2013 THE HEALTHCARE ENVIRONMENT Anne M. Guglielmo Engineering Department The Joint Commission © Copyright, The Joint Commission 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. Department of Engineering 2013 - 2 © Copyright, The Joint Commission All products will display a single icon at the EP level RANKING RESULTS: 11 OUT OF 21 IN 2012 Standard 2012 RFIs 2011 RFIs 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 Subject Department of Engineering 2013 - 3 © Copyright, The Joint Commission Top 20 Rank #2: LS.02.01.20 51% 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 Department of Engineering 2013 - 4 © Copyright, The Joint Commission The hospital maintains the integrity of the means of CORRIDOR STORAGE “If the corridor looks cluttered…it probably is” Carts Allowed: Crash Carts Isolation 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 Department of Engineering 2013 - 5 © Copyright, The Joint Commission Chemo Carts SUITES Not identified on drawings Boundaries Dimensions Department of Engineering 2013 - 6 © Copyright, The Joint Commission Exits LS DRAWING INFORMATION A legend that clearly identifies features of fire safety 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 Department of Engineering 2013 - 7 © Copyright, The Joint Commission Areas of the building that are fully sprinklered (if the #3: LS.02.01.10 46% 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 Department of Engineering 2013 - 8 © Copyright, The Joint Commission Building and fire protection features are #5: EC.02.03.05 40% The hospital maintains fire safety equipment Risk Icons: EP4: Audio/Visual Alarms EP11: Water flow alarm to fire pump flow test EP19: Automatic shutdown of AHU Department of Engineering 2013 - 9 © Copyright, The Joint Commission and fire safety building features. Features of fire protection NEED FOR INVENTORY EC.02.03.05 EP 1 – 20: 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 Department of Engineering 2013 - 10 © Copyright, The Joint Commission Each device that is required to be tested must be EC.02.03.05 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 Department of Engineering 2013 - 11 © Copyright, The Joint Commission During survey specific documentation is EPs 1 -20: Missing documentation: score the EP as noncompliant 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 Department of Engineering 2013 - 12 © Copyright, The Joint Commission EC.02.03.05 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 waterbased fire protection systems includes the following: Note: For additional guidance on documenting activities: NFPA 25, 1998 edition (Section 2-1.3) NFPA 72, 1999 edition (Section 7-5.2) Department of Engineering 2013 - 13 © Copyright, The Joint Commission Below for Contents 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 Department of Engineering 2013 - 14 © Copyright, The Joint Commission EC.02.03.05 EP 25 #6: LS.02.01.30 39% The hospital provides and maintains Department of Engineering 2013 - 15 © Copyright, The Joint Commission building features to protect individuals from the hazards of fire and smoke. EPs 16 – 23 Smoke Barriers & Doors EP2 Hazardous Areas #7: EC.02.06.01 35% 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 Department of Engineering 2013 - 16 © Copyright, The Joint Commission EP 1 Interior spaces meet the needs of the EC.02.06.01 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 Department of Engineering 2013 - 17 © Copyright, The Joint Commission EP 13 The organization maintains ventilation, #9: LS.02.01.35 34% Risk Icon: EP 1: monitor authorized automatic sprinkler system EP 2: water flow alarm maintained below the sprinkler deflector to the top of storage. NOTE: Perimeter wall and stack shelving may NFPA 13-1999, 5-6.6 Department of Engineering 2013 - 18 © Copyright, The Joint Commission There are 18” or more of open space Perimeter Shelving 18” RULE Perimeter Shelving Ceiling 18” 18” Wall OK Wrong OK OK Department of Engineering 2013 - 19 © Copyright, The Joint Commission Wall #11: EC.02.05.01 33% EC.02.05.01 EP 1: Improper system design 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 Department of Engineering 2013 - 20 © Copyright, The Joint Commission Inability of the mechanical system to EC.02.05.01 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 Department of Engineering 2013 - 21 © Copyright, The Joint Commission EC.02.05.01 EP 6: Ventilation system is unable to provide #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 Department of Engineering 2013 - 22 © Copyright, The Joint Commission #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 Areas served • Accuracy Department of Engineering 2013 - 23 © Copyright, The Joint Commission Contents of piping 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 Department of Engineering 2013 - 24 © Copyright, The Joint Commission #17: EC.02.05.07 22% #21: EC.02.03.01 19% Fire Plan (EP 9 & 10) Lack of fire safety training as per fire plan Surgical site fires Department of Engineering 2013 - 25 © Copyright, The Joint Commission 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 LIFE SAFETY CODE SURVEYOR LSCS Background Facilities or Environment of Care based 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 Department of Engineering 2013 - 26 © Copyright, The Joint Commission Prefer CHFM certification 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 Department of Engineering 2013 - 27 © Copyright, The Joint Commission WHAT TRIGGERS ITL (IMMEDIATE THREAT TO LIFE) Significantly compromised fire alarm system Significantly compromised sprinkler system supply system Significantly compromised medical gas master panel Significantly compromised exits Other situations that place patients, staff or visitors at extreme danger Department of Engineering 2013 - 28 © Copyright, The Joint Commission Significantly compromised emergency power WHAT TRIGGERS ITL (IMMEDIATE THREAT TO LIFE) CONT01 The Immediate Treat to Health or Safety has been successfully abated and verified through the direct observation or other determining method. Department of Engineering 2013 - 29 © Copyright, The Joint Commission PDA01 An Immediate Threat to Health or Safety exists for patients or the public within the hospital. AFS 10 IS RELATED TO THE SOC AND PFIS 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 Department of Engineering 2013 - 30 © Copyright, The Joint Commission Failure to make sufficient progress on previously 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 Department of Engineering 2013 - 31 © Copyright, The Joint Commission DEFICIENCY RESOLUTION 45 DAY CORRECTIVE ACTION Documented Origination date Completion date Kept available for rolling 3 years Life Safety deficiencies Must not exceed 45 days (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 Department of Engineering 2013 - 32 © Copyright, The Joint Commission If greater than 45 days create a Plan For Improvement HOW MANY OPEN PFIS ARE TOO MANY? 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 Department of Engineering 2013 - 33 © Copyright, The Joint Commission The PFI process was created to allow organizations to HOW MANY OPEN PFIS ARE TOO MANY? Survey Process: There is no limit to the number of PFIs 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) Department of Engineering 2013 - 34 © Copyright, The Joint Commission Evaluate both closed and currently open PFIs in the 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”) Department of Engineering 2013 - 35 © Copyright, The Joint Commission TWO FORMS OF EQUIVALENCIES Fire Safety Evaluation System (FSES) 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 Department of Engineering 2013 - 36 © Copyright, The Joint Commission A process of calculating the features of life safety and HISTORY AUDIT TRAIL 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 Department of Engineering 2013 - 37 © Copyright, The Joint Commission The History Audit Trail is used by SIG Engineers Department of Engineering The Joint Commission © Copyright, The Joint Commission 2012 LIFE SAFETY CODE 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” Department of Engineering 2013 - 39 © Copyright, The Joint Commission NFPA 101-2012 NFPA 101-2012 Department of Engineering 2013 - 40 © Copyright, The Joint Commission 2. Fixed seating permitted provided 6ft clear width < 50sqft with 10’ between groupings Groupings must be on same side of the egress corridor 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) Department of Engineering 2013 - 41 © Copyright, The Joint Commission NFPA 101-2012 CORRIDOR COOKING 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 Department of Engineering 2013 - 42 © Copyright, The Joint Commission NFPA 101-2012 FIREPLACES 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 Department of Engineering 2013 - 43 © Copyright, The Joint Commission NFPA 101-2012 DECORATIONS BUILDING MAINTENANCE PROGRAM (BMP) All EPs related to the original ten BMP items are ‘C’ categories © Copyright, The Joint Commission The BMP is no longer available to offset findings during survey, but is considered “best practice” © Copyright, The Joint Commission RISK ASSESSMENT EC.02.01.01 EP 1 (A CATEGORY) 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 Department of Engineering 2013 - 46 © Copyright, The Joint Commission The hospital identifies safety and security risks associated with 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 Department of Engineering 2013 - 47 © Copyright, The Joint Commission assessment and correct the identified risk? Identify Safety & Security Risks Risk Assessment EC.02.01.01 Established Process? No Yes Yes No Resolved? Yes EP 1 No Unsafe conditions? Consider EC.02.06.01 EP 1 EP 3 Department of Engineering 2013 - 48 © Copyright, The Joint Commission EP 1 Identify Risk? EC.02.06.01 EP 1 Interior spaces meet the needs of the patient Department of Engineering 2013 - 49 © Copyright, The Joint Commission 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 WHEN TO CONDUCT A RISK ASSESSMENT 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 Department of Engineering 2013 - 50 © Copyright, The Joint Commission Use to evaluate any issue that lacks a clear CONDUCTING A RISK ASSESSMENT: SEVEN STEPS 2. 3. 4. 5. 6. 7. Develop arguments in support of the issue Develop arguments against the issue Objectively evaluate both arguments Reach a conclusion Document the process Monitor and reassess the conclusion to ensure it is right conclusion Department of Engineering 2013 - 51 © Copyright, The Joint Commission 1. Identify the issue 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 Department of Engineering 2013 - 52 © Copyright, The Joint Commission 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 Department of Engineering 2013 - 53 © Copyright, The Joint Commission PRA INTERIM LIFE SAFETY MEASURES Order of Standards (LS.01.02.01) EP 1 & 2 regardless of ILSM policy including AFS 10 Process When to implement What to do to protect occupants Both construction related and noncompliance with the LSC EPs 4 – 14 align with policy and implementation strategies Department of Engineering 2013 - 54 © Copyright, The Joint Commission EP 3 must clearly define the ILSM policy 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 OPEN Engineer Position OPEN Engineer Position Department of Engineering 2013 - 55 © Copyright, The Joint Commission Engineer THE JOINT COMMISSION DISCLAIMER 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 2013 - 56 © Copyright, The Joint Commission These slides are current as of 5/1/2013. The Joint Commission