1. The Survey Process in 2011 Healthcare Engineering Consultants Typical Survey Activities in 2011 will Include:  Communication to hospital by JC liaison with tentative agenda, number of surveyors, survey days  Extranet posting (by 7:30 AM local time)  Survey arrival, ID verification  Surveyors include a Physician, Nurse(s), Life Safety Specialist; others may include an administrator and specialty surveyors (lab, behavioral health, home health care, ambulatory, etc.)  Opening Conference (15 minutes)  Organization Orientation (30 to 60 minutes)  Preliminary Planning Session (1 hour)

2. The Survey Process in 2011 Healthcare Engineering Consultants Survey Activities (continued)  On-Site Survey Activities (including tracers)  Special Issue Resolution (end of day, 30 minutes)  Daily Briefing (end of day, 30 minutes)  Critical Survey Activities for the “Physical Environment” (Life Safety Specialist - minimum of two days, one additional day than in previous surveys, effective 1/1/2011) - Environment of Care - Life Safety - Emergency Management  CEO Exit Briefing (15 minutes)  Organization Exit Conference (30 minutes)

3. The Survey Process in 2011 Healthcare Engineering Consultants Post-Survey Activities  Summary of Survey Findings Report (laptop computer generated by end of survey)  Official report posted on Connect site after the survey  Central office review performed for situation decision rules, CMS condition-level deficiency and “flagged” issues  Hospital submits ESC for all RFI’s (direct and indirect) and applicable Measures of Success  Clarifications can be submitted to the JC within 10 days of the final report Connect site posting  Quality Report and Accreditation seal received Reference: 2011 JC Accreditation Process Guide

4. Revised Accreditation Categories for 2011 Healthcare Engineering Consultants Preliminary Accreditation: early survey policy Accredited: in compliance with all standards Accreditation with Follow-Up Survey: follow-up survey required within 30 to 180 days (new for 2011)* Contingent Accreditation: follow-up survey within 30 days (new for 2011)* Preliminary Denial of Accreditation: immediate threat or failure to resolve requirements Denial of Accreditation: Organization denied accreditation; appeals exhausted *Note: Provisional Accreditation category eliminated

5. The Unannounced Survey Timeline Healthcare Engineering Consultants Unannounced Surveys will Occur:  Between 30 and 36 months from the date of the previous unannounced survey (changed for 2011) Note: The chance of a survey is not equally distributed from 30 to 36 months from the previous survey  The timing of all surveys after the previous survey may be based on Priority Focus Process (PFP) data and other factors  Surveys will probably occur between the 33 and 36 month anniversary date  Prior to the survey (usually 6 weeks to 3 months), a discussion with the JC liaison to discuss the surveyor team members and agenda will occur

6. 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  Sentinel event follow-up  Adverse media coverage of specific issue  Complaint from the public  Any other time that the JC decides it’s appropriate!

7. Meeting the Scoring Challenges Healthcare Engineering Consultants Understanding Survey Scoring Decisions

8. Scoring Decisions Healthcare Engineering Consultants  Few scoring changes in the in the EC, EM and LS chapters have occurred for 2011  “A” and “C” scores remain  Four levels of scoring risk exist (surveyor discretion): 1. Immediate Threat to Health and Safety: results in preliminary DOA until follow-up evidence of compliance 2. Situation Decision: results in preliminary DOA or CA 3. Direct Impact Requirements: immediate care impact; must submit ESC within 45 days 4. Indirect Impact: no immediate risk; ESC submission within 60 days

9. Explanation of Scoring Levels Healthcare Engineering Consultants Immediate Threat to Health and Safety 1. Immediate Preliminary Denial of Accreditation 2. Action expected during survey 3. Upon resolution, status changes to Conditional Accreditation based on follow-up survey 4.Triggered by unaddressed issues with: - F ire alarm or extinguishing system - Emergency power supply system - Medical gas master panel Note: Refer to EC News, November 2010 edition

10. Explanation of Scoring Levels Healthcare Engineering Consultants “Situational” Decision Rule 1. Immediate Preliminary Denial of Accreditation or Conditional Accreditation issued 2. ESC submission required within 45 days 3. Follow-up survey occurs to validate corrective action 4.Examples include: - Failure to implement interim life safety measures - Failure to meet PFI timelines on SOC

11. Explanation of Scoring Levels Healthcare Engineering Consultants Direct Impact Requirements 1. If non-compliance is likely to have an impact on patient safety or quality of care 2. ESC submission required within 45 days 3. A single Direct Impact “EP” results in the entire standard being non-compliant 4.Examples include: - Failure to perform risk assessments - Improper disposal of hazardous medications - Insufficient PM on life support equipment

12. Explanation of Scoring Levels Healthcare Engineering Consultants Indirect Impact Requirements 1. Based on planning and care processes 2. If non-compliance is likely to have an increased risk to patient safety or quality of care 3. ESC submission required within 60 days 4. Examples include: - Incomplete management plan - Non-compliance to smoking policy - Insufficient fire drills performed or critiqued - Insufficient disaster drills

13. Joint Commission Scoring Decisions Healthcare Engineering Consultants Total Surveyor “Person Days” *Non-Compliant “Direct Impact” 1-47 5-68 7-99 10-1311 >1313 Meeting or exceeding the “Direct Impact” number results in “outlier” status and SIG review Note: May be revised or eliminated in 2011

14. Joint Commission Scoring Decisions Healthcare Engineering Consultants Performance Category Number Immediate Threat0 Situation Decision0 Direct Impact41 Indirect Impact98 “EC” Scoring Categories

15. Joint Commission Scoring Decisions Healthcare Engineering Consultants Performance Category Number Immediate Threat0 Situation Decision0 Direct Impact3 Indirect Impact111 “EM” Scoring Categories

16. Joint Commission Scoring Decisions Healthcare Engineering Consultants Performance Category Number Immediate Threat0 Situation Decision2 Direct Impact21 Indirect Impact98 “LS” Scoring Categories for Hospitals

17. Joint Commission Scoring Decisions Healthcare Engineering Consultants Performance Category Number Immediate Threat0 Situation Decision2 Direct Impact65 Indirect Impact307 “EC”, “EM” and “LS” Scoring Categories Note: Minimal changes in scoring categories in 2011

18. Joint Commission Standards Scoring Healthcare Engineering Consultants “A” Scores: High priority, One and Done! Example: EC.01.01.01, EP 1; Safety officer appointment You either have the letter or you don’t – Compliant or non-compliant, no partial credit! Good News (sort of!) – This is only an “indirect” impact requirement!

19. Joint Commission Standards Scoring Healthcare Engineering Consultants “C” Scores: Three strikes and you’re out! Example: EC.02.03.05, EP 15 Portable fire extinguishers Three missed monthly checks (aggregated) is an Indirect Impact Citation

20. Joint Commission Scoring Decisions Healthcare Engineering Consultants Timeframe Test Interval Expectations  Trienniel: 36 months +/- 45 days from the previous test month  Annual: 1 year +/- 30 days from the previous test month  Semiannual: 6 months +/- 20 days from the previous test month  Quarterly: 4 times per year, each quarter  Monthly: within the calendar month

21. Joint Commission Scoring Decisions Healthcare Engineering Consultants Timeframe Test Interval Expectations  Weekly: Defined as Sunday 12:01 AM through midnight Saturday  Daily: once per day, beginning at 12:01 AM  Other definitions take priority (example: emergency generator testing) Note 1: These will be default test interval expectations unless the organization defines other acceptable intervals in a policy that is approved by the safety committee Note 2: Published in EC News, November 2010 edition

22. Challenging Physical Environment Standards Healthcare Engineering Consultants What were the most challenging standards for hospitals during 2010?  LS.02.01.20 – 50% (means of egress)  LS.02.01.10 – 44% (fire compartmentation)  EC.02.03.05 – 38% (fire device testing)  LS.02.01.30 – 37% (smoke compartmentation)

23. Challenging Environment of Care Standards Healthcare Engineering Consultants What were the most challenging standards for “critical access” hospitals during 2010?  EC.02.03.05 – 47% (fire device testing)  LS.02.01.10 – 44% (fire compartmentation)  EC.02.05.07 – 40% (emergency power tests)  LS.02.01.20 – 33% (means of egress)  EC.02.06.01 – 27% (safe, functional environ.)

24. The Top Sentinel Events for 2010 Healthcare Engineering Consultants DescriptionNumber Unintended retention of object91 Wrong-site surgery66 Op/post-op complication54 Delay in treatment54 Suicide47 Patient fall38 Medication error28 Perinatal death/ loss of function23

25. The Top Ten Health Technology Hazards - 2010 Healthcare Engineering Consultants Flexible endoscope cross-contamination Alarm hazards Surgical fires CT radiation dose Retained devices, unretrieved fragments Needlesticks/ sharps injuries Computerized equipment problems Surgical stapler hazards Ferromagnetic objects in MRI area Fiber optic light source burns

26. “EC”-Related Patient Safety Goals Healthcare Engineering Consultants Ambulatory, Behavioral Health and Hospital Facilities Goal #7: Reduce the risk of healthcare associated infections Goal #9: Reduce the risk of patient harm resulting from falls Goal #11: Reduce the risk of surgical fires - Eliminated in 2010 (sort of) 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) This applies to all areas of the hospital where behavioral patients are treated – don’t forget about the ED and outpatient areas! (refer to Sentinel Event Alert #46) Note: No new Patient Safety Goals for 2011

27. 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

28. Competition for the Joint Commission Healthcare Engineering Consultants DNV (Det Norske Veritas) Healthcare has received CMS “Deemed Status” Headquarters; Oslo, Norway; 9,000 employees, 300 offices, in 100 countries Approximately 150 accredited hospitals Integrates ISO 9001 standards with CMS Conditions of Participation in annual survey Averages three surveyors, including Life Safety Focus on processes to manage patient safety and quality practices Accredited or Not Accredited outcome

29. Competition for the Joint Commission Healthcare Engineering Consultants Health Facilities Accreditation Program (HFAP) Originally intended for Osteopathic Hospitals First program introduced in 1943; received “Deemed Status” in the 1960’s Have accredited over 200 hospitals Requirements closely parallel the CMS “Conditions of Participation” Accreditation levels include: - Full Accreditation - Interim Accreditation - Denial of Accreditation

30. The 2011 Survey Process Healthcare Engineering Consultants Questions?