The Safety/EOC Committee
WHY A STRONG COMMITTEE BRINGS BETTER
SURVEY RESULTS
WM. (BILL) MORGAN, FASHE, CHFM
© MSL Healthcare Partners, 2016
WHAT’S YOUR BACKGROUND
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HOW MANY
FACILITY LEADERS?
EMERGENCY MANAGERS?
CHAIR THE ENVIRONMENT OF CARE COMMITTEE
ARE MEMBERS OF THE EOC
WHAT SIZE IS YOUR FACILITY?
CRITICAL ACCESS
100 – 200 BED FACILITY
200 +
SYSTEM PROCESS IN PLACE?
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© MSL Healthcare Partners, 2016
STRONG COMMITTEE/STRONG COMPLIANCE
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EXPERIENCE FROM SURVEYS
EXPERIENCE FROM MANAGEMENT OF THE EOC
IT’S ALL ABOUT MANAGING RISK
THREE BASIC ELEMENTS BEING MONITERED
– BUILDINGS OR SPACE SUPPORTING PATIENT CARE
– EQUIPMENT
– PEOPLE
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WHY A COMMITTEE?
• IS IT REQUIRED?
• WHAT ARE THE OPTIONS?
• TJC EXPECTATIONS:
– MANAGE RISK
– SOMEONE TO INTERVEN
– OVERSEE SAFETY, SECURITY, HAZARDOUS MATERIALS, FIRE
SAFETY, MEDICAL EQUIPMENT, AND UTILITIES
RESPONSIBILITIES
– USE THE STANDARDS AS A BUSINESS PLAN VS REG
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MANAGEMENT BY ATTILA THE HUN
• THE EOC STANDARDS AND RESPONSIBILITY OF THE
EOC IS SUCH A LARGE RESPONSIBILITY A STRONG
LEADER IS NEEDED TO MANAGE THE PROCESS
• VALUE OF LEADERSHIP INVOLVEMENT IN THE
PROCESS.
• AUTHORITY, SUPPORT, ACCOUNTABILITY
• KNOW WHAT YOUR IMPACT IS ON PATIENT CARE
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SO YOU MISSED A MEETING AND NOW YOU
ARE THE NEW EOC CHAIR
• WHERE DO YOU STARTF.
• YOU WANT TO KNOW THE BUSINESS OF OVERSIGHT IS BEING
DONE.
• YOU WANT MEMBERS ON YOUR TEAM THAT HAVE THE
PASHION, KNOWLEDGE, AND ATTITUDE TO MAKE THE
HOSPITAL SAFE.
• YOU WANT TO GIVE PEOPLE CLEAR DIRECTION ON WHAT YOU
WANT TO ACHIEVE.
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STAND ALONE FACILITY OR SYSTEM
• HOW WILL BELONGING TO A SYSTEM IMPACT THE
MANAGEMENT OF THE ENVIRONMENT OF CARE?
• DIRECTION FROM REGIONAL OR NATIONAL SYSTEMS
MAY DICTATE MUCH OF HOW YOU MANAGE
• TEAM MEMBERSHIP?
• RISK MEASUREMENT POINTS FOR DATA COLLECTION
• REPORTING PROCESSES
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FORMING A TEAM
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MEMBERSHIP
MEETING TIMES AND LENGTH
FOCUSED MEETINGS USING AGENDAS,
MINUTES, PROCESSES FOR SUCCESS
TASK FORCES?
BUILDING TEAM BUY IN
MEMBERSHIP
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MEMBERSHIP (SEE HANDOUT)
KEY MEMBERS
SENIOR LEADERSHIP ATTEND?
ALTERNATES
AD HOC
OPEN MEETINGS
TIME KEEPER/SCRIBE
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MEETING LOCATION/TIME FRAME
• TIMES TO BE DECIDED BY THE HOSPITAL FROM THE
NEEDS OF THE FACILITY
• CALENDAR IT FOR A YEAR THEN REVISIT TIME AND
LOCATION TO MEET NEEDS
• CALL IT WHAT YOU WANT, SAFETY COMMITTEE OR?
• HOW LONG SHOULD IT TAKE?
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PROCESS FOR RUNNING A BUSINESS MEETING
• AGENDA (WHAT IS YOUR DESIGN)
• ROLL CALL? THIS WILL BE SHOPPED BY TJC TO SEE IF PEOPLE
ARE ATTENDING AND INVOLVED
• REPORTS – OLD BUSINESS – NEW BUSINESS
• ISSUE CLOSE OUT
• MINUTES TO ?
• NOT ON AGENDA, NOT IN THE MEETING?
• AVOID SOLVING WORLD PROBLEMS “FOCUS”
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CONDUCTING THE BUSINESS OF THE MEETING
• TIME KEEPER?
• THE BIGGER THE GROUP THE HARDER IT IS TO GET
ANYTHING DONE.
• EVERYONE HAS TO KNOW THEY ARE THERE FOR A
REASON.
• DOES THE TEAM HAVE A COPY OF THE EOC
STANDARDS AND HAVE THEY READ THEM?
• CELIBRATE SUCCESS!!!!
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INVLOLVE TEAMS FOR SUCCESS
• NO ONE SOULD BE IN THE MEETING THAT DOESN’T
HAVE A REASON AND RESPONSIBILITY FOR AREAS OF
THE ENVIRONMENT OF CARE.
• IF THEY DON’T HAVE A PART OF THE PROCESS THEY
WILL QUIT COMING.
• MAKE SURE MEMBERS BOSS KNOWS HOW VALUABLE
AND HELPFUL THEY ARE.
• RECOGNITION IDEAS
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SYSTEM IMPACT ON THE EOC COMMITTEE
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FULL COMMITTEE AT ALL FACILITIES
MEMBERS FROM EACH FACILITY
ROTATE MEETINGS FROM FACILITY TO FACILITY
HOW DO YOU FEED INFORMATION UP AND DOWN
THE CHAIN OF COMMAND
• WHAT ARE BEST PRACTICES YOU HAVE SEEN?
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MANAGEMENT PLANS
WRITING GREAT PLANS
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TJC DIRECTION
• EC.01.01.01 IDEAS FOR DEVELOPMENT ARE OPEN
BUT IDENTIFIED IN GENERAL IN THE DESCRIPTION OF
THE STANDARD.
• CAN BE SEPARATE FOR THE KEY ELEMENTS OR A
SINGLE PLAN
• NOT OPERATIONAL PLANS
• NEED TO CONTAIN KEY ELEMENTS:
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SCOPE
• WHAT BUILDINGS AND OR SERVICES ARE COVERED BY
THE PLAN.
• WHAT SYSTEMS ARE COVERED?
• IF WRITTEN FOR A SYSTEM WOULD THE PLAN
IDENTIFY ALL BUILDINGS OR ?
• SCOPE CAN CHANGE WITH ADDITION OF SPACE OR
CHANGES IN SERVICES PROVIDED.
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OBJECTIVES
• DON’T CONFUSE WITH GOALS.
• WHAT ARE THE MAJOR FUNCTIONS AND PURPOSE OF
THE MANAGEMENT PLAN (UTILITY PLAN IDEAS)
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Provide a safe, controlled, comfortable environment for patients, visitors, and staff members.
Provide for reliable utility systems and minimize the risk of failures
Reduce the potential for organization-acquired illness.
Provide an appropriate and timely response to utility system failures.
Educate Hospital Name utility system users and maintainers for their responsibilities in the
Utilities Management Plan.
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SAFETY OBJECTIVE IDEAS
• Provide a forum and a framework for the analysis and management of
safety risks.
• Coordinate the approach to safety through the development and ongoing
review of programs, policies, and procedures.
• Provide for timely and accurate communication of safety issues from and to
all hospital staff members.
• Effectively use environmental tour and other data to improve conditions in
the environment.
• Comply with applicable law and regulation governing safety management.
• Educate Hospital Name staff members as to their role in safety
management.
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SECURITY OBJECTIVE IDEAS
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Protect patients, personnel, visitors, and property.
Evaluate Security trends and take appropriate action based on risk assessment.
Minimize loss, theft, and damage to Hospital Name resources.
Provide services that contribute to the preservation of life, protection of property
and the safety of the community.
Prevent crime through security patrol, education of employees, and investigation of
criminal activity.
Work effectively with local law enforcement.
Assist during time of natural or unnatural occurrences or disasters.
Train staff members working in security sensitive areas to understand their unique
risks, and access and egress controls.
Educate Hospital Name staff members as to their role in security management.
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HAZARDOUS MATERIALS AND WASTE
OBJECTIVE IDEAS
• Provide for the safe and legal management of hazardous materials and
waste.
• Appropriately manage hazardous materials emergency situations.
• Provide for investigation and cleanup of significant spills and exposures.
• Provide for the safe use of radiopharmaceuticals and radiation producing
devices.
• Provide for the appropriate disposal of hazardous medications.
• Minimize and monitor exposure to hazardous gases and vapors.
• Educate Hospital Name staff members as to their role in hazardous
materials and waste management.
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FIRE SAFETY OBJECTIVE IDEAS
• Provide an environment as free as possible from fire hazards.
• Maintain the continuous effective function of all life safety
features, equipment, and systems.
• Plan, install, test, maintain and monitor fire detection, alarm,
and control systems in accordance with appropriate standards.
• Appropriately manage any fire situation, whether an actual
event or a drill.
• Educate Hospital Name staff members as to their role in fire
safety management.
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MEDICAL EQUIPMENT OBJECTIVE IDEAS
• Provide equipment that is operational, safe, and properly
maintained for patient care.
• Provide a structure to report medical equipment problems,
failures and user errors.
• Provide an appropriate and timely response to medical
equipment failures.
• Educate Hospital Name medical equipment operators and
maintainers for their responsibilities in the Medical Equipment
Management Plan.
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RESPONSIBILITY OF INDIVIDUALS OR GROUPS
TIME FRAMES FOR ACTIVITIES IDENTIFIED
• SEVERAL WAYS TO DISPLAY THIS IN THE PLAN
• USE OF THE STANDARD COVERED IN THE MANAGEMENT PLAN
WITH THE ELEMENTS OF PERFORMANCE.
• DON’T DRAG AND DROP, WRITE WHO IS RESPONSIBLE FOR
WHAT AND WHAT THE TIME FRAME IS FOR THE ACTIVITY
• REPORTS ARE DUE TO EOC QUARTERLY, MONTHLY, TESTING IS
DONE TO TIME FRAMES IDENTIFIED BY NFPA, ETC.
• INFORMATION CAN BE SHOWN AS A POLICY BY NUMBER
• KEEP POLICIES IN DATE IF USED AS REFERENCE (READ THEM)
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© MSL Healthcare Partners, 2016
SAMPLES FROM EXPERIENCE AND ON LINE
• WHAT HAVE YOU SEEN?
• CAN FIND A GREAT NUMBER OF PLANS POSTED ON
LINE.
• AVERAGE NUMBER OF PAGES?
• HOW DO YOU WRITE THESE PLANS FOR A SYSTEM VS.
A STAND ALONE HOSPITAL.
• DO THEY ALL NEED TO LOOK ALIKE
• WHAT ABOUT CONTRACTED CLINICAL ENGINEERING?
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ANNUAL REVIEW
• OFTEN MISSED BY HOSPITALS
• REQUIRED BY EC.04.01.01 ELEMENT OF
PERFORMANCE #15.
• WILL CONTAIN A REVIEW OF THE OBJECTIVES, SCOPE,
PERFORMANCE, AND EFFECTIVENESS.
• CAN BE 1 OR TWO PAGES.
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PERFORMANCE IMPROVEMENT
• EC.04.01.05 IDENTIFIES EXPECTATIONS FOR
IMPROVEMENT IN THE ENVIRONMENT OF CARE
• CAN BE DONE BY COLLECTING GOOD DATA REVIEW
AT THE EOC &
• CAN BE DONE PARTIALY BY EACH MANAGEMENT
PLAN SETTING GOALS IN THEIR PLAN.
• DON’T OVERLOAD WITH “WORLD PEACE” TYPE
GOALS
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PERFORMANCE IMPROVEMENT II
• ONE MAJOR GOAL SHOULD BE SET AS A MINIMUM
FROM THE COMMITTEE DATA COLLECTED.
• GOALS CAN NOT BE A POINT THAT IS REQUIRED BY
STANDARD SUCH AS 100% COMPLETION OF FIRE
DRILLS (THEY HAVE TO BE DONE)
• CAN BE IMPROVING THE SCORES ON FIRE DRILLS OR
TO IMPROVE THE RESPONSE BY STAFF….
• CAN ROLL OVER IF NOT COMPLETED.
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DATA COLLECTION AND RISK
ASSESSMENT
IT’S ALL ABOUT THE DATA…..
© MSL Healthcare Partners, 2016
EC:04.01.03 THE HOSPITAL ANALYZES
IDENTIFIED ENVIRONMENT OF CARE DATA
• EP 1 REPRESENTATIVES FROM CLINICAL,
ADMINISTRATIVE, AND SUPPORT SERVICES INVOLVED
• EP-2 USE DATA ANALYSIS TO IDENTIFY OPPORTUNITY
TO EOC ISSUES
• EP-3 ANNUALLY THE CLINICAL, ADMINISTRATIVE, AND
SLUPPORT SERVICES WILL RECOMMEND ONE OR
MORE PRIORITY FOR IMPROVEMENT IN THE EOC
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IF I’M THE CHAIR OF THE EOC WHAT DATA DO I
WANT REPORTED TO BE REVIEWED?
• EC.04.01.01 - The hospital collects information to
monitor conditions in the environment
• EP 1. The hospital establishes a process(es) for
continually monitoring, internally reporting, and
investigating the following: (next slide)
• Based on its process(es), the hospital reports &
investigates the following:
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MONITOR, REPORT & INVESTIGATE….
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Injuries to patients or others in hospital facilities
Occupational illnesses and staff injuries
Incidents of damage to property
Security incidents involving patients, staff, or others within its facilities
Hazardous materials spills and exposures
Fire safety problems, deficiencies, and failures
Medical or laboratory equipment management problems, failures, and use
errors
• Utility systems management problems, failures, or use errors
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EC.04.01.01 EP REQUIREMENTS
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EP 3 INJURIES TO PATIENTS OR OTHERS
EP 4 OCCUPATIONAL ILLNESSES AND STAFF INJURIES
EP 5 INCIDENTS OF DAMAGE TO PROPERTY
EP 6 SECURITY INCIDENTS INVOLVING PATIENTS,
STAFF OR OTHERS.
• EP 8 HAZARDOUS MATERIALS AND WASTE SPILLS
AND EXPOSURES.
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EC.04.01.01 EP REQUIREMENTS
• 9. FIRE SAFETY MANAGEMENT PROBLEMS AND
DEFICIENCIES
• 10 MEDICAL/LAB EQUIPMENT MANAGEMENT
PROBLEMS, FAILURES, AND DEFICIENCIES
• 11 UTILITY SYSTEM MANAGEMENT DEFICIENCIES,
PROBLEMS, FAILURES
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HOW TO COLLECT AND REPORT DATA TO EOC
• THE CHAIR OF THE EOC WANTS TO KNOW THE
INDIVIDUAL MEMBERS ARE REVIEWING THE AREAS
THEY ARE RESPONSIBLE FOR WITH THEIR EXPERTISE
THEY HAVE LOOKING FOR RISK
• NOT JUST RAW DATA.
• WHAT ABOUT LIFE SAFETY AND EMERGENCY
MANAGEMENT IDEAS
• WHAT ARE IMPACTS FROM A SYSTEM APPROACH
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THOUGHTS ON DATA
• FROM THE LEADERSHIP ROLE I WANT TO KNOW
EVERYTHING IS BEING DONE AND ISSUES ARE BEING
IDENTIFIED.
• THINK OF THE MOST COMMON FINDINGS FROM
JOINT COMMISSION IN EC AND LS, DON’T YOU WANT
TO KNOW THEY ARE ON TRACK AT YOUR FACILITY?
• CONSENT REPORTS TO THE COMMITTEE, JUST TALK
ABOUT AND WORK ON DATA OUT OF THRESHOLD
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WHAT DO YOU USE
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LOOK AT ATTACHMENT
KEEP IT SIMPLE
USE GRAPHS AND CHARTS
SET AN ACCPTIBLE LIMIT FOR MEASURE
IS ONE ELEVATOR FAILURE A QUARTER OK?
IS ONE BACK INJURY?
WHAT ABOUT DATA OUTSIDE THE MGMT PLANS?
WHAT ABOUT MEASUREMENT OF SUCCESS ?
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ROUNDING
ONE OF OUR MOST
UNDERUSED TOOLS
© MSL Healthcare Partners, 2016
EOC ROUNDING REQUIREMENTS
• EC.04.01.01 EP 12 REQUIRES A TOUR EVERY 6
MONTHS IN PATIENT CARE AREAS
• EP 13 REQUIRES AN ANNUAL TOUR IN “ALL” NON
PATIENT CARE AREAS.
• EP 14 STATES THAT THESE TOURS WILL BE USED TO
IDENTIFY DEFICIENCIES, HAZARDS, AND UNSAFE
PRACTICES.
• THIS IS A GREAT TOOL FOR GATHERING DATA.
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WHY WE FAIL AT THE BUILDING TOUR DURING
SURVEYS
• LOOK AT THE COMMON FINDINGS IN HEALTHCARE
AND SEE WHERE THE ROUNDING TOOL WOULD HELP
• 18” FIRE SPRINKLER CLEARANCE
• DOOR WEDGED
• PANELS BLOCKED
• HALL CLUTTER
• O2 BOTTLE STORAGE ISSUES AND ON AND ON
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WHY ARE WE FAILING AT THIS
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IT ISN’T TAKE SERIOUS
NO TIME
NOT TRAINED
NO FOLLOW UP
PROCESS ISSUES
ACCOUNTABILITY
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PROCESS
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2 – 3 PERSON TEAMS
SECTIONED REPORT BY FUNCTION
AUTOMATED
AGGREGATE SCORES
DATA IDENTIFIES AREAS FOR IMPROVEMENT AND
ADDED EDUCATION OF STAFF
• HOW’D THEY DO ON THE LAST SURVEY
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ALL NON PATIENT CARE AREAS
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GROUNDS
PLANT
BUSINESS OCCUPANCIES
CLINICS
SURGERY
CARROT VS STICK FOR DEPARTMENTS
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REVIEW OF FORMS USED
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CAN FIND EXAMPLES ON LINE
WHAT DO YOU USE?
ELECTRONIC WORK FOR ANYONE
SOFTWARE AVAILABLE?
CHANGE UP EACH YEAR TO GET FRESH EYES ON
THINGS.
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EMERGENCY MANAGEMENT
PREPARING FOR THE JOINT
COMMISSION SURVEY
© MSL Healthcare Partners, 2016
SURVEY PROCESS
• DOCUMENTATION NORMALLY REVIEWED
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EMERGENCY OPERATIONS PLAN
ANNUAL PLAN REVIEW
HAZARDS VULNERABILITY ANALYSIS
INVENTORY FOR DISASTERS
96 HR SUPPLY REVIEW
DRILL DOCUMENTATIO
BY-LAWS DESCRIBING VOLUNTEER L.I.P. RULES
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EMERGENCY OPERATIONS PLAN
• THE PLAN DESCRIBES HOW YOU WILL PREPARE FOR A
DISASTER. PLAN INCLUDES:
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COMMUNICATIONS
RESOURCES AND ASSETS
SECURITY AND SAFETY
STAFF
UTILITIES
PATIENTS
DISASTER VOLUNTEERS
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E.O.P STRUCTURE
• FOLLOW A FLOW THAT WORKS FOR YOU
• STATEMENTS SIMILAR TO OTHER MANAGEMENT
PLANS OR POLICY/PROCEEDURES
• USE OF A GUIDE FOR EASE OF SURVEY
• REVIEW EACH STANDARD AND ELEMENT OF
PERFORMANCE TO VERIFY THE PLAN COVERS THE
REQUIREMENT.
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HVA REVIEW
• DEFINITELY WILL BE REVIEWED BY TEAM
– IS IT CURRENT (YEARLY REVIEW REQUIREMENT)
– DO YOU REVIEW IT WITH THE SENIOR LEADERSHIP
– DO YOU REVIEW THE HOSPITAL PLAN WITH THE
COMMUNITY ORGANIZATION FOR EM
– DOES YOUR HVA AND THE COMMUNITY HVA FINDINGS
MATCH (IT IS USED TO DETERMINE SUPPORT NEEDED)
– SYSTEM IMPACT ON A HVA DOCUMENT
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EMERGENCY MATERIAL RESOURSE LIST
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EM.02.01.01 EP 3
COULD BE DIGITAL OR WRITTEN
96 HOUR PLANNING PROCESS
WHY AND HOW THE 96 HOUR LIST PLAYS SUCH AN
IMPORTANT PART IN PLANNING.
• REQUIRES AN ANNUAL REVIEW
• UTILITIES AND COMMUNICATIONS REVIEWED MOST
OFTEN
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VOLUNTEERS
• READ THIS SECTION CAREFULLY IT IS USUALLY
REVIEWED BY SEVERAL MEMBERS OF TJC TEAM
• IDENTIFICATION AND VERIFICATIONS OF
QUALIFICATIONS FOR BOTH LICENSED INDEPENDENT
PRACTITONERS AND
LICENSED/CERTIFIED/REGISTERED VOLUNTEER
PRACTITONER
• MANAGEMENT AND DOCUMENTATION
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DRILLS AND CRITIQUES
• REQUIREMENTS IDENTIFIED IN EM.03.01.03
• TWO ANNUAL DRILLS
• CAN BE ACTUAL EVENTS (DOCUMENT AS A DRILL)
MUST INCLUDE EP’S 13 - 17
• ONE A YEAR IN BUSINESS OCCUPANCIES (THEY
WON’T RECEIVE PATIENTS)
• TABLETOP EXERCISES ARE GREAT, BUT DON’T COUNT
AS A DRILL, BUT CAN SUPPORT A DRILL
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DRILLS AND CRITIQUES II
• ONE MUST BE A COMMUNITY-DESIGNATED DISASTER
DRILL RESPONSE
• ONE MUST INCLUDE AN INFLUX OF SIMULATED
PATIENTS.
• ONE MUST ESCALATE TO A POINT THE COMMUNITY
CANNOT SUPPORT THE FACILITY
• DRILLS OF ANY KIND MUST VERIFY ISSUES IDENTIFIED
IN PRIOR DRILLS WERE REVIEWED FOR CORRECTION
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DRILLS AND CRITIQUES
• MUST USE SCENARIOS THAT ARE IDENTIFIED ON THE
HVA IF POSSIBLE
• MUST MEASURE CRITICAL ELEMENTS IDENTIFIED IN
STANDARD
• MUST BE A DESIGNATED KNOWLEDGEABLE PERSON
EVALUATING THE DRILL
• ACTIVATE PLAN AND EM OPERATIONS CENTER
• IDENTIFY DEFICIENCIES AND OPPORTUNITIES
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NUMBER ONE HIT FROM TJC FOR 1ST QUARTER
OF 2014
• ENVIRONMENT OF CARE NEWSLETTER APRIL 2015
HAS A GREAT ARTICLE ON HOW TO CORRECT THE
IDENTIFIED ISSUES.
• www.jcrinc.com/assets/1/7/echo415_checklist.xls
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COMMON FINDINGS
WHAT IS TJC FINDING
© MSL Healthcare Partners, 2016
AIR PRESSURE/TEMP/HUMIDITY PROBLEMS
• OVER 50% OF HOSPITALS HAVE THIS FINDING
– IS THERE A PLAN TO MANAGE THIS
– WHAT MEASUREMENT OR OVERSITE IS IN PLACE
– WHAT DO YOU DO WHEN IT ISN’T IN STANDARD WITH FGI
GUIDELINES
– WHAT YEAR WAS IT BUILT DICTATES THE FGI USED
– KEY AREAS REVIEWED ON BUILDING TOUR TO VERIFY THE
PLAN IS WORKING
– AUTOMATION VS HANDS ON
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AIR PRESSURE/TEMP/HUMIDITY PROBLEMS II
• HOW TO MANAGE CONSTRUCTION PROJECTS
• FINDING ESCILATES TO A LEADERSHIP AND COP FROM
CMS
• HOW TO BUILD A SOLID PLAN
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FIRE DOORS
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DO A RISK BASED INSPECTION
INVENTORY
USE PFI PROCESS
2012 ADOPTION WILL REQUIRE AN ANNUAL
INSPECTION OF DOORS
• SECURITY HARDWARE
• ROUNDING LOOKING AT THESE?
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EC.02.06.01 ELEMENT OF PERFORMANCE 1
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GENERAL RULE FOR CONDITION OF SPACE
MED GAS OR ELECTRICAL PANELS BLOCKED
FIRE EXTINGUISHER BLOCKED
APPLIANCES NOT IN PM INVENTORY
DAMAGED FLOORS AND UNSAFE CONDITIONS
MEDICAL GAS “E” CYLINDERS NOT SECURE
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MEDICAL GAS MANAGEMENT
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EMPTY AND FULL BOTTLES MIXED
MORE THAN 12 E CYLINDERS IN A ROOM
BOTTLES NOT IN RACK OR SECLURED
BULK TANK ROOM REVIEW
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DOCUMENTATION REVIEW
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ORGANIZED
KNOW YOUR SYSTEMS
ELEMENT OF PERFORMANCE 25 COVERED
REVIEW POINT
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INVENTORY OF DEVICES
FAILED ITEMS FOLLOW THROUGH
ILSM
REPAIR/REPLACE RE-TEST PASS
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GENERATORS
• DOCUMENTATION INCLUDES NAME PLATE RATING
SHOWING WHAT THE 30% LOAD NEEDS ARE FOR THE
GENERATOR
• ALL TRANSFER SWITCHES TESTED MONTHLY
• ANNUAL LOAD BANK DONE AND DOCUMENTED
• 3 YEAR RUN FOR FOUR HOURS
• WHAT IF YOU HAVE A SINGLE GENERATOR, HOW DO
YOU TAKE IT OFF LINE FOR MAINTENANCE?
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MEDICAL GAS SYSTEMS
• DOCUMENTED IN POLICY OR MANAGEMENT PLAN
HOW YOU TEST AND FREQUENCY
• AT LEAST ANNUALLY
• FOLLOW UP ON ALL DISCREPANCIES FROM REPORTS
• MED GAS PANELS LABELED AND CLEAR
• ALARM PANELS NOT BLOCKED
• MASTER ALARM PANEL OBSERVED 24/7
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INFECTION CONTROL
• DAMAGED WALLS/FLOORS CEILINGS IN OR’S
• DIRTY UNITS/SHOWER ROOMS
• DAMAGED GURNEY COVERS, CHAIRS, OR PADDING
FOR TABLES
• ENDOSCOPY SCOPE CLEANING AND STORAGE
• NO ICRA ON CONSTRUCTION PROJECTS
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PENETRATIONS
• WILL REVIEW ON BUILDING TOUR
• AUDIT, NOT A FULL INSPECTION
• MOVE AWAY FROM ABOVE DOORS TO MORE
REMOTE AREAS
• MIXING FIRESTOP MATERIALS
• CABLE MANAGEMENT
• WHILE THEY ARE IN THE CEILING THEY LOOK AT OPEN
JUNCTION BOXES, STUFF TIED TO SPRINKLER LINES
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RISK BASED PM PROGRAM FOR UTILITIES
• FOLLOWS PATTERN USED BY CLINICAL ENGINEERING
• HIGH RISK AND LOW RISK REQUIREMENTS
• BEWARE OF USING 100% FOR LS ITEMS AND A
LOWER STANDARD FOR EQUIPMENT.
• USING AN ALTERNATIVE EQUIPMENT MANAGEMENT
PROCESS
• NO PM REQUIRED, BUT IT IS IN INVENTORY
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GENERAL ITEMS COMMONLY FOUND
• CORRIDOR CLUTTER IS STILL A MAJOR ISSUE IN OUR
HOSPITALS
• SPRINKLER 18” RULE, MIXED HEADS, WIRE TIED TO
LINES
• EYEWASH ISSUES
• PORTABLE POWER STRIP USE
• STAINED AND DAMAGED CEILING TILES
• DISHWASHER TEMPERATURE LOGS INCOMPLETE
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ROUNDING
• IMPRESS THE IMPORTANCE OF THESE ITEMS FOR
OBSERVATION
• IF YOU ARE FINDING IT YOU CAN PICK UP FREQUENCY
OF INSPECTIONS TO VERIFY CORRECTION IS DONE.
• TAKE AWAY THE EASY ONES.
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CHANGES
WHAT’S NEW, WHAT’S NEW ON
THE RADAR AT TJC
© MSL Healthcare Partners, 2016
STANDARDS CHANGES
• 1ST HALF OF 2016 STANDARDS FOR EC, LS, AND EM
HAVE NO CHANGES.
• ARE THE STANDARDS CHANGED IN 2015
INCORPORATED INTO YOUR PROGRAMS
– ALTERNATIVE EQUIPMENT MANAGEMENT REQUIREMENTS
FOR UTILITY SYSTEMS EC.02.05.01 EP 4 AND 5 DISCUSS
THE USE OF AEM
– AEM REQUIREMENTS FOR MEDICAL EQUIPMENT
EC.02.04.01 EP 4 AND 5 DISCUSS THE USE OF AEM
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STANDARDS CHANGES
• NEW IN 2015 EC.02.04.03
– EP 17 & 19 REQUIRES AN ANNUAL DIAGNOSITC MEDICAL PHYSICIST
TESTING AND DOCUMENTATION FOR CT
– EP 20 REQUIRES AN ANNUAL DIAGNOSTIC MEDICAL PHYSICIST OR MRI
SCIENTIST TESTING AND DOCUMENTATION FOR MRI
– EP 21 REQUIRES AN ANNUAL DIAGNOSTIC MEDICAL PHYSICIST OR A
NUCLEAR MEDICINE PHYSICIST TO TEST AND DOCUMENT NM
EQUIPMENT
– EP 22 REQUIRES AN ANNUALDIAGNOSTIC MEDICAL PHYSICIST TESTING
OF PET IMAGING EQUIPMENT
– EP 23 FURTHER IDENTIFIES REQUIREMENTS FOR THESE TESTS.
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CHANGES ON THE HORIZON
• RESTRUCTURE AND DESIGN OF TJC STANDARDS
– CONSOLIDATION OF SOME
– NEW REQUIREMENTS FOR DOCUMENTATION OF ILSM IN THE
ELECTRONIC STATEMENT OF CONDITIONS
– MODIFICATION OF THE ILSM STANDARDS (AT LEAST MOVEMENT OF
SOME OF THE EP’S
– CHANGES TO THE EMERGENCY MANAGEMENT STANDARDS MAY
FOLLOW ONCE THE CMS ROLL OUT THEIR NEW REQUIREMENTS
– CHANGES IN THE BULDING TOUR AND DOCUMENT REVIEW SCHEDULE
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NEW EMPHASIS FROM SURVEYS
•
•
•
•
•
VENTILATION REQUIREMENTS
MEDICAL GAS STORAGE
PORTABLE POWER STRIPS
EMERGENCY MANAGEMENT DRILL DOCUMENTATION
ELECTRONIC STATEMENT OF CONDITIONS BBI
BUILDING CONSTRUCTION TYPE INCLUDED
• HAZARDOUS MATERIALS
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HAZARDOUS MATERIALS AND WASTE
MANAGEMENT EC.02.02.01
• IDENTIFIED AS A PLACE FOR ADDITIONAL FOCUS BY
TJC
–
–
–
–
–
–
INVENTORY
TRAINING
PPE ESPECIALLY EYE WASH STATIONS
EMPLOYEE RIGHT TO KNOW
SPILL PLANS AND STORAGE
MONITORING STAFF EXPOSURE TO CT, PET, NM
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INVENTORY
• ANNUAL INVENTORY REQUIREMENT CONTAINS
– WHAT THE MATERIAL IS
• CHEMICAL NAME AND CHEMICAL ABSTRACT SERVICE
NUMBER OR DOT NUMBER
• COMMON NAME
– WHEN DID THE PRODUCT ARRIVE
– WHAT ARE THE SAFETY REQUIREMENTS
– WHERE ARE THEY STORED
– WHAT IS THE QUANTITY ON HAND
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EYE WASH STATIONS
• REQUIREMENTS FOR INSTALLATION COME FROM CFR
1910.151 (C) IF A SUBSTANCE IS A CAUSTIC OR
CORROSIVE WITH A PH BELOW 2.5 OR ABOVE 11.
• ANSI STANDARD Z 358.1 IS REFERENCED TO IDENTIFY
THE REQUIREMENTS FOR EYE WASH AND SHOWER
INSTALLATION.
• MANY EYE WASH STATIONS NOW INSTALLED ARE NOT
A REQUIRED STATION.
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CORE RULES FROM ANSI Z358.1
•
•
•
•
•
SINGLE MOTION TO ACTIVATE
WATER TEMPERATURE OF 60 – 100 DEGREES
PROPER SIGNAGE
MUST BE CLEAR AND UNOBSTRUCTED
MUST BE WITHIN 10 SECONDS OF HAZARD AND
UNOBSTRUCED (DOORS?)
• FLUSHED WEEKLY, INSPECTED ANNUALLY
DOCUMENTED AND COMPLETE
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MRI COMMON FINDINGS
• USE OF THE FOUR SAFETY ZONES AND THE MAGNET
IS ALWAYS ON SIGNS IN MRI AREAS.
• USE OF NON FERREOUS FIRE EXTINGUISHERS IN THE
IMMEDIATE LOCATION OF THE MRI.
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OSHA AND COMPLIANCE
• WITH HAZARDOUS MATERIALS MANAGEMENT
REMEMBER THE REQUIREMENTS OF OSHA AND
EMPLOYEE RIGHT TO KNOW.
• DOCUMENTED TRAINING FOR PROTECTION OF ALL
STAFF WHEN WORKING IN ANY ENVIRONMENT
• INITIAL, ANNUAL, WHEN ANY CHANGE IS MADE IN
SERVICE OR PRODUCTS
• ALSO IMPACTS FACILITIES FOR OTHER HAZARDS.
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QUESTIONS
• CONTACT INFORMATION
• WM. (BILL MORGAN)
• [email protected]
• 888-951-1114
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© MSL Healthcare Partners, 2016