2017 CHALLENGING STANDARDS 2018 NEW ELEMENTS OF PERFORMANCE HOSPITAL ENVIRONMENT OF CARE AND

Transcription

1 CHALLENGING STANDARDS AND 2018 NEW ELEMENTS OF PERFORMANCE IN HOSPITAL ENVIRONMENT OF CARE James Woodson, Engineer Engineering Department The Joint Commission

2 DISCLOSURE STATEMENT Disclosure Statement The following staff and speakers have disclosed that they do not have any financial arrangements or affiliations with corporate organizations that either provide educational grants to this program or may be referenced in this activity: James Woodson Leslie LaBelle George Riccio Steve Chinn The listed staff and speakers have verbally disclosed their arrangements and affiliations: Not Applicable to this presentation Furthermore, each of the previously named speakers has also attested that their discussions will not include any unapproved or off-label use of products. Department of Engineering

3 PUBLICATIONS AND RECORD RESTRICTIONS The program may be electronically recorded by JCR and is subject to the protection of the copyright laws of the US. No individual or entity other than JCR may electronically record any portion of these programs for any purpose without the written permission of JCR. Any and all reproduction or publication of these proceedings and programs for commercial purposes by anyone other than JCR is prohibited. Department of Engineering

4 PUBLICATIONS AND RECORD RESTRICTIONS Copyright 2017 by Joint Commission Resources, Inc. All rights reserved. No part of this publication may be reproduced in any form or by any means without written permission from the publisher. Request for permission to make copies of any part of this work should be mailed to: Publication and Education Resources, Joint Commission Resources, 1515 West 22 nd Street Suite 1300W, Oak Brook, Illinois Department of Engineering

5 NFPA ADOPTION / IMPLEMENTATION CMS adopted 2012 edition of NFPA 101 and NFPA 99 Federal Register / Vol. 81, No. 86 / Wednesday, May 4, 2016 / Rules and Regulations for detail July 5, 2016 Accrediting Organizations (AO) began surveying exclusively to NFPA As of November 1, 2016 As an AO The Joint Commission followed suit Department of Engineering

6 PROPOSED ELEMENTS OF PERFORMANCE Organizations are required to be in compliance with the full adopted content of the adopted codes See wildcard elements of performance Example, EC EP 7 meets all other requirements related to NFPA Ch 6 Electrical Systems and Ch 9 HVAC Standards / Elements of Performance were revised and sent to CMS for approval For July 2017 publication (current manual) More changes directed by CMS Release date is January 2018 Department of Engineering

7 TOP 10 FINDINGS COMPARISON (JAN JUN 2017) Standard % Noncompliant Summary LS % Maintains systems for extinguishing fires LS % Maintains building features protect from fire/smoke EC * 73% Manages risks associated with its utility systems IC % Reduces risk of infections EC * 68% Maintains a safe, functional environment LS % Minimizes the effects of fire, smoke, and heat EC * 62% Manages risks associated with hazardous materials LS % Maintains the integrity of the means of egress EC * 60% Inspects, tests, and maintains utility systems RC % Accurate medical records for each individual patient * EC in Top 10 noted within presentation Department of Engineering

8 EC MINIMIZE RISKS Individual(s) assigned to manage risk and to intervene for environmental threats Management plans EP 3 (new 2018) Library of service manuals, instruction manuals, technical bulletins, etc. Electronic or written Use to establish maintenance program and policies/procedures, manage unexpected events Department of Engineering

9 EC MANAGES SAFETY AND SECURITY RISKS No 2018 change Environmental risk assessment Minimize or eliminate identified risks Maintain facility entry/exiting risks Manage security sensitive areas Respond to notices and recalls Manage MRI safety risks Department of Engineering

10 EC PROHIBIT SMOKING Develop a policy (applies to tobacco and electronic) Take action to maintain compliance EP 4 (new 2018) Manage at-risk patients using oxygen NFPA TIA 12-6 Smoking materials removed from respiratory therapy patients No solid fuel burning appliances or ignition sources were oxygen is used No nonmedical appliances with hot surfaces or sparking mechanisms Department of Engineering

11 EC MANAGES HAZ MATERIAL & WASTE * No 2018 change Hazardous material and waste inventory Establish policies, procedures, precautions Protective and post-event equipment and supplies Manage hazardous chemicals, energy sources, medications, vapors and gasses, trash per SDS, regulation (federal & state) and accepted practices Radiation management in diagnostic imaging Proper hazard labeling and management of records Train staff and provide needed resources Department of Engineering

12 EC MANAGES FIRE RISKS Risks may include open flames, combustible items, etc. Unobstructed path of egress in Business occupancy EP 9 (modified 2018) Fire response plan Duties at and away from origin for staff and LIPs Staff instruction; copy of plan kept at PBX or Security EP 11 (new 2018) Surgical fire safety - planning NFPA Fire Loss Prevention in ORs Procedures and periodic evaluations for flammable germicides or antiseptics Department of Engineering

13 EC MANAGES FIRE RISKS EP 12 (new 2018) Surgical fire safety - implementation Flammable germicides or antiseptics Nonflammable packaging, safe unit does, time out, dry application site, no pooling, remove soaked materials EP 13 (new 2018) Wildcard NFPA Ch 15 Features of Fire Protection Labs, utilities, operating rooms, fire alarms Department of Engineering

14 EC CONDUCTS FIRE DRILLS At least 1 drill per shift per quarter 1 drill per year in Business occupancies Activate the fire alarm Audible alarms can be silenced from 9pm to 6am Drills critique the fire response in relation to the plan EP 3 (modified 2018) Drills at unexpected times and under varying conditions Move the point of origin; space throughout the shift Removed at least 50% unannounced Department of Engineering

15 EC MAINTAINS FIRE SAFETY SYSTEMS Fire alarms, fire sprinklers, suppression systems, portable fire extinguishers, fire-rated doors If installed and identified by an EP, then maintain as described Inventory required EP 25 (note) Fire-rated door inspection CMS S&C 17-38: compliance by Jan 1, 2018; specifies requirements at NFPA 80 EP 27 (new 2018) Test elevator firefighter s service Monthly check (by staff or elevator contractor) Department of Engineering

16 EC MANAGES MEDICAL EQUIPMENT No 2018 change Identify medical equipment (see glossary) Create an inventory Maintenance activities per manufacturers recommendations Monitor and report incidents Quality control activities for imaging equipment Procedures and clinical intervention if equipment fails Department of Engineering

17 EC MANAGES MEDICAL EQUIPMENT EP 4 (note) Identify maintenance activities Manufacturers recommendations or an AEM program Note 1: AEM uses accepted practices Note 2: (Jul 2017) Removed > 90% allowance (< 10% deferral) for non-high-risk equipment Note 3: (Jul 2017) Completion rate 100% of schedule regardless of high-risk or non-high risk regardless of mfg recommendations or AEM Tip: use the AEM to extend intervals, minimum run time; but do not compromise program effectiveness Department of Engineering

18 EC MAINTAINS MEDICAL EQUIPMENT Check before initial use Adhere to maintenance schedule Emergency equipment maintained by qualified staff Maintain sterilization equipment high purity water for dialysis nuclear medicine diagnostic imaging Department of Engineering

19 EC MAINTAINS MEDICAL EQUIPMENT EP 8 (new 2018) Equipment used in a oxygen-rich environment Proper labeling gas designation, durable, color coding not the primary method Cylinders, pressure-regulators, metering (flowmeters), pressure-reducing, dispensing (humidifier and nebulizers) EP 10 (new 2018) Wildcard NFPA Ch 14 Hyperbaric Facilities Determine if Class A (multi-occupant) or Class B (single occupant) Department of Engineering

20 EC MAINTAINS MEDICAL EQUIPMENT EP 26 (new 2018) Maintain anesthesia apparatus Maintain/service in a clean area Maintain per schedule After adjusted/modified/repaired tested at the final path to the patient After maintenance check all connections before use Remove defective equipment from service Department of Engineering

21 EC MAINTAINS MEDICAL EQUIPMENT EP 27 (note 2018) Wildcard NFPA Ch 10 Electrical Equipment Patient care-related electrical appliances and equipment Patient vicinity: 6 ft radius around the patient Department of Engineering

22 EC MANAGES UTILITY SYSTEMS * Design per applicable NFPA codes NFPA 99 and NFPA 101 with mandatory references and adopted TIAs Identify utility systems (see glossary) Create an inventory; identify high-risk equipment Maintenance activities per manufacturers recommendations; or an AEM if allowed AEM vetting by qualified individual(s) Department of Engineering

23 EC MANAGES UTILITY SYSTEMS * Provide/manage ventilation for IC using ASHRAE 170 NFPA Ch 9 for Critical spaces: evidence of continuous compliance Non-critical spaces: sampling during survey Manage waterborne pathogens for IC CMS S&C Reduce Legionella Risk Map systems as built consolidate building phases Procedures and clinical interventions if eqp fails Department of Engineering

24 EC MANAGES UTILITY SYSTEMS * NFPA adopted Chapters: less IT and Plumbing Chapter 1 Administration Chapter 2 Referenced Publications Chapter 3 Definitions Chapter 4 Fundamentals Chapter 5 Gas and Vacuum Systems Chapter 6 Electrical Systems Chapter 9 HVAC Chapter 10 Electrical Equipment Chapter 11 Gas Equipment Chapter 14 Hyperbaric Facilities Chapter 15 Features of Fire Protection Department of Engineering

25 EC MANAGES UTILITY SYSTEMS * EP 2 (new 2018) Establish design Category by risk assessment Use NFPA Ch 4 to establish Category; design infrastructure accordingly per system Chapter Within system Chapter, take note of existing compliance requirements Assess existing does not constitute a distinct hazard to life Department of Engineering

26 EC MANAGES UTILITY SYSTEMS * EP 20 (new 2018) Operating rooms are considered wet locations with isolated power or GFCI NFPA Ch 6 Unless otherwise determined by risk assessment EP 21 (new 2018) Design/install electrical distribution to support patient risk Category NFPA Ch 6 Determines Type 1/2 EES (Egen), or Type 3 (battery) see CMS S&C Department of Engineering

27 EC MANAGES UTILITY SYSTEMS * EP 22 (new 2018) Use of hospital-grade receptacles NFPA Ch 6 At patient beds, sedation/anesthesia Properly labeled and tested Tamper-resistant in pediatric locations Department of Engineering

28 EC MANAGES UTILITY SYSTEMS * EP 23 (modified 2018) Multi-outlet devices (power strips/relocatable power taps) NFPA Ch ; CMS S&C Applicable to patient vicinity Permanently attached; properly sized for the loads Check patient med eqp power strip wall plug TIA 12-5 removes requirement to cover unused plugs Use UL 1363A or UL (patient vicinity); UL 1363 (away from patient vicinity) Department of Engineering

29 EC MANAGES UTILITY SYSTEMS * EP 24 (new 2018) Extension cords No permanent extension cords EP 25 (new 2018) Design/install piped medical gas/vacuum to support anesthetizing locations NFPA Ch 5 Placement of shut-off valves, alarm sensors and alarm panels; alarming criteria (20%, 12 in-hgv deviation) Department of Engineering

30 EC MANAGES UTILITY SYSTEMS * EP 26 (new 2018) Electrical power to support anesthetizing locations NFPA Ch 6 EES Critical Branch: illumination, equipment power, receptacles, ventilation Department of Engineering

31 EC EMERGENCY ELECTRICAL SOURCE Design per NFPA Ch 6 since 1983 EES branches: life safety, critical, equipment Emergency power within 10-seconds of loss Alarm systems, illumination, communications, critical and life support systems, critical areas Egen remote stop device and annunciator; batterypowered task light Department of Engineering

32 EC EMERGENCY ELECTRICAL SOURCE EP 4 (new 2018) Exit route and Exit sign illumination NFPA Ch 18/ & 18/ ; NFPA Ch 6 Task illumination reqmts at anesthetizing locations EP 12 (new 2018) Elevators NFPA ; NFPA Ch 6 Design freedom (like staging) as long as appropriate service to non-ambulatory patients is provided EP 16 (new 2018) Emergency supply source Task illumination per NFPA Department of Engineering

33 EC MAINTAINS UTILITY SYSTEMS * Established/implemented process to manage risks to patients during repair and maintenance activities Check systems before initial use Adhere to subsequent maintenance schedule Same 100% of schedule maintenance completion requirements as for medical equipment Meet the requirements of NFPA Ch 6 Electrical Systems and Ch 9 HVAC Department of Engineering

34 EC MAINTAINS UTILITY SYSTEMS * EP 7 (new 2018) Maintain line isolation monitors NFPA Ch 6 LIM testing monthly or annually self-testing; per mfg recommendations for regular maintenance Department of Engineering

35 EC MAINTAINS EMERGENCY POWER EQP No 2018 change Illumination tests/inspections: inventory; monthly and annual for egress, Exit signs, task lights SEPSS per NFPA : monthly inspection, annual test, mfg recommendations EPSS (Egen to ATS load side): weekly inspection Egen / ATS: monthly test; 30 continuous minutes under load (unloaded cool-down not included) Egen: annual load bank if needed; 4-hour load test Egen fuel quality: annual test per ASTM; specific tests per assessment of conditions Department of Engineering

36 EC MAINTAINS MED GAS / VACUUM SYS Design, install, maintain, operate per NFPA Ch 5 Gas and Vacuum Systems and Ch 11 Gas Eqp Inventory/maintain source, distribution, inlet/outlets, and the alarms that protect them When systems are modified, before use, check purity, correct gas, and proper pressure Bulk oxygen systems are properly configured, offset from other risks, and properly labeled Emergency oxygen connection properly configured Department of Engineering

37 EC MAINTAINS MED GAS / VACUUM SYS EP 1 (new 2018) Design criteria Category 1, 2, or 3 determined by NFPA Ch 4 assessment then use NFPA Ch 5 EP 2 (new 2018) Master, area and local alarm criteria As applicable to the assessed Category EP 3 (new 2018) Cylinders, containers, tanks Properly designed, fabricated, tested, and marked Department of Engineering

38 EC MAINTAINS MED GAS / VACUUM SYS EP 4 (new 2018) Spaces containing gasses signage Oxygen and Medical Air "Medical Gases: NO Smoking or Open Flame Other gasses Positive Pressure Gases: NO Smoking or Open Flame. Room May Have Insufficient Oxygen. Open Door and Allow Room to Ventilate Before Opening. EP 5 (new 2018) Spaces where cylinders are stored Signage "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING. Cylinders used in order of which received Department of Engineering

39 EC MAINTAINS MED GAS / VACUUM SYS EP 6 (new 2018) Cylinder storage Room design and storage limits based upon aggregate volume < 300 cu-ft < 3,000 cu-ft > 3,000 cu-ft Spacing from combustibles from oxidizing gasses Individual cylinders available for immediate use EP 12 (modified 2018) Cylinder management Storage full vs empty labeling, segregation Protected from contamination, damage, contact with oil and grease, temperature extremes Department of Engineering

40 EC MAINTAINS MED GAS / VACUUM SYS EP 13 (new 2018) Transfilling criteria Prohibited in a patient care room Separated by 1-hr fire-rated construction No mixing of gasses Criteria for transfilling of liquid oxygen; room design and storage Department of Engineering

41 EC MAINTAINS SAFE / FUNCTIONAL ENV * No 2018 change Interior spaces meet patient needs Acute care inpatient behavioral health environment criteria harm-resistive Provides separate waiting and post-anesthesia recovery areas. Lighting is suitable Clean spaces Provide emergency access to all locked and occupied spaces Department of Engineering

42 EC CONSTRUCTION RISK MITIGATION No 2018 change Construct per state rules and regulations, 2014 FGI, reputable guidelines Assess construction risks, create a mitigation strategy, and implement effectively Assess shielding requirements and effectiveness for imaging equipment and radioactive material storage Department of Engineering

43 EC STAFF / LIP RESPONSIBILITIES Staff and LIPs can identify environmental risks encountered, know how to take appropriate action and know how to inform those that can take action EP 1 (new 2018) Staff are trained and are competent in their duties Those responsible for maintaining and using environment of care-related systems and equipment No specific certification or credential requirements Department of Engineering

44 EC XX MONITOR/ASSESS/IMPROVE THE ENV No 2018 change Continually monitor the environment of care EC meetings, environmental tours, work request system, staff feedback, incident report, environmental evaluations Investigate and report Representatives from clinical, administrative and support services analyze data and other information Steps are taken to improve the environment of care Department of Engineering

45 KEY POINTS Use NFPA 99 properly assessment, new versus existing know what is applicable to you Review Federal Register / Vol. 81, No. 86 / Wednesday, May 4, 2016 / Rules and Regulations Review CMS S&C letters Conduct/document risk assessments Train in-house staff and select competent, reliable contractors Department of Engineering

46 the_physical_environment.aspx Department of Engineering

47 TJC Connect: intranet site Leading Practice Library: Resources and Tools E-alerts: via s Perspectives: monthly publication EC News: monthly publication the_physical_environment.aspx Department of Engineering

48 DEPARTMENT OF ENGINEERING George Mills, MBA, FASHE, CEM, CHFM, CHSP, Green Belt Director Andrea Browne, PhD., DABR Medical Physicist Kate Dolezal Technical Coordinator John Maurer, CHFM, CHSP, SASHE Engineer Herman McKenzie, MBA, CHSP Engineer Kathy Tolomeo, CHEM, CHSP Engineer James Woodson, P.E., CHFM Engineer Department of Engineering