Q4 ASHE Advocacy Liaison Webinar 12/7/16 ASHE Advocacy Team Chad E. Beebe, AIA, CHFM, CFPS, CBO, SASHE Deputy Executive Director of Advocacy cbeebe@aha.org Tim Adams, FASHE, CHFM, CHC Director of Leadership Development tadams@aha.org Jonathan Flannery, CHFM, CHC, FASHE, MHSA Senior Associate Director of Advocacy jflannery@aha. org Monika Berrier Senior Instructional Designer mberrier@aha.org 1
Housekeeping Please mute your line to reduce background noise. Do not put us on hold if you have background music on your hold line. We will unmute for the interactive discussion. This session will be recorded. The slides will be distributed after the meeting. Chapter Attendance Poll Contact Avis Gordon agordon@aha.org with updates or changes to your Chapter s advocacy liaison appointment 2
Agenda 1. Joint Commission 2017 LS and EC standards 2. SAFER Matrix, Joint Commission scoring and response to findings 3. CMS K-Tags 4. Discussing accreditation with your chapters 5. Region reports 2017 Joint Commission EC and LS Standards Pre-publication versions of EC and LS available on the Joint Commission website: https://www.jointcommission.org/ standards_information/ prepublication_standards.aspx Comparison Table same webpage 3
Disclaimer The following discussion of changes in Joint Commission Standards and Elements of Performance (EPs) is based on prepublication releases of the Standards and EPs. The actual requirements in the published Standards and EPs could vary from those in the pre-publication releases. Dates Print versions of the standards will be produced in December E-dition (electronic) Standards available January 9, 2017 Until then, the Joint Commission is surveying to the 2012 editions of NFPA 101 and 99 using the existing Joint Commission Standards 4
Highlights of Changes (Hospital Accreditation) EC and LS EPs (Healthcare Occupancy) 54 Retained 99 Revised 78 Moved and revised 1 Moved 14 Deleted 17 Consolidated 11 Split 35 New Highlights of Changes 2012 editions of NFPA 101 and NFPA 99 Items in corridors Suites Certain testing frequencies Fire places Limited cooking facilities 5
Highlights of Changes List of topics added to include in the fire response plan Fire safety equipment and building features the words results added to the documentation requirements Requirement for annual testing and inspection of door assemblies Highlights of Changes Labeling utility system controls notes with additional details added Examples provided in a note Utility source valves Utility system main switches and valves Individual circuits in an electrical distribution panel. Fire alarm system circuit breakers: Labeled Marked in red Access restricted 6
Highlights of Changes Required temperature, humidity and pressure relationships in non-critical areas Examples General care nursing units Clean and soiled utility rooms in acute care areas Laboratories Pharmacies, Diagnostic and treatment areas Food preparation area Other support departments. Highlights of Changes Emergency generator Lighting Remote stop Remote annunciator (battery powered) 7
Highlights of Changes EC.02.05.05 EP 1 When performing repairs or maintenance activities, the hospital has a process to manage risks associated with air-quality requirements; infection control; utility requirements; noise, odor, dust, vibration; and other hazards that affect care, treatment, or services for patients, staff, and visitors. Highlights of Changes 100% completion of ITM for high risk utility system components and infection control utility system components Weekly inspect the Emergency Power Supply System (EPSS) Annually test generator fuel quality to ASTM standards 8
Highlights of Changes Bulk oxygen supply located in a locked enclosure with correct signage Emergency oxygen supply located where a temporary connection can be made Cylinders: Handling Labeling Segregation of full and others Transfilling Highlights of Changes References NFPA 101 Chapter 43 for building rehabilitation At least 6 spare sprinkler heads and associated wrenches for each type of system Health care occupancy high rise building sprinklers 12 years to complete as of July 5, 2016 9
Changes is Survey Process and Scoring From the August 2008 Edition of The Joint Commission Perspectives 20 10
A 3 2 C SAFER Survey Analysis for Evaluating Risk 11
A New SAFER Model Immediate Threat to Life (follows current ITL processes) HIGH Likelihood to Harm a Patient/Visitor/Staff MODERATE LOW LIMITED PATTERN WIDESPREAD Scope Copyright, The Joint Commission SAFER January 1, 2017 SAFER Matrix will be provided in the Accreditation Survey Findings Report Where a finding is placed on the Matrix is based on the likelihood of the issue to cause harm to patients, staff, or visitors and according to how widespread the problem is based on surveyors observations. 12
SAFER Matrix Examples Single observation could represent a widespread threat: Example - Failure top perform recommended high-level disinfection or proper storage of endoscopes Immediate Threat to Life (follows current ITL processes) HIGH Likelihood to Harm a Patient/Visitor/Staff MODERATE LOW LIMITED PATTERN WIDESPREAD Scope Copyright, The Joint Commission 13
Impact of survey and scoring changes Potential increase in citations due to Scoring changes See it, cite it 60 days to correct deficiencies SAFER Matrix provides focus on deficiencies that pose the greater risk to patients CMS K-Tags Issued in October ASHE Developing Crosswalk To 2007 Edition of the 2000 LSC To Other Codes & Standards Available Early 2017 52 New K-Tags 29 Expanded K-Tags 49 Matching K-Tags 7 Deleted 2000 K-Tags 14
CMS K-Tags New K-Tags General Requirements - Other Catch-all In Every Section Section 1 - General Requirements Section Sprinkler Requirements, Multiple Occupancies, Roof Systems for Type I Buildings Section 2 Means of Egress Multiple Occupancies, Delayed Egress/Special Locking, Suites, Discharge from Exits Section 3 Protection Fire Alarm Notification Section 4 Special Provisions High-Rise Buildings CMS K-Tags New K-Tags Section 5 Building Services Suspended Unit Heaters, Fireplaces Section 6 Reserved No Requirements at this time Section 7 Operating Features 700 Series - Smoke Control, Construction, Repair and Improvement Operations, 900 Series Part II Health Care Facilities Code Requirements Fundamentals Systems Categories, Medical Gases 14/4, Electrical 8/3, Fire Protection 2/0 15
Actions to take Health care organizations should continue to be proactive in managing known life safety and environment of care deficiencies and should focus on continuous compliance. Actions to take Share information with your chapters Share information with the leadership in your health care organizations 16
2018 Editions of NFPA 101 and 99 NFPA 2017 Technical Meeting June 7, Boston MA Documents to be voted on: NFPA 101 NFPA 99 NFPA 70E Many others Regional Updates 17
Questions Mark Your Calendars The next Advocacy Liaison webinar will be held Wednesday, 3/1/17 at 12:00 Central Time 18
2017 ASHE Advocacy Liaison webinars Q1 3/1/17 Q2 6/21/17 Q3 9/20/17 Q4 12/6/17 All webinars are at 12:00 pm Central Time 19
Q4 ASHE Advocacy Liaison Webinar 12/7/16 -- Thank You --