TIPS FOR BETTER JOINT COMMISSION SURVEYS

Transcription

1 TIPS FOR BETTER JOINT COMMISSION SURVEYS Washington Society for Healthcare Engineering September 21, 2011 Yakima, Washington

2 The BASICS Most Failed Standards. Scoring. Electronic S. O. C. I.L.S.M. Building Tour Systems. Construction Client name/ Presentation Name/ 12pt - 2

3 Top 5 most cited standards Hospitals 2 LS LS EC LS Critical Access Hospitals 1 EC LS EC LS EC Client name/ Presentation Name/ 12pt - 3

4 LS Maintain the integrity of the means of egress. EP 13 Corridor Clutter EP 12 Projections EP Suite issues EP 1 Doors locked in means of egress Client name/ Presentation Name/ 12pt - 4

5 LS Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat. EP 9 Penetrations EP 5 7 Door issues EP 1 & 2 Building Type issues EP 8 Duct issues. Client name/ Presentation Name/ 12pt - 5

6 LS Hospital maintains fire safety equipment and fire safety building features. Documentation of testing Inventory Frequency Client name/ Presentation Name/ 12pt - 6

7 LS The hospital provides and maintains building features to protect individuals from the hazards of fire and smoke EPs Smoke barriers and doors EP 2 Hazardous areas Client name/ Presentation Name/ 12pt - 7

8 LS Maintain building features. EP 9. Walls and wall penetrations EP 5-7 Doors Client name/ Presentation Name/ 12pt - 8

9 GENERATORS EC Monthly test of egress lights (Inventory) Annual test or battery replacement? Required 10% test after replacement. Quarterly test for SEPSS, what counts? Generator monthly (Forms) 30% rule? Don t forget to document transfer switches Generator annual (Time frame) 30 min. at 25%, 30 min at 50%, 60 min at 75% Client name/ Presentation Name/ 12pt - 9

10 Medical Gas Systems EC What does your policy say? Master Alarm Panels, are they in a occupied area 24/7? Zone Alarm Panels, power light on, area served identified? Medical Air moisture and carbon dioxide alarms also? Shut off valves, labeled and clear Client name/ Presentation Name/ 12pt - 10

11 Medical Gas Flexible connections Outlets New Construction and modification/repair requirements? Labels on shut off and alarm panels Make sure you do what you say. E cylinders Client name/ Presentation Name/ 12pt - 11

12 Utilities EC What are you doing to verify AIA Guidelines requirements in your facility? OR temp, pressure, humidity? What about sterile processing? What rooms do you monitor? What time frames do you use? How do you manage water testing? Client name/ Presentation Name/ 12pt - 12

13 Preventive Maintenance EC What do you base your PM system on Formal assessment tool. Inventory what to include? No PM required Shut down policy Emergency procedures and support How do you ID your equipment? Client name/ Presentation Name/ 12pt - 13

14 Building tour Tour is an audit, not a full inspection Sampling vs. full inspection Above ceilings, penetrations, open J boxes, stuff hung from sprinkler lines, fire dampers, mold Doors, latches, damage, plates, toe kicks, labels, match drawings? Fire extinguishers, height, signed, in the green, not obstructed. Client name/ Presentation Name/ 12pt - 14

15 BuildingTour Hall clutter, things obstructing halls Furniture, equipment in halls Storage in stairwells Exit path from building What s on the roof? Look for completed PFI s Suites. Are they on your plans? Client name/ Presentation Name/ 12pt - 15

16 Building Tour Boiler plant, safety, permits/license Medical gas storage room Bulk O2 storage tanks Hazardous materials storage Exit paths clearly identified Kitchen, K extinguisher, hood clean? Bio Hazard management Client name/ Presentation Name/ 12pt - 16

17 Construction? Pre construction risk assessment? Separation from occupied areas? Fire Drills? I.L.S.M. and Fire Watch? Access issues, project cleanliness? General safety on site? Client name/ Presentation Name/ 12pt - 17

18 Questions? Client name/ Presentation Name/ 12pt - 18