ASHE 7 07 Emerg Mgmt · Department of Engineering 2013 - 10 on NEED FOR INVENTORY EC.02.03.05 EP 1 – 20: Each device that is required to be tested must be documented in an inventory

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2013

THE HEALTHCARE ENVIRONMENT

UPDATE

Anne M. Guglielmo

Engineering Department

The Joint Commission

Department of Engineering 2013 - 2

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RISK ICON

Integrated into the Manuals, E-dition, AMP, & FSA Tool

All products will display a single icon at the EP level

for three risk-focused categories:

1. National Patient Safety Goals

2. Accreditation program-specific risk area standards

3. Selected direct/indirect impact standards

In addition, the FSA Tool will use the R icon to identify the fourth risk category:

4. RFI standards from current cycle survey events.

Risk

• Proximity to patient

• Probability of harm

• Severity of harm

• Number of patients at risk


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RANKING RESULTS: 11 OUT OF 21 IN 2012

Top 20

Rank

Standard

2012 RFIs

2011 RFIs

Subject

2 LS.02.01.20 51% 56% Means of Egress

3 LS.02.01.10 46% 52% General LSC Requirements

5 EC.02.03.05 40% 40% Features of Fire Safety

6 LS.02.01.30 39% 45% Life Safety Protection

7 EC.02.06.01 35% 31% Built Environment

9 LS.02.01.35 34% 29% Fire Suppression Systems

10 EC.02.05.01 33% 23% Utility Systems (Ventilation)

11 EC.02.02.01 30% 25% Hazardous Materials & Waste

15 EC.02.05.09 23% 22% Medical Gases

17 EC.02.05.07 22% 26% Emergency Power

21 EC.02.03.01 19% 21% Fire Safety


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#2: LS.02.01.20 51%

The hospital maintains the integrity of the means of egress.

EP 13 Corridor Clutter

Also scored

EPs 16 – 21 Suites issues

Boundaries & Size defined

• Sleeping Suite <5000 sq ft

• Non-sleeping suite <10,000 sq ft

EP 22: Patient sleeping room is not locked


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CORRIDOR STORAGE

“If the corridor looks cluttered…it probably is”

Carts Allowed:

Crash Carts

Isolation Carts

Chemo Carts

Anything in the egress corridor more than 30 minutes is storage

Dead end corridors may be used for storage

Less than or equal to 50sqft space


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SUITES

Not identified on drawings

Boundaries

Dimensions

Exits


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LS DRAWING INFORMATION

A legend that clearly identifies features of fire safety

Areas of the building that are fully sprinklered (if the building is partially sprinklered)

Locations of all hazardous storage areas

Locations of all rated barriers

Locations of all smoke barriers

Suite boundaries, including the size of the identified suites—both sleeping (max 5,000 sq ft) and non-sleeping (max 10,000 sq ft)

Locations of designated smoke compartments

Locations of chutes and shafts

Any approved equivalencies or waivers


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#3: LS.02.01.10 46%

Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat.

EP 9 Fire Barrier Penetrations

EPs 5 – 7 Door issues

EPs 1 & 2 Building Type issues

EP 8 Duct issues


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#5: EC.02.03.05 40%

The hospital maintains fire safety equipment and fire safety building features.

Features of fire protection

Risk Icons:

EP4: Audio/Visual Alarms

EP11: Water flow alarm to fire pump flow test

EP19: Automatic shutdown of AHU


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NEED FOR INVENTORY

EC.02.03.05 EP 1 – 20:

Each device that is required to be tested must be documented in an inventory

If x devices were tested last year, and x-1 were tested this year, which device was missed?

• Each device must be on the inventory to identify which device was missed

• Total number of devices (quantity) is not adequate

Lack of an inventory (written, electronic or other) results in a finding at the EP

Findings solely for lack of inventory is not scored at EC.02.03.05 EP 25


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EC.02.03.05

During survey specific documentation is reviewed

If the documentation for a specific EP is not available a finding is written as non-compliant for that EP

The documentation should be readily available

If the organization clarifies after survey:

Joint Commission Engineers will review and evaluate compliance

LD.04.01.05 EP 4 remains


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EC.02.03.05 EPs 1 -20:

Missing documentation: score the EP as non-compliant

Also write a finding at EP 25 for documentation not being readily available to the AHJ

• If acceptable documentation appears, finding at EP 1 – 20 might be removed during survey

• EP 25 remains

LD.04.01.05 EP 4: Staff held accountable

If 3 or more findings at EC.02.03.05 EP 1 – 20


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EC.02.03.05 EP 25

For hospitals that use Joint Commission accreditation for deemed status purposes:

Documentation of maintenance, testing, and inspection activities for fire alarm and water-based fire protection systems includes the following:

Below for Contents Note: For additional guidance on documenting activities:

NFPA 25, 1998 edition (Section 2-1.3)

NFPA 72, 1999 edition (Section 7-5.2)


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EC.02.03.05 EP 25

Name of the activity

Date of the activity

Required frequency of the activity

Name and contact information, including affiliation, of the person who performed the activity

NFPA standard(s) referenced for the activity

Results of the activity


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#6: LS.02.01.30 39%

The hospital provides and maintains building features to protect individuals from the hazards of fire and smoke.

EPs 16 – 23 Smoke Barriers & Doors

EP2 Hazardous Areas


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#7: EC.02.06.01 35%

EP 1 Interior spaces meet the needs of the patient population and are safe and suitable to the care, treatment and services provided

The organization must provide a safe environment

Unsecured oxygen cylinders

Outdoor safety is scored at EC.02.01.01 EP 5


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EC.02.06.01

EP 13 The organization maintains ventilation, temperature and humidity levels suitable for the care, treatment and services provided

Ventilation:

• i.e. doors held open by air pressure; odors

Temperature:

• Hot / Cold calls

Humidity

• Primary concern is for areas >60%RH

− Mold growth is possible

EP 20: Patient care areas are clean and free of offensive odors


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#9: LS.02.01.35 34%

Risk Icon:

EP 1: monitor authorized automatic sprinkler system

EP 2: water flow alarm

There are 18” or more of open space maintained below the sprinkler deflector to the top of storage.

NOTE: Perimeter wall and stack shelving may NFPA 13-1999, 5-6.6


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18” RULE

18” 18”

OK OK OK

Wrong

Wall Wall

Ceiling

Perimeter

Shelving Perimeter

Shelving


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#11: EC.02.05.01 33%

EC.02.05.01 EP 1: Improper system design

Inability of the mechanical system to achieve required results

EC.02.05.01 EP 4: Lack of written inspection, testing & maintaining frequencies

Continuous monitoring by a building automation system (BAS) is acceptable


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EC.02.05.01

EC.02.05.01 EP 6: Ventilation system is unable to provide appropriate pressure relationships, air-exchange rates and filtration efficiencies

Specific areas lack

negative or positive pressures in relationship to adjacent areas

• i.e. Endoscopy Processing Room should be negative to the egress corridor

the correct number of air changes per hour

Improper filtration

• MERV = minimum efficiency reporting value


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#11: EC.02.02.01 30%

EP’s 3 – 5: Personal Protective Equipment and the process to manage hazardous materials and waste handling and exposures

EP 4 is a RISK ICON

EP’s 6 – 7: Hazardous energy sources

Escorts to Hot Lab based on organization policy

Perspectives, July 2012

EP 7 is a RISK ICON


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#15: EC.02.05.09 23%

Medical Gas Systems

EP 1: Inspection Testing and Maintaining

EP 2: Test when modified, installed or repaired

EP 3: Obstructions

EP 3: Labeling

Contents of piping

Areas served

• Accuracy


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#17: EC.02.05.07 22%

EPs 4 – 7

Missed Generator & Automatic Transfer Switch (ATS) Tests

12 times per year between 20 & 40 days

Each emergency generator must be tested with a load of at least 30% of nameplate

Each ATS must be tested

Missed triennial 4 hour test


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#21: EC.02.03.01 19%

Fire Safety (EP 1)

Open junction boxes

More than 300cuft of nonflammable medical gases (i.e. oxygen) per smoke compartment, open to the egress corridor

Fire Plan (EP 9 & 10)

Lack of fire safety training as per fire plan

Surgical site fires


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LIFE SAFETY CODE SURVEYOR

LSCS Background

Facilities or Environment of Care based

Prefer CHFM certification

All HAP and CAH will be surveyed for a minimum of 2 days by a LSCS

Greater than 1.5 million sq ft will be surveyed for a third day by the LSCS

An additional day is added for every three buildings that are classified as healthcare


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LIFE SAFETY CODE SURVEYOR Interfaces with survey team member(s)

LSCS Survey Focus

Life Safety Chapter

EC.02.03.05

EC.02.05.07

EC.02.05.09

May conduct the EC Session

May conduct the EM Session

Other “Observations”

May also survey

LD.04.01.05 EP 4 Accountability

LD.04.04.01 EP 2 Hi-Priority

LD.01.03.01 EP 5 Resources


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WHAT TRIGGERS ITL (IMMEDIATE THREAT TO LIFE)

Significantly compromised fire alarm system

Significantly compromised sprinkler system

Significantly compromised emergency power supply system

Significantly compromised medical gas master panel

Significantly compromised exits

Other situations that place patients, staff or visitors at extreme danger


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WHAT TRIGGERS ITL (IMMEDIATE THREAT TO LIFE)

PDA01

An Immediate Threat to Health or Safety exists for patients or the public within the hospital.

CONT01

The Immediate Treat to Health or Safety has been successfully abated and verified through the direct observation or other determining method.


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AFS 10 IS RELATED TO THE SOC AND PFIS

Failure to make sufficient progress on previously accepted PFIs (LS.01.01.01 EP 2)

Failure to develop ILSM policy and implement appropriate ILSMs (LS.01.02.01 EP 3)

Failure to manage previously accepted PFIs affects the Joint Commission

Both organizations are aware of deficiencies that have been managed using the PFI process


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DEFICIENCY RESOLUTION

Resolution to a deficiency:

Resolve it immediately

Correct it within 45 days:

Management process that documents the deficiency and actions to resolve

ILSM must be considered

Plan For Improvement located in the Statement of Conditions™

Corrected within 6 months of the Projected Completion Date

ILSM must be considered


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45 DAY CORRECTIVE ACTION

Documented

Origination date

Completion date

Kept available for rolling 3 years

Life Safety deficiencies

Must not exceed 45 days

If greater than 45 days create a Plan For Improvement (PFI)

If originally a work order, close out as complete and generate the PFI

Must be made available to the Joint Commission

During survey to confirm management of the deficiency

Upon request by the Joint Commission


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HOW MANY OPEN PFIS ARE TOO MANY?

The PFI process was created to allow organizations to self assess and create a Plan for Improvement

The self disclosure has never defined how many is too many

The ILSM process was created to allow both the organization and The Joint Commission to be aware of Life Safety Code deficiencies

Failure to make progress on previously accepted PFIs, including failure to implement ILSMs results in Conditional Accreditation


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HOW MANY OPEN PFIS ARE TOO MANY?

Survey Process:

There is no limit to the number of PFIs

Evaluate both closed and currently open PFIs in the View All screen

Spot check during building tour both some closed and open PFIs to evaluate how well the organization is managing the PFI process

Evaluate the scope of PFI entries

Are there life safety deficiencies

Are they greater than maintenance items (i.e. screws missing from a door hinge)


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STATEMENT OF CONDITIONS: PFI

PFIs should be related to the LS Chapter

PFIs should provide specific information

No blanket statements

“…penetrations on 3rd floor”

Specific references to Life Safety Drawings is acceptable

32 penetrations as identified on LS Drawing 3rd Floor, Center Tower dated 3/3/2010

Projected Completion Date is for all listed items (i.e. “32 penetrations”)


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TWO FORMS OF EQUIVALENCIES

Fire Safety Evaluation System (FSES)

A process of calculating the features of life safety and deducting any deficiencies, with the outcome determining if the building is equivalized based on the FSES

Traditional Equivalency

A process of field verification identifying alternative methods of fire safety that off-set the identified deficiency

Field verification from one of the following:

Registered Architect

Fire Protection Engineer

Local AHJ responsible for fire safety


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HISTORY AUDIT TRAIL

The History Audit Trail is used by SIG Engineers when considering extensions or other activities related to an organization

Prior to surveying, the surveyor must preview the History Audit Trail to discover if equivalencies or other actions have occurred by SIG Engineers

When surveying, brief but accurate information entered in the File Room is important

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BUILDING MAINTENANCE PROGRAM (BMP)

The BMP is no longer available to offset findings during survey, but is

considered “best practice”

All EPs related to the original ten BMP items are ‘C’ categories

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2012 LIFE SAFETY CODE

Department of Engineering

The Joint Commission


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NFPA 101-2012

1.Means of Egress Enhanced

Patient lift & transport equipment may be stored in the Means of Egress, provided

5ft clear corridor width is maintained

Fire plan addresses management of storage

Accommodates current “equipment in use”


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NFPA 101-2012

2. Fixed seating permitted

provided 6ft clear width

< 50sqft with 10’ between groupings

Groupings must be on same side of the egress corridor


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NFPA 101-2012 CORRIDOR COOKING

3. Cooking Facilities

One cooking area may be open to the egress corridor per smoke compartment

Any additional cooking areas must be in protected room similar to hazardous areas

Provisions:

No deep fat fryers

Safety equipment to de-activate fuel supply

Grease baffles installed

No solid fuel (i.e. charcoal)


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NFPA 101-2012 FIREPLACES

4. Fireplaces in smoke compartments with patient sleeping rooms

Section 18/19.5.2(2), (3) and (4)

Allow the installation of direct vent gas fireplaces

In smoke compartments containing patient sleeping rooms

Installation of solid fuel burning fireplaces in areas other than patient sleeping areas


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NFPA 101-2012 DECORATIONS

5. Allow the use of Furnishings, Mattresses, and Decorations including Section 18/19.7.5

Allows the installation of combustible decorations on

Walls

Doors

Ceilings

LSC Section 18/19.7.5.6

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RISK ASSESSMENT


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EC.02.01.01 EP 1 (A CATEGORY)

The hospital identifies safety and security risks associated with the environment of care that could affect patients, staff and other people coming into the hospital’s facilities.

NOTE: 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. (See also EC.04.01.01 EP 14).

Is there a risk assessment process?

Quality of the risk assessment process


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EC.02.01.01 EP 3 (C CATEGORY)

The hospital takes action to minimize or eliminate identified safety and security risks in the physical environment.

Did the organization respond to the risk assessment and correct the identified risk?


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Identify Safety &

Security Risks

Established

Process?

No Yes

EC.02.01.01 Risk

Assessment

Identify Risk?

EP 3

No Yes

Resolved?

Yes No

EP 1

EP 1

Unsafe

conditions?

Consider

EC.02.06.01

EP 1


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EC.02.06.01 EP 1

Interior spaces meet the needs of the patient population and are safe and suitable to the care, treatment and services provided.

Unsafe patient care areas

Behavioral Healthcare Unit: Clinical or Physical?

• Ensure the risk is not being managed clinically

• Does not include non-patient care areas


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WHEN TO CONDUCT A 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


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CONDUCTING A RISK ASSESSMENT: SEVEN STEPS

1. Identify the issue

2. Develop arguments in support of the issue

3. Develop arguments against the issue

4. Objectively evaluate both arguments

5. Reach a conclusion

6. Document the process

7. Monitor and reassess the conclusion to ensure it is right conclusion


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ENVIRONMENTAL TOURS

The organization monitors conditions in the environment of care.

EP 12 Environmental tours

patient care areas every six months

EP 13 Environmental tours

non-patient care areas annually

EP 14 Ongoing monitoring of actual / potential risk

EP 15 Evaluation of objectives, scope, performance and effectiveness of all EOC management plans


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PRA EC.02.06.05 EPS 2 & 3

Preconstruction Risk Assessment (PRA) Construction or renovation in occupied

healthcare facilities can result in environmental problems such as: Noise Vibration Creation or spread of contaminants Disruption of essential services Emergency Procedures Air quality


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INTERIM LIFE SAFETY MEASURES

Order of Standards (LS.01.02.01)

EP 1 & 2 regardless of ILSM policy

EP 3 must clearly define the ILSM policy including

AFS 10 Process

When to implement

What to do to protect occupants

Both construction related and non-compliance with the LSC

EPs 4 – 14 align with policy and implementation strategies

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MAINTENANCE STRATEGIES TO

MAXIMIZE RESOURCES & ENHANCE QUALITY


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EC.02.05.01 EP 2

The hospital maintains a written inventory of all operating components of utility systems or maintains a written inventory of selected operating components of utility systems based on risks for infection, occupant needs, and systems critical to patient care (including all life-support systems).

The hospital evaluates new types of utility components before initial use to determine whether they should be included in the inventory.

(See also EC.02.05.05, EPs 1, 3-5)


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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.02.05.05, EPs 3 - 5; EC.02.05.09, EP 1)

Note: Hospitals may use different approaches to maintenance. For example, activities such as predictive maintenance, reliability- centered maintenance, interval-based maintenance, corrective maintenance, or metered maintenance may be selected to ensure dependable

performance.


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EC.02.05.01 EP 4

The hospital identifies, in writing, the intervals for inspecting, testing, and maintaining all operating components of the utility systems on the inventory, based on criteria such as

Manufacturer‘s recommendations

Risk levels

hospital experience

(See also EC.02.05.05, EPs 3-5)


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EQUIPMENT SURVEY PROCESS

Documentation is completed for both life support and non-life support devices on the inventory

Accuracy of Inventory

All Life Support equipment must be on the inventory

Preventive maintenance frequencies must be clearly defined in writing

Confirm work done as per scheduled activities

Ensure appropriate work is scheduled based on maintenance strategies

Evaluate equipment failure and scheduled actions


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SURVEY PROCESS: STAFF INTERVIEWS

Department Leader

Establish how the inventory was created

Establish the Maintenance Strategies used

Evaluate the Monitoring processes

Evaluate the effectiveness of the program

Equipment Maintainers

Evaluate their understanding of the maintenance process/strategies

Evaluate competencies based on repeat work orders

Evaluate work scheduled against completed


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SURVEY PROCESS: STAFF INTERVIEW

Users of the Equipment

Evaluate equipment reliability

Evaluate response time when equipment fails

Evaluate emergency response process

Evaluate “Culture of Safety”

Appropriate training of staff related to equipment use

Customer satisfaction with department

Contract Services

Evaluate reliability of equipment serviced

Evaluate integration of the process


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SURGICAL SITE FIRES

>50 million hospital & ASC surgeries

Estimated 100 surgery fires per year

20 Serious

1 – 2 deaths

Fire sites:

34% airway

28% head/face

38% other

74% occurred in oxygen enriched environment


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SURGICAL SITE FIRES

Source:

68% electrosurgical equipment

13% lasers

Recommendations:

Fire drills & Staff Education (including how to prevent surgical site fires)

Review alarm procedures

Review rescue techniques

Review shut off locations

Joint Commission response:

Life Safety Code Surveyors gown and survey


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CLINICAL ALARMS

In the past there was a NPSG on clinical alarms

Goal retired, but can survey the issue under Environment of Care

EC.02.04.01

EC.02.04.03

CoP Physical Environment 482.41

Clinical Alarm Device Summit http://www.aami.org/hottopics/alarms/AAMI/2011_Alarms_Summit_publication.pdf

http://www.aami.org/publications/AlarmHorizons/index.html

http://www.aami.org/hottopics/alarms/AAMI/2011_Alarms_Summit_publication.pdf

http://www.aami.org/publications/AlarmHorizons/index.html


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CLINICAL ALARMS

Incidents of alarms being silenced or shut off

Default settings

Incidents of inadequate staffing to support

No mechanisms for monitoring/responding

Incidents of “alarm fatigue”

Overuse, too many types of alarms, etc.

Patient deaths have occurred


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CLINICAL ALARMS

PC.02.01.11: Resuscitation services are available throughout the hospital

PC.02.01.19: The hospital recognizes and responds to changes in the patient’s condition

LD.03.06.01 EP3: Leaders provide for a sufficient number and mix of individuals to support safe, quality care, treatment and services. CoP 482.23 (b) Nursing Services

HR.01.06.01: Staff are competent to perform their responsibilities. CoP 482.23 (b)(5) Nursing Services


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CLINICAL ALARMS

EC.02.04.01: Equipment Management

EP 2 Inventory

EP 3 maintenance, inspection and testing activities

EC.02.04.03: Equipment Reliability

EP 2 Life support devices

EP 3 Non-life support devices

EC.04.01.01: Monitoring & Reporting

Continually monitoring medical equipment problems or failures.

CoP 482.13(c)(2) Patient Rights


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DEPARTMENT OF ENGINEERING 630 792 5900

George Mills, MBA, FASHE, CEM, CHFM, CHSP

Director

Anne Guglielmo, CFPS, LEED, A.P., CHSP

Engineer

John Maurer, CHFM, CHSP

Engineer

OPEN Engineer Position

OPEN Engineer Position


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These slides are current as of 3/1/2013. 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.

THE JOINT COMMISSION DISCLAIMER

Documents

ASHE 7 07 Emerg Mgmt · Department of Engineering 2013 - 10 on NEED FOR INVENTORY EC.02.03.05 EP 1 – 20: Each device that is required to be tested must be documented in an inventory