Top 8 Findings & SAFER Matrix for the 2017 ACE Summit & Expo

Transcription

1 Top 8 Findings & SAFER Matrix for the 2017 ACE Summit & Expo February 20, 2017 Atlanta, GA Larry F. Rubin CHFM, CHSP, CPE, CEM Life Safety Code Surveyor The Joint Commission Engineering Department

2 Disclosure Statement The employees and/or speakers for this presentation 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. Furthermore, each of the previously named speakers has also attested that their discussions will not include any unapproved or off-label use of products. Engineering Department

3 Learning Objectives: At the conclusion of this presentation, the participant will be able to: ID the top 8 compliance issues in the LS & EC areas Be able to describe and implement tips for a successful survey Understand the new survey process using the SAFER Matrix Engineering Department

4 Top Eight Cited Standards: Standard EC : Built Environment #1 #1 #8 #7 EC : Utility Systems Risks #3 #2 #4 #10 LS : Means of Egress #4 #4 #1 #2 LS : Protection #6 #8 #6 #6 LS : General Building Requirements #7 #7 #3 #3 LS : Extinguishment #8 #9 #9 #9 EC : Fire Safety Systems #9 #6 #7 #5 EC : HazMat & Waste #10 #10 #11 #11 Please Note: Other standards not listed are clinical or leadership related. Engineering Department

5 Engineering Department Copyright, The Joint Commission

6 WHY? Engineering Department

7 January 2017 EC The hospital manages risks associated with its utility systems Engineering Department

8 EC Top Findings (Based on 1,111 findings) #1 - Inappropriate Room Pressurization findings (42.2%) #2 Failure to Label Electric Panel findings (27.4%) #3 Lack of Emergency Lighting - 83 findings (7.5%) #4 Failure to Label Utilities - 59 findings (5.3%) #5 Inappropriate Electrical Issues - 47 findings (4.2%) Engineering Department

9 #1 - Inappropriate Room Pressurization findings (42.2%) NEED PIC Engineering Department

10 #2 Failure to Label Electric Panel findings (27.4%) Engineering Department

11 #3 Lack of Emergency Lighting - 83 findings (7.5%) NEED PIC Engineering Department

12 #4 Failure to Label Utilities - 59 findings (5.3%) NEED PIC Engineering Department

13 #5 Inappropriate Electrical Issues - 47 findings (4.2%) Engineering Department

14 #5 Inappropriate Electrical Issues - 47 findings (4.2%) Engineering Department

15 January 2017 LS The hospital maintains the integrity of the means of egress. Engineering Department

16 LS Top Findings (Based on 1,573 findings) #1 - Obstructions in Means of Egress findings (32.2%) #2 Inappropriate Electromagnetic Lock Usage findings (16.9%) #3 Inappropriate Locking Mechanisms findings (11.1%) #4 Suite Issues findings (10.4%) #5 Storage in Stairways findings (9.2%) Engineering Department

17 #1 - Obstructions in Means of Egress findings (32.2%) Engineering Department

18 #1 - Obstructions in Means of Egress findings (32.2%) Engineering Department

19 #2 Inappropriate Electromagnetic Lock Usage findings (16.9%) NEED PIC Engineering Department

20 #3 Inappropriate Locking Mechanisms findings (11.1%) NEED PIC Engineering Department

21 #4 Suite Issues findings (10.4%) An accommodation with two or more contiguous rooms comprising a compartment, with or without doors between such rooms, that provides sleeping, sanitary, work, and storage facilities. And: A series of rooms or spaces or a subdivided room separated from the remainder of the building by walls and doors. Engineering Department

22 #5 Storage in Stairways findings (9.2%) Engineering Department

23 #1 - Obstructions in Means of Egress findings (32.2%) Engineering Department

24 January 2017 EC The hospital establishes and maintains a safe, functional environment. Engineering Department

25 EC Top Findings (Based on 3,109 findings) #1 - Medical Gas Storage Cylinder findings (30.0%) #2 Safety Hazard findings (16.3%) #3 - Air Flow & HVAC Issues findings (8.8%) #4 - OR Humidity findings (7.7%) #5 - Nurse Call Pull Cord findings (6.6%) Engineering Department

26 #1 - Medical Gas Storage Cylinder findings (30.0%) Engineering Department

27 #2 Safety Hazard findings (16.3%) Engineering Department

28 #3 - Air Flow & HVAC Issues findings (8.8%) Ventilation: i.e. doors held open by air pressure; odors Temperature: Hot / Cold calls Humidity Primary concern is for areas >60%RH o Mold growth is possible Guidelines for Design & Construction of Health Care Facilities, FGI Engineering Department

29 Air Balance Issues con t This is NOT considered repaired Engineering Department

30 #4 - OR Humidity findings (7.7%) Engineering Department

31 #4 - OR Humidity findings (7.7%) Engineering Department

32 #5 - Nurse Call Pull Cord findings (6.6%) Engineering Department

33 EC The January 2017 hospital maintains fire safety equipment and fire safety building features. Engineering Department

34 EC Top Findings (Based on 2,172 findings) #1 - Lack of Inventory findings (30.0%) #2 - Insufficient Documentation findings (28.5%) #3 - Standard not Listed findings (20.5%) #4 - Incorrect Duration 316 findings (14.5%) #5 - Incorrect Test Method - 88 findings (4.1%) #6 Repairs not Performed - 22 findings (1.0%) Engineering Department

35 #1 - Lack of Inventory findings (30.0%) Engineering Department

36 #2 - Insufficient Documentation findings (28.5%) Engineering Department

37 Time Defined The Joint Commission EC chapter defines time as: Daily, weekly, monthly are calendar references Quarterly is once every three months +/- 10 days Semi-annual is 6 months from the last scheduled event month +/- 20 days Annual is 12 months from the last scheduled event month +/- 30 days 3 years is 36 months from the last scheduled event month +/- 45 days NOTE 1: The above does not apply to required frequencies NOTE 2: An alternative of developing either a unique, written policy or adopting NFPA definitions when available is acceptable Engineering Department

38 #5 - Incorrect Test Method - 88 findings (4.1%) It s important to compare this test s results to previous fire-pump-under-flow tests to look for any system degradation. This comparison is typically done using a performance (graphic) curve of pressure versus flow but can also be accomplished with written data. Engineering Department

39 #6 Repairs not Performed - 22 findings (1.0%) Engineering Department

40 January 2017 LS Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat. Engineering Department

41 LS Top Findings (Based on 2,354 findings) #1 - Penetrations findings (40.9%) #2 - Fire Door Failure findings (30.1%) #3 Fire ratings findings (7.5%) #4 - Fire Door Hardware findings (7.0%) #5 - Fire Door Labels findings (6.3%) Engineering Department

42 #1 - Penetrations findings (40.9%) Engineering Department

43 #2 - Fire Door Failure findings (30.1%) Engineering Department

44 #3 Fire rating findings (7.5%) Fire door to mechanical room Engineering Department

45 #4 - Fire Door Hardware findings (7.0%) Engineering Department

46 #5 - Fire Door Labels findings (6.3%) Engineering Department

47 LS The hospital provides and maintains building features to protect individuals from the hazards of fire and smoke. Copyright, The Joint Commission Smoke barriers extend from the floor slab to the floor or roof slab above, through any concealed spaces (such as those above suspended ceilings and interstitial spaces), and extend continuously from exterior wall to exterior wall. All penetrations are properly sealed. Engineering Department

48 LS Top Findings (Based on 2,488 findings) #1 - Door Issues findings (38.8%) #2 - Penetrations findings (22.0%) #3 - Latch Failure findings (13.7%) #4 Smoke barriers findings (8.4%) #5 - Suite Issues findings (8.3%) #6 Separation of Hazardous Areas findings (7.6%) Engineering Department

49 #1 - Door Issues findings (38.8%) Engineering Department

50 #2 - Penetrations findings (22.0%) Engineering Department

51 #3 - Latch Failure findings (13.7%) Engineering Department

52 #4 Smoke barriers findings (8.4%) Engineering Department

53 #5 - Suite Issues findings (8.3%) Suites are used to create groupings of rooms and spaces that can function more efficiently than individual rooms located off of a corridor. The specific limitations on suite size and design in the 2000 LSC limit their efficiency and the ability for facilities to accommodate suites in their building space, which results in undue burden. Sections 18/ of the 2000 LSC requires every habitable room to have an exit access door leading directly to an exit access corridor; Allows for exit access from a suite to include intervening rooms only under certain circumstances; Requires suites of certain size to have two exit access doors remotely located from one another; And limits the size of sleeping room suites to 5,000 ft2. In the 2006 LSC, NFPA began to include additional provisions to further accommodate the use of suites, and continue to be reflected in sections 8/ of the 2012 LSC. See CMS Waiver Engineering Department

54 2012 LSC 18/ Suites 18/ (B) which allow, under certain circumstances, one of the exit access doors in a sleeping suite be permitted to be directly to an exit stair, exit passageway or exit to the exterior; 18/ (B) which allow, under certain circumstances, one of the exit access doors in a non-sleeping suite be permitted to be directly to an exit stair, exit passageway or exit to the exterior; 18/ which allow, under certain circumstances, suites to be separated by corridor wall requirements; Engineering Department

55 #6 Separation of Hazardous Areas findings (7.6%) Engineering Department

56 LS The hospital provides and maintains equipment for extinguishing fires. January 2017 Piping for approved automatic sprinkler systems is not used to support any other item. Sprinkler heads are not damaged and are free from corrosion, foreign materials, and paint. There is 18 inches or more of open space maintained below a sprinkler deflector to the top of storage. The hospital meets all other Life Safety Code automatic extinguishing requirements related to NFPA : 18/ Prior to July 5 th, 2016 is considered existing. (Approved plans) Engineering Department

57 LS Top Findings (Based on 2,444 findings) #1 - Cables/Wiring findings (19.6%) #2 - Dust/Foreign Material findings (18.1%) #3 - Ceilings/Installation/Damage findings (16.9%) #4 - Storage/Signage findings (13.8%) #5 - Fixtures/Equipment findings (13.1%) #6 - Escutcheon/Obstructions findings (11.7%) Engineering Department

58 #1 - Cables/Wiring findings (19.6%) NEED PIC Engineering Department

59 #1 - Cables/Wiring findings (19.6%) Engineering Department

60 #2 - Dust/Foreign Material findings (18.1%) Engineering Department

61 #3 - Ceilings/Installation/Damage findings (16.9%) Engineering Department

62 This is NOT considered art Engineering Department

63 #4 - Storage/Signage findings (13.8%) Engineering Department

64 #5 - Fixtures/Equipment findings (13.1%) (EP 4 & EP 6) Engineering Department

65 #6 - Escutcheon/Obstructions findings (11.7%) NEED PIC Engineering Department

66 #6 - Escutcheon/Obstructions findings (11.7%) Engineering Department

67 EC The hospital manages risks related to hazardous materials and waste. January 2017 The hospital minimizes risks associated with selecting, handling, storing, transporting, using, and disposing of hazardous chemicals. The hospital minimizes risks associated with selecting and using hazardous energy sources. Engineering Department

68 EC Top Findings (Based on 1,150 findings) #1 - Eye Wash None findings (26.7%) #2 - Eye Wash Inspection findings (16.7%) #3 - Eye Wash Temperature findings (12.0%) #4 - Lead Apron Inspection findings (8.9%) #5 - Lead Apron Storage - 54 findings (4.7%) Engineering Department

69 #1 - Eye Wash None findings (26.7%) Engineering Department

70 #2 - Eye Wash Inspection findings (16.7%) Engineering Department

71 #3 - Eye Wash Temperature findings (12.0%) What is tepid water? For the purposes of eyewash safety, the American National Standards Institute (ANSI) defines it as between 60 and 100 F. Engineering Department

72 #4 - Lead Apron Inspection findings (8.9%) Engineering Department

73 #5 - Lead Apron Storage - 54 findings (4.7%) Engineering Department

74 Survey Analysis for Evaluating Risk (SAFER) A transformative approach for identifying and communicating risk levels associated with deficiencies cited during surveys Helps organizations prioritize and focus corrective actions Provides one, comprehensive visual representation of survey findings Replaces current scoring methodology Implementation: January 2017 Was implemented June 6 th, 2016 for deemed Psychiatric Hospitals only Engineering Department

75 Likelihood to Harm a Patient/Visitor/Staff A Picture is Worth 1000 Words Immediate Threat to Life HIGH MM , EP8 MM , EP7 MODERATE MS , EP5 PC , EP4 PC , EP6 PC , EP1 PC , EP5 IM , EP3 MS EP1 MS , EP3 IC , EP2 IC , EP4 LOW RC , EP19 RC , EP4 LIMITED PATTERN WIDESPREAD

76 What is NOT Changing? 1. Adverse decision process 2. Immediate Threat to Life process Determination of Condition Level Deficiency (CLD) process (applies to those using TJC for deeming purposes) 3. Onsite survey activities utilized during survey (i.e. Tracer Methodology, Record Review, etc.) 4. Risk icons within ICM will remain same Engineering Department

77 Questions? Engineering Department

78 Accreditation and Certification Operations (ACO) Tim Markijohn, MBA/ MHA, CHFM, CHE Field Director Larry F. Rubin, M.Ed., CHFM, CHSP, CPE, CEM, Green Belt Life Safety Code Surveyor Engineering Department

79 The Joint Commission Disclaimer These slides are current as of January The Joint Commission reserves the right to change the content of the information, as appropriate. These slides are only meant to be cue points, which were expounded upon verbally by the original presenter and are not meant to be comprehensive statements of standards interpretation or represent all the content of the presentation. Thus, care should be exercised in interpreting Joint Commission requirements based solely on the content of these slides. These slides are copyrighted and may not be further used, shared or distributed without permission of the original presenter or The Joint Commission. Engineering Department

80 Engineering, Facilities & Construction Track Top Trends in Healthcare Construction Presenter: Russ Alford, General Manager, Turner Medical & Research Solutions

81 EQUIPMENT TIMELINE Placeholder Equipment Selected SD Equipment Planning DD Equipment Plan CD Final Equipment Decision Construction mos HCD AORN.RSNA ASHE ACE

82 Planning Key Activities for Planning and Coordination during Design: Cost Estimate Development User Group Meetings & Clinical Input Architectural Document Development (DD/CD/Revit) Detailed Cut Sheets and/or Vendor Design Submittals Design Coordination Reports

83 Revit

84 Procurement Key Activities in Procurement: Prioritization Schedule Structured Approach Bid Packages Status Report Item Level Comparison by Supplier Supplier Summary

85 Status Report

86 Status Report

87 Item Level Comparison by Supplier

88 Item Level Comparison by Supplier

89 Receiving Management Phase Key Aspects of Receiving Management Phase: Communication / Collaboration Coordination: 2 levels Design Coordination Construction Coordination Matrix Field Coordination Field Observation Reports Delivery Management Scheduling, Tracking and Documentation ROJ Date & Delivery Schedule Warehouse Management Warehouse vs. JIT deliveries Onsite Delivery and Receiving

90 Receiving Management Phase Managing the Gap: Placeholder Equipment Selected SD Design Coordination Field Coordination DD Equipment Planning Equipment Plan CD Group 1 Equipment Deliveries Onsite Deliveries Construction Post-Const mos HCD.. AORN..RSNA ASHE..ACE

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93 Consensus Building Through Virtual Reality Interactive Immersive BIM Visualization System Walk through the BIM model Visualize the space that creates a Real experience

94 Why we need VR

95 User View August 9, 2016

96 Why we use VR Create true-to-life experiences VR works to pull feelings, emotions & physiological responses Able to memorize information in a highly realistic & interactive environment Presence is the key characteristic

97 Benefits Feel Portable Experience Eliminates 2D Confusion..... Collaborative Reduced Learning/Decision Time Reduced Clinician/Client Time Raises Confidence/ Understanding Functional change on the fly Test Solutions with Group

98 Team View

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