1. What’s New for 2008? Healthcare Engineering Consultants Does the Joint Commission Manual Have Major Changes for 2008?

2. Organization of the 2008 Accreditation Manual Healthcare Engineering Consultants Section 1 - Patient Focused Functions  Ethics, Rights and Responsibilities (RI)  Provision of Care, Treatment and Services (PC)  Medication Management (MM)  Surveillance, Prevention and Control of Infection (IC) Section 2 - Organization-Focused Functions  Improving Organization Performance (PI)  Leadership (LD) - (includes previous governing body)  Management of the Environment of Care (EC)  Management of Human Resources (HR)  Management of Information (IM) Section 3 - Clinical Functions  Medical Staff (MS)  Nursing (NR) No Major Change! Note: Standards rewrite in 2009

3. What’s New for 2008? Healthcare Engineering Consultants What Will the Survey Process be Like in 2008?

4. Unannounced Surveys in 2008 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; multiple days for >750K square feet  Review of documents (survey planning meeting)  Life safety-focused facility tour  Three-part “EC” interview  Questions to staff based on tracer methodology  Summary conference to present tentative findings

5. Unannounced Surveys in 2008 Healthcare Engineering Consultants Can Occur Due To:  Regular unannounced survey  Random off-cycle selection (5%)  Sentinel event follow-up  Adverse media coverage of specific issue  Complaint from the public Note: All new applicants for the accreditation process as well as changes to a new classification (example: critical access designation) will now have unscheduled surveys

6. What’s New for 2008? Healthcare Engineering Consultants What Scoring Rules Apply for 2008?

7. Joint Commission Scoring Guidelines Healthcare Engineering Consultants No major scoring changes for 2008, except SOC:  “EP’s” scored 0, 1 or 2 0 = insufficient compliance 1 = partial compliance 2 = satisfactory compliance  Scoring categories have been continued for each EP: A, B or C (B may be eliminated later!)  Standards are scored “compliant” or “non- compliant”  No grid score calculation  Rationale is not scored

8. Joint Commission Scoring for EP’s Healthcare Engineering Consultants Category A: usually used for policies and procedures or the presence or absence of a requirement Scored either “0” or “2” A “2” may become a “1” or “0” if the track record is insufficient Category B: used for process requirements If requirement exists, then process design and track record is scored (may be eliminated during 2008!) Category C: instances of non-compliance Score “2”: 1 or no instances of non-compliance Score “1”: 2 instances of non-compliance Score “0”: 3 or more instances of non-compliance

9. Joint Commission Scoring for EP’s Healthcare Engineering Consultants If any “EP” is scored “0”, the standard is not compliant If 65% of the EP’s are scored “2”, then the standard is considered “compliant”, unless any other EP is scored “0” (up to 35% of the EP’s may be scored a “1”!)

10. Special Scoring for SOC Deficiencies Healthcare Engineering Consultants  “X” is considered a minor deficiency Example: a fire door does not latch properly (item 1C2) – Score 1  “Y” is considered a midrange deficiency Example: the same fire door above is missing hardware (item 1C2) – Score 2  “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 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: Use of the BMP “caps” scores for each category at “1”

11. Joint Commission Scoring Decisions Healthcare Engineering Consultants Accreditation Decision Rules for 2008  Accredited (same)  Provisional Accreditation (same)  Conditional Accreditation (change) 10 or more non-compliant standards (< 100 ADC) 14 or more non-compliant standards (>100 ADC)  Preliminary Denial of Accreditation (change) 14 or more non-compliant standards (<100 ADC) 18 or more non-compliant standards (>100 ADC)  Denial of Accreditation (same)  Preliminary Accreditation (same)

12. “EC”-Related Scoring Rules 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 2 standard deviations above the mean (10 or 14 RFI’s) Note: In 2008, will be 1.5 deviations above the mean CON03 - Failure to clear repeat non-compliant standards CON04 - Delayed PFI or no ILSM’s when required

13. What’s New for 2008? Healthcare Engineering Consultants Which Areas Have Historically Been the Lowest Scoring?

14. Lowest Scoring JC Areas Healthcare Engineering Consultants Percent Scored Not Compliant for Hospitals IM.3.10 (44%) – Information management MM.2.20 (36%) – Medications storage PC.13.20 (29%) – Operative procedure planning EC.5.20 (19%) – Compliance with the Life Safety Code MM.3.20 (19%) – Clear medication orders IM.6.50 (15%) – Transcription of verbal orders IM.6.10 (15%) – Complete and accurate medical record PC.8.10 (14%) – Pain assessment and treatment PC.2.120 (13%) – Definition of initial assessment time frame EC1.10 (12%) – Safety management risk assessment

15. Lowest Scoring “EC” Areas Healthcare Engineering Consultants Percent Scored Not Compliant for Other Facilities Assisted Living – EC.1.5 (33%) Fire prevention planning Assisted Living – EC.2.2 (33%) Security planning Assisted Living – EC.2.5 (33%) Fire prevention implementation Assisted Living – EC.1.4 (33%) Emergency planning Ambulatory Care – EC.4.10 (19%) Emergency management Behavioral Health Care – EC.4.10 (10%) Emergency management Behavioral Health Care – EC.4.20 (5%) Emergency drills Critical Access Hospital – EC.1.10 (10%) Safety risk management Critical Access Hospital – EC.7.10 (4%) Utility management

16. Lowest Scoring “EC” Areas Healthcare Engineering Consultants Percent Scored Not Compliant for Other Facilities Laboratory – EC.6.20 (11%) Equipment testing and inspection Long Term Care – EC.4.10 (18%) Emergency management Long Term Care – EC.9.10 (14%) Monitoring the environment Office Based Surgery – EC.4.20 (13%) Emergency drills Office Based Surgery – EC.1.20 (8%) Safe environment Office Based Surgery – EC.5.40 (8%) Fire equipment maintenance Home Care – EC.4.10 (20%) Emergency management Home Care – EC.4.20 (10%) Emergency management drills Home Care – EC.6.60 (7%) Medical equipment testing

17. What’s New for 2008? Healthcare Engineering Consultants What will be the Other Major EC Changes for 2008?

18. Possible Change for 2008 Healthcare Engineering Consultants 2006 AIA Document: Approval voted June, 2005 May be adopted by JCAHO in the future Available for purchase now! (AIA.org or ASHE.org) Multiple changes for single rooms, expanded ICRA, space revisions, HVAC changes, patient safety language, surge capacity information in Appendix

19. Other Changes for 2008 Healthcare Engineering Consultants Electronic SOC Document  All BBI’s and PFI’s must be electronically entered into the Joint Commission Connect site  Deadlines: BBI’s: 1/1/07 PFI’s: 9/1/07  Annual submission of SOC with PPR delayed!  Entered data will be “frozen” after approval by surveyor  PFI entries should be continuous  Password for organization will be required for data entry  Actual completion dates must be entered as they occur  Be sure to fill out forms, even if “No Deficiencies” on PFI  Download the data and put “hard copy” in notebook

20. Other Changes Continued for 2008 Healthcare Engineering Consultants Electronic SOC Document  PPR process will now include questions about the e-SOC  No longer “busted plan” – now termed “Non-Compliant”  e-SOC will track when completion dates are changed prior to approval by surveyor  PFI’s completed beyond 6 months of intended date may be cited under: EC.5.20, LD.2.20, LD.3.80 or LD.4.50  Can delete buildings on BBI, but not sites!  PFI summary uses the following colors: - Yellow for 4 months beyond intended completion date - Orange when beyond the 6-month grace period - Salmon when PFI completed after 6 months of intended date

21. Other Changes Continued for 2008 Healthcare Engineering Consultants Generator Run Tests (EC.7.40)  4-hour run at greater than 30% of nameplate load every three years; first due 7/1/07  Load test should be dynamic (actual hospital load), although the Joint Commission will accept load bank tests  Any 4-hour @ 30% load test since July 1, 2004 will count and the next test will not be required until the 3-year anniversary date  Test failure requires interim measures until repairs are completed; successful retest is required after initial failure  All other existing generator tests still required; reference NFPA 110, 2005 edition  Simultaneous monthly, annual load bank and trienniel tests will count, as long as first 30 minutes are at 30%, rather than 25% of load (NFPA 70 panel does not yet agree!)

22. Expectations for 2008 Healthcare Engineering Consultants Sentinel Event Alert #37 Recommendations  Perform emergency power system gap analysis  Maintain complete, labeled, accurate inventory of loads served by the emergency power system (EPS)  Ensure competency training of staff who are responsible for the testing and maintenance of the EPS  Test generator fuel oil on an annual basis and filter or replace, as necessary  Communicate EPS capabilities and limitations to clinical staff and hospital management  Establish clinical contingency plans in the event of brief or prolonged failure of the EPS

23. Other Changes for 2008 Healthcare Engineering Consultants Operational Damper Tests  Re-inspection now every six rather than four years in hospitals; other occupancies still four years per NFPA  Change effective January 1, 2008  Result of move from NFPA 90A to NFPA 80 (fire dampers) and NFPA 105 (smoke dampers), the 2007 editions  For smoke dampers, the inspection shall occur one year after installation and then on a six-year basis  Inaccessible dampers should be placed on the PFI form and given a 6-year time period for completion; completion date can be extended after the 6-year period has expired

24. Emergency Management Healthcare Engineering Consultants What are the Newly-Adopted Changes for 2008? EC.4.11: Plans for managing emergencies EC.4.12: Development of emergency operations plan EC.4.13: Emergency communications strategies EC.4.14: Management of resources and assets EC.4.15: Strategies for managing safety and security EC.4.16: Management of staff roles and responsibilities EC.4.17: Strategies for managing utilities EC.4.18: Management of clinical and support activities EC.4.20: Implementation of emergency drills 2X per year Note: One drill requires external “non-support” simulation

25. Top “EC” Focus Areas for 2008 Healthcare Engineering Consultants  Patient Safety  Infection Control  Emergency Management (Katrina impact – 2008 changes)  Life Safety (life safety specialist surveyor change)  Risk Assessment

26. “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)

27. What’s New for 2008? Healthcare Engineering Consultants What Other Chapters in the Manual Will Impact EC in 2008?

28. Organizational Function Overview Healthcare Engineering Consultants  Human Resources (HR) Staff training, competency and performance  Leadership (LD) Compliance, resources, patient safety (LD.3.50, oversight of contracts/ services; 7/1/07)  Performance Improvement (PI) Data collection, aggregation, analysis, action  Information Management (IM) Data collection, aggregation, security  Infection Control (IC) Measurement and reduction of infections

29. What’s New for 2009? Healthcare Engineering Consultants What will the EC Chapter look like in 2009?

30. 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 will be combined into one standard An entirely new numbering system will be used

31. Numbering the EC Standards Healthcare Engineering Consultants  EC.1.01 – Management Plan Requirements  EC.2.01, 2.03 – Safety and Security  EC.3.01 – Hazardous Materials and Wastes  EC.4.01 through 4.04 – Fire Safety  EC.5.01, 5.02 – Medical Equipment  EC.6.01 through 6.05 – Utilities Management  EC.7.01, 7.03 – Other Physical Environment  EC.8.01 – Staff Competency  EC.9.01 through 9.03 – Monitoring, Improvement

32. Understanding the Four “EC” Vulnerabilities Healthcare Engineering Consultants What are the Four Survey Points of EC Vulnerability for 2008?

33. The Four Survey Points of Vulnerability Healthcare Engineering Consultants  The Survey Planning Session  LSC Facility Tour  The “EC” Interview Session Involves all seven EC areas Documents and staff must be available Consists of three phases  “EC” Tracers

34. The Four “EC” Vulnerabilities Healthcare Engineering Consultants What is the Expectation Triad?

35. The Expectation Triad Healthcare Engineering Consultants Regulatory Compliance Performance Improvement Risk Assessment

36. The Expectation Triad Healthcare Engineering Consultants Regulatory Compliance: “Ensuring that all of the required standards are being met”

37. The Expectation Triad Healthcare Engineering Consultants Performance Improvement: “Attempting to measure and improve performance on an ongoing basis in the Environment of Care”

38. The Expectation Triad Healthcare Engineering Consultants Risk Assessment: “Prioritization and management of resources through an assessment of probability and impact”