1. The Preliminary Planning Session
How Should I Prepare for the Preliminary Planning Session?
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2. The Preliminary Planning Session
Occurs on the morning of the first survey day
Will be performed by the surveyors “alone”
Will create strong first impressions (“Blink!”)
Will impact the rest of the survey!
Will be document-based (documents should
always be up-to-date and ready)
Hospital must be prepared for this!
Should trigger the “Rapid Response Team”
The Life Safety Surveyor may come at a later time
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3. The Preliminary Planning Session
Documents to be reviewed include:
The six required management plans plus the “EOP”
Safety committee minutes from the last 12 months
The most recent annual effectiveness evaluations from each “EC”
area and Emergency Management
Statement of Condition documents (reviewed by the LSS)
Fire plans and fire drill evaluations
Interim life safety measures policy
Safety officer signed appointment letter with intervention
authority statement
Categorical waiver letter, if applicable
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4. Expectations Include:
The Management Plans
Expectations Include:
A description of the program, not a rewrite of the program!
Consistent format, in a labeled, tabbed binder
A list of applicable facilities to avoid multiple plans
A description of each “element of performance”
Responsibilities from governing body to staff
Performance improvement and training information
Risk assessment and ICES information
An annual review by the safety committee
Note 1: Emergency Management requires an Emergency Operations Plan (EOP), not a management plan
Note 2: “High Risk” plans include safety, hazmat, biomed, utilities
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5. Best Practices Include:
The Management Plans
Best Practices Include:
Cross-reference or cite supporting policies that already exist
Note when the AHJ has a stricter interpretation or code reference
Reference other related Joint Commission standards (example: HR, LD, PI, IM standards)
Distribute plans to each applicable “off-site” facility
Don’t just list or restate the required standards or EC numbers
Consider the plans to be a “roadmap” to effective EC management
Consider appendix documents that reference applicable policies, define responsibilities and list performance indicators
Note: Refer to additional information regarding “EC management Plans” in the June, 2013 issue of Perspectives
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6. The Emergency Operations Plan
Expectations Include:
The Emergency Operations Plan (EOP) is not a management plan, but a robust description of emergency operations procedures and information
At a minimum, the EOP should describe the following:
1. The Hazard Vulnerability Analysis (HVA)
2. Mitigation, Preparedness, Response, Recovery (MPRR)
3. The Incident Command System structure (ICS)
4. The six critical core areas of emergency management, including:
communications, resources and assets, safety and security, staff roles
and responsibilities, utilities and patient management
Also include a description in the EOP of emergency drills and reference emergency codes, procedures, and other materials that exist and supplement the program
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7. Best Practices Include:
The Safety Committee
Best Practices Include:
Leadership representative (VP-level or equivalent) present at every meeting
Multi-disciplinary membership
Attendance of standing members at least 70%
Meet often enough to limit meeting time to 1 hour or less
Document and distribute meeting minutes within two weeks of the meeting and use the C-R-A-F format
Use dashboards or spreadsheets to track regulatory and performance improvement data
Track the resolution of issues with a monitoring chart
Use the meeting time to solve problems, not to review data or information that does not require any action
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8. Safety Committee Issue Monitoring
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9. Healthcare Engineering Consultants
Annual Evaluations
The written Annual Evaluations must include the following sections:
SCOPE - What is being evaluated?
OBJECTIVES - What are the numerical goals/ benchmarks?
PERFORMANCE - What does the data show?
EFFECTIVENESS - How does the performance (data) compare to the objectives?
WHAT NEXT? - What objectives do we define for next year, based on this year’s performance?
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10. “Best Practice” Guidelines for the Evaluations
Annual Evaluations
“Best Practice” Guidelines for the Evaluations
Demonstrate that the program has improved
Provide numerical data
Demonstrate “effectiveness” rather than “busyness”
To effectively communicate the report to others, include a narrative explanation, spreadsheets and graphs and charts
Indicate whether the regulatory and performance improvement goals and objectives have been “met” or “not met”, with a clear method of determination
Include goals and objectives for the following year, based on the results of the previous year
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11. Additional “Best Practice” Guidelines
Annual Evaluations
Additional “Best Practice” Guidelines
Document evaluations for every “EC” area, and Emergency Management
Create the evaluations as soon as possible at the end of the fiscal or calendar year (within 30 days, if possible)
Review and approve by the Safety Committee (within 60 days)
Review and approve by the Governing Body (within 90 days)
Re-read the annual evaluations before the survey to be prepared for the Physical Environment Interview session
The annual evaluations are a “Direct Impact” score
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12. The Statement of Conditions Review
LS : SOC and Life Safety Code
The SOC completion will be verified through the Joint Commission Connect site (BBI’s and PFI’s)
Have the SOC notebook available for review
The PFI documents from the previous survey may be reviewed to verify completion of deficiencies (have them available, if requested)
The compartmentation drawings will be reviewed to assist in planning the facility tour
Life Safety Code compliance will be verified during the facility tour
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13. The Statement of Conditions
What is the SOC?
The Statement of Conditions (SOC) is a document that is required to be completed by every healthcare facility that applies for accreditation by the Joint Commission. It references the *2000 edition of the Life Safety Code and consists of the following sections:
Basic Building Information (BBI) Form – electronic on Connect site
Life Safety Assessment (LSA) Form – not on Connect site
Plan for Improvement (PFI) Form – electronic on Connect site
*Note 1: The Joint Commission permits other LSC editions to be selected, but the entire edition must then be followed; CMS also requires compliance with the 2000 Life Safety Code
Note 2: It is likely that the 2012 Life Safety Code will be adopted by CMS and the Joint Commission in 2015
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14. The Statement of Conditions SOC Notebook (Best Practice)
A SOC notebook is strongly recommended to contain “hard copies” of the SOC documents
The notebook should include at least the following sections:
Section 1: The SOC policy and responsibility statement
Section 2: Current copies of the downloaded BBI forms
Section 3: Accurate, color-coded compartmentation prints
Section 4: The latest, completed LSA-type document
Section 5: Current and previous, downloaded PFI forms
Section 6: Any correspondence with the Joint Commission, including equivalencies, letters and s
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15. The Statement of Conditions Why Should I have an SOC Policy?
The SOC policy describes how the Statement of Conditions program is organized for the facility
What Should the SOC Policy Include?
Who is responsible for completing and maintaining the SOC
How often the SOC documents are reviewed
Who reviews the SOC documents for timeliness
PFI guidelines (when does a work order become a PFI?)
Whether a BMP is implemented
Whether an above-the-ceiling program is in place
How the SOC documents are organized
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16. The Statement of Conditions Document
The current Statement of Conditions “hard copy” document is dated 5/2004 and can still be downloaded as a pdf file from JointCommission.org for the LSA form only (do not use the BBI or PFI “hard copies” – they are obsolete)
Note: Most organizations do not use this document at all!
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17. Statement of Conditions Document Notes About the e-BBI Form
List on the e-BBI cover page every occupancy that will be surveyed, even for business occupancies (make sure that the BBI and survey list match!)
The e-BBI questionnaires are only required for ambulatory and healthcare facilities, not business occupancies
Fill in the e-BBI comments section regarding SOC preparer, location of building drawings, mixed occupancies, equivalencies, special building features or local AHJ requirements, including the CMS “Categorical Waivers”
If multiple occupancies are entered, the greatest percentage defaults to the BBI form, so multiple BBI entries are required
Be sure to print the electronic version of the BBI form at least annually so that a “back-up” is available, and place a copy in the SOC Notebook
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18. Statement of Conditions Document Compartmentation Requirements
Mixed Occupancies: (LSC sections: , )
Sections of health care facilities shall be permitted to be classified as other occupancies (such as business), provided that they meet the following conditions:
They are not intended to serve health care occupants for purposes of housing, treatment, or customary access by patients incapable of self-preservation
They are separated from the health care occupancy by a fire rating of at least 2 hours
The facility is not intended to provide services simultaneously for four or more health care patients who are “litterborne”
Separation between ambulatory and business occupancies only requires a 1-hour rating (LSC: )
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19. Statement of Conditions Document
e-BBI Form – Buildings
Be sure to complete for all healthcare and ambulatory facilities
Optional for business occupancies, but strongly suggested to include the cover page to indicate “surveyable facilities”
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20. Statement of Conditions Document
e-BBI Form – page 3
“Previous inspections” data provides valuable information to the survey team!
Be sure to list local or regional requirements (example: limited generator testing due to high pollution days) in the “Comments” section at the bottom of the form as well as other requested information, including: 1) location of the compartmentation drawings; 2) e-SOC preparer; 3) mixed occupancies, and; 4) equivalencies or issued variances, including CMS “Categorical Waivers”
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21. Statement of Conditions Document
Life Safety Building Compartmentation Drawings
Typical line colors might include:
Blue – smoke barrier Green – 1 hour fire wall (typically a hazardous area) Red – 2 hour fire wall
Note 1: A color-coded drawing is “best practice”
Note 2: Be sure to indicate the following features on the drawings:
Hazardous areas
Smoke/ fire barriers
Suites w/ sizes, other information
Linen/ waste chutes, shafts, chases
Exits
Sprinkled/ non-sprinkled areas
Approved equivalencies
A legend with fire safety features
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22. Statement of Conditions Document
LSA Form (is not electronic):
Is a voluntary assessment tool, although some assessment is required at least annually
Is not required for “Business Occupancies”
The Joint Commission surveyor normally expects some type of form, document or evaluation to be completed
Dated 5/2004, so a cover sheet that is signed annually is recommended
Can still be downloaded from the Joint Commission home page website JointCommission.org (type “Statement of Conditions” in the search box)
Can use other assessment tools (2011 form) or checklists for the LSA
Comments in LSA must match PFI deficiencies
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23. Statement of Conditions Document
LSA Documentation Options:
Can manually complete the 2004 LSA form available on the Joint Commission home website (JointCommission.org) in Adobe format
Can complete the updated 2011Joint Commission questionnaire form available from the “EC Essentials” book
Can create a new form or process for internal use
Can contract with an outside vendor
May, 2004 Form
2011 Form
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24. Statement of Conditions Document Notes About the PFI Forms
The forms should not be used for “operational deficiencies”, such as exit lights burned out, doors out of minor adjustment or small penetrations that can be easily filled – these should be completed using the routine work order system
The normal “trigger time” from a work order to PFI is 45 days
Document the “PFI’s” on a continuing basis – be sure that the PFI log is up-to-date and ready to be reviewed by the surveyor
Don’t forget to enter the projected start and completion dates and the actual completion date
Be sure to document an ILSM evaluation for every PFI!
Failure to meet the completion dates without a delay approval results in Contingent Accreditation 6 months after the projected completion date has passed!
If applicable, keep any previously signed PFI copies available
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25. Statement of Conditions Document
The second page for the electronic PFI forms is used to indicate the deficiency resolutions
Don’t forget to complete all of the requested information, including the proposed action, source of funds and the projected start and completion dates
The projected completion dates can be altered until they are “frozen” before or during the actual survey!
Be sure to check “YES” on the form to indicate that interim life safety measures (ILSM) have been evaluated for the PFI
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26. Statement of Conditions Document
Changes to the SOC Process – effective 7/1/2014
Open PFI’s will now be listed in the final decision report, so will be available to anyone who has access to the report
Failure to resolve a PFI beyond the 6-month “grace” period will result in a phone call from the Joint Commission and a possible on-site survey if it is not resolved in a timely basis
Once a delay for a PFI is granted, the 6-month grace period is no longer applicable!
Equivalencies that are requested from the Joint Commission will now be forwarded to the CMS regional (state) office for review and possible approval – the Joint Commission will no longer issue equivalencies unless approved by CMS!
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27. The Safety Officer Appointment
Should be in a letter format
Should identify an individual (or multiple people) by name
Must include an “intervention authority statement”
Should be signed by the organization CEO and
CMO if they are on the same organizational level
Can be signed by the Governing Body President to indicate additional organizational support
Only requires a re-issue if any individuals change positions
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28. The Preliminary Planning Session
Questions?
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