2017 Accreditation Updates

Transcription

1 2017 Accreditation Updates Tennessee Healthcare Engineers Association 2017 Spring Conference Pickwick Landing State Park Counce, Tennessee Presented May 17, 2017 By Ken Gregory Vice President, Accreditation TSIG Consulting, Inc.

2 WHAT S NEW? Joint Commission The WORLD has changed! The ENTIRE scoring process has been completely updated The survey process has changed EC Standard/Element of Performance (EP) changes 13 EP s we added 31 EP s were modified 1 EP s deleted # LS standard/ep changes 21 EP s were added 32 EP s were modified 5 EP s were deleted No major changes to EM standard/ep s BUCKLE UP. IT S GONNA BE A LONG YEAR!!

3 WHAT S NEW? For DNV-GL NO scoring/survey process change # Standard/Standard Requirements (SR) changes PE.1 Facility 1 SR added 1 SR revised PE.2 Life Safety 4 SR s added 4 SR s revised PE.3 Safety 2 SR s added 1 SR revised

4 WHAT S NEW? For DNV-GL PE.4 Security Completely re-written. Reduced from 6 to 4 SR s PE.5 Hazmat 2 SR s added 1 SR revised PE.6 Emergency Management Completely re-written Reduced from 7 to 4 SR s PE.7 Medical Equipment 1 SR revised PE.8 Utility NO changes.

5 PREVIOUS TJC SCORING PROCESS There are multiple different tags that The Joint Commission used previously for the Elements of Performance (EPs). For example, they tagged EPs as Direct versus Indirect, A category vs. C category, Measure of Success (MOS) required or not, Risk Icon or not, etc. While the tags attempted to prioritize those EPs that are most critical, they often result in one size fits all follow-up as it is determined by the EP itself rather than the context of the actual finding written under it.

6 THE NEW WORLD BEGINS!

7 SURVEY ANALYSIS FOR EVALUATING RISK (SAFER) MATRIX

8 A new SAFER concept Scope Likelihood to Harm a Patient

9 A New SAFER Matrix

10 Prioritized Follow-up Action Placement of RFI on SAFER Matrix and Follow-Up Activity LOW / LIMITED MODERATE / LIMITED LOW / PATTERN LOW / WIDESPREAD MODERATE/PATTERN MODERATE/ WIDESPREAD HIGH/LIMITED HIGH/PATTERN HIGH/WIDESPREAD Evidence of Standards Compliance (ESC) 60 Evidence of Standards Compliance (ESC) 60 -Plus - Additional fields for sustainment plan Pull into surveyor technology for potential review during subsequent surveys

11 NEW JOINT COMMISSION EC MOTTO They are calling their process: See it, Cite it!!

12 REDUCING POST-SURVEY CLARIFICATIONS What is a Clarification? After a survey event, organizations have the opportunity to submit clarifying ESC if they believe that their organization was in compliance with a particular standard at the time of Survey.

13 RECENT HOSPITAL CLARIFICATIONS 50% of Hospitals (HAP) request Clarifications Dominate clarification themes: Lack of Documentation (65%) Incorrect Findings Survey Process Issues 51% of HAP Clarifications are in the EC & LS Chapters

14 IMPROVE: DOCUMENTATION Required Documents not available at the time of survey will generate RFIs and are not eligible for clarification. The organization must complete the Required Documentation check list prior to the start of survey Sign and date the checklist

15 PRE-SURVEY CHECKLIST: EC, EM & LS

16 PRE-SURVEY CHECKLIST: EC & LS

17 POSSIBLE HOSPITAL CLARIFICATIONS Incorrect findings Findings cited at incorrect Standard/EP Survey finding does not document non-compliance at the cited EP Misinterpretation of standards compliance Corridor clutter in a suite for example Limited opportunities to follow-up with Surveyors i.e. observations discussed but implied they will not be cited until the observation appears in the final report leaving no opportunity to discuss with the surveyor

18

19 2017 STANDARD CHANGES/ADDITONS/DELETIONS FOR TJC AND DNV-GL

20 EC EP 2 DELETED EP 2. Leaders identify an individual(s) to intervene whenever environmental conditions immediately threaten life or health or threaten to damage equipment or buildings. Rational: Duplicate of EC EP 1: Leaders identify an individual(s) to manage risk, coordinate risk reduction activities in the physical environment, collect deficiency information, and disseminate summaries of actions and results.

21 EC EP 9 & 10 DELETED EP 9 If a required emergency power system test fails, the hospital implements measures to protect patients, visitors, and staff until necessary repairs or corrections are completed. EP 10 If a required emergency power system test fails, the hospital performs a retest after making the necessary repairs or corrections. Rationale: Part of regular operations/processes

22 CHANGES TO ELEMENTS OF PERFORMANCE EC , EP 3 When quarterly fire drills are required, at least 50% are unannounced. Fire drills are held at unexpected times and under varying conditions. Added: Fire drills are held at unexpected times and under varying conditions.

23 CHANGES TO ELEMENTS OF PERFORMANCE EC EP 4 Staff who work in buildings where patients are housed or treated participate in drills according to the hospital s fire response plan. Note: When drills are conducted between 9:00 p.m. and 6:00 a.m., the hospital may use alternative methods to notify staff instead of activating audible alarms. Replaced building s fire alarm system. See NFPA , 18/ a coded announcement shall be permitted to be used instead of audible alarms.

24 EC CHANGES/ADDITIONS Ep 2 6 months for testing of vain type flow switches and tamper switches EP 5 Every 12 months for testing fire alarm equipment for notifying off-site responders. EP 6 Now allows monthly testing of fire pump instead of weekly Ep 25 Now requires annual fire and smoke door inspections according to NFPA & NFPA These are detailed inspections

25 EC CHANGES/ADDITIONS EP 4 Requires 100% PM completion rate on High Risk Equipment EP 5 Requires 100% PM completion rate on Infection Control equipment EP 6 No completion rate requirement for non-highrisk equipment UNLESS it is on an Alternate Equipment Maintenance (AEM) program, then there is a 90% completion rate requirement EP 7 Must meet requirements for NFPA chapters 6 for electrical and 9 for HVAC

26 EC CHANGES/ADDITIONS EP 8 Requires annual fuel quality test

27 LIFE SAFETY CHANGES/ADDITIONS LS EP 2 In time frames defined by the hospital, the hospital performs a building assessment to determine compliance with the Life Safety chapter LS EP 1 - Fire watch required if fire alarm system out of service for 4 hours, or fire sprinkler system out for more than 10 hours 14 requirements for ILSM now instead of 11 If during a survey a LS item is cited, and ILSM assessment will be done at that time with the surveyor, and any identified ILSM measure that need to be implemented will be recorded on the report

28 DNV-GL NIAHO STANDARDS PE.1 Facility SR.3 Except as otherwise provided in this section, the hospital must meet the applicable provisions and must proceed in accordance with the 2012 Health Care Facilities Code (NFPA 99 and Tentative Interim Amendments TIA 12-2, TIA 12-3, TIA 12-4, TIA 12-5 and TIA 12-6). Chapters 7 and 8 of the adopted Health Care Facilities Code do not apply to a hospital. If application of the Health Care Facilities Code required under paragraph (c) of this section would result in unreasonable hardship for the hospital, CMS may waive specific provisions of the Health Care Facilities Code, but only if the waiver does not adversely affect the health and safety of patients.

29 DNV-GL NIAHO STANDARDS PE.1 Facility SR.10 The organization, through its senior leadership shall ensure that a tobacco-free policy be developed and enforced campus-wide. Substantial progress toward complete conformity shall be demonstrated over time. DNV GL- Healthcare will permit temporary tobacco use in the areas of the hospital where patient visits may be abbreviated, in behavioral health units and other areas near the main campus that are not under hospital control. In order for this to be permissible the hospital must obtain from the local and/or state fire prevention agencies (Authority Having Jurisdiction or AHJ) written documentation stating that these areas can be used for smoking while the hospital continues to demonstrate progression toward a tobacco free campus over time. (See the PE.1 Interpretive Guidelines for specific direction on this procedure.)

30 DNV-GL NIAHO STANDARDS PE.2 Life Safety SR.1 The hospital must meet the applicable provisions and must proceed in accordance with the 2012 Life Safety Code (NFPA 101 and Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4.) Outpatient surgical departments must meet the provisions applicable to Ambulatory Health Care Occupancies, regardless of the number of patients served.

31 DNV-GL NIAHO STANDARDS PE.2 Life Safety SR.4 The organization must have written fire control plans that contain provisions for prompt reporting of fires; extinguishing fires; protection of patients, personnel, and visitors; evacuation; and cooperation with firefighting authorities. The fire control plan shall provide for the following (NFPA , & ): SR.4a Use of alarms SR.4b Transmission of alarms to fire department SR.4c Emergency phone call to fire department SR.4d Response to alarms SR.4e Isolation of fire SR.4f Evacuation of immediate area SR.4g Evacuation of smoke compartment SR.4h Preparation of floors and building for evacuation SR.4i Extinguishment of fire

32 DNV-GL NIAHO STANDARDS PE.2 Life Safety SR.5 The Life Safety Management System shall include in the elements of SR.4e a written barrier protection plan for the preservation of the integrity of hospital smoke and fire barriers. The plan shall include: Name(s) of Responsible hospital staff for barrier protection program Requirement for written permission for anyone (including all hospital staff, contractors and vendors) to penetrate a smoke or fire barrier wall, ceiling or floor Input from Infection Control and Prevention Practitioner on critical clinical areas prior to issuance of written permit for performing work on barriers Establishment of monitoring process to ensure all work is completed correctly

33 DNV-GL NIAHO STANDARDS PE.2 Life Safety SR.9 Buildings must have an outside window or outside door in every sleeping room, and for any building constructed after July 5, 2016 the sill height must not exceed 36 inches above the floor. Windows in atrium walls are considered outside windows for the purposes of this requirement. The sill height requirement does not apply to newborn nurseries and rooms intended for occupancy for less than 24 hours. The sill height in special nursing care areas of new occupancies must not exceed 60 inches.

34 DNV-GL NIAHO STANDARDS PE.2 Life Safety SR.12 All sleeping rooms shall be equipped with an approved, single station smoke alarm. Note: NFPA 101, : System smoke detectors in accordance with NFPA 72, National Fire Alarm and Signaling Code, and arranged to function in the same manner as single-station or multiplestation smoke alarms shall be permitted in lieu of smoke alarms.

35 DNV-GL NIAHO STANDARDS PE.3 Safety SR.7 All eyewashes and emergency showers shall be tested and maintained according to the ANSI Z Standard. SR.8 The hospital must have procedures for the proper routine storage and prompt disposal of trash. PE.4 Security SR.2 The organization shall meet the requirements set forth in NFPA 99, 2012 Chapter 13, Security Management. SR.3 The Security Management System shall require that the organization conduct a Security Vulnerability Assessment (SVA) and shall implement procedures and controls in accordance with the risks identified by the SVA.

36 DNV-GL NIAHO STANDARDS PE.5 Hazmat SR.5 All compressed gas cylinders in service and in storage shall be individually-secured and located to prevent mechanical shock from falling or being knocked over. PE.6 Emergency Management Re-Written entirely Sr.2 The organization shall meet the requirements set forth in NFPA 99 (2012), Chapter 12, Emergency Management

37 CATEGORICAL WAIVERS Don t need them anymore. They are now part of the code

38 RELATIVE HUMIDITY (RH) CMS S&C Hospital, CAH & ASC letter dated 2/20/2015 stated S&C LSC & ASC permits hospitals and CAH to use a LSC categorical waiver to establish an RH level <35% in anesthetizing (i.e. OR) locations Before electing to use the categorical waiver hospitals and CAHs are expected to ensure the humidity levels in their ORs are compatible with manufactures instructions for use (IFUs) for supplies and equipment used in that setting

39 QUESTIONS

40 Ken Gregory Vice President of Accreditation TSIG Consulting 1001 Olivia Court Mount Juliet, TN (615)