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1 Today s Webcast starts at 1:00 p.m. Eastern. You will not hear audio until the Webcast begins

2 Today's Moderator Cathy Jakicic Editor

3 Today's Presenter Esteban Cota National Business Manager for Fire Safety and Security Services, Siemens Industry, Inc. Esteban Cota is a National Business Manager for Fire Safety and Security Services with Siemens Industry, Inc. With more than 20 years of experience working in the healthcare industry, Cota has worked in roles from the field technical level and project engineering to program management, and service and sales operations. His experience spans handson testing and installing systems to selling systems, along with engineering to business development roles creating programs targeted at the healthcare industry. He is a member of the NFPA 72 Chapter 14 Test and Inspection Technical Committee, as well as a member of the American Society for Healthcare Engineering (ASHE), the International Association for Healthcare Security & Safety (IAHSS), the National Fire Protection Association (NFPA), and the Texas Association of Healthcare Facilities Management (TAHFM).

4 Disclosure: Today s presenter is currently employed by Siemens, which manufactures the technology referenced in this presenta<on.

5 To ask Ques<ons: Please use the ques<on and answer panel on the right- hand side of the screen, and send to all panelists.

6 Polling Ques<ons Today s event will include a series of mul<ple- choice polling ques<ons. Your par<cipa<on is appreciated.

7 Presenta<on Handouts All par<cipants will receive an e- mail by the end of the day with a link to download a PDF copy of today s presenta<on slides.

8 CEU Informa<on Trade Press Media Group has been accredited as an authorized Provider by the International Association for Continuing Education and Training (IACET), 1760 Old Meadow Road, Suite 500, McLean VA 22102; (703) To successfully earn 0.1 CEUs, you must attend the entire webcast and earn a 70% or higher on the assessment.

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14 Best Practices for Meeting Joint Commission Documentation Requirements Testing and Inspection of Fire and Life Safety Systems

15 Agenda q Objectives q Overview / Background q A Closer Look at EP25 q Compliance Challenges q Methods of Compliance q Impact of Non-Compliance q Conclusion Page 15

16 Objectives q Review requirements outlined in EC , specifically documentation management requirements (EP25) q Review challenges in compliance with EC q Discuss best practices for compliance Page 16

17 Overview q Accreditation status vital to hospital s survival; CMS gives Deemed Authority q Condition of Participation (COPs) q Code of Federal Regulations (CFR s) q The Joint Commission (TJC) accredits more than 80% of hospitals in the United States q American Osteopathic Association / HFAP q Det Norske Veritas / NIAHO q Center for Improvement of Healthcare Quality / CIHQ Page 17

18 Overview q TJC Accreditation Manual ü Chapters ü Standards ü Elements of Performance q Environment of Care (EC) Chapter q EC The hospital maintains fire safety equipment and fire safety features q TJC Standard, EC repeatedly makes TJC s top ten list of most frequentlycited standards Page 18

19 Background Joint Commission Standard EC q EC addresses requirements for maintenance, testing, and inspection of fire safety equipment and building features q 6 th most frequently-cited standard in hospital surveys in 2013 q 44% of hospitals non-compliant in 2013 (up from 2012) q Compliance review of EC is extremely documentation-intensive and frequency driven for the task Page 19

20 Increased Focus on Documentation A Closer Look at EP25 q EP 25 added to EC in July of 2011 q Targets the importance of proper documentation and applies to all 20 other EPs in the standard q EP 25 applies whether the documentation is produced by a third-party vendor or inhouse staff q EP 25 only applicable to those hospitals that use The Joint Commission survey for deemed status purposes Page 20

21 Increased Focus on Documentation A Closer Look at EP25 Page 21

22 Challenges in Compliance with EC q Maintenance staff may not understand the differences in maintenance, inspection, and testing activity requirements q Additional training is required to educate staff q Healthcare organizations need to understand source NFPA standard, which governs EP items q Healthcare organization should educate staff about rationale behind the testing Page 22

23 Challenges in Compliance with Documentation Requirements (EP 25) q Missing / incomplete inventories q Failure to record pass / fail result for every item on inventory q No record of correction for device failures and subsequent retest q No indication of NFPA code reference or testing frequency Page 23

24 Polling Ques<ons Today s event will include a series of mul<ple- choice polling ques<ons. Please make your selec<on to the right of this screen.

25 Methods of Compliance q Ensure concise documentation in your in-house and vendor paperwork, including: ü Name of the activity ü Date of the activity ü Required frequency of activity ü Name and contact information, including affiliation, of the person who performed the activity ü NFPA standard(s) referenced for activity ü Results of activity ü Review NFPA 25, 1998 edition (Section 2-1.3) and NFPA 72, 1999 edition (Section 7-5.2) Page 25

26 Methods of Compliance q List the devices on an inventory q Ask outside contractors to include a list of all devices in their bid q Establish process to document and communicate any deficiency items that may arise daily q Create list of action items, including targeted completion dates for correction of items q Avoid non-compliance with Leadership standards (LD , EP4) Page 26 Source: Tips for Documenting Fire Response Testing, Joint Commission Online Newsletter, October 24, 2012 Edition

27 Methods of Compliance q When selecting a vendor to perform the testing, maintenance, and inspection: ü Communicate clear expectations ü Ask for samples of vendor s standard paperwork prior to entering into an agreement ü Ask to demonstrate their knowledge of specific requirements related to healthcare such as Joint Commission standards and CMS standards ü Ask about their company s training programs for their technicians ü Ask for a list of the vendor s team members that will be assigned to the contract and their roles Page 27

28 Methods of Compliance q When selecting a vendor to perform the testing, maintenance, and inspection: ü Ask for a descriptive project approach and work plan ü Ask for the vendor to discuss any difficulties, challenges, or risks they may foresee ü Require the vendor to submit an Annual Delivery Schedule prior to entering into any agreement Page 28

29 Impact of Non-Compliance q Scored for non-compliance at the respective Element of Performance in EC q Most EPs in this standard are indirect impact - 60-day window to respond q The following EPs are direct impact 45-day window for ESC: ü EP 4: Visual and audible fire alarms, including speakers ü EP 11: Fire pump under flow ü EP 19: Smoke detection shutdown for air handling equipment Page 29 3 Direct Impact Icon

30 Impact of Non-Compliance q Risk icon introduced with 2013 standards updates indicates an identified risk q Denotes EPs that must be assessed through new Focused Standards Assessment (FSA) process q Risk assessed by system s proximity to patient, probability of harm, severity of harm, and number of patients at risk q The following EPs are identified as risk factors: ü EP 4: Visual and audible fire alarms, including speakers ü EP 11: Fire pump under flow ü EP 19: Smoke detection shutdown for air handling equipment Page 30 R Risk Icon

31 Impact of Non-Compliance q Failure to comply with EC can also be scored at the Leadership chapter of The Joint Commission accreditation manual for failure to hold staff accountable (LD , EP 4) q Adds one more item to which the hospital must respond Page 31

32 Conclusion q Maintenance, testing, and inspection must be performed as required by NFPA and expected by TJC in compliance with federal regulations q For EC , survey outcome heavily dependent on testing documentation q Non-compliance increased from 40% (2012) to 44% (2013) q Inventory and itemized listing for each system / component and device q Supporting documentation to close the loop on each failure, to include dates corrected, retested, and passing Page 32

33 Conclusion q A solid documentation management system is crucial q If reports and documentation are completed inhouse, training and obtaining the necessary qualification for in-house personnel is key q If documentation is provided by an outside vendor, take the time to interview and request samples q Working in a healthcare facility is unique compared to other industries. There are additional layers of consciousness that need to be considered by staff and vendors Page 33

34 Conclusion Best Practices for Success q Compliance - setting a priority focus on fire & life safety and the impact it has to patient safety and care q Organization - implementing a proven scheduling and documentation system q Technical - a testing and inspection team that understands life safety systems and applies the NFPA standards while performing the required task q Acumen - a commitment of being versed in the healthcare accreditation process and requirements Page 34

35 Contact Siemens Esteban Cota National Business Development Mgr Siemens Industry, Inc. Building Technologies 1000 Deerfield Parkway Buffalo Grove, IL Phone: usa.siemens.com/fire-healthcare-accreditation Page 35