Best Practices and Programs:
Getting “Survey Ready” in 2014
HFMADV Annual Conference
Radisson Hotel - Philadelphia, Pennsylvania
October 7, 2014
Best Practices
and Programs
Presented by: Gary D. Slack, PE, CCE
Healthcare Engineering Consultants
The Survey Process
Typical Survey Activities 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
Surveyor; 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)
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The Survey Process
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 Surveyor - minimum of two days for any
hospital survey; >1.5 million square feet – 3 days;
additional day for every three healthcare buildings!
- Environment of Care
- Life Safety
- Emergency Management
 CEO Exit Briefing (15 minutes)
 Organization Exit Conference (30 minutes)
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Accreditation Categories
 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
 Contingent Accreditation: follow-up survey within 30
days (replaces conditional accreditation)
 Preliminary Denial of Accreditation: immediate
threat or failure to resolve requirements
 Denial of Accreditation: Organization denied
accreditation; appeals exhausted
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The Unannounced Survey Timeline
Unannounced Surveys will Occur:
 Between 18 and 36 months from the date of the
previous unannounced survey
Note: The chance of a survey is not equally distributed
from 18 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,
sentinel events and other factors
 Very high probability surveys will occur between the
33 and 36 month anniversary date, but some surveys
are scheduled earlier than expected!
 Prior to the survey (usually 6 weeks to 3 months), a
discussion with the JC liaison to review the surveyor
team members and agenda will occur
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The Unannounced Survey Surprise
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!
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Survey Scoring
Understanding Survey
Scoring Decisions
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Scoring Decisions
 Some scoring changes in the in the EC, EM and LS
chapters have occurred for 2014; also, remember the
inclusion of the identified risk (R) icon
 “A” and “C” scores remain (changes to “C” scores)
 Four levels of scoring risk exist (surveyor discretion on 1):
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
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Explanation of Scoring Levels
Immediate Threat to Health and Safety
1. Immediate Preliminary Denial of Accreditation
2. Action expected during survey
3. After PDA official notification, 72 hours to eliminate the threat;
23 day maximum time with abatement measures
4. Follow-up abatement survey conducted
5. Upon resolution, status changes to Conditional Accreditation
based on follow-up survey
6. Triggered by unaddressed issues with:
- Fire alarm or extinguishing system
- Emergency power system
- Medical gas master panel
- Serious Life Safety deficiencies
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Explanation of Scoring Levels
Examples of “Immediate Threat” Finding
Life Safety

Blocked or locked exit

Potential for serious injury or death to patients, staff or
visitors

Serious construction safety deficiencies
Fire detection or extinguishing system

Fire system disconnected without interim measures

Fire system not functioning properly without ILSM

Fire pump “out of service” without alternate pump

Fire alarm signal not connected or not functioning
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Explanation of Scoring Levels
Examples of “Immediate Threat” Finding
Emergency Power System

Generators unreliable or not repaired without
implementing “interim utility system measures” (IUSM)

One or more generators “out of service” without an
alternate generator connected

Aware of contaminated fuel that may not power the
generators, but no action taken
Medical Gas and Vacuum System

Unresolved leaks in the liquid oxygen system

Non-functioning master or area alarms without IUSM

Serious particulate or algae growth in the medical air
system

Uncorrected deficiencies without IUSM
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Explanation of Scoring Levels
“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. Only two scored “Situation Decision” items in
the Physical Environment:
- Failure to evaluate, implement or document interim
life safety measures
- Failure to meet PFI timelines on SOC after grace
period
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Explanation of Scoring Levels
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 address safety risks
- Improper disposal of hazardous medications
- Insufficient PM on life support equipment
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Explanation of Scoring Levels
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
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Joint Commission Scoring Decisions
“EC”, “EM” and “LS” Scoring Categories
Performance
Category
Immediate Threat
Number
Situation Decision
2
Direct Impact
66
Indirect Impact
311
0
Note: Some changes in scoring categories occurred
effective July 2, 2014
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Joint Commission Standards Scoring
Safety and Security Scoring Sheet
“A” Scores: One and
done!
“C” Scores: Three
strikes and you’re out!
“R” Icon: An identified
risk for the Focused
Standards
Assessment (FSA)
“D” Icon:
Documentation
required
EC
Standard
02.01.01
1
3
5
7
8
9
10
11
02.01.03
1
4
6
Element of Performance
Safety and Security Risks
Risk identification
Minimize identified risks
Grounds and equipment
Identification procedure
Security sensitive access
Infant abduction procedures
Security incident procedures
Product recall procedures
Smoking Policy
Policy in buildings
Patient exceptions to policy
Compliance to policy
Scoring Documents
Category and Risk?
A
C
C
C
A
A
A
C
A
A
C
R
R
D
D
Score
Rule
4
3
4
4
3
4
3
4
4
4
4
Score Rule: “2” – Situation Decision
“3” – Direct Impact
“4” – Indirect Impact
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Explanation of New Scoring
Effective on July 1, 2014
1. “C”-scored items are no longer “three strikes
and you’re out!”
2. A single identified deficiency will now be scored
as an “OFI” – “opportunity for improvement”,
and will be listed on the final report
3. A second identified deficiency will be listed on
the report as a “RFI” – “requirement for
improvement” and will require corrective
action through an “ESC” – evidence of
standards compliance
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Joint Commission Scoring Decisions
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, +/- 10
days from the previous test month (change for
2014!)
 Monthly: within the calendar month
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Joint Commission Scoring Decisions
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, if they are in the
regulatory requirements
Note: These will be default test interval expectations unless
the organization defines other acceptable intervals in a
policy that is approved by the safety committee
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Challenging Physical Environment
Standards
What have been the most challenging
recent “PE” standards for hospitals?
 EC.02.05.01, EP6 (53%) – ventilation, pressure
relationships
 LS.02.01.20, EP13 (52%) – means of egress
 EC.02.06.01, EP13 (51%) – unsecured cylinders,
temperature and humidity
 EC.02.03.05, EP1-20 (50%) – fire device testing
 LS.02.01.10, EP5,6,7,9 (49%) – compartmentation
 LS.02.01.30, EP 16-23 (46%) – hardware, hazardous areas
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Challenging Physical Environment
Standards
What have been the most challenging recent
“PE” standards for hospitals? (cont’d)
 LS.02.01.35, EP4, 5, 14 (44%) – sprinkler
piping and heads
 EC.02.02.01, EP3-5 (36%) - PPE, eyewashes,
hot lab security
 EC.02.05.09, EP3 – medical gas systems
 EC.02.05.07, EP6 – emergency power
Note: 90% of the “Top 10” citations are “PE-related for
hospitals!
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The Top Recent Sentinel Events
Description
Number
Wrong patient, site or procedure
Unintended object retention
Delay in treatment
Patient Falls
60
56
56
48
Unanticipated events
Operative/ Post-op complication
Suicide
40
37
35
Assault/ rape/ homicide
26
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The Top Health Technology Hazards
Alarm hazards
Medication errors from infusion pumps
CT radiation burns in pediatric patients
Patient/ data mismatches in EHR
Radiation hazards in hybrid OR’s
Inadequate reprocessing of endoscopes
and surgical instruments
Problems with changes to inter-related
networked devices
Pediatric risk due to adult technologies
Insufficient training for robotics
Retained devices/ unretrieved fragments
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Priority Focus Areas
1.
Assessment and Care/ Services
2.
Communication
3.
Credentialed Practitioners
4.
Equipment Use
5.
Infection Control
6.
Information Management
7.
Medication Management
8.
Organizational Structure
9.
Orientation and Training
10. Patient Safety
11. Physical Environment
12. Quality Improvement Expertise/ Activities
13. Rights and Ethics
14. Staffing
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Possible ISO Option
As a response to DNV, the Joint Commission may
be unveiling a new “ISO Certification Option”
In the 2014 Hospital Accreditation manual, it
states:
“The Joint commission continues to evaluate the
integration of an ISO Certification Option in its
accreditation process. At the publication deadline
for this manual, no decision has been made. As
soon as information becomes available, the field
will be notified through official Joint Commission
communication channels (for example, manual
updates, Perspectives and JCOnline)”
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Changes for the LSS in 2014
Life Safety Surveyor Responsibilities
With the “on-site” time that the Life Safety
Surveyor will have scheduled (2-days minimum),
it is likely to result in:
 Additional facility tour time, including visits to
the OR and Central Sterile Supply areas
 Additional documentation review, especially on
fire systems, emergency power and medical gas
and vacuum
 Conducting the Physical Environment Interview
 Conducting the Emergency Management
Interview
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Changes for the LSS in 2014
Life Safety Surveyor Responsibilities (cont’d)
With the hiring of Jim Kendig, the new Field Manager for the
Life Safety Surveyors, additional changes will include:
 A standardized agenda to require the documentation
review first, followed by the facility tour
 Additional focus on other areas, such as OSHA and DOT
 Some leniency in fixing problems found during the survey
 Pressure tests (tissue) in the OR, CSR and Endo
 Additional focus on falls reduction
 New LSS hires will have “broader” credentials
 Surveyors will have access to older codes to verify
“grandfathering” of HVAC and pressure relationship issues
 Jim does not report to George Mills!
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“PE”-Related Patient Safety Goals
Ambulatory, Behavioral Health and Hospital Facilities
Goal #6: Reduce harm associated with Clinical Alarm Systems
Goal #7: Reduce the risk of health care associated infections
Goal #9: Reduce the risk of patient harm resulting from falls
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)
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Critical Clinical Alarms
Patient Safety Goal #6: NPSG.06.01.01
 Phase I:
- Effective January 1, 2014
- Establish alarms as an organizational priority
- Identify the critical alarms to manage (issue: alarm fatigue)
 Phase II:
- Effective January 1, 2016
- Develop applicable alarm policies and procedures
- Implement components of procedures
- Provide alarm system management education
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New Changes for Emergency Management
 Effective January 1, 2014
 Appointment of an individual who has specific emergency
management accountability for MPRR and the six critical
areas; implementation and collaboration across clinical and
operational areas, and identification and planning with
community response partners (LD.04.01.05)
 Effectiveness of emergency management program
planning reviewed by senior leadership (EM.03.01.01)
 Drill monitoring includes LIP’s as well as staff affected by
the drill or actual event; review of drill by leadership
(EM.03.01.03)
 Leadership establishes priorities for improvement in the
emergency management program (LD.04.04.01)
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Compressed Gas Cylinders
Compressed Gas Cylinder Storage
 EMPTY and FULL cylinders must be physically separated
 Segregated = physically separated with separate racks,
physical barriers or color codes to indicate FULL and EMPTY
 Unopened cylinder = FULL; Opened cylinder = EMPTY
 Don’t store partially filled cylinders with FULL cylinders
 Noncompliance cited under EC.02.06.01, EP1
 Solutions?
Reference: EC News, February 2014 issue, pages 5-6
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Medical Equipment Management
Issue: New Power Strip Requirements
Expectations include:
- Effective immediately per CMS and Joint Commission
- Not permitted for medical devices (diagnostic, therapeutic and
clinical analytical) in patient care areas
- Patient care areas include “areas in which patients are intended to
be examined or treated”
- May permit RPT’s on consolidated equipment on a rack in
anesthetizing locations (reference: NFPA 99, 1999 edition, section
7-5.1.2.5, exception 2
- NFPA 99, 2012 edition permits mounting on a movable rack, table,
cart or pedestal in any patient care area (reference: section 10.2.3.6)
(“regular” electrical and mechanical verification is required)
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CMS Medical Equipment Guidance
Issue: Changes in Medical Equipment Maintenance
Requirements, effective December 20, 2013
Description: Permits a facility to adjust
maintenance testing procedures and intervals
from manufacturer recommendations if a
documented risk assessment is utilized, unless:
1.
Other Federal or State laws require manufacturer
recommendations
2.
The equipment is a medical laser, imaging or radiologic
device
3.
New equipment does not have sufficient maintenance
history
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Medical Equipment Management
Issue: Changes in the Medical Equipment
Standards Effective July 2, 2014
What’s New?
 Whether manufacturer recommendations are followed
(EC.02.04.01, EP5)
 Criteria that is used for the Alternate Equipment
Management (AEM) program (EC.02.04.01, EP6)
 An inventory list of devices in the AEM program
(EC.02.04.01, EP7)
 Inventory classifications now termed “high risk” and
“non-high risk” (EC.02.04.03, EP2, 3)
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Medical Equipment Management
Issue: Changes in the Medical Equipment
Standards Effective July 2, 2014
What’s the Impact of the Changes?
 All medical equipment must now be included in the
biomed inventory (Note: “Fixed and portable equipment
used for the diagnosis, treatment, monitoring, and direct
care of individuals”) - EC.02.04.01, EP2
 Test procedures and PM intervals must be defined for
all items on the inventory - EC.02.04.01, EP4
 All “high risk” devices must now have an on-time PM
completion rate of 100%! – EC.02.04.03, EP2
Reference: EC News, September, 2014 issue
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Medical Equipment Management
Other Important Definitions:
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 leas to patient death in the absence of
immediate intervention”
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”
Joint Commission “High Risk” = CMS “Critical” Equipment
Reference: EC News, September, 2014 issue
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Medical Equipment Management
An AEM Notebook is recommended that
includes the following sections:
1. A copy of the medical equipment management plan
that includes a description of the AEM program
2. An inventory of the devices included in the AEM
program
3. A copy of the process used to determine that a
device does not have to meet the recommended test
procedure or PM interval from the manufacturer
4. A list of staff who are qualified to determine which
devices may be included in the AEM program
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Medical Equipment Management
Issue: Expectations for Clinical Engineering
Departments from the Joint Commission
Expectations include:
How the inventory was created and maintenance
strategies are devised
-
- How the PM and program effectiveness is measured
- How well biomed staff understand the maintenance
process
- How the work schedule and repeat repairs are
managed
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Medical Equipment Management
Issue: Expectations for Clinical Engineering
Departments from the Joint Commission
Expectations include:
- How equipment reliability is determined
- How “customers” rate response time to work order calls
- Training for equipment users and maintainers
- Monitoring of contract services
- Clinical alarm audibility and “alarm fatigue”
- Whether an AEM program exists and how it is managed
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Utility Systems Management
Issue: Impact of the AAMI ST-79 Standard,
3.3 and the ASHRAE Standard 170
Section
What’s expected?
1. Central sterile supply areas must:
- Include physically separated clean and dirty work areas
- Adequate work space is required
- Clean and dirty sides must include sinks
- Surveyor will perform a “tissue test” at the pass-through
2. Endoscopy must have a specific room for equipment cleaning that
is properly sized, has a sink, negative air pressure in reprocessing,
10 total and 2 outside air changes, clean/ dirty separation and scope
storage areas
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Utility Systems Management
Issue: Changes to the Utility Management
Standards, effective July 2, 2014
What’s New?
 Whether manufacturer recommendations are followed
(EC.02.05.01, EP5)
 Criteria that is used for the Alternate Equipment
Management (AEM) program (EC.02.05.01, EP6)
 An inventory list of utility equipment in the AEM program
(EC.02.05.01, EP7)
 Inventory classifications now termed “high risk”,
“infection control” and “non-high risk” (EC.02.05.03,
EP3, 4, 5)
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Utility Systems Management
Issue: Changes to the Utility Management
Standards, effective July 2, 2014
What’s New?
 All utility systems must now be included in the
inventory (EC.02.05.01, EP2)
Utility Systems Definition: “Building systems that provide
support to the environment of care, including electrical
distribution and emergency power; vertical and
horizontal transport; heating, ventilating and air
conditioning (HVAC); plumbing, boiler and steam;
refrigeration; piped gases; vacuum systems; fire alarm
and suppression systems, and; communication
systems, including data exchange systems”
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Utility Systems Management
Issue: Changes to the Utility Management
Standards, effective July 2, 2014
What’s New?
 Test procedures and PM intervals must be defined for
all items on the inventory - EC.02.05.01, EP4
 All “high risk” devices must now have an on-time PM
completion rate of 100%! – EC.02.05.05, EP3
Reference: EC News, September, 2014 issue
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Healthcare Facilities
Issue: Publication of NFPA 101, the
edition
New?

2012
What’s
Effective date of NFPA 101, the 2012 edition, was August 31, 2011
 Wheeled equipment is now permitted in the corridor (Section
19.2.3.4) if:
1. The equipment does not reduce the clear width to less than 5 feet
2. Staff are trained to move the wheeled equipment during an
emergency
3. The equipment is limited to carts “in use” (no time limit), emergency
equipment and patient lifts and transport equipment
Impact: Additional flexibility if CMS or the Joint Commission adopts the 2012
edition of NFPA 101 (JC will accept CMS “Categorical Waivers”)
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Healthcare Facilities
Issue: Publication of NFPA 101, the
edition
New?
2012
What’s
Fixed furniture is permitted in the corridor if:
1. The clear corridor width is no less than 6 feet
2. The furniture is securely attached to the floor or wall and on one side
only
3. Smoke detection is installed and the smoke compartment is fully
sprinkled
Impact: Additional flexibility if CMS or the Joint Commission adopts the 2012
edition of NFPA 101 (JC will accept CMS “Categorical Waivers”)
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Healthcare Facilities
Issue: Publication of NFPA 101, the
2012 edition
What’s New?
Other significant changes in the 2012 edition include:
 Clarification for business or ambulatory occupancies that are
contiguous to healthcare facilities
 Revisions to egress requirements for sleeping and non-sleeping
suites
 Relaxed requirements for cooking facilities that are used for food
warming or limited cooking, such as in obstetrics, long-term care or
hospice areas
 Changes to alcohol-based hand dispensers to permit 1-inch
clearance to electrical receptacle or switch (automatically accepted by
JC now!)
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Healthcare Facilities
Issue: Publication of NFPA 101, the
2012 edition
What’s New?
Other significant changes in the 2012 edition include:
Fewer restrictions for the use of direct vent and solid fuel burning
fireplaces
 Exceptions permitting the use of some combustible decorations
 Exceptions to the 32 gallon requirement for containers used for
recycling clean waste and patient records awaiting shredding (96
gallons permitted)
Impact: Additional flexibility if CMS or the Joint Commission adopts the
2012 edition of NFPA 101(JC will accept CMS “Categorical Waivers”)
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Healthcare Facilities
Issue: Publication of NFPA 99, the
2012 edition
What’s New?

NFPA 99 is now a Code rather than a Standard
 The 2012 edition is a “risk-based” document, based on patient risk,
which now includes categories 1 through 4 (category 1 is highest risk)
 Occupancy chapters have been eliminated
 Changes in test requirements for medical gas and vacuum systems
have been adopted (refer to section 5.1.12 and Table B.5.1)
 Operating rooms are considered “wet locations” unless a risk
assessment is performed by the governing body (section 6.3.2.2.8.4)
 RPT’s would be permitted if they are permanently attached to
movable racks, pedestals, tables or carts and are regularly tested
(section 10.2.3.6)
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Healthcare Facilities
Issue: Publication of NFPA 99, the
edition
New?
2012
What’s
Medical equipment leakage tests have been reduced and incoming
equipment tests for non-patient care-related equipment now only require
visual inspections! (section 10.4.2.1)
 New chapters cover information technology, plumbing, HVAC,
security management and features of fire protection
Impact: Significant changes for electrical and medical gas and vacuum
systems if CMS or the Joint Commission adopts the 2012 edition of
NFPA 99
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Healthcare Facilities
Issue: CMS Adoption of NFPA 101 and
99, the 2012 editions
NFPA
What’s New? – Proposed changes!
 Revised definition of “healthcare” in NFPA 101 to include a single
patient who is rendered incapable of self-preservation, rather than four
or more
 Elimination of the emergency management chapter in NFPA 99, due
to new CMS emergency management proposals (2017?)
 Other possible changes
 Proposal period closed - were due by June, 2014
 Possible adoption date?
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CMS “Categorical Waivers”
Issue: Relative humidity in anesthetizing
locations
Description: Reduces the requirement for
relative humidity in anesthetizing locations
from 35% to 20%
Code Reference: Addendum D of ASHRAE
170
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CMS “Categorical Waivers”
Issue: Medical gas master alarms
Description: Allows a centralized computer
system to be used for one of the two
required Category 1 medical gas master
alarms
Code Reference: NFPA 99, 2012 edition,
section 5.1.9.2.2
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CMS “Categorical Waivers”
Issue: Openings in exit enclosures
Description: Permits existing openings in
exit enclosures to mechanical equipment
spaces if they are protected by fire-rated
door assemblies, the area is fully sprinkled
and there are no combustibles stored
Code Reference: NFPA 101, 2012 edition,
section 7.1.3.2.1(9)(c)
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CMS “Categorical Waivers”
Issue: Emergency generator annual load
test
Description: Reduces the load test (when
required) from 2 to 1.5 hours, and requires
the load to be 50% @ 30 minutes and 75%
@ 60 minutes
Code Reference: NFPA 110, 2010 edition,
section 8.4.2.3
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CMS “Categorical Waivers”
Issue: Door locking arrangements
Description: Allows door locking exceptions
in areas where there are clinical needs,
security risks or specialized protective
measures required for safety
Code Reference: NFPA 101, 2012 edition,
section 18/19.2.2.2.5.1
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CMS “Categorical Waivers”
Issue: Multiple delayed egress locks
Description: Allows more than one delayedegress lock in the egress path where the
clinical needs require specialized security
measures or when a patient requires
specialized protective measures for safety
Code Reference: NFPA 101, 2012 edition,
section 18/19.2.2.2.4; 7.2.1.6.1
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CMS “Categorical Waivers”
Issue: Relaxation of suite requirements
Description: Allows: 1) suite egress through
another suite; 2) one of the two suite exits to
be an exit stair, exit passageway or exit door
to the exterior, and; 3) an increase in
sleeping suite size up to 10,000 square feet
Code Reference: NFPA 101, 2012 edition,
section 18/19.2.5.7
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CMS “Categorical Waivers”
Issue: Fire system waterflow alarm and fire
pump churn test intervals
Description: Permits vane and pressureswitch type waterflow alarm devices to be
tested semiannually (from quarterly) and
electric fire pumps to be churn tested
monthly (from weekly)
Code Reference: NFPA 25, 2011 edition,
sections 5.3 and 8.3
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CMS “Categorical Waivers”
Issue: Clean waste and confidential records
recycling container sizes
Description: Containers outside of a
hazardous storage area used for recycling
clean waste or confidential patient records
can be 96 gallons rather than the previous
limit of 32 gallons (.5 gallons per square foot
does not apply for these containers)
Code Reference: NFPA 101, 2012 edition,
section 18/19.7.5.7.2
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CMS “Categorical Waivers”
Issue: Items stored in an egress corridor
Description: Permits crash carts, patient lifts and
patient transport devices (beds, gurneys and
wheelchairs) to be placed in an egress corridor
without “in-use” restrictions; also permits “fixed
furniture” – does not apply to non-medical
equipment such as housekeeping carts and
computers on wheels
Code Reference: NFPA 101, 2012 edition, section
18/19.2.3.4
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CMS “Categorical Waivers”
Issue: Kitchens open to the corridor
Description: Allows alternative cooking
arrangements, including kitchens, to be open
to corridors if they are in smoke
compartments with no more than 30 beds
Code Reference: NFPA 101, 2012 edition,
section 18/19.3.2.5 through 18/19.3.2.5.5
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CMS “Categorical Waivers”
Issue: Gas fireplaces in common areas
Description: Allows that installation of direct
vent gas fireplaces in smoke compartments
with patient sleeping rooms (not in the room)
and solid fuel fireplaces in other than patient
sleeping areas
Code Reference: NFPA 101, 2012 edition,
section 18/19.5.2.3
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CMS “Categorical Waivers”
Issue: Combustible decorations
Description: Increases the wall space that
may be covered with combustible
decorations up to 50% in patient rooms if
fully sprinkled
Code Reference: NFPA 101, 2012 edition,
section 18/19.7.5.6
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CMS “Categorical Waivers”
How to Adopt “Categorical Waivers”
Step 1: Make sure that the hospital meets all of the
applicable code provisions of the categorical waiver
Step 2: Create a hospital letter that describes the
categorical waiver(s) and have it approved by the
safety committee and signed by the CEO
Step 3: For Joint Commission approval, list the
adopted categorical waivers in the “Comments”
section of the e-BBI questionnaire
Step 4: Announce at the opening conference of a
CMS or Joint Commission survey which waivers
have been adopted
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Joint Commission Changes in 2014
Issue: Safety, Hazmat and Medical Equipment
Related changes effective on July 1, 2014
Description:

Safety in the MRI environment (EC.02.01.01,
EP14)

Management of MRI safety risks (EC.02.01.01,
EP16)

Quarterly review of staff radiation levels
(EC.02.02.01, EP17)

Quality and maintenance of diagnostic images
(EC.02.04.01, EP7, 17)
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Joint Commission Changes in 2014
Issue: Safety, Hazmat and Medical Equipment
Related changes effective on July 1, 2014
Description:

Annual performance evaluation of CT, MRI, NM, PET
(EC.02.04.03, EP19-23)

Physicist determines shielding requirements for new
installations of CT, PET and NM and performs radiation
protection survey (EC.02.06.05, EP4, 6)

Qualifications and training for CT and MRI services staff
(HR.01.02.05, HR.01.05.03)
Full text at: www.jointcommission.org/assets/1/6/PREPUB-1220-2013-Diagimaging_HAP_CAH.pdf
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Organizational Function Overview
 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 Prevention and Control (IC)
Measurement and reduction of infections
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Competition for the Joint Commission
 DNV (Det Norske Veritas) Healthcare has
received CMS “Deemed Status”
 Headquarters; Oslo, Norway; 9,000 employees,
300 offices, in 100 countries
 Approximately 350 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
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Competition for the Joint Commission
 Health Facilities Accreditation Program (HFAP)
 Originally intended for Osteopathic Hospitals
 First program introduced in 1943; received
“Deemed Status” in the 1960’s
 Has accredited over 200 hospitals
 Requirements closely parallel the CMS
“Conditions of Participation”
 Accreditation levels include:
- Full Accreditation
- Interim Accreditation
- Denial of Accreditation
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The Survey Process and Standards
Changes for 2014 and 2015
Questions?
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