)
Decisions more accurately reflect organizational performance
New numbering conventions
EC EP 2 The organization inspects, tests & maintains all life support equipment. These activities are documented. (See also EC EPs 3 &4; PC.02.01,11 EP 2)

5. Naming of Chapter EC. [Environment of Care] EM. [Emergency Management]
This is the chapter title designator
EM. [Emergency Management]
LS. [Life Safety Chapter]

6. Numbering of the Standards
EC.01 [Plan]
The organization plans activities to minimize risk in the Environment of Care.
EC.02 [Implement]
The organization manages safety and security risks.
EC.03 [Educate/Train]
Staff and LIP are familiar with their roles and responsibilities relative to the EC.
EC.04 [Information, Collection Evaluation System (ICES)]
The organization collects information to monitor conditions in the EC.

7. Numbering of the Subject
Safety & Security
EC.02.02
Hazardous Materials & Waste
EC.02.03
Fire Safety
EC.02.04
Medical Equipment
EC.02.05
Utilities Management
EC.02.06
Safe, Functional Environment

8. Numbering of the IssuesEC
Implementation | Fire Safety | Maintains Fire Safety Equipment & Fire Safety Building Features LS
Healthcare | One Building Type | [3] Protection [4] Fire Alarm Systems EM
Develop Emergency Operations Plan | Overview Administrative Features in the Emergency Operations Plan | Response Procedures and Capabilities EM
Emergency Operations Plan | Addresses One of the six (6) Critical Functions | Utilities

9. Elements of PerformanceEC
Implementation | Safety & Security | Safety & Security Issues
EP 3 The organization takes action to minimize or eliminate identified safety and security risks in the physical environment
EP 4 The organization maintains all grounds and equipment EC
Implementation | Safety & Security | Smoking Prohibited
EP 1 The organization develops a written policy prohibiting smoking in all buildings. Exceptions for patients in specific circumstances are defined.

10. Scoring

11. Scoring & Decision Process
Scoring Scale
0 = Insufficient Compliance
1 = Partial Compliance
2 = Full Compliance
Requirement for Improvement (RFI)
All findings of less than full compliance will be cited as a RFI
All RFIs require resolution through an Evidence of Standards Compliance (ESC)
This includes findings scored partial
“Supplemental Findings” (2008 term) are eliminated

12. EP Scoring Categories A: Structural requirements
EP’s scored yes (2) or no (0)
May address issues requiring full compliance
C: Based on number of times an EP is not met
Score 2: 0-1 instances of non-compliance
Score 1: 2 instances of non-compliance
Score 0: > 3 instances of non-compliance
Above is based on a sample of 10
NOTE: The ‘B’ Category has been eliminated

13. Criticality
Criticality defined as “the immediacy of risk to patient safety or quality of care as a result of noncompliance with a Joint Commission requirement.”
4 Levels of Criticality
1. Immediate Threat to Life (ITL)
PDA until resolved
2. Situational Decision Rules
Based on specific situations at time of survey
3. Direct Impact Requirements [45 Day Resolution]
Noncompliance may create an immediate risk to patient safety or quality of care
4. Indirect Impact Requirements [60 Day Resolution]
Based on planning and evaluation or care processes

14. 2009 Scoring Decision Model

15. 2009 Scoring Decision Model
Immediate Threat to Life
Situations, identified during survey, which have or may potentially have a serious adverse effect on patient health and safety.
The Joint Commission President can issue an expedited Preliminary Denial of Accreditation (PDA) decision.
PDA remains until corrective action is demonstrated, via an on-site validation review.
PDA changes to Conditional Accreditation which includes a follow-up review to assess sustained implementation of corrective action.
Examples:
Inoperable fire alarm system
Lack of Master Alarms for Medical Gas System

16. 2009 Scoring Decision Model
Situational Decision Rules
Situations in which a decision of PDA or CON is recommended to the Accreditation Committee
Demonstration of resolution through submission of Evidence of Standards Compliance (ESC).
Onsite review to validate implementation of corrective action.
Examples:
Failure to implement corrective action in response to accepted PFI
unlicensed facility

17. 2009 Scoring Decision Model
Direct Impact Requirements
Non-compliance results in direct impact on quality of care and patient safety
“Implementation” based requirements
Non-compliant requirements must be addressed via ESC submission process
Short time-frame (45 days)
Decision is pending submission of ESC within established timeframe
Failure to resolve results in progressively more adverse decision (e.g., Provisional, Conditional, PDC)
Example:
Inspects, tests & maintains Life Support Systems

18. 2009 Scoring Decision Model
Indirect Impact Requirements
Initially less immediacy of risk; failure to resolve non-compliance increases risk
“Planning” and “Evaluation” based requirements
Non-compliant requirements must be addressed via ESC submission process
Longer time-frame (60 days)
Decision is pending submission of ESC within established timeframe
Failure to resolve = progressively more adverse certification decision (e.g., Provisional, Conditional, PDC)
Examples:
Piping used for AASS is not used to support any other item
Hospital provides storage space to meet patient needs

19. Direct Impact Count Environment of Care 38 Direct Impact
Life Safety Chapter
7 Administrative (LS.01)
20 Healthcare (LS.02)
56 Total (62 ‘z’ items in 2008)
Emergency Management
3 Direct Impact

20. Survey Process

21. Periodic Performance Review
What: self assessment for compliance with all standards
When: 12 months from last Survey activity
Where: via extranet (secure/password accessible site)
Why: Continuous Survey Readiness
Like Statement of Conditions
assess & improve
So what is different – it’s the process – periodic performance review (PPR) is completed by the organization at the mid cycle point of their survey. It is performed by the organization (no on site surveyor) with all scoring and results reporting via an electronic worksheet on a secure website termed the extranet. JCAHO has adopted this mid cycle activity to promote continuous survey readiness. Similar to the SOC it is designed to identify performance areas for assessment and if non compliant, for improvement. Because it is not possible to survey all standards during the onsite survey, the information generated from this process is combined with other pre survey data to establish a “game plan” for surveyors during the tiennual survey.

22. Plan of Action for non-compliance
PPR Process
Plan of Action for non-compliance
Submit to JC for review
Telephone interaction with JC staff
No change in accreditation status
No scores under corrective action plan
Measures of success (MOS)

23. Measure of Success (MOS)
“A numerical or other quantitative measure usually related to an audit that validates that an action was effective and sustained.”
Indicated for some EP’s (M)
Required for PPR: included as part of Plan for Action for non-compliant stds
Required for ESC: following an on-site survey for select EPs if the std is scored Out of Compliance
Not to be used as performance monitor

24. Survey Process
Survey is scheduled between 18 and 39 months of previous survey activity
Survey process
Opening conference
Leadership interview
Validation of self assessment
Tracing patients through system
“Tracer methodology”
Discussion and education
Closing conference

25. TRACER METHODOLOGY SAMPLE PATIENT VENTILATION EMERGENCY DEPARTMENT
MEDICAL
EQUIPMENT
SURGERY
SECURITY
ICU
INFECTION
CONTROL
MED/SURG

26. Contingency Planning
Utilities exist to provide a safe and comfortable environment of care
Failure of utilities could directly impact patient care delivery
Activities associated with managing utilities are designed to ensure the reliability of the systems day to day
Contingency plans are developed to ensure reliability of utilities systems
Contingency plans address at least two issues:
Equipment failure or disruption
Emergency related failures or disruption

27. Contingency Planning: Survey
Organizations ensure their contingency plans are current and accurate
Discuss the organization Memorandum of Understanding and its impact in the community
Evaluate against Standards & Elements of Performance
Suggest the organization include exercising these contingency plans with their Emergency Exercise

28. EC Utilities Mgmt.
EP 7 The hospital maps the distribution of utility systems
EP 8 The hospital labels controls for a partial or complete emergency shutdown
EP 9 The hospitals has procedures for responding to utility system disruptions
EP 10 The hospitals' procedures address shutting off the malfunctioning system and notifying staff in affected areas
EP 11 The hospitals procedures address performing emergency clinical interventions during utility systems disruptions
EP 12 The hospitals procedures addresses the following: How to obtain emergency repair services
EP 13 The hospital responds to utility system disruptions as described in its procedures

29. EM
Emergency Operations Plan identifies alternative means of providing:
EP 2 electricity
EP 3 water needed for consumption and essential care activities
EP 4 water needed for equipment and sanitary purposes
EP 5 fuel required for building operations or essential transport activities
EP 6 medical gas/vacuum systems
EP 7 Utility systems defined as essential, such as
Vertical & horizontal transport
Heating & cooling systems
Steam for sterilization
EP 8 Utility needs identified in the HVA

30. Survey Expectations Current Documentation EC/Safety Committee Minutes
EC Management Plans
Annual Evaluations of EC Plans
EC EP 15
Statement of Conditions
LS EP 2
Inspect, Test & Maintain EC EC

31. Life Safety Code Specialist
LSCS Background
Facilities or Environment of Care based
Prefer CHFM certification
LSCS Agenda
On-Site one day (typically on day 1 or day 2)
Interfaces with survey team member(s)
LSCS Focus
EC Fire Protection Systems
EC Emergency Power
EC Medical Gas and Vacuum
LS Life Safety Code
LS Interim Life Safety Measures (ILSM)
Other EC “Observations”

32. Life Safety Code Specialist Update
May also survey
LD EP 4
LD EP 4
LD EP 2
Greater than 750,000 sq ft second survey day for the LSCS
Critical Access Hospitals ONLY:
LSCS will survey all of the EC
In 2009 will survey EC, LS and EM

33. Environment of Care

34. Environment of Care: Structure
Plan (EC )
Implement
Safety and Security (EC , )
Hazardous Materials and Wastes (EC )
Fire Safety (EC , , )
Medical Equipment (EC , )
Utilities (EC , , , , )
Other Physical Environment Requirements (EC , )
Staff Demonstrate Competence (EC )
Monitor and Improve (EC , , )

35. Environment of Care: Issues
EC : The hospital plans activities to minimize risks in the environment of care.
Note: One or more persons can be assigned to manage risks associated with the management plans described in this standard.
EP 3 The hospital has a written plan for managing: environmental safety of everyone who enters the hospitals facilities
EP 4 The hospital has a written plan for managing: security of everyone who enters the hospitals facilities

36. EC EPs 1 & 3
1 The hospital identifies safety & 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 analysis, results of annual proactive risk assessments of high risk processes, and from credible external sources such as Sentinel Event Alerts.
3 The hospital takes actions to minimize or eliminate identified safety and security risks in the physical environment.

37. Does Every mean Every ?
For the Physical Environment the Joint Commission has defined time in the Introduction of all 3 chapters:
Daily, weekly, monthly and quarterly are calendar references
Semi-annual is 6 months from last occurrence +/- 20 days
Annual is 12 months from last occurrence +/- 30 days

38. Does Every mean Every ? EC.02.03.05
EP 2 Every 6 months the hospital tests valve tamper switches and water-flow devices. The completion date of the test is documented.
Every 6 months +/- 20 days
EP 12 Every 12 months the hospital tests visual and audible alarms, including speakers. The completion date of the test is documented.
Every 12 months +/- 30 days
At least monthly the hospital inspects portable fire extinguishers. The completion dates of the inspections are documented.
Tested within the calendar month

39. Medical Equipment
EC The hospital manages medical equipment risks.
EP 1 The hospital solicits input from individuals who operate and service equipment when it selects and acquires equipment.
EP 2 The hospital maintains either a written inventory of all medical equipment or a written inventory of selected equipment categorized by physical risk associated with use (including all life support equipment) and equipment incident history. The hospital evaluates new types of equipment before initial use to determine whether they should be included in the inventory. (see also EC EP 7)

40. Utilities Management EC.02.05.01 EP 3
The hospital identifies in writing inspection and maintenance activities for all operating components of utility systems on the inventory. (See also EC EPs 3 – 5 and EC EP 1)
NOTE: Hospitals may use different approaches to maintenance. For example, activities such as predictive maintenance, reliability-centered maintenance, interval based inspections, corrective maintenance, or metered maintenance may be selected to ensure dependable performance.

41. Utilities Management EC.02.05.07 EP 4
Twelve times a year, at intervals of not less than 20 days and not more than 40 days, the hospital tests each generator for at least 30 continuous minutes. The completion date of the tests is documented.

42. Life Safety Chapter

43. Life Safety Chapter Based on the Life Safety Code® NFPA 101-2000
Format to be consistent with NFPA
CMS K-Tags reconciled
Three occupancies
Healthcare
Ambulatory
Residential
EPs are sequentially listed as found in LSC
Exception language accepted
Annual Life Safety Assessment will occur as part of Periodic Performance Review

44. Life Safety Chapter
Removed optional Building Maintenance Program (BMP)
Standards & Elements of Performance
LS Administrative
LS Interim Life Safety Measures (includes construction and non-construction) LS
LS.02 Healthcare
LS.03 Ambulatory
LS.04 Residential
LS < 16 Rooming & Lodging
LS > 17 Hotel & Dormitory

45. Life Safety Process
Overview: When an [organization] finds that it is out of compliance with Standards LS through LS , the hospital either resolves the deficiencies immediately or manages it through one of the following options:
a maintenance management process that documents the deficiency and corrective resolution within 45 days; or
a Plan For Improvement derived from the Statement of Conditions™; or
a Life Safety Code Equivalency approved by The Joint Commission.

46. Traditional Equivalencies
Alternative means of complying with the LSC
In the SOC select PFI
Select PFI Change Request
This routes the user to a Web Request page
Identify deficiency using specific Life Safety Code references
Identify alternative solution
Provide timeline of actions
Have one of the following certify proposed actions:
Fire Protection Engineer
Registered Architect
Local AHJ (over enforcement of fire safety)

47. FSES Equivalencies Submit in writing Include the following:
Completed FSES evaluation
Identify all deficiencies that are being addressed
Use specific Life Safety Code references
Identify why the equivalency is being made
Confirmation that all open PFIs will receive high priority resolution
Provide summary of FSES findings

48. Life Safety Chapter LS.01.01.01 (Administrative) EP 3
When the hospital plans to resolve a deficiency through a Plan for Improvement (PFI), the hospital meets the time frame identified in the PFI accepted by The Joint Commission.

49. Life Safety Chapter LS.01.02.01 (ILSM) EP 3
The hospital has a written Interim Life Safety Measures (ILSM) policy that covers periods of construction or situations when the Life Safety Code deficiencies cannot be immediately corrected or when The Joint Commission has not granted an equivalency. The policy includes criteria for evaluating when and to what extent the hospital follows special measures to compensate for increased risk.

50. Life Safety Chapter LS
The organization maintains the integrity of the means of egress
EP 13 Exits, exit accesses, and exit discharges are clear of obstructions or impediments to the public way, such as clutter (for example, equipment, carts, furniture), construction material, and snow and ice. (For full text and any exceptions, refer to: NFPA , 18/ )

51. Electronic Statement of Conditions (eSOC)

52. Security Administrator

53. Sites & Buildings: Revised

54. Government Suspension

55. BBI Enhancements

56. After Gov’t Suspension

57. Sites & Building Page

59. Emergency Management

60. Overview Is now an accreditation manual chapter
All Standards and Elements of Performance from 2008 are incorporated into the 2009 Emergency Management Chapter
No new Standards or Elements of Performance in 2009
This new chapter contains some standards that were in HR, EC and MS
Survey Process is similar to 2008

61. History of Disasters Hospital/Community Debriefings:
Tropical Storm Allison-June 2001
Terrorist Attacks-September 2001
Power Outage- Summer 2003
S. California Wild Fires-Summer 2003
SARS (Asia/Toronto)-Spring 2003
Florida Hurricanes (Frances, Charley, Jeanne) - Aug/Sept 2004
Hurricane Katrina, Rita, Wilma- Aug, Sept & Oct 2005 G

62. Assessment Conclusions
Major Issues Began to Surface:
Scalable approach emergency management
Problems with Communication
Inadequate emergency generator backup
Faulty Incident Command Systems
Lack of Involvement with Emergency Operations Center (EOC)
The extend of an organization’s planning is dictated by the impact of their worst recent disaster

63. Chapter Outline Foundation for the Emergency Plan [EM.01.01.01]
Plan for Emergency Operations Plan
General Requirements [EM ]
Specific Requirements
Evaluation
Evaluating the planning [EM ]
Evaluating the plan through exercises [EM ]

64. Conduct a Hazard Vulnerability Analysis
Documented
Annual Review
Site specific: one or many
Organization and community partners prioritize HVA
Includes disclosing to community needs and vulnerabilities
HVA to plan mitigation
HVA to plan preparedness
EP 8 Documented inventory of resources & assets
Fuel
Personal Protective Equipment (PPE)
Water
Medical/surgical supplies
Other

65. Emergency Operations Plan
Emergency Operations Plan (EOP) describes response procedures
Written plan
Capabilities to self-sustain for up to 96 hours
EOP describes
Recovery strategies
Initiation and termination of response and recovery phases
Defines authorities
Alternative care sites
Actual implementation is documented

66. Six Critical Components
Communication [EC ]
Resources & Assets [EC ]
Safety & Security [EC ]
Staff responsibilities [EC ]
Utilities Management [EC ]
Patient, clinical & support activities [EC ]

67. Relief: until 12/31/2008
The following 15 EPs will not impact your accreditation status
These EPs will be cited but not aggregated
EC.4.11, EP 9 & 10
EC.4.12 EP 6
EC.4.13 EP 7
EC.4.14 EP 8 & 10
EC.4.15 EP 2, 3 & 5
EC.4.16 EP 2 & 3
EC.4.17 EP 4
EC.4.18 EP 4, 5, & 6
NOTE: EC.4.20 has until the end of 2008 to show compliance, so they are not included here

68. Issue Resolution & Clarification
Corridor Clutter & Other Life Safety Code Interpretations

69. Damper Inspection: Actual EP Language: EC.02.05.05 EP 18
The hospital operates fire and smoke dampers one year after installation and then at least every six years to verify that they fully close. The completion date is documented.1
Note: The initial test that must occur one year after installation applies only to dampers installed on and after January 1, 2008.
1For additional guidance, see NFPA ( ) and NFPA (6.5.2).

70. LD.04.01.05 EP 4: What to do when the documentation isn’t there…
During survey documentation is reviewed
If the information is not readily available, but will be available later in the survey this may result in a finding at LD EP 4
The requested information should be utilized by the organization, so not having the information may indicate a lack of responsibility by the organization
If the documentation arrives late, non-compliance has already been established
Scored at LD EP4
Leaders hold staff accountable for their responsibilities

71. Corridor Clutter If the corridor looks cluttered, it probably is
Carts with wheels that are not parked and forgotten (not longer than 30 minutes), but are actively used are allowed provided they are "in use"
Crash Carts are always considered "in use" and allowed with staff understanding that in an emergency situation the cart is moved out of the corridor
Isolation carts, located outside a occupied patient room & required would be “in use”

72. Computers on Wheels
Computers on Wheels and other wheeled carts may be stored in a corridor for not more than 30 minutes
Computers on Wheels may be charging in the corridor while being used
Computers on Wheels may be stored in alcoves
The corridor width must not be compromised

73. Computers on Wheels What about the Batteries?
Battery and charging systems must meet the following design requirements to ensure safe operation:
Sealed Lead-Acid Batteries:
Absorbed Glass Mat design and
Sealed Case (Sealed Lead-Acid)
All Battery Systems (SLA, NiMH, Li+ Ion, Li+ Ion Polymer):
Smart Charging system with overcharge protection and
Shorted cell protection that shuts down upon detecting a shorted cell

74. General Life Safety Interpretations
Rated doors must have legible labels on the door and jambs
Doors installed prior to 1967 may have jambs without rating labels
Missing labels may be equivalized if evidence of compliance is provided to central office
Alternative is to have third party testing agency re-label doors
Are ILSM in place where non-compliant door assemblies are found?

75. General Life Safety Interpretations
Fire stop: existing application is acceptable if:
It was installed in a manner consistent with original design specifications
It is in acceptable condition currently
If the firestop is cracking, etc, then it is to be removed and repaired using current technologies
JC does not accept the expanding foam used for insulation in any fire or smoke barrier
This product does have a UL label, for insulation properties
Easily ignited
Toxic gases when burned
Testing has confirmed foam alcohol based hand rub (ABHR) is equivalent to gel

76. General Life Safety Issues
Fully sprinklered buildings
Not required in elevator mechanical rooms if state codes do not allow (i.e. Ohio, Massachusetts)
Ensure sprinkler piping is not used to support wiring or other material
Score as life safety code deficiency (LS EP 4)
Piping supports are not damaged or loose (LS EP 3)

77. Non Flammable Medical Gas Storage: General Issues
<300 ft³: 12 ‘e’ cylinders per smoke compartment, in rack or appropriate holders
Each ‘e’ cylinder is ft³
Smoke Compartment is limited to 22,500 ft²
Between 300 and 3000 ft³ must be stored in a room that is limited construction with doors that can be locked
“In use” verses “in storage”
On gurney is considered “in use”
In rack is “in storage”
limited to 12 unprotected, racked per smoke compartment (i.e. open to egress corridor)
“Empty” are NOT considered part of the 12 “in storage”
Process to remove empties in a timely manner

78. Non-Flammable Gas Storage: NFPA 99-2005
NFPA edition has additional language regarding O2 storage requirements, specifically:
Storage of nonflammable gases:
9.4.1 > 3000 cubic feet
– 3000 cubic feet
cubic feet
Other:
design and construction
ventilation of locations for manifolds
ventilation for motor driven equipment
ventilation for outdoors
NOTE: CMS also uses NFPA , 9.4.3

79. Questions?

80. SIG Support: 630 792 5900 George Mills, MBA, FASHE, CEM, CHFM
Senior Engineer SIG
Jerry Gervais, CHSP, CHFM Engineer SIG
Charles “Skip” Wilson, MBA
Engineer SIG
John Maurer CHFM, CHSP Engineer SIG