2010 UPDATE The Healthcare Environment George Mills, Sr. Engineer Standard Interpretation Group The Joint Commission
Human Factor Trust Report Improve TRUST REPORT IMPROVE Communication SIG Engineering 2010-2
Scoring & Decision Process Scoring Scale 0 = Insufficient Compliance 1 = Partial Compliance 2 = Full Compliance Requirement for Improvement (RFI) All findings of less than full compliance will be cited as a RFI All RFIs require resolution through an Evidence of Standards Compliance (ESC) This includes findings scored partial SIG Engineering 2010-3
EP Scoring Categories A: Structural requirements EP s scored yes (2) or no (0) May address issues requiring full compliance C: Based on number of times an EP is not met Score 2: 0-1 instances of non-compliance Score 1: 2 instances of non-compliance Score 0: > 3 instances of non-compliance Above is based on a sample of 10 SIG Engineering 2010-4
Example: Category A EC.02.05.05 EP 3: The hospital inspects, tests & maintains all life support utility system components on the inventory. These activities are documented. Did you do it? Yes or No [100%] Is there documentation? SIG Engineering 2010-5
Example: Category C EC.02.05.05 EP 5: The hospital inspects, tests & maintains all non-life support utilities system components identified on the inventory. These activities are documented. How many times did you not do it? Is there documentation? SIG Engineering 2010-6
Criticality Criticality defined as the immediacy of risk to patient safety or quality of care as a result of noncompliance with a Joint Commission requirement. 4 Levels of Criticality 1. Immediate Threat to Life (ITL) PDA until resolved 2. Situational Decision Rules Based on specific situations at time of survey 3. Direct Impact Requirements Noncompliance may create an immediate risk to patient safety or quality of care 4. Indirect Impact Requirements Based on planning and evaluation or care processes SIG Engineering 2010-7
Criticality of Findings & Immediacy of Risk The amount of time for submitting the ESC is based on the criticality of the finding and the immediacy of risk as follows: Direct Impact Within 45 Days Indirect Impact Within 60 Days SIG Engineering 2010-8
Direct Impact Count Environment of Care 40 Direct Impact Life Safety Chapter 10 Administrative (LS.01) 13 Healthcare (LS.02) Emergency Management 3 Direct Impact SIG Engineering 2010-9
Internal Intensive Review Quantitative measure for identifying organization whose survey findings should be subject to a more intensive review by Central Office Bands of screening points have been established to adjust for differences in size and complexity HAP Screening Points: # Non-compliant Surveyor Days Direct Impact Stds 1 4 7 5 6 8 7 9 9 10 13 11 > 14 13 SIG Engineering 2010-10
Accreditation Decisions: 2010 and 2011 Preliminary Accreditation Accredited 201 0 Provisional Accreditation Conditional Accreditation Preliminary Denial of Accreditation Denial of Accreditation Preliminary Accreditation Accredited Accredited with Follow-up Survey Requires a follow-up survey typically ranging from 30 days to six months Contingent Accreditation 201 1 Requires a follow-up survey within 30 days Preliminary Denial of Accreditation Denial of Accreditation SIG Engineering 2010-11
Criteria for Determining 2011 Accreditation Decisions PDA Factors Considered: --Single or multiple instances --Nature and significance of findings --Failed On-site ESC --Decision rules triggered --Repeat findings THE GREATER THE UMBER OF FACTORS, THE MORE SEVERE THE DECISION! Severit y (EX: ITL) CONTINGENT ACCREDITATION (Follow-up Survey within 30 days (EX: 2 ACCREDITATION nd Failed CLD WITH FOLLOW- UP SURVEY (1-6 Months) (EX: 1 st Failed CLD) SIG Engineering 2010-12
Top 5 Most Cited Standards in the First ½ of 2010 Hospitals 1. 62% RC.01.01.01 2. 50% LS.02.01.20 3. 44% LS.02.01.10 4. 38% EC.02.03.05 5. 37% LS.02.01.30 Critical Access Hospitals 1. 47% EC.02.03.05 2. 44% LS.02.01.10 3. 40% EC.02.05.07 4. 33% LS.02.01.20 5. 27% EC.02.06.01 SIG Engineering 2010-13
#2: LS.02.01.20 (50%) Up From 45% in 2009 The hospital maintains the integrity of the means of egress. EP 13 Corridor Clutter EP 12 Projections EPs 16 22 Suites issues Equivalize > 5000 sq ft EP 1 Doors locked in means of egress SIG Engineering 2010-14
Corridor Storage If the corridor looks cluttered it probably is Corridor clutter is not a PFI issue Allowed: Not Allowed: Isolation Carts Linen Hampers Crash Carts Latex Carts Chemo Carts Anything in the egress corridor more than 30 minutes is storage SIG Engineering 2010-15
Corridor Storage Dead end corridors may be used for storage Less than or equal to 50sqft space Converting patient room: Long term include door closure Surge issue: based on policy patients may be treated in the egress corridor during surge conditions SIG Engineering 2010-16
#3: LS.02.01.10 (44%) Up From 43% in 2009 Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat. EP 9 Penetrations EPs 5 7 Door issues EPs 1 & 2 Building Type issues EP 8 Duct issues SIG Engineering 2010-17
#4: EC.02.03.05 (38%) No Change From 2009 The hospital maintains fire safety equipment and fire safety building features. Features of fire protection NOTE: #1 for Critical Access Hospitals SIG Engineering 2010-18
#5: LS.02.01.30 (37%) Up From 36% in 2009 The hospital provides and maintains building features to protect individuals from the hazards of fire and smoke. EPs 16 23 Smoke Barriers & Doors EP 2 Hazardous Areas SIG Engineering 2010-19
What Triggers ITL (Immediate Threat to Life) Significantly compromised fire alarm system Significantly compromised sprinkler system Significantly compromised emergency power supply system Significantly compromised medical gas master panel Significantly compromised exits Other situations that place patients, staff or visitors at extreme danger SIG Engineering 2010-20
Life Safety Code Specialist LSCS Background Facilities or Environment of Care based Prefer CHFM certification LSCS Agenda On-Site one day (typically on day 1 or day 2) Interfaces with survey team member(s) LSCS Survey Focus Life Safety Chapter EC.02.05.03 EC.02.05.07 EC.02.05.09 Other Observations SIG Engineering 2010-21
Life Safety Code Specialist May also survey LD.04.01.05 EP 4 LD.03.03.01 EP 4 LD.04.04.01 EP 2 All HAP and CAH will be surveyed for a minimum of 2 days by a LSCS Greater than 1.5 million sq ft will be surveyed for a third day by the LSCS An additional day is added for every three buildings that are classified as healthcare Example: for a HAP organization with 2 million square feet of healthcare occupancy and 5 buildings classified as healthcare occupancy: the number of LSCS days would be 4 SIG Engineering 2010-22
LD.04.01.05 EP 4: What to do when the documentation isn t there During survey documentation is reviewed If the information is not readily available, but will be available later in the survey this may result in a finding at LD.04.01.05 EP 4 The requested information should be utilized by the organization, so not having the information may indicate a lack of responsibility by the organization If the documentation arrives late, noncompliance has already been established Scored at LD.04.01.05 EP4 Leaders hold staff accountable for their responsibilities SIG Engineering 2010-23
Deficiency Resolution Resolution to a deficiency: Resolve it immediately Correct it within 45 days: Management process that documents the deficiency and actions to resolve ILSM must be considered Plan For Improvement located in the Statement of Conditions Corrected within 6 months of the Projected Completion Date ILSM must be considered SIG Engineering 2010-24
45 Day Corrective Action Documented Origination date Completion date Kept available for rolling 3 years Life Safety deficiencies Must not exceed 45 days If greater than 45 days create a Plan For Improvement (PFI) If originally a work order, close out as complete and generate the PFI Must be made available to the Joint Commission During survey to confirm management of the deficiency During CMS/Joint Commission validation process upon request SIG Engineering 2010-25
Equivalencies The Joint Commission accepts two forms of equivalencies Traditional Equivalency A process of field verification identifying alternative methods of fire safety that offset the identified deficiency Fire Safety Evaluation System (FSES) A process of calculating the features of life safety and deducting any deficiencies, with the outcome determining if the building is equivalized based on the FSES SIG Engineering 2010-26
How Many Open PFIs Are Too Many? The PFI process was created to allow organizations to self assess and create a Plan for Improvement The self disclosure has never defined how many is too many The ILSM process was created to allow both the organization and The Joint Commission to be aware of Life Safety Code deficiencies Failure to make progress on previously accepted PFIs, including failure to implement ILSMs results in Conditional Accreditation SIG Engineering 2010-27
How Many Open PFIs Are Too Many? Survey Process: Evaluate both closed and currently open PFIs in the View All screen Spot check during building tour both some closed and open PFIs to evaluate how well the organization is managing the PFI process Evaluate the scope of PFI entries Are there life safety deficiencies Are they greater than maintenance items (i.e. screws missing from a door hinge) SIG Engineering 2010-28
Statement of Conditions: PFI PFIs should be related to the LS Chapter Corridor clutter is not a legitimate PFI PFIs should provide specific information No blanket statements penetrations on 3 rd floor Specific references to Life Safety Drawings is acceptable 32 penetrations as identified on LS Drawing 3 rd Floor, Center Tower dated 3/3/2010 Projected Completion Date is for all listed items (i.e. 32 penetrations ) SIG Engineering 2010-29
Contingency Planning Utilities exist to provide a safe and comfortable environment of care Failure of utilities could directly impact patient care delivery Activities associated with managing utilities are designed to ensure the reliability of the systems day to day Contingency plans are developed to ensure reliability of utilities systems Contingency plans address at least two issues: Utility/Equipment failure or disruption Emergency related failures or disruption SIG Engineering 2010-30
Contingency Planning: Survey Organizations ensure their contingency plans are current and accurate Discuss the organization Memorandum of Understanding and its impact in the community Evaluate against Standards & Elements of Performance Suggest the organization include exercising these contingency plans with their Emergency Exercise SIG Engineering 2010-31
EC.02.05.01 Utilities Mgmt. EP 7 The hospital maps the distribution of utility systems EP 8 The hospital labels controls for a partial or complete emergency shutdown EP 9 The hospitals has procedures for responding to utility system disruptions EP 10 The hospitals' procedures address shutting off the malfunctioning system and notifying staff in affected areas EP 11 The hospitals procedures address performing emergency clinical interventions during utility systems disruptions EP 12 The hospitals procedures addresses the following: How to obtain emergency repair services EP 13 The hospital responds to utility system disruptions as described in its procedures SIG Engineering 2010-32
EM.02.02.09: Utility Disruption Emergency Operations Plan identifies alternative means of providing: EP 2 electricity EP 3 water needed for consumption and essential care activities EP 4 water needed for equipment and sanitary purposes EP 5 fuel required for building operations or essential transport activities EP 6 medical gas/vacuum systems EP 7 Utility systems defined as essential, such as Vertical & horizontal transport Heating & cooling systems Steam for sterilization EP 8 Utility needs identified in the HVA SIG Engineering 2010-33
PRA EC.02.06.03 Preconstruction Risk Assessment (PRA) Construction or renovation in occupied healthcare facilities can result in environmental problems such as: Noise Vibration Creation or spread of contaminants Disruption of essential services Emergency Procedures Air quality SIG Engineering 2010-34
Interim Life Safety Measures Order of Standards (LS.01.02.01) EP 1 & 2 regardless of ILSM policy EP 3 must clearly define the ILSM policy including CON 04 Process When to implement What to do to protect occupants Both construction related and noncompliance with the LSC EPs 4 14 align with policy and implementation strategies SIG Engineering 2010-35
Fire Watch An organization experiencing a compromising situation (4 out of 24 hours) must implement a fire watch until the fire alarm system or sprinkler system has been returned to service or is stable. In many situations, this distinction comes down to whether an event or activity is scheduled or unscheduled. A scheduled activity would be an event known to and under the knowledge of and control of organization staff a construction project servicing or upgrading the fire alarm system or sprinkler system. SIG Engineering 2010-36
Fire Watch Other situations would typically be considered unscheduled activities The fire alarm system or the sprinkler system was disrupted for 2 hours in the morning, restored, and then failed again for at least another 2 hours. The fire watch should be implemented until the fire alarm system or sprinkler system is once again stable and fully functioning. SIG Engineering 2010-37
Who conducts the fire watch? In 1998, the Healthcare Interpretations Task Force (HITF) agreed that Clinical staff in an area affected by a fire alarm impairment or a sprinkler system impairment can be used to satisfy the requirements for a fire watch, provided there is adequate staffing to continuously patrol the affected area staff have the means to make proper notification to other occupants in the event of a fire Fire watch is documented SIG Engineering 2010-38
Service Situation Putting a shield over one smoke detector to prevent dust/false alarms for more than 4 hours Fire Watch Required? No ILSM Evaluation Required? Recommended Rationale: Other features of fire protection are not compromised during the event, such as additional smoke detectors or sprinkler heads in the affected area. Covering all smoke detectors during a controlled event, such as only during the time contractors are working in an affected area, although after hours, the entire area is fully operational No Yes Rationale: During a controlled event the organization is managing the deficien-cy. The area would be continually monitored, and ILSM should be implemented as per policy. Shutting off a zone valve to the sprinkler system or disabling a fire alarm zone for more than 4 hours Scheduled event (that is, working on, servicing, or upgrading fire alarm system or sprinkler system) Not in all cases Yes (emphasis on occupant notification) Rationale: During a controlled event, the organization is managing the defi-ciency. The area would be continually monitored, and ILSM would be implemented as per policy. Unscheduled event (that is, shutting off a zone valve to the sprinkler system or disabling a smoke zone for more than 4 hours in response to a system failure) Yes Yes SIG Engineering 2010-39
Building Maintenance Program (BMP) The BMP is no longer available to offset findings during survey, but is considered best practice All EPs related to the original ten BMP items are C categories
BMP Implementation Strategy These three activities are related to the Building Maintenance Program: 1. Begin with compliant building features 2. Maintain these building features Maintaining the feature is not counted, but evaluated for effectiveness 3. Inspect by random sampling to determine program effectiveness Sample rate of 20, 1 failure = 95% Adjust #2 above (maintaining) to achieve program effectiveness SIG Engineering 2010-41
Fire & Smoke Damper Inspections Ensure inaccessible dampers truly are by random sampling Confirm ILSM policy is implemented for any horizontal exits or egress enclosures that are compromised by inaccessible dampers Evaluate adequacy of damper accessibility plan SIG Engineering 2010-42
LS.02.01.34 EP 2 Master Alarm Panel The master fire alarm control panel is located in a protected environment (an area enclosed with 1-hour firerated walls and ¾ hour fire rated doors) that is continuously occupied OR in an area with a smoke detector. NFPA 72-1999 1-5.6 & 3-8.4.1.3.3.2 SIG Engineering 2010-43
Time Defined The Joint Commission EC chapter defines time as: Daily, weekly, monthly and quarterly are calendar references Semi-annual is 6 months from the last occurrence +/- 20 days Annual is 12 months from the last occurrence +/- 30 days 3 years is 36 months from the last occurrence +/- 45 days NOTE: An alternative of developing either a unique, written policy or adopting NFPA definitions when available is acceptable SIG Engineering 2010-44
Semiannual: +/- 20 days Annual: +/- 30 days Due Date Due Date + + 20 20 20 20 Scheduled Month Scheduled Month 30 30 30 30 Semiannual Annual June Jul y Aug Sept Oct Nov Jan F M A M J J A S O N D Dec Jan SIG Engineering 2010-45
Does Every mean Every? EC.02.03.05 EP 2 Every 6 months the hospital tests valve tamper switches and water-flow devices. The completion date of the test is documented. Every 6 months +/- 20 days EP 12 Every 12 months the hospital tests visual and audible alarms, including speakers. The completion date of the test is documented. Every 12 months +/- 30 days At least monthly the hospital inspects portable fire extinguishers. The completion dates of the inspections are documented. Tested within the calendar month SIG Engineering 2010-46
Fire Extinguisher: Dating Month, day year and initials of inspector as per NFPA 10-1998 EC.02.03.05 EP 15 4-3.4 Inspection Recordkeeping. 4-3.4.1 Personnel making inspections shall keep records of all fire extinguishers inspected, including those found to require corrective action. 4-3.4.2 At least monthly, the date the inspection was performed and the initials of the person performing the inspection shall be recorded. 4-3.4.3 Records shall be kept on a tag or label attached to the fire extinguisher, on an inspection checklist maintained on file, or in an electronic system (e.g., bar coding) that provides a permanent record. SIG Engineering 2010-47
Perimeter Shelving Ceiling 18 rule Perimeter Shelving 18 18 Wall Wall OK Wrong OK OK SIG Engineering 2010-48
General Life Safety Interpretations Perimeter shelving and sprinkler provision: Are perimeter wall shelving that extends to the ceiling required to be fastened to the wall? NO Shelving is not required for storage There is no correlation between Shelving Clearance The need to secure any shelving SIG Engineering 2010-49
General Life Safety Interpretations Rated doors must have legible labels on the door and jambs Jambs prior to 1966 may not have a rating label Missing labels may be equivalized if evidence of compliance is provided to central office Alternative is to have third party testing agency re-label doors Are ILSM in place where noncompliant door assemblies are found? SIG Engineering 2010-50
General Life Safety Interpretations Firestop: Existing application is acceptable when It was installed in a manner consistent with original design specifications It is in acceptable condition currently If the firestop is cracking, etc, then it is to be removed and repaired using current technologies JC does not accept the expanding foam used for insulation in any fire or smoke barrier This product does have a UL label: for insulation properties Easily ignited Toxic gases may occur when burned NOTE: There are several acceptable fire stop products that expand when installed SIG Engineering 2010-51
Non Flammable Medical Gas Storage: General Issues <300 ft³: 12 e cylinders per smoke compartment, in rack or appropriate holders Each e cylinder is 24.96 ft³ Smoke Compartment is limited to 22,500 ft² Between 300 and 3000 ft³ must be stored in a room that is limited construction with doors that can be locked In use verses in storage On gurney is considered in use In rack is in storage limited to 12 racked, per smoke compartment Empty are NOT considered part of the 12 in storage SIG Engineering 2010-52
Non-Flammable Gas Storage: NFPA 99-2005 NFPA 99-2005 edition has additional language regarding O 2 storage requirements, specifically: Storage of nonflammable gases: 9.4.1 > 3000 cubic feet 9.4.2 300 3000 cubic feet 9.4.3 0-300 cubic feet Other: 5.1.3.3.2 design and construction 5.1.3.3.3 ventilation of locations for manifolds 5.1.3.3.3.2 ventilation for motor driven equipment 5.1.3.3.3.3 ventilation for outdoors NOTE: CMS also recognizes 9.4.3 reference SIG Engineering 2010-53
General Life Safety Interpretations EC.02.05.09 Tank Farm EC.02.05.09, EP 1 states the hospital tests, inspects and maintains critical components of the piped medical gas systems. The bulk storage tank(s) and associated systems are critical components of the piped medical gas system. SIG Engineering 2010-54
General Life Safety Interpretations Q. Is a UPS used to condition power or supply power when normal power is interrupted until emergency power is established a SEPSS? A. The UPS in this application is a bridging device, and is not a SEPSS SIG Engineering 2010-55
NFPA 110: Emergency & Standby Power Systems Automatic Transfer Switches (ATS) are self-acting devices that have normal electrical power entering and leaving the ATS The power continues on to distribution panels When a ATS senses a disruption in power it sends a signal to the alternative power source seeking power This start circuit initiates the emergency generator starter The ATS is also equipped with a test switch to simulate the power disruption Recommended practice is to rotate which ATS initiates the start circuit to the emergency generator SIG Engineering 2010-56
Lessons Learned from 2009 Scope issues Contamination issues Alarm Hazards Disabled or otherwise compromised Telemetry Infusion pumps Surgical Site Fires Sentinel Event Alert SIG Engineering 2010-57
Defibrillators: FAQ Q. Are defibrillators considered life support equipment? A.YES. Maintenance activities then must be identified for equipment on the inventory A maintenance strategy for defibrillators could include a range of activities from a visual inspection of the single-use AED (automatic external defibrillator) to the scheduled PM maintenance of a defibrillator Note: the daily and weekly observations are assessed as per policy (see PC.02.01.11 EP2)
Emergency Management: Key Concepts All hazards approach Collaboration with community partners Situational awareness Active mitigation and preparation, not just a written plan Monitor and evaluate SIG Engineering 2010-59
Hazard Vulnerability Analysis Conducted by EM Committee/Team Use Multi-disciplinary Approach Experts within your facility Community Share information with: Community-prioritizes events Hospital Leadership For each emergency, the organization defines Mitigation, Preparation, Response, Recovery Directs the survey process related to EM SIG Engineering 2010-60
Six Critical Areas 1. Communication 2. Resources & Assets 3. Safety & Security 4. Staff Responsibilities 5. Utilities Management 6. Patient Clinical & Support Activities SIG Engineering 2010-61
Overview of the 2011 EM Changes Stand alone EM session Up to 90 minutes Focus on mitigation and preparedness No disaster scenarios; use hospital disaster critiques Data collection tool and EM Tips document Focused discussion on six critical areas Look at resources and assets inventory; appropriate storage, expirations, training SIG Engineering 2010-62
Surveying Maintenance Strategies
Manufacturer s Recommendations CMS requires that organizations determine testing frequencies based on manufacturer s recommendations (see 42 CFR 482.26(b)(2) and 42 CFR 482.41(c)(2)) The Joint Commission allows organizations to determine testing frequencies based on one of the following: Manufacturer s recommendations Risk levels Current hospital experience SIG Engineering 2010-64
Manufacturer s Recommendations In January 2010 a formal complaint was made to CMS regarding this issue The Joint Commission advocated to CMS the importance of allowing the organizations to continue using the Joint Commission process Based on these discussions, CMS noted that they understand the principles behind applying risk assessment and hospital experience to the frequency of hospital preventive maintenance SIG Engineering 2010-65
Manufacturer s Recommendations CMS also stated that there may be merit to a risk-based preventive maintenance schedule and would be willing to accept the Joint Commission s interpretation if the Joint Commission provides more detailed surveyor instructions or a survey protocol. Pending CMS approval of the Joint Commission process there has been no formal change in the CMS survey requirements In response to concerns of CMS, the Joint Commission is providing additional training to the surveyors and focusing on the organization process for establishing PM frequencies SIG Engineering 2010-66
CMS Response CMS technical review team has completed its review if the Joint Commission s submission of surveyor instructions and survey protocol for evaluating an organizations preventive maintenance schedule. The purpose of this review was to ensure that Joint Commission s surveyors were properly trained to evaluate the adequacey of an organization s recommended frequency of preventive maintenance. SIG Engineering 2010-67
CMS Response I am happy to inform you that the Joint Commission s approach of utilizing a preventive maintenance schedule has been approved. Thank you for your cooperation and collaboration. CMS Deputy Director July 26, 2010 SIG Engineering 2010-68
Maintaining Utilities Equipment Inventory based on one of two strategies: All equipment inclusion Based on physical risks for Infection Occupant needs Systems critical to patient care All life support equipment is included All new types of equipment is evaluated for inclusion EC.02.04.01 EP 2 & EC.02.05.01 EP 2 SIG Engineering 2010-69
Maintaining Equipment: Strategies Written strategies identify the activities for Maintaining, Inspection & Testing Strategies may include Predictive maintenance Reliability-centered maintenance Interval based maintenance Corrective maintenance Metered maintenance Other recognized strategy Manufacture s recommendations EC.020401 EP 3 & EC.02.05.01 EP 3 SIG Engineering 2010-70
EC.02.04.01 EP 4 & EC.02.05.01 EP 4 The hospital identifies, in writing, the intervals for inspecting, testing, and maintaining all operating components of the utility systems on the inventory, based on criteria such as Manufacturer s recommendations Risk levels hospital experience (See also EC.02.05.05, EPs 3-5) SIG Engineering 2010-71
Case Study #1 A manufacturer s recommendation for an air handler required the Building Engineer to change the filters on a quarterly frequency based on the manufacturer s industrial application Hospital experience identified that those filters were not soiled to the point where they needed to be changed at the end of the quarter Slightly soiled filters actually increase the efficiencies The organization determined that by measuring the pressure differential across the filter bank the filters could be replaced semi-annually Should the organization continue to change the filters quarterly? SIG Engineering 2010-72
Case Study #2 Manufacturer s recommendations for greasing a 165# washer is 2 strokes of the grease gun per week to the main bearing This was based on industrial laundry applications running two shifts per day, 6 days per week The Facility Director determined that the frequency was excessive as the hospital laundry is operated one shift per day for 5 days per week Should the organization change to every other week grease application although the manufacturer s recommendations is weekly? SIG Engineering 2010-73
Survey Process: Utility Systems Evaluate the program documentation Logs are completed and reflect both Life Support Systems, Infection Control equipment, and Non-life support equipment on the inventory Accuracy of Inventory All Life Support equipment must be represented on the inventory Preventive maintenance frequencies must be clearly defined in writing Confirm work done as per scheduled activities Ensure appropriate work is scheduled based on maintenance strategies Evaluate equipment failure and scheduled actions SIG Engineering 2010-74
Survey Process: Staff Interviews Department Leader Establish how the inventory was created Establish the Maintenance Strategies used Evaluate the Monitoring processes Evaluate the effectiveness of the program Equipment Maintainers Evaluate their understanding of the maintenance process/strategies Evaluate competencies based on repeat work orders Evaluate work scheduled against completed SIG Engineering 2010-75
Survey Process: Staff Interview Users of the Equipment Evaluate equipment reliability Evaluate response time when equipment fails Evaluate emergency response process Evaluate Culture of Safety Appropriate training of staff related to equipment use Customer satisfaction with department Contract Services Evaluate reliability of equipment serviced Evaluate integration of the process SIG Engineering 2010-76
Questions?
SIG Support: 630 792 5900 George Mills, MBA, FASHE, CEM, CHFM, CHSP Senior Engineer SIG Jerry Gervais, CHFM Engineer SIG Michael Chisholm, CPE, CHFM Engineer SIG Anne Guglielmo, LEED, A.P. Engineer SIG SIG Engineering 2010-78
The Joint Commission Disclaimer These slides are current as of 9/22/2010. 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. SIG Engineering 2010-79
General Life Safety Interpretations Exit to Public Way In a healthcare occupancy, are sidewalks required between the exit door and the public way in order to qualify as an exit discharge as stated in Section 7.7.1? NO, See NFPA 101: Annex Section A.7.7.1. If the answer to the question above is NO, when is grass or similar surfaces not acceptable as a means of exit discharge? NFPA 101: Annex Section A.7.7.1 that provides guidance on the appropriate conditions to utilize a non-paved surface. Provide evidence that the organization can demonstrate how they maintain the exit of discharge Is it being applied? SIG Engineering 2010-80