The

1
The Joint Commission 2007-2008 Environment of
Care Survey Focus Prepared by Dean Samet
NEHES Fall Conference October 3,
2007 Portland, Maine
2
Contents

• TJC Unannounced Survey Notification
• Emergency Management Focus
• Life Safety Code Specialist Surveyors
• e-Statement of Conditions and CON-O4
• Emergency Power Systems TJC SEA 37
• Building Maintenance Program
• Damper Inspection/Testing Revisions
• National Patient Safety Goals15 15A
• EOC Risk Assessment Focus

3
Unannounced Survey Note

• At 700 a.m. of your time zone, on the morning of
  a hospitals survey, The Joint Commission will
  post the following information to the
  organizations secure extranet site
• Biographies pictures of surveyors assigned to
  conduct survey.
• Priority Focus Process summary report. (PFP info
  includes e-App data, previous survey findings,
  any complaint data, etc.)
• Survey agenda.

4
Joint Commission Black-out Dates

• Joint Commission is allowing accredited orgs. to
  identify up to 10 days each year in which an
  unannounced survey should be avoided! (Should not
  include federal holidays). Joint Commission
  reserves right to conduct a survey during an
  avoid period if they feel the reason provided
  by the org. is not reasonable.

5
EC Documents for Review

• Annual evaluations of EC management plans (most
  recent)
• EC multidisciplinary team (safety committee)
  meeting minutes (previous twelve months)
• e-Statement of Conditions (Basic Building
  Information, e-BBI and Plan for Improvement,
  e-PFI)
• Emergency Management Plan w/ Hazard Vulnerability
  Analysis EM exercise results

6
Emergency Management Focus

• Hospitals w/ 200 licensed beds or more to have an
  enhanced survey focus and process to evaluate
  emergency preparedness.
• Discussion phase Surveyor will examine overall
  emergency management structure operations and
  planning activities including mitigation,
  response, recovery, community involvement, and
  relationship w/ other HCOs.
• Observation phase Surveyor will focus on how
  org. would handle an emergency.

7
Emergency Management FocusObservation Phase

• Surveyor to select an emergency from orgs hazard
  vulnerability analysis (HVA) and follow processes
  pertinent to that event by visiting relevant
  departments and interviewing staff to assess
  their knowledge of their roles and
  responsibilities for that particular emergency.

8
Emergency Management FocusObservation Phase
(cont.)

• Surveyor to also assess availability of
  supplies, equipment, personal protective
  equipment, effectiveness of staff training,
  communication systems including backup systems.
• Note Relevant JCAHO Standards EC.4.11- 4.18
  EC.4.20 IC.6.10 MS.4.110 HR.4.35 HR.1.25
  IM.2.30 and LD.3.15

9
Note

• EC.4.11 thru 4.18 Emergency Management
• EC.4.20 Periodic Exercises
• IC.6.10 Influx of infectious patients
• MS.4.110 HR.4.35 Credentialing and privileges
  of volunteer licensed independent practitioners
  (LIPs)-physicians
• HR.1.25 Credentialing of volunteer nurses and
  other licensed, certified or registered volunteer
  practitioners
• IM. 2.30 Maintaining continuity of information
• LD.3.15 Leaders developing implementing plans
  to identify and mitigate impediments to efficient
  patient flow throughout the hospital

10
Standard EC.4.20 Exercises (cont.)

• All exercises are critiqued
• For identifying deficiencies and opportunities
  for improvement.
• Through a multidisciplinary process that includes
  administration, clinical (including physicians),
  and support staff.
• For modification of EM plan per critiques.

11
2008 Revisions to Emergency Management Standards

• Effective January 1, 2008, EM standards will
  focus on management of six critical functions
  during emergency conditions
• Communications (EC. 4.13)
• Managing resources and assets (EC.4.14)
• Managing safety and security (EC.4.15)
• Defining and managing staff role and
  responsibilities (EC.4.16)
• Managing utilities (EC.4.17)
• Managing patient clinical and support activities
  (EC.4.18)

12
2008 Revisions to Emergency Management Standards

• Use an all-hazards approach when facilitys
  infrastructure, communitys infrastructure, or
  both are compromised.
• Hazard vulnerability analysis (HVA) helps assess
  and prioritize risks.
• Regularly test organizations Emergency
  Operations Plan (EOP) per the Emergency
  Management Program (EMP)
• Note new terminology in blue.

13
2008 Revisions to Emergency Management Standards

• EC.4.15 The organization establishes strategies
  for managing safety and security during
  emergencies. (e.g., hurricanes earth quakes
  floods ice/snow storms wild-fires wide-spread
  electrical outages, terrorist attacks, etc.)
• Note A single event can escalate into multiple
  events, therefore, a scalable response
  capability is now emphasized for emergency
  management. Example Hurricane Katrina leading
  to flooding power outages loss of homes, water
  food civil unrest, etc.

14
Resource

• See The Joint Commission Perspectives, June
  2007, Volume 27, Number 6, for complete listing
  of Approved Revisions to the Emergency
  Management Standards for Critical Access
  Hospitals, Hospitals, and Long Term Care.

15
Life Safety Code Specialist Surveyors

• Effective January 2005, hospitals with 200 beds
  or more are being evaluated for LSC compliance by
  JCAHO LSC Specialist Surveyors (One day only)
• Effective January 2008, all hospitals will be
  evaluated for LSC compliance by LSC Specialist
  Surveyors. (Two days for Hospitals w/ more than
  750,000 sq. ft.)

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Facility Orientation

• Inform surveyor
• Building layout arrangement of smoke
  compartments suites age of building(s) areas
  w/sprinkler protection areas under construction
  or renovation.
• If any LSC Equivalencies have been granted
  Traditional or Fire Safety Evaluation System
  (FSES) per 2001 NFPA 101A.
• Your process for Interim Life Safety Measures
  (ILSM).
• If you have adopted any portion of the optional
  SOC Building Maintenance (BMP) Program.

17
LSC Specialist Interim Exit Briefing

• LSC Specialist Interim Exit Briefing
• LSC Specialist surveyor to review their
  observations/findings and address any questions
  organization may have about Life Safety Code
  deficiencies discovered during building tour at
  the end of LSC Specialist surveyors one-day
  survey.
• Note No scoring will be shared at this time.
  That will be provided at the CEO Exit Briefing
  after all findings have been aggregated.

18
Environment of Care Standards

• EC.5.20 Life Safety Code/e-SOC
• Org. has a current hospital-wide
• e-Statement of Conditions (SOC).
• Org. is making sufficient progress toward the
  corrective actions described in a previously
  approved SOC.

19
Environment of Care Standards

• EC.5.20
• Sufficient progress Failure to make
  sufficient progress toward the corrective actions
  described in an approved Statement of
  Conditions, Part 4 Plan For Improvement, or
  failure to implement or enforce applicable ILSM
  per EC.5.50, could result in a recommendation of
  Conditional Accreditation (see TJC Conditional
  Accreditation rule CON04).

20
SOC Standard Scoring Revisions

• Annual PPR w/SOC-PFI now due.
• If org. requests a PFI extension after 6-mo.
  grace period has expired, org. may be cited at
  time of survey at LD.2.20, EP 2 (attributed to
  management issues) or LD.3.80, EP 4 (attributed
  to lack of resources). Anything beyond the 6-mo.
  grace period for which an extension has not been
  granted may result in Conditional Accreditation!
  PFI entries that have excessively long projected
  completion dates or list non-LSC deficiencies
  could be scored as non-compliant at LD.4.50 (PI
  activities not reprioritized).

21
Testing and Drilling Timeframes

• Daily, Weekly, Monthly, and Quarterly will be on
  a calendar basis
• Bi-monthly is 6 times a year
• Semi Annual six months /- 20 days
• Annual - one year /- 30 days
• Per Healthcare Interpretations Task Force
• (NFPA,TJC,CMS, ASHE,VA,DOD,IHS,IFMA, AHCA)
• Per The Joint Commission

22
Emergency Generator Test

• Per EC.7.40, EP 1, orgs. still required to test
  each generator 12 times a year with testing
  intervals not less than 20 days and not more than
  40 days apart. These tests shall be conducted for
  at least 30 continuous minutes under a dynamic
  load that is at least 30 of the nameplate rating
  of the generator.

23
Emergency Generator Test Revisions (New 3-Year
Test)

• EP 5 Facilities that have a generator providing
  emergency power for the services listed in
  elements of performance 5 through 18 of standard
  EC.7.20 The organization tests each emergency
  generator at least once every 36 months for a
  minimum of four continuous hours. This test shall
  be conducted under a load (dynamic or static)
  that is at least 30 of the nameplate rating of
  the generator.

24
Emergency Generator Test Revisions (New 3-Year
Test)

• Footnote 3 This test may satisfy one of the
  tests required by element of performance 1
  (monthly tests).
• Footnote 4 After the 3-yr test, the fuel
  supply should be replenished. Any problems
  identified during the test shall be resolved
  promptly. For additional guidance, see NFPA 110
  (2005 edition) Standard for Emergency Standby
  Power Systems.

25
Emergency Generator Test Revisions (New 3-Year
Test)

• Note 1 To be in initial compliance with this
  element of performance, organizations must have
  performed this test by July 1, 2007.
  Organizations that have successfully operated
  their generator(s) since July 1, 2004, according
  to the test criteria described above, will be
  considered to be in initial compliance with this
  element of performance and are required to retest
  before their three year anniversary date of such
  occurrence.

26
Emergency Generator Test Revisions (New 3-Year
Test)

• Note 2 Organizations that cannot achieve a
  minimum load of 30 of the emergency generators
  nameplate rating must assess the prime movers
  exhaust gas temperature and meet the minimum
  temperature recommended by the manufacturer.
• 
  

27
Emergency Generator Test Revisions (New 3-Year
Test)

• EP 6 If a test(s) required by EC.7.40 fails, the
  organization implements interim measures to
  compensate for the risk to patients/residents/cli
  ents, visitors, and staff until necessary
  repairs or corrections are completed.
• EP 7 If a test(s) required by EC. 7.40 fails,
  the organization performs a retest after making
  the necessary repairs or corrections.

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JCAHO Sentinel Event Alert 37Emergency Power
System Failures

• SEA-37 (Issued Sep. 2006) purpose Improve the
  reliability of healthcare facility emergency
  power systems to reduce risks to patients from
  both internal and external power failures.
• Note For more comprehensive information see ASHE
  Management Monograph, Managing Hospital
  Emergency Power Systems-Testing, Operation and
  Maintenance by Dave Stymiest, PE, CHFM, FASHE,
  CEM
• ASHE website www.ashe.org

29
JCAHO Sentinel Event Alert 37Emergency Power
System Failures

• Suggested Steps
• Conduct thorough EP system vulnerability analysis
• Assess utility power reliability in conjunction
  with the electrical utility
• Look at brownouts and blackouts as symptomatic of
  more generic issues
• Fully test the entire emergency power supply
  system
• Conduct EP system infrastructure master planning
• Assess the use and application of portable
  truck-mounted generator sets
• Review monthly test results for more than just
  generator set data
  

30
JCAHO Sentinel Event Alert 37Emergency Power
System Failures

• Perform a gap analysis on the equipment connected
  to the EP system to identify needs that may apply
  during extended disaster-related outages
• Expand EP system documentation,
  operator/maintainer competency training and
  communication about EP system limitations between
  engineering, management and clinical leaders
• Expand fuel oil management process
• Expand clinical contingency planning and training
  for EP system failures

31
Building Maintenance Program

• Way to mitigate Joint Commission and CMS Life
  Safety Code deficiencies !
• Per SOC Part 3A, Item 6J and Part 3B, Item 6I
• An organization may choose to establish a BMP to
  resolve certain LSC deficiencies in lieu of
  reporting on the org.s SOC/PFI.
• LSC deficiencies may be addressed thru the org.s
  normal work order process with a typical 30 day
  completion period.

32
Building Maintenance Program

• Org. has to inform surveyors if they are using
  the optional BMP process.
• Org. also has to list LSC areas covered by BMP
• Org. may chose any one or all of 10 items listed.
• Note For a BMP to be considered effective, the
  JCAHO requires greater than or equal to 95 of
  program items to properly function at any one
  time.

33
Damper Testing Revisions

• For health care occupancies, damper inspection
  testing requirements have been moved by the NFPA
  from NFPA 90A to 2007 editions of NFPA 80 NFPA
  105.
• Inspection/testing frequencies extended from at
  least once every four years to at least once
  every six years.
• Expected TJC Effective date July 1, 2008.

34
Damper Testing Revisions (cont.)

• NFPA 80, Section 19.4.1.1 states, The fire
  damper test and inspection frequency shall then
  be every 4 years, except in hospitals, where the
  frequency shall be every 6 years.
• NFPA 105, Section 6.5.2 states, Each smoke
  damper shall be tested and inspected one year
  after installation. The smoke damper test and
  inspection frequency shall then be every 4 years,
  except in hospitals, where the frequency shall be
  every 6 years.

35
Inaccessible Damper Locations

• TJC now requires inaccessible smoke fire
  dampers to be noted on your e-SOC.
• Projected Completion Date is a required field
  on the e-PFI and cannot be left open.
• TJC is allowing a 6-year completion date to be
  entered for any inaccessible dampers. If
  identified dampers cannot be rectified by end of
  6-year period, org. to submit a PFI Extension
  Request to TJC.

36
CMS Medical Gas Storage Requirements per 2005
NFPA 99

• Effective January 12, 2007, the Centers for
  Medicare and Medicaid Services has adopted
  language from the 2005 edition of the NFPA 99
  Health Care Facilities Code, Section 9.4.3, for
  storage of nonflammable gases with a total volume
  (compressed) equal to or less than 300 cu. ft.
  (12 E-cylinders).

37
CMS Medical Gas Storage Requirements per 2005
NFPA 99

• CMS Ref SC-07-10
• Memorandum Summary Up to 300 cu. ft. of
  nonflammable medical gas may be accessible as
  operational supply rather than storage, when
  properly secured in a max. 22,500 sq. ft. smoke
  compartment. An individual container of medical
  gas placed in a patient room for as needed (but
  regular) individual use is not required to be
  stored in an enclosure, when properly secured.

38
National Patient Safety Goals 15 15A

• Effective January 1, 2007 TJC National Patient
  Goals 15 15A address the need for orgs. to
  identify safety risks inherent in their patient
  populations in psychiatric hospitals and general
  hospitals treating patients for emotional or
  behavioral disorders, specifically for those
  patients at risk for suicide.

39
NPSGs 15 15A (cont.)

• NPSG 15 The organization identifies safety risks
  inherent in its patient population.
• NPSG 15A The organization identifies patients at
  risk for suicide.
• Note Per TJC, suicide of care recipients while
  in a staffed 24-hour care setting has been the
  most frequently reported type of Sentinel Event
  since inception of TJC Sentinel Event Policy in
  1996.

40
NPSGs 15 15A (cont.)

• TJC Implementation Expectations for NPSG 15A
• 1) The risk assessment includes identification of
  specific factors and features that may increase
  or decrease risk for suicide.
• 2) The patients immediate safety needs and most
  appropriate setting for treatment are addressed.
• 3) The org. provides information such as a crisis
  hotline to individuals and their family members
  for crisis situations.

41
Risk Assessments

• EOC - Risk Assessments
• The EC standards require a formal risk assessment
  only for Safety Management (EC.1.10 EP4), and for
  Security management (EC.2.10 EP3) however the
  following also needs to be risk assessment based
• Emergency management (EC.4.10 EP1) JCAHO accepts
  the Hazard vulnerability analysis (HVA) as a risk
  assessment for emergency management.
• Fire safety management (EC5.20 EP2) JCAHO
  accepts a current Statement of Conditions (SOC)
  as a risk assessment for fire safety management.
• Medical Equipment Management (EC6.20 EP1) JCAHO
  accepts an inclusion in inventory risk assessment
  using the ECRI, ASHE or AHA method for assessing
  medical equipment for inclusion or for
  non-inclusion in the
• inventory.
• Utility management (EC.7.10 EP 9) A risk
  assessment is not required if a facility wants to
  include all utility systems and components in the
  utility management inventory. But if a facility
  wants to exclude some less than critical
  components they have to conduct an inclusion risk
  assessment.
• Hazardous materials and medical waste (EC.3.10)
  JCAHO does not mandate a stand-alone risk
  assessment as long as Hazmat issues are assessed
  as part of the safety management risk assessment.

42
Joint Commission Seven-Step Risk Assessment
Process

• Identify safety issues by performing risk
  assessments per JCAHO Standard EC.1.10, EP No.4
  which states, The hospital conducts
  comprehensive, proactive risk assessments that
  evaluate the potential adverse impact of
  buildings, grounds, equipment, occupants, and
  internal physical systems on the safety and
  health of patients, staff, and other people
  coming to the hospitals facilities.

43
Joint CommissionSeven-Step Risk Assessments

• 1) Identify the issue(s)
• 2) Develop arguments in support of an issue
• 3) Develop arguments against that issue
• 4) Objectively evaluate both arguments
• 5) Reach a conclusion
• 6) Document the process
• 7) Monitor and reassess the conclusion to ensure
  that it is the best decision

44
CONCLUSION

• Stop sweating the Unannounced Surveys Relax!
• Shift from a focus on survey preparation to a
  focus on - ongoing operational readiness!

45
Joint Commission Contacts

• For LSC equivalencies and SOC PFI extension
  requests contact George Mills or Jerry Gervais of
  the Joint Commission Standards Interpretation
  Group (SIG) in writing or at
• 630-792-5900 or via e-mail
• gmills_at_jointcommission.org
• jgervais_at_jointcommission.org

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END

• Questions?
• Thank You!
• Dean Samet
• Smith Seckman Reid
• 615-388-0332
• dsamet_at_ssr-inc.com
•