2014
John Maurer, SASHE, CHFM, CHSP
Engineering Department
The Joint Commission
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THE HEALTHCARE ENVIRONMENT
THE TOP 20 ISSUES
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2013/2014
CHALLENGING
STANDARDS
2013 Non
Compliance
EC.02.05.01
53%
47%
LS.02.01.20
52%
52%
EC.02.06.01
51%
39%
EC.02.03.05
50%
45%
IC.02.02.01
50%
46%
LS.02.01.10
49%
48%
RC.01.01.01
49%
52%
LS.02.01.30
46%
45%
LS.02.01.35
44%
36%
EC.02.02.01
36%
34%
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2014 Non Compliance,
First 6 months
Standard/NPSG
2013 Non
Compliance
MM.03.01.01
32%
35%
PC.01.03.01
29%
27%
EC.02.05.09
27%
21%
PC.02.01.03
27%
18%
MM.04.01.01
24%
22%
PC.03.01.03
24%
20%
LD.01.03.01
23%
19%
LD.04.01.05
22%
14%
EC.02.05.07
21%
23%
MM.05.01.01
20%
16%
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2014 Non Compliance,
First 6 months
Standard/NPSG
TOP 10 CITED STANDARDS: 2011 – 2014 (YTD)
2014 2013 2012 2011
EC.02.05.01: Utility Systems Risks
#1
#4
#10
#13
LS.02.01.20: Means of Egress
#2
#1
#2
#2
EC.02.06.01: Built Environment
#3
#8
#7
#11
EC.02.03.05: Fire Safety Systems
#4
#7
#5
#5
LS.02.01.10: General Bldg Req’s
#6
#3
#3
#3
LS.02.01.30: Protection
#8
#6
#6
#4
LS.02.01.35: Extinguishment
#9
#9
#9
#10
EC.02.02.01: HazMat & Waste
#10
#11
#11
#15
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Standard
#18 LD.4.01.05
 The hospital effectively manages its
programs, services, sites, or departments
Problematic EP:
 EP 4: Staff are held accountable for their
responsibilities

to exist without correction
 Sometimes used when situation is serious but does
not warrant a “decision rule”
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 Used when leadership has allowed non compliance
WHAT IS YOUR APPROACH TO ESC?




responsible?
Do you do what you need to do to “make it go away” or
are the issues analyzed to determine why the non
compliance is present?
Do you use this standard ESC response: “We have reeducated the “Fill In The Blank”?”
Have you looked at patient safety events and near
misses/close calls in relation to non compliance identified
during your survey?
Have you considered what the short term and long term
impact will be if you are unsuccessful in correcting the
RFIs?
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 Do you have a team approach or is one person
WHAT IS YOUR APPROACH TO ESC?
root causes of the RFIs?
 Does the safety culture in your organization encourage staff
and medical staff to identify system and process problems so
they can be addressed quickly or do you wait until something
happens or a surveyor finds it?
 When you develop your ESC do you find a way to incorporate
it into daily activities and processes or do you lay it on top of
everything else staff have to do?
 Is the culture in your organization one that allows the
importance of the ESC to fade after a few months or is patient
safety and compliance embedded in your mission/vision?
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 Do you develop generic ESC or are your ESC specific to the
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Bottom Line!
If you don’t address the
issues the first time you will
be continually be doing
rework and patient safety and
quality suffer!
SOME THINGS TO CONSIDER…
 Do you have the right people at the table to address
the issues identified?
 Are you focusing on systems and processes and how
to improve them?
 Have you had an issue with this requirement on
previous surveys?
determine whether or not the ESC has been effective
over the long term?
 If you find that your ESC hasn’t worked how do you go
about fixing that?
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 What kind of follow up monitoring have you planned to
2014
THE HEALTHCARE ENVIRONMENT
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STANDARDS UPDATE
Risk
RISK ICON
•
•
•
•
Proximity to patient
Probability of harm
Severity of harm
Number of patients at risk
 Integrated into the Manuals, E-dition, AMP, & FSA Tool
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.
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 All products will display a single icon at the EP level
The Joint Commission EC chapter defines time as:
 Daily, weekly, monthly are calendar references
 Quarterly is once every three months +/- 10 days
effective January 1, 2014
 Semi-annual is 6 months from the last scheduled event
month +/- 20 days
 Annual is 12 months from the last scheduled event
month +/- 30 days
 3 years is 36 months from the last scheduled event
month +/- 45 days
NOTE 1: The above does not apply to required frequencies
NOTE 2: An alternative of developing either a unique, written policy or adopting
NFPA definitions when available is acceptable
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TIME RE-DEFINED
Quarterly: +/- 10 days
Semiannual: +/- 20 days
Annual: +/- 30 days
10
20
Scheduled
Month
Due
Date
+
10
10
20
20
30
30
Quarterly
Jan
Semiannual
June
Annual
Jan
Aug
Sept
March
Apr
Oct
Dec
Nov
F M A M J J A S O N
10
20
30
30
February
July
Scheduled
Month
+
D
Jan
Frequencies required by Code may not be modified
(e.g. EC.02.05.07 EP 4 & 7)
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Due
Date
Changes to Elements of Performance
Effective 7/1/2014
 Added: “Fire drills are held at unexpected
times and under varying conditions.”
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EC.02.03.03, EP 3
 When quarterly fire drills are required, at
least 50% are unannounced. Fire drills are
held at unexpected times and under
varying conditions.
Changes to Elements of Performance
Effective 7/1/2014
Staff who work in buildings where patients are housed
or treated participate in drills according to the
hospital’s fire response plan.
Note: When drills are conducted between 9:00 p.m.
and 6:00 a.m., the hospital may use alternative
methods to notify staff instead of activating audible
alarms.
Replaced: “…the buildings fire alarm system.”
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EC.02.03.03, EP 4
EC.02.02.01 EP 18
Effective July 2, 2014
 For hospitals that use Joint Commission for
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deemed status purposes: Radiation workers are
checked periodically, by use of exposure meters
or badge tests, for the amount of radiation
exposure
EC.02.02.01 EP 19
Effective July 2, 2014
 For hospitals that use Joint Commission for
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deemed status purposes: The hospital has
procedures for the proper routine storage and
prompt disposal of trash.
EC.02.03.03 EP 3
 When quarterly fire drills are required, at least
50% are unannounced. Fire drills are held at
unexpected times and under varying conditions.
 Added: “Fire drills are held at unexpected times
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and under varying conditions.”
EC.02.03.03 EP 4
Staff who work in buildings where patients are housed
or treated participate in drills according to the
hospital’s fire response plan.
Note: When drills are conducted between 9:00 p.m. and 6:00
a.m., the hospital may use alternative methods to notify staff
instead of activating audible alarms.
Replaced “building’s fire alarm system.”
 See NFPA 101-2000, 19.7.1.2 “…a coded
announcement shall be permitted to be used
instead of audible alarms.”
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
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CLINICAL ALARM SAFETY
Clinical Alarms – Brief History
 In 2004 there was a NPSG on clinical alarms
Goal retired, 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
 Healthcare Technology Safety Institute (HTSI)
 Plan, Do, Check, Act: Using Action Research to Manage Alarms,
Signals, and Responses

http://www.aami.org/htsi/safety_innovation.html
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
Clinical Alarms – Brief History
 Number 1 on ECRI top 10 for 2013 and 2014
 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 – Brief History
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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 PC.02.01.11: Resuscitation services are available
Clinical Alarms – Brief History
 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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
The Alarming Problem
 More and more devices and alarms
based devices
 150-400+ alarms per patient per day in a typical
critical care unit
 Alarm-based devices are not standardized in
many organizations
 Inconsistent use of alarms due to flexible alarm
setting features
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 More patients connected to alarms or alarm-
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NPSG on Alarm Mgmt
 In Phase I (beginning January 2014)


(by 7/14) establish alarms as an organization priority
(during 2014) identify the most important alarms to
manage based on their own internal situations.
 Input from medical staff and clinical depts
 Risk to patients due to lack of response,
malfunction
 Are specific alarms needed or contributing to
noise/fatigue
 Potential for patient harm based on internal
incident history
 Published best practices/guidelines
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Hospitals will be required to:
NPSG on Alarm Mgmt
 In Phase II (as of January 2016)


develop and implement specific components of
policies and procedures that address at minimum:
 Clinically appropriate settings
 When they can be disabled
 When parameters can be changed
 Who can set and who can change parameters and
who can set to “off”
 Monitoring and response expectations
 Checking individual alarm signals for accurate
settings, proper operation and detectability
educate those in the organization about alarm system
management for which they are responsible
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Hospitals will be expected to:
Questions to Consider
a priority?
 Who is on the team addressing the NPSG?
 How far along are you in identifying the
most important alarm signals to manage?
 What is your biggest challenge?
 Remember that the entire goal must be
fully implemented by January of 2016!
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 Have you identified clinical alarm safety as
What’s in a Name?
name, which indicates that technology that impacts patient care is
managed.
 CE: Clinical Engineer. 4 year Engineering degree with emphasis in
Clinical Engineering.
 BME: BioMedical Engineer: 4 year degree, typically working in
Research and Manufacturing for Healthcare
 BMET: BioMedical Equipment Technologist. Typically has a 2 or 4
year degree (or military equivalent), working directly in a
healthcare setting.
 CBET: Certified Biomedical Equipment Technician. A formal
certification by the International Certification Commission (ICC)
for the BMET who achieve this certification
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 HTM: Healthcare Technology Management is the department
EQUIPMENT MANAGEMENT
APPLIES ONLY TO
HOSPITAL & CRITICAL ACCESS HOSPITAL
PROGRAMS
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MEDICAL EQUIPMENT: EC.02.04.01, EC.02.04.03
UTILITY SYSTEMS: EC.02.05.01, EC.02.05.05
S&C 14-07-HOSPITAL
 S&C 12-07-Hospital Superceded
A hospital may adjust its maintenance, inspection, and
testing frequency and activities for facility and medical
equipment from what is recommended by the
manufacturer, based on a risk-based assessment by
qualified personnel, unless:
 Other Federal or state law; or hospital Conditions of
Participation (CoPs) require adherence to manufacturers’
recommendations and/or set specific requirements.
•
For example, all imaging/radiologic equipment must be
maintained per manufacturers’ recommendations; or
The equipment is a medical laser device; or
 New equipment without a sufficient amount of
maintenance history has been acquired.

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
S&C 14-07-HOSPITAL
 The organization inspects, tests & maintains New



Provided by the organization’s contractors
Available publically from nationally recognized
sources
Through the organization’s experience over time
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medical equipment or operating components of
utility systems in accordance with manufacturers’
recommendations with insufficient maintenance
history to support the use of alternative maintenance
strategies.
 Maintenance history may be gathered from
documented evidence such as
EC.02.04.01
Standard EC.02.04.01
The hospital manages medical equipment risks
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EC.02.04.01 EP 1
The hospital solicits input from individuals who operate
and service equipment when it selects and acquires
medical equipment.
For hospitals that do not use Joint Commission
accreditation for deemed status purposes: 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.
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EC.02.04.01 EP 2
EFFECTIVE JULY 2, 2014
MAINTAINING MEDICAL EQUIPMENT
 Inventory is populated based on one of two strategies:
 All equipment inclusion
 Physical risk based process
For example, evaluating:
• Function
• Risk Levels
• Maintenance Requirement
 Utilize resources, i.e. the FDA MAUDE report
 All life support equipment is included
 All new types of equipment evaluated for inclusion
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
EC.02.04.01 EP 2
CONTINUED
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For hospitals that use Joint Commission
accreditation for deemed status purposes:
The hospital maintains a written inventory of
all medical equipment.
INVENTORY DEFINITIONS
diagnosis, treatment, monitoring, and direct care of individuals.
 Life-support equipment—Any device used for the purpose of
sustaining life and whose failure to perform its primary function,
when used according to the manufacturer’s instructions and clinical
protocol, will lead to patient death in the absence of immediate
intervention (for example, ventilators, anesthesia machines, heartlung bypass machines, defibrillators).
 High-risk equipment—Any device or components of building utility
systems for which there is a risk of serious injury or death to a patient
or staff member if the device or component fails. High-risk equipment
includes life support equipment.
Source: Glossary from the Comprehensive Accreditation Manual for Hospitals,
The Joint Commission.
See also September 2014 Perspectives
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 Medical equipment—Fixed and portable equipment used for the
EC.02.04.01 EP 3
EFFECTIVE JULY 2, 2014
Note: High-risk medical equipment includes life-support
equipment
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The hospital identifies high-risk medical equipment
on the inventory for which there is a risk of serious
injury or death to a patient or staff member should
the equipment fail.
HIGH-RISK MEDICAL EQUIPMENT
 High-risk equipment
 Includes Life Support
Heart/lung bypass machine
 Anesthesia equipment
 Circulatory Assist Equipment
• IABP
• LVAD
 Ventilations
• Adult; Infant; MRI-Compatible
 Other High-risk equipment
 Defibrillators
 Robotic surgery devices
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
JOINT COMMISSION
MEDICAL EQUIPMENT
 Medical equipment includes equipment
used in for monitoring, such as
 Bedside monitors
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 Telemetry monitors
JOINT COMMISSION
MEDICAL EQUIPMENT

Electro-surgery

Lasers

Diathermy
 Diagnostic, such as

Laboratory analyzers

Radiology equipment

Endoscopes
Taken from the
Environment of
Care Handbook
Chapter 5 (page 73) 3rd
edition
 Patient support, such as

Patient beds

Specialty beds

Lifts
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 Treatment, such as
CMS INVENTORY
 Biomedical equipment
 Radiological equipment
 Patient beds, stretchers
 IV infusion equipment
 Ventilators
 Laboratory equipment
 Etc.
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 Medical Equipment includes
SCOPES
 Number 6 on ECRI Top 10 for 2014, #8 in 2013
result in follow-up survey under COP §482.42
 IC.02.02.02 EP 1 &2 hi/lo level disinfection
 IC.01.03.01 EP 1 – 5 risk assess & surveillance
 IC.01.05.01 EP 1 for policy issues
 Score at EC.02.05.01 EP 6 for ventilation issues,
will result in follow-up survey under COP §482.42
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 Score at IC. For infection control issues, and will
EC.02.04.01 EP 4
Note: The strategies of an AEM program must not reduce the safety of
equipment and must be based on accepted standards of practice.
An example of standards for a medical equipment program is ANSI/AAMI
EQ56:2013, Recommended Practice for a Medical Equipment Management
Program
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The hospital identifies the activities and associated
frequencies, in writing, for maintenance, inspecting, and
testing all medical equipment on the inventory. These
activities and associated frequencies are in accordance with
manufacturers’ recommendations or with strategies of an
alternative equipment maintenance (AEM) program.
EC.02.04.01 EP 5

Equipment subject to federal or state law or Medicare
Conditions of Participation in which inspecting, testing,
and maintaining be in accordance with manufacturers’
recommendations, or otherwise establishes more
stringent maintenance requirements
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For hospitals that use Joint Commission for deemed
status purposes: The hospital’s activities and
frequencies for inspecting, testing, and maintaining
the following items must be in accordance with
manufacturers’ recommendations
EC.02.04.01 EP 5
CONTINUED
Medical laser devices
 Imaging and radiologic equipment (whether used for
diagnostic or therapeutic purposes)
 New medical equipment with insufficient maintenance
history to support the use of alternative maintenance
strategies
Note: Maintenance history includes any of the following documented
evidence:
 Records provided by the hospital’s contractors
 Information made public by nationally recognized sources
 Records of the hospital’s experience over time
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
EC.02.04.01 EP 6
For hospitals that use Joint Commission for deemed
status purposes: A qualified individual(s) uses written
criteria to support the determination whether it is
safe to permit medical equipment to be maintained in
an alternative manner that includes the following:
and prevalence of harm during normal use
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 How the equipment is used, including the seriousness
EC.02.04.01 EP 6
CONTINUED
 Likely consequences of failure or malfunction,
(For more information on defining staff qualifications,
refer to Standard HR.01.02.01)
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including seriousness of and prevalence of harm
 Availability of alternative or back-up equipment in the
event the equipment fails or malfunctions
 Incident history of identical or similar equipment
 Maintenance requirements of the equipment
EC.02.04.01 EP 7
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For hospitals that use Joint Commission for
deemed status purposes: The hospital
identifies medical equipment on its inventory
that is included in an alternative equipment
maintenance program.
EC.02.04.03
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Standard EC.02.04.03
The hospital inspects, tests, and maintains medical
equipment
MEDICAL EQUIPMENT TESTING
 EC.02.04.03 The hospital inspects, tests, and
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maintains medical equipment
 EP 1: For hospitals that do not use Joint
Commission accreditation for deemed status
purposes: Before initial use of medical
equipment on the inventory the organization
performs safety, operational, and functional
checks.
MEDICAL EQUIPMENT TESTING
 EP 1 (continued): For hospitals that use Joint
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Commission accreditation for deemed status
purposes: Before initial use and after major
repairs or upgrades of medical equipment on
the medical equipment inventory, the hospital
performs safety, operational, and functional
checks.
MEDICAL EQUIPMENT TESTING
 EC.02.04.03 The hospital inspects, tests, and
maintains medical equipment
 EP 2. The hospital inspects, tests, and
maintains all life support high-risk equipment.
These activities are documented.
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Note: High-risk medical equipment includes life support
equipment
MEDICAL EQUIPMENT TESTING
EP 4: The hospital conducts performance testing
of and maintains all sterilizers. These activities
are documented.
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EP 3: The hospital inspects, tests, and maintains
non-life support non-high-risk equipment
identified on the medical equipment inventory.
These activities are documented.
MEDICAL EQUIPMENT TESTING
EP 14: For hospitals that use Joint Commission
accreditation for deemed status purposes:
Qualified hospital staff inspect, test, and
calibrate nuclear medicine equipment annually.
The dates of these activities are documented.
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EP 5: The hospital performs equipment
maintenance and chemical and biological testing
of water used in hemodialysis. These activities
are documented.
MEDICAL EQUIPMENT TESTING
EP 17: For hospitals in California that provide
computed tomography (CT) services: A qualified
medical physicist measures actual radiation dose
produced by each CT imaging system at least
annually.
abdomen, and pediatric brain protocols is within
20 percent of actual dose delivered.
 Dates of the verifications are documented
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 Verifies dose displayed for adult brain, adult
Documentation is completed for High-risk, life support
and non-high-risk devices on the inventory
 Accuracy of Inventory
 All High-risk and Life Support equipment must be on
the inventory and identified
 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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EQUIPMENT SURVEY PROCESS
SURVEY PROCESS: STAFF INTERVIEWS
 Department Leader
 Evaluate the qualifications of the leader
Review appropriate documentation
 Evaluate how the inventory was created
 If an alternative maintenance program is in use,
evaluate the inclusion process
 Evaluate the Monitoring processes
 Evaluate the effectiveness of the program
 What criteria is used to evaluate
 Evaluate the Completion rate of maintenance
activities
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
SURVEY PROCESS: STAFF INTERVIEWS
 Equipment Maintainers
of the
maintenance process/strategies
 Evaluate staff knowledge related to the
alternative maintenance program
 Evaluate assignment of maintenance activities
 Evaluate competencies based on repeat work
orders
 Evaluate work scheduled against completed
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 Evaluate their understanding
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SURVEY PROCESS: STAFF INTERVIEW
 Contract Services
 Evaluate the process used to ensure contractors use
qualified personnel
 Evaluate reliability of equipment serviced
 Evaluate integration of the process
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 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
EVALUATING PROGRAM EFFECTIVENESS
policies & procedures
 Evaluating the program:
 How is equipment evaluated to ensure no degradation
of performance?
 Consider miscalibration of equipment
 Consider test equipment calibration confirmation
 How are equipment-related incidents investigated?
 Could the malfunction have been avoided?
 Did the alternative maintenance strategy contribute
to the malfunction?
 How to sequester equipment deemed unsafe?
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 The equipment management programs must have written
EVALUATING PROGRAM EFFECTIVENESS
modifications to the maintenance strategy are
needed?
 Evaluate the accuracy of the inventory
 High-risk equipment segregated in the inventory?
 Equipment in an alternative maintenance program
segregated?
 Grouping of like equipment is acceptable
 Are imaging/radiologic equipment and medical
laser devices exempt from the alternative
maintenance program?
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 Is there a performance process to evaluate if
EVALUATING PROGRAM EFFECTIVENESS:
MISCELLANEOUS TOPICS
 Survey should focus on High-risk equipment
maintenance schedules available?
 Verify the inspection, testing & maintaining
activities and frequencies are documented
 Evaluate the various maintenance strategies used
 Are they appropriate?
 Are they effective?
 Is the equipment reliable?
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 Are appropriate operation manuals and
EQUIPMENT NOT FOUND OR IN USE
 If a device is not available because it is not found or in use


Create policy describing how the device will be
looked for
• How will the users be involved
• How it impact the users
If the device was looked for “on time” then the PM
Completion rate will not be impacted
• The device must be reconciled
• Surveyors will be reviewing those “equipment not
found” or “in use” for reconciliation
−
Example: during the next month if 500 scheduled, 10 not
found the total activities should be 510
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 Manage the situation
EQUIPMENT NOT FOUND OR IN USE
 If the device was looked for “on time” then the PM
Completion rate will not be impacted
 The device must be reconciled
 Surveyors will be reviewing those “equipment
not found” or “in use” for reconciliation
• Example:
Each month 500 activities are scheduled
− One month 10 devices are “not available”
− Next month the 500 scheduled devices will be
done plus the missed 10 devices
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−
DIAGNOSTIC IMAGING
 Three phases of implementation for hospitals, critical
access hospitals, and ambulatory care organizations
Includes ambulatory care organizations that have achieved
Advanced Diagnostic Imaging certification
 Phase 1 Deferred to January 1, 2015

Exceptions: not applicable to dental cone beam CT radiographic
imaging studies performed for diagnosis of conditions affecting
the maxillofacial region or to obtain guidance for the treatment
of such conditions.
Phase 1.5: minimum qualifications for radiologists
performing CT scans
 Phase 2: fluoroscopy qualifications for non-radiologists
performing imaging exams and cone beam CT, and for dental
or oral surgical procedures

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
 Phase 1: Deferred to January 1, 2015
 Computed tomography (CT), nuclear medicine (NM),
positron emission tomography (PET), and magnetic
resonance imaging (MRI)
 Minimum competency for radiology technologists,
including registration and certification by July 1, 2015
 Annual performance evaluations of imaging equipment
by a medical physicist
 Documentation of CT radiation dose in the patient’s
clinical record
 Meeting the needs of the pediatric population through
imaging protocols and by considering patient size or
body habitus when establishing imaging protocols
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DIAGNOSTIC IMAGING
 Phase 1: Deferred to January 1, 2015
 Management of safety risks in the MRI environment
 Collection of data on incidents during which identified
radiation dose limits have been exceeded
 Minimum quarterly review of staff dosimetry results
 New, replacement or modification to rooms
 Medical physicist to perform structural shielding
design
 New equipment or rooms where ionizing radiation is
emitted or radioactive material is stored
 Medical physicist to perform radiation protection
survey
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DIAGNOSTIC IMAGING
DIAGNOSTIC IMAGING STANDARDS COMMENTS
OPEN TO OCTOBER 24, 2014
 We are interested in your comments on standards changes
http://www.jointcommission.org/standards_information/field_reviews.aspx?Stan
dardsFieldReviewId=C9K2vcyLB3mFHMTk7hiBm7aLRzbz3AxdZHBivEICNzc%3d
for more information
Department of Engineering 2014 - 74
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that address the following areas:
 Minimum qualifications for radiologic and nuclear
medicine technologists that perform computed
tomography (CT) exams.
 Orientation of technologists on safe practices related to
the provision of diagnostic imaging
 Documentation of CT radiation dose
RELOCATABLE POWER TAPS (RPTS)
70, NFPA 99 and NFPA 101 all have regulations that control
the electrical components and equipment in a patient room.
It appears that it is the intent of these documents to restrict
RPT use so that it is not used in conjunction with medical
equipment
 CMS 3/2014:
 “RPT’s are not to be used with medical equipment in
patient care areas.
 This includes critical areas such as operating rooms,
recovery areas, intensive care areas, and non-critical
patient care areas such as patient rooms, diagnostic
areas, exam areas, etc.”
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 Healthcare Interpretation Task Force (12/2007) stated NFPA
RELOCATABLE POWER TAPS
equipment assembly. See NFPA 99-1999 7-5.1.2.5(2)
 Ceiling drops are acceptable. See NFPA 99-1999 7-5.1.2.5(3)
 RPTs may be used for non-patient care equipment such as
computers/monitors/printers, and in areas such as waiting rooms,
offices, nurse stations, support areas, corridors, etc.
 Precautions needed if RPT’s are used include:
 ensuring they are never “daisy-chained”
 preventing cords from becoming tripping hazards
 installing internal ground fault and over-current protection
devices
 using power strips that are adequate for the number and types
of devices used
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 RPTs may be used in anesthetizing locations if they are part of the
 CMS is permitting a categorical waiver to allow for
the use of power strips in existing and new health
care facility patient care areas, if you are in
compliance with all applicable 2012 LSC power strip
requirements and with all other 2000 LSC electrical
system and equipment provisions.
 The organization must follow all requirements of the
categorical waiver process
 This includes identifying where they are located
at the unit level
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S&C: 14-46-LSC 9/26/2014
If the organization decides to use this categorical waiver they
must
1. Ensure full compliance with the appropriate code
reference
2. Document the decision to adopt the categorical waiver
 The Relocatable Power Tap is not a LSC issue but an
Environment of Care issue
• For Environment of Care items document by Minutes
in discussion at the Environment of Care Committee
(or equivalent)
3. Declare the decision at the beginning of any survey
See also November 2013 Perspectives
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CATEGORICAL WAIVER PROCESS
DEFINITIONS FROM NFPA 99-2012
patient sleeping bed, or the bed or procedure table of a critical care
area.
 Patient-care-related electrical equipment is defined in section 3.3.137
as electrical equipment that is intended to be used for diagnostic,
therapeutic, or monitoring purposes in the patient care vicinity;
 Patient care room is defined in section 3.3.138 as any room of a health
care facility wherein patients are intended to be examined or treated.
Note that this term replaces the term “patient care area” used in the
1999 NFPA 99, but the definition has not changed.
 Patient care vicinity is defined in section 3.3.139 as a space, within a
location intended for the examination and treatment of patients (i.e.,
patient care room) extending 6 ft. beyond the normal location of the
bed, chair, table, treadmill, or other device that supports the patient
during examination and treatment and extends vertically 7 ft. 6 in.
above the floor.
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 Patient bed location is defined in section 3.3.136 as the location of a
REQUIREMENTS
 Power strips may be used in a patient care vicinity to power rack-, table-,





The receptacles are permanently attached to the equipment assembly.
The sum of the ampacity of all appliances connected to the receptacles
shall not exceed 75 percent of the ampacity of the flexible cord supplying
the receptacles.
The ampacity of the flexible cord is suitable in accordance with the
current edition of NFPA 70, National Electric Code.
The electrical and mechanical integrity of the assembly is regularly verified
and documented through an ongoing maintenance program.
Means are employed to ensure that additional devices or nonmedical
equipment cannot be connected to the multiple outlet extension cord
after leakage currents have been verified as safe.
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pedestal-or cart-mounted patient care-related electrical equipment
assemblies, provided all of the following conditions are met, as required
by section 10.2.3.6:
REQUIREMENTS
existing facilities that undergo renovation or a change in
occupancy, shall be provided with the minimum number of
receptacles as required by section 6.3.2.2.6.2.
 Power strips providing power to rack-, table-, pedestal-, or
cart-mounted patient care-related electrical equipment
assemblies are not required to be an integral component of
manufacturer tested equipment. Power strips may be
permanently attached to mounted equipment assemblies by
personnel who are qualified to ensure compliance with
section 10.2.3.6.
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 Patient bed locations in new health care facilities, or in
REQUIREMENTS
power non-patient care-related electrical equipment (e.g.,
personal electronics).
 Power strips may be used outside of the patient care vicinity
for both patient care-related electrical equipment & nonpatient-care-related electrical equipment.
 Power strips providing power to patient care-related
electrical equipment must be Special-Purpose Relocatable
Power Taps (SPRPT) listed as UL 1363A or UL 60601-1.
 Power strips providing power to non- patient-care-related
electrical equipment must be Relocatable Power Taps (RPT)
listed as UL 1363.
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 Power strips may not be used in a patient care vicinity to
DEPARTMENT OF ENGINEERING
630 792 5900
George Mills, MBA, FASHE, CEM, CHFM, CHSP, Green Belt
Director
Anne Guglielmo, CFPS, LEED, A.P., CHSP, CHFM
Engineer
John Maurer, SASHE, CHFM, CHSP
Kathy Tolomeo,
CHEM
Engineer
James Woodson, P.E., CHFM
Engineer
Department of Engineering 2014 - 83
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Engineer
THE JOINT COMMISSION DISCLAIMER
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.
Department of Engineering 2014 - 84
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 These slides are current as of 10/1/2014. The Joint