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 2015-1
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 2015-2
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 2015-3
Top Eight Cited Standards: 2012 2015 Standard 2015 2014 2013 2012 EC.02.06.01: Built Environment #1 #1 #8 #7 EC.02.05.01: Utility Systems Risks #3 #2 #4 #10 LS.02.01.20: Means of Egress #4 #4 #1 #2 LS.02.01.30: Protection #6 #8 #6 #6 LS.02.01.10: General Building Requirements #7 #7 #3 #3 LS.02.01.35: Extinguishment #8 #9 #9 #9 EC.02.03.05: Fire Safety Systems #9 #6 #7 #5 EC.02.02.01: HazMat & Waste #10 #10 #11 #11 Please Note: Other standards not listed are clinical or leadership related. Engineering Department 2015-4
Engineering Department 2015-5 Copyright, The Joint Commission
WHY? Engineering Department 2015-6
January 2017 EC.02.05.01 The hospital manages risks associated with its utility systems Engineering Department 2015-7
EC.02.05.01 Top Findings (Based on 1,111 findings) #1 - Inappropriate Room Pressurization - 469 findings (42.2%) #2 Failure to Label Electric Panel - 304 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 2015-8
#1 - Inappropriate Room Pressurization - 469 findings (42.2%) NEED PIC Engineering Department 2015-9
#2 Failure to Label Electric Panel - 304 findings (27.4%) Engineering Department 2015-10
#3 Lack of Emergency Lighting - 83 findings (7.5%) NEED PIC Engineering Department 2015-11
#4 Failure to Label Utilities - 59 findings (5.3%) NEED PIC Engineering Department 2015-12
#5 Inappropriate Electrical Issues - 47 findings (4.2%) Engineering Department 2015-13
#5 Inappropriate Electrical Issues - 47 findings (4.2%) Engineering Department 2015-14
January 2017 LS.02.01.20 The hospital maintains the integrity of the means of egress. Engineering Department 2015-15
LS.02.01.20 Top Findings (Based on 1,573 findings) #1 - Obstructions in Means of Egress - 507 findings (32.2%) #2 Inappropriate Electromagnetic Lock Usage - 266 findings (16.9%) #3 Inappropriate Locking Mechanisms - 174 findings (11.1%) #4 Suite Issues - 164 findings (10.4%) #5 Storage in Stairways - 145 findings (9.2%) Engineering Department 2015-16
#1 - Obstructions in Means of Egress - 507 findings (32.2%) Engineering Department 2015-17
#1 - Obstructions in Means of Egress - 507 findings (32.2%) Engineering Department 2015-18
#2 Inappropriate Electromagnetic Lock Usage - 266 findings (16.9%) NEED PIC Engineering Department 2015-19
#3 Inappropriate Locking Mechanisms - 174 findings (11.1%) NEED PIC Engineering Department 2015-20
#4 Suite Issues - 164 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 2015-21
#5 Storage in Stairways - 145 findings (9.2%) Engineering Department 2015-22
#1 - Obstructions in Means of Egress - 507 findings (32.2%) Engineering Department 2015-23
January 2017 EC.02.06.01 The hospital establishes and maintains a safe, functional environment. Engineering Department 2015-24
EC.02.06.01 Top Findings (Based on 3,109 findings) #1 - Medical Gas Storage Cylinder - 934 findings (30.0%) #2 Safety Hazard - 506 findings (16.3%) #3 - Air Flow & HVAC Issues - 273 findings (8.8%) #4 - OR Humidity - 238 findings (7.7%) #5 - Nurse Call Pull Cord - 205 findings (6.6%) Engineering Department 2015-25
#1 - Medical Gas Storage Cylinder - 934 findings (30.0%) Engineering Department 2015-26
#2 Safety Hazard - 506 findings (16.3%) Engineering Department 2015-27
#3 - Air Flow & HVAC Issues - 273 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 2015-28
Air Balance Issues con t This is NOT considered repaired Engineering Department 2015-29
#4 - OR Humidity - 238 findings (7.7%) Engineering Department 2015-30
#4 - OR Humidity - 238 findings (7.7%) Engineering Department 2015-31
#5 - Nurse Call Pull Cord - 205 findings (6.6%) Engineering Department 2015-32
EC.02.03.05 The January 2017 hospital maintains fire safety equipment and fire safety building features. Engineering Department 2015-33
EC.02.3.05 Top Findings (Based on 2,172 findings) #1 - Lack of Inventory - 651 findings (30.0%) #2 - Insufficient Documentation - 618 findings (28.5%) #3 - Standard not Listed - 446 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 2015-34
#1 - Lack of Inventory - 651 findings (30.0%) Engineering Department 2015-35
#2 - Insufficient Documentation - 618 findings (28.5%) Engineering Department 2015-36
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 2015-37
#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 2015-38
#6 Repairs not Performed - 22 findings (1.0%) Engineering Department 2015-39
January 2017 LS.02.01.10 - Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat. Engineering Department 2015-40
LS.02.01.10 Top Findings (Based on 2,354 findings) #1 - Penetrations - 962 findings (40.9%) #2 - Fire Door Failure - 709 findings (30.1%) #3 Fire ratings - 176 findings (7.5%) #4 - Fire Door Hardware - 165 findings (7.0%) #5 - Fire Door Labels - 149 findings (6.3%) Engineering Department 2015-41
#1 - Penetrations - 962 findings (40.9%) Engineering Department 2015-42
#2 - Fire Door Failure - 709 findings (30.1%) Engineering Department 2015-43
#3 Fire rating - 176 findings (7.5%) Fire door to mechanical room Engineering Department 2015-44
#4 - Fire Door Hardware - 165 findings (7.0%) Engineering Department 2015-45
#5 - Fire Door Labels - 149 findings (6.3%) Engineering Department 2015-46
LS.02.01.30 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 2015-47
LS.02.01.30 Top Findings (Based on 2,488 findings) #1 - Door Issues - 966 findings (38.8%) #2 - Penetrations - 548 findings (22.0%) #3 - Latch Failure - 342 findings (13.7%) #4 Smoke barriers - 209 findings (8.4%) #5 - Suite Issues - 207 findings (8.3%) #6 Separation of Hazardous Areas - 190 findings (7.6%) Engineering Department 2015-48
#1 - Door Issues - 966 findings (38.8%) Engineering Department 2015-49
#2 - Penetrations - 548 findings (22.0%) Engineering Department 2015-50
#3 - Latch Failure - 342 findings (13.7%) Engineering Department 2015-51
#4 Smoke barriers - 209 findings (8.4%) Engineering Department 2015-52
#5 - Suite Issues - 207 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 18/19.2.5 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 8/19.2.5.7 of the 2012 LSC. See CMS Waiver Engineering Department 2015-53
2012 LSC 18/19.2.5.7 Suites 18/19.2.5.7.2.1(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; 18/19.2.5.7.3.1(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; 18/19.2.5.7.1.2 which allow, under certain circumstances, suites to be separated by corridor wall requirements; Engineering Department 2015-54
#6 Separation of Hazardous Areas - 190 findings (7.6%) Engineering Department 2015-55
LS.02.01.35 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 101-2012: 18/19.3.5. Prior to July 5 th, 2016 is considered existing. (Approved plans) Engineering Department 2015-56
LS.02.01.35 Top Findings (Based on 2,444 findings) #1 - Cables/Wiring - 479 findings (19.6%) #2 - Dust/Foreign Material - 443 findings (18.1%) #3 - Ceilings/Installation/Damage - 413 findings (16.9%) #4 - Storage/Signage - 338 findings (13.8%) #5 - Fixtures/Equipment - 320 findings (13.1%) #6 - Escutcheon/Obstructions - 286 findings (11.7%) Engineering Department 2015-57
#1 - Cables/Wiring - 479 findings (19.6%) NEED PIC Engineering Department 2015-58
#1 - Cables/Wiring - 479 findings (19.6%) Engineering Department 2015-59
#2 - Dust/Foreign Material - 443 findings (18.1%) Engineering Department 2015-60
#3 - Ceilings/Installation/Damage - 413 findings (16.9%) Engineering Department 2015-61
This is NOT considered art Engineering Department 2015-62
#4 - Storage/Signage - 338 findings (13.8%) Engineering Department 2015-63
#5 - Fixtures/Equipment - 320 findings (13.1%) (EP 4 & EP 6) Engineering Department 2015-64
#6 - Escutcheon/Obstructions - 286 findings (11.7%) NEED PIC Engineering Department 2015-65
#6 - Escutcheon/Obstructions - 286 findings (11.7%) Engineering Department 2015-66
EC.02.02.01 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 2015-67
EC.02.02.01 Top Findings (Based on 1,150 findings) #1 - Eye Wash None - 308 findings (26.7%) #2 - Eye Wash Inspection - 192 findings (16.7%) #3 - Eye Wash Temperature - 138 findings (12.0%) #4 - Lead Apron Inspection - 101 findings (8.9%) #5 - Lead Apron Storage - 54 findings (4.7%) Engineering Department 2015-68
#1 - Eye Wash None - 308 findings (26.7%) Engineering Department 2015-69
#2 - Eye Wash Inspection - 192 findings (16.7%) Engineering Department 2015-70
#3 - Eye Wash Temperature - 138 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 2015-71
#4 - Lead Apron Inspection - 101 findings (8.9%) Engineering Department 2015-72
#5 - Lead Apron Storage - 54 findings (4.7%) Engineering Department 2015-73
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 2015-74
Likelihood to Harm a Patient/Visitor/Staff A Picture is Worth 1000 Words Immediate Threat to Life HIGH MM.03.01.01, EP8 MM.03.01.01, EP7 MODERATE MS.01.01.01, EP5 PC.01.02.01, EP4 PC.01.02.03, EP6 PC.01.03.01, EP1 PC.01.03.01, EP5 IM.02.02.01, EP3 MS.08.01.01. EP1 MS.08.01.03, EP3 IC.02.01.01, EP2 IC.02.02.01, EP4 LOW RC.01.01.01, EP19 RC.02.03.07, EP4 LIMITED PATTERN WIDESPREAD
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 2015-76
Questions? Engineering Department 2015-77
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 2015-78
The Joint Commission Disclaimer These slides are current as of January 2017. 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 2015-79
Engineering, Facilities & Construction Track Top Trends in Healthcare Construction Presenter: Russ Alford, General Manager, Turner Medical & Research Solutions
EQUIPMENT TIMELINE Placeholder Equipment Selected SD Equipment Planning DD Equipment Plan CD Final Equipment Decision Construction 18-24 mos HCD AORN.RSNA ASHE ACE
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
Revit
Procurement Key Activities in Procurement: Prioritization Schedule Structured Approach Bid Packages Status Report Item Level Comparison by Supplier Supplier Summary
Status Report
Status Report
Item Level Comparison by Supplier
Item Level Comparison by Supplier
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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 18-24 mos HCD.. AORN..RSNA ASHE..ACE
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Why we need VR
User View August 9, 2016
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