THE HEALTHCARE ENVIRONMENT

Transcription

1 2015 THE HEALTHCARE ENVIRONMENT Anne M. Guglielmo, Engineer Department of Engineering The Joint Commission

2 2013/2014 CHALLENGING STANDARDS THE TOP 20 ISSUES Department of Engineering

3 TOP SCORED STANDARDS Standard 2014 Non Compliance 2013 Non Compliance EC % 39% EC % 47% IC % 46% LS % 52% RC % 52% EC % 45% LS % 48% LS % 36% LS % 45% EC % 34% Department of Engineering

4 TOP SCORED STANDARDS Standard 2014 Non Compliance 2013 Non Compliance MM % 35% PC % 27% PC % 18% EC % 21% PC % 20% MM % 22% LD % 19% LD % 14% EC % 23% IC % 13% Department of Engineering

5 TOP10 CITEDSTANDARDS: Standard EC : Built Environment #1 #8 #7 #11 EC : Utility Systems Risks #2 #4 #10 #13 LS : Means of Egress #4 #1 #2 #2 EC : Fire Safety Systems #6 #7 #5 #5 LS : General Building Req s #7 #3 #3 #3 LS : Extinguishment #8 #9 #9 #10 LS : Protection #9 #6 #6 #4 EC : Haz Materials & Waste #10 #11 #11 #15 Department of Engineering

6 BARRIER MANAGEMENT SYMPOSIUM Department of Engineering

7 BARRIER MANAGEMENT SYMPOSIUM Program Developers: Joint Commission Firestop Contractors International Association Underwriters Laboratories Participating Organizations: American Society for Healthcare Engineering AWCI& Gypsum Institute Fire Damper Industry Fire Rated Glazing Industry National Concrete Masonry Association Department of Engineering

8 WHAT IS YOUR APPROACH TOESC? Do you have a team approach or is one person responsible? Do you do what you need to do to make it go away or are the issues analyzed to determine why the non compliance is present? Do you use this standard ESC response: We have reeducated the Fill In The Blank? Have you looked at patient safety events and near misses/close calls in relation to non compliance identified during your survey? Have you considered what the short term and long term impact will be if you are unsuccessful in correcting the RFIs? Department of Engineering

9 WHAT IS YOUR APPROACH TOESC? Do you develop generic ESC or are your ESC specific to the root causes of the RFIs? Does the safety culture in your organization encourage staff and medical staff to identify system and process problems so they can be addressed quickly or do you wait until something happens or a surveyor finds it? When you develop your ESC do you find a way to incorporate it into daily activities and processes or do you lay it on top of everything else staff have to do? Is the culture in your organization one that allows the importance of the ESC to fade after a few months or is patient safety and compliance embedded in your mission/vision? Department of Engineering

10 STANDARDS LANGUAGE CHANGES

11 TIME RE-DEFINED The Joint Commission EC chapter defines time as: Daily, weekly, monthly are calendar references Quarterly will beonce every three months +/-10 days January 1, 2014 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 Department of Engineering

12 Due Date QUARTERLY: +/- 10 DAYS SEMIANNUAL: +/- 20 DAYS ANNUAL: +/- 30 DAYS Due Date Scheduled Month Scheduled Month Quarterly Jan February March Apr Semiannual Annual June July Aug Sept Oct Nov Jan F M A M J J A S O N D Dec Jan Frequencies required by Code may not be modified (e.g. EC EP 4 & 7) Department of Engineering

13 EQUIPMENT MANAGEMENT STANDARDS CHANGES MEDICAL EQUIPMENT: EC , EC UTILITY SYSTEMS: EC , EC APPLIES TO HOSPITAL & CAH PROGRAMS CHANGES EFFECTIVE 7/2/1014

14 EC Standard EC The hospital manages risks associated with its utility systems. EC EP 1 The hospital designs and installs utility systems that meet patient care and operational needs. (See also EC , EP 1) Department of Engineering

15 EC EP 2 The hospital maintains a written inventory of all operating components of utility systems or maintains a written inventory of selected operating components of utility systems based on risks for infection, occupant needs, and systems critical to patient care (including all life-support systems). The hospital evaluates new types of utility components before initial use to determine whether they should be included in the inventory. For hospitals that use Joint Commission accreditation for deemed status purposes:the hospital maintains a written inventory of all operating components of utility systems. (See also EC , EPs 1, 3-5) Department of Engineering

16 UTILITY SYSTEMS& OPERATING COMPONENTS Utility Systems are those systems that support the use and function of the physical environment, such as the heating system the cooling system water distribution system Department of Engineering

17 UTILITY SYSTEMS& OPERATING COMPONENTS Utility Systems are those systems that support the use and function of the physical environment, such as the heating system the cooling system water distribution system Components on the inventory would include the equipment that is performance-related and delivers a measurable outcome. For example, the heating system may have the following components: boiler, DA tank (de-aeration tank), feed water pumps, distribution (including circulation pumps, piping, and condensate return). Support parts to the components, such as belts, filters and steam traps, might not need to be individually listed, although they would likely be part of a preventive maintenance program. Support parts of components such as pumps and motors might also be considered sub-components and may or may not be reflected on the inventory, depending on the maintenance strategies used. Department of Engineering

18 EC EP 3 The hospital identifies high-risk operating components of utility systems on the inventory for which there is a risk of serious injury or death to a patient or staff member should the component fail. Note: High-risk utility system components include life-support equipment. Department of Engineering

19 EC EP 4 The hospital identifies the activities and associated frequencies, in writing, for inspecting, testing and maintaining all operating components of utility systems on the inventory. These activities and associated frequencies are in accordance with manufacturers recommendations or with strategies of an alternative equipment maintenance (AEM) program. Note 1: The strategies of an AEM program must not reduce the safety of equipment and must be based on accepted standards of practice. An example of guidelines for physical plant equipment maintenance is the American Society for Healthcare Engineering (ASHE) book Maintenance Management for Health Care Facilities. Note 2: For guidance on maintenance and testing activities for Essential Electric Systems (Type I), see NFPA 99, 1999 edition (Section 3-4.4). Department of Engineering

20 EC EP 5 For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital s activities and frequencies for inspecting, testing, and maintaining the following items must be in accordance with manufacturers recommendations: Equipment subject to federal or state law or Medicare Conditions of Participation in which inspecting, testing, and maintaining be in accordance with the manufacturers recommendations, or otherwise establishes more stringent maintenance requirements New operating components with insufficient maintenance history to support the use of alternative maintenance strategies Department of Engineering

21 EC EP 5 Note: Maintenance history includes any of the following documented evidence: Records provided by the hospital s contractors Information made public by nationally recognized sources Records of the hospital s experience over time Department of Engineering

22 EC EP 6 For hospitals that use Joint Commission accreditation for deemed status purposes: A qualified individual(s) uses written criteria to support the determination whether it is safe to permit operating components of utility systems to be maintained in an alternate manner that includes the following: How the equipment is used, including the seriousness and prevalence of harm during normal use Likely consequences of equipment failure or malfunction, including seriousness of and prevalence of harm Availability of alternative or back-up equipment in the event the equipment fails or malfunctions Incident history of identical or similar equipment Maintenance requirements of the equipment For more information on defining staff qualifications, refer to Standard HR Department of Engineering

23 EC EP 7 For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital identifies operating components of utility systems on its inventory that is included in an alternative equipment maintenance program. Department of Engineering

24 EC EP 5 14 The hospital minimizes pathogenic biological agents in cooling towers, domestic hot-and cold-water systems, and other aerosolizing water systems. Department of Engineering

25 EC EP 6 15 In areas designed to control airborne contaminants (such as biological agents, gases, fumes, dust), the ventilation system provides appropriate pressure relationships, air-exchange rates, and filtration efficiencies. Note: Areas designed for control of airborne contaminants include spaces such as operating rooms special procedure rooms delivery rooms for patients diagnosed with or suspected of having airborne communicable diseases (for example, pulmonary or laryngeal tuberculosis) patients in "protective environment" rooms (for example, those receiving bone marrow transplants), laboratories, pharmacies, and sterile supply rooms Department of Engineering

26 EC EP 1 The hospital tests utility system components on the inventory before initial use and after major repairs or upgrades. The completion date of the tests is documented. (See also EC , EP 2) Department of Engineering

27 EC EP 3 The hospital inspects, tests, and maintains the following: life-supporthigh-riskutility system components on the inventory. These activities are documented. (See also EC , EPs 2 and4) Note: High-risk utility system components includes life-support utility system components. Department of Engineering

28 EC EP 4 The hospital inspects, tests, and maintains the following: Infection control utility system components on the inventory. These activities are documented. (See also EC , EPs 2 and 4) Department of Engineering

29 EC EP 5 The hospital inspects, tests, and maintains the following: Non life-support Non-highriskutility system components on the inventory. These activities are documented. (See also EC , EPs 2 and4) Department of Engineering

30 EQUIPMENTSURVEYPROCESS Documentation is completed for High-risk, life support and non-life support devices on the inventory Accuracy of Inventory All High-risk and Life Support equipment must be on the inventory and identified 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 Department of Engineering

31 SURVEY PROCESS: STAFF INTERVIEWS Department Leader Evaluate the qualifications of the leader Review appropriate documentation Evaluate how the inventory was created If an alternative maintenance program is in use, evaluate the inclusion process Evaluate the Monitoring processes Evaluate the effectiveness of the program What criteria is used to evaluate Evaluate the Completion rate of maintenance activities Department of Engineering

32 SURVEY PROCESS: STAFF INTERVIEWS Equipment Maintainers Evaluate their understanding of the maintenance process/strategies Evaluate staff knowledge related to the alternative maintenance program Evaluate assignment of maintenance activities Evaluate competencies based on repeat work orders Evaluate work scheduled against completed Department of Engineering

33 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 the process used to ensure contractors use qualified personnel Evaluate reliability of equipment serviced Evaluate integration of the process Department of Engineering

34 EVALUATING PROGRAM EFFECTIVENESS The equipment management programs must have written policies & procedures Evaluating the program: How is equipment evaluated to ensure no degradation of performance? Consider mis-calibration of equipment Consider test equipment calibration confirmation How are equipment-related incidents investigated? Could the malfunction have been avoided? Did the alternative maintenance strategy contribute to the malfunction? How to sequester equipment deemed unsafe? Department of Engineering

35 EVALUATINGPROGRAMEFFECTIVENESS: MISCELLANEOUS TOPICS Survey should focus on High-risk equipment Are appropriate operation manuals and maintenance schedules available? Verify the inspection, testing & maintaining activities and frequencies are documented Evaluate the various maintenance strategies used Are they appropriate? Are they effective? Is the equipment reliable? Department of Engineering

36 RELOCATABLE POWER TAPS

37 RELOCATABLE POWER TAPS(RPTS) Healthcare Interpretation Task Force (12/2007) stated NFPA 70, NFPA 99 and NFPA 101 all have regulations that control the electrical components and equipment in a patient room. It appears that it is the intent of these documents to restrict RPT use so that it is not used in conjunction with medical equipment CMS 3/2014: RPT s are not to be used with medical equipment in patient care areas. This includes critical areas such as operating rooms, recovery areas, intensive care areas, and non-critical patient care areas such as patient rooms, diagnostic areas, exam areas, etc. Department of Engineering

38 RELOCATABLE POWER TAPS RPTs may be used in anesthetizing locations ifthey are part of the equipment assembly. See NFPA (2) Ceiling drops are acceptable. See NFPA (3) RPTs maybe used for non-patient care equipment such as computers/monitors/printers, and in areas such as waiting rooms, offices, nurse stations, support areas, corridors, etc. Precautions needed if RPT s are used include: ensuring they are never daisy-chained preventing cords from becoming tripping hazards installing internal ground fault and over-current protection devices using power strips that are adequate for the number and types of devices used Department of Engineering

39 S&C: LSC 9/26/2014 CMS is permitting a categorical waiver to allow for the use of power strips in existing and new health care facility patient care areas, if you are in compliance with all applicable 2012 LSC power strip requirements and with all other 2000 LSC electrical system and equipment provisions. The organization must follow all requirements of the categorical waiver process This includes identifying where they are located at the unit level Department of Engineering

40 CATEGORICAL WAIVER PROCESS If the organization decides to use this categorical waiver they must 1. Ensure full compliance with the appropriate code reference 2. Document the decision to adopt the categorical waiver The Relocatable Power Tap is not a LSC issue but an Environment of Care issue For Environment of Care items document by Minutes in discussion at the Environment of Care Committee (or equivalent) 3. Declare the decision at the beginning of any survey See also November 2013 Perspectives Department of Engineering

41 DEFINITIONS FROM NFPA Patient bed location is defined in section as the location of a patient sleeping bed, or the bed or procedure table of a critical care area. Patient-care-related electrical equipmentis defined in section as electrical equipment that is intended to be used for diagnostic, therapeutic, or monitoring purposes in the patient care vicinity; Patient care roomis defined in section as any room of a health care facility wherein patients are intended to be examined or treated. Note that this term replaces the term patient care area used in the 1999 NFPA 99, but the definition has not changed. Patient care vicinity is defined in section as a space, within a location intended for the examination and treatment of patients (i.e., patient care room) extending 6 ft. beyond the normal location of the bed, chair, table, treadmill, or other device that supports the patient during examination and treatment and extends vertically 7 ft. 6 in. above the floor. Department of Engineering

42 REQUIREMENTS Power strips may be used in a patient care vicinity to power rack-, table-, pedestal-or cart-mounted patient care-related electrical equipment assemblies, provided all of the following conditions are met, as required by section : The receptacles are permanently attached to the equipment assembly. The sum of the ampacity of all appliances connected to the receptacles shall not exceed 75 percent of the ampacity of the flexible cord supplying the receptacles. The ampacity of the flexible cord is suitable in accordance with the current edition of NFPA 70, National Electric Code. The electrical and mechanical integrity of the assembly is regularly verified and documented through an ongoing maintenance program. Means are employed to ensure that additional devices or nonmedical equipment cannot be connected to the multiple outlet extension cord after leakage currents have been verified as safe. Department of Engineering

43 REQUIREMENTS Patient bed locations in new health care facilities, or in existing facilities that undergo renovation or a change in occupancy, shall be provided with the minimum number of receptacles as required by section Power strips providing power to rack-, table-, pedestal-, or cart-mounted patient care-related electrical equipment assemblies are not required to be an integral component of manufacturer tested equipment. Power strips may be permanently attached to mounted equipment assemblies by personnel who are qualified to ensure compliance with section Department of Engineering

44 REQUIREMENTS Power strips may notbe used in a patient care vicinity to power non-patient care-related electrical equipment (e.g., personal electronics). Power strips maybe used outside of the patient care vicinity for both patient care-related electrical equipment & nonpatient-care-related electrical equipment. Power strips providing power to patient care-related electrical equipment must be Special-Purpose Relocatable Power Taps (SPRPT) listed as UL 1363A or UL Power strips providing power to non-patient-care-related electrical equipment must be Relocatable Power Taps (RPT) listed as UL Department of Engineering

45 QUESTIONS? Department of Engineering

46 DEPARTMENT OF ENGINEERING George Mills, MBA, FASHE, CEM, CHFM, CHSP Director Anne Guglielmo, CFPS, CHFM, CHSP, LEED, A.P. Engineer John Maurer, CHFM, CHSP, SASHE Engineer Kathy Tolomeo, CHEM Engineer James Woodson, P.E., CHFM Engineer Department of Engineering

47 THE JOINT COMMISSION DISCLAIMER These slides are current as of 3/31/2015. 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. Department of Engineering