Joint Commission Resources Quality & Safety Network (JCRQSN)

Transcription

1 Quality & Safety Network (JCRQSN) Resource Guide Environment of Care Update: A Focus on Life Safety Code Compliance Issues July 23, 2015

2 About Joint Commission Resources Joint Commission Resources (JCR) is a client-focused, expert resource for healthcare organizations. It partners with these organizations, providing consulting services, educational services, and publications to assist in improving the quality, safety, and efficiency of healthcare services, and to assist in meeting the accreditation standards of The Joint Commission. JCR is a subsidiary of The Joint Commission, but provides services independently and confidentially, disclosing no information about its clients to The Joint Commission or others. Visit our web site at: Disclaimers Joint Commission Resources educational programs and publications support, but are separate from, the accreditation activities of The Joint Commission. Attendees at Joint Commission Resources educational programs and purchasers of Joint Commission Resources publications receive no special consideration or treatment in, or confidential information about, the accreditation process. The information in this Resource Guide has been compiled for educational purposes only and does not constitute any product, service, or process endorsement by The Joint Commission or organizations collaborating with The Joint Commission in the content of these programs. NOTE: Interactivation Health Networks is the distributor of the Joint Commission Resources Quality & Safety Network series and has no influence on the content of the series Joint Commission Resources. The purchaser of this educational package is granted limited rights to photocopy this Resource Guide for internal educational use only. All other rights reserved. Requests for permission to make copies of this publication for any use not covered by these limited rights should be made in writing to: Department of Education Programs, Joint Commission Resources, One Renaissance Boulevard, Oakbrook Terrace, IL Joint Commission Resources 2 of 35

3 TABLE OF CONTENTS Program Summary...4 Program Outline...5 Continuing Education (CE) Credit...6 Top Standards Compliance Data for EC and LS trouble spots show up for many settings...7 Take a Walk-Through...8 Make an environmental tour part of your spring cleaning...8 Remaining Vigilant: Key Safety Issues to Watch For on EC Tours...11 What the CMS Life Safety Code Waivers Mean for You...13 The Top Five Hot Button Issues in EC...16 EC Dashboard Keeps Compliance Front and Center...19 Not Documented, Not Done...25 Appendix A: Additional Resources...29 Appendix B: Faculty Biography...30 Appendix C: Continuing Education (CE) Accrediting Bodies...31 Appendix D: Discipline Codes Instructions...32 Appendix E: Post-Test...33 Appendix F: JCRQSN Contact Information Joint Commission Resources 3 of 35

4 Program Summary This page provides an overview of the program content and learning objectives. Please refer to the Table of Contents and Program Outline for a detailed list of the topics covered. The information included in this Resource Guide is intended to support but not duplicate the video presentation content. There may be additional information available online for this topic. Program Description Because of the increased emphasis on patient safety and emergency management, the responsibilities of staff involved in the environment of care (EC) and those involved in direct patient care overlap. With the recognition that the EC is crucial to the successful delivery of care, more leaders are educating staff about EC issues and using a team approach to share EC responsibilities. The Environment of Care and Life Safety chapters in The Joint Commission's Comprehensive Accreditation Manual for Hospitals (CAMH) focus on how everyone in the organization should participate in activities that make the care environment safe. The standards require organizations to establish plans and identify key individuals for managing the environment of care; identify physical risks to which the organization is susceptible; establish activities to minimize these risks; train staff to implement these activities; and monitor the effectiveness of these activities and implement improvements. Through in-depth expert panel discussion and featured case studies, this 60-minute live event analyzes and explains the staff's role in the environment of care. The most common standards compliance issues related to life safety (LS) are also identified. Program Objectives After completing this activity, the participant should be able to: 1. Identify problematic LS standards (LS , LS , and LS ) and strategies for achieving compliance. 2. Create streamlined processes and procedures to avoid duplication of efforts and encourage cooperation between direct care staff and EC staff in managing the environment of care. 3. Describe the most common compliance issues related to life safety. Target Audience This activity is relevant to all hospital staff, medical staff, volunteers, and contracted staff, particularly those who are responsible for life safety-related activities, including safety officers and committees, engineering staff, facility managers, department managers and supervisors, performance improvement (PI) staff, training and education staff, and risk managers Joint Commission Resources 4 of 35

5 Program Outline July 23, 2015 I. Introduction A. Program Content B. Objectives C. Faculty II. Ongoing Improvement of the Environment of Care III. Categorical Waivers IV. Building Tour V. Conclusion VI. Post-Program Live Question and Answer Session A. Audio only telephone seminar with program faculty for 30 minutes following the program. B. Call ; enter conference code: Or your questions or comments to: Program Broadcast Time Eastern: Central: Mountain: Pacific: 2:00 p.m. to 3:00 p.m. 1:00 p.m. to 2:00 p.m. 12:00 p.m. to 1:00 p.m. 11:00 a.m. to 12:00 p.m. Program Question and Answer Session During the live airing of this program on July 23, 2015, you may be able to talk directly with the faculty when prompted by the program s host. After this date, your message will be forwarded to the appropriate personnel. Immediately following the program, we invite you to join in a live discussion with the program presenters. Call and enter Conference Code: to be included in the teleconference. To submit your question ahead of time or for additional details, please send an to questions@jcrqsn.com. If you submit your questions after this date, your message will be forwarded to the appropriate personnel. You can also receive answers to your questions by calling The Joint Commission s Standards Interpretation Hotline at , option Joint Commission Resources 5 of 35

6 Continuing Education (CE) Credit After viewing the JCR Quality & Safety Network presentation and reading this Resource Guide, please complete the required online CE/CME credit activities (test and feedback form). The test measures knowledge gained and/or provides a means of self-assessment on a specific topic. The feedback form provides us with valuable information regarding your thoughts on the activity s quality and effectiveness. NOTE: Effective April 1, 2012, the Learning Management System web site URL changed as noted below. Prior to the Program Presentation Day 1. Login to the JCRQSN Learning Management System web site at 2. Enroll yourself into the program Note: Your administrator may have already enrolled you in the program Select All Courses from the courses menu. Select the course category for the current year, 2015 Programs. Select the course for this program, Environment of Care Update: A Focus on Life Safety Code Compliance Issues When prompted, choose Yes to confirm that you would like to enroll yourself. 3. Display and print the desire documents (Resource Guide, etc.). Online Process for CE/CME Credit 1. Read the course materials and view the entire presentation. 2. Login to the JCRQSN Learning Management System web site at 3. Select from the courses menu block. Note: This assumes you have already been enrolled in the program as described above. 4. If you didn t view the broadcast video presentation, view it online. 5. Complete the online post test (see Appendix E). You have up to three attempts to successfully complete the test with a minimum passing score of 80%. Physicians must take the post test to obtain credit. 6. Complete the program feedback form. 7. On the top right corner of the main course page, you will see your completion status in the Status block. 8. Select Print Certificate from within the Status block to print your completion certificate Joint Commission Resources 6 of 35

7 Top Standards Compliance Data for 2014 EC and LS trouble spots show up for many settings The Joint Commission regularly aggregates standards compliance data to pinpoint areas that present the greatest challenges to accredited organizations. These data help The Joint Commission recognize trends and tailor education around challenging standards. In turn, they can help accredited organizations focus improvements and educate staff. The table at right identifies The Joint Commission environment of care (EC), life safety (LS), and tightly related infection control (IC) requirements with which organizations were most frequently not compliant during surveys and reviews from January 1, 2014, through December 31, The data represent citations only from organizations due to be surveyed during this time period; that is, data from for-cause surveys are not included. While the text of the requirements appears in the table, the full text of each (including elements of performance and scoring information) is published in the respective accreditation or certification manual. Percentages (rounded to the nearest whole point) indicate the number of organizations that received Requirements for Improvement (RFIs) for the standards shown. The most frequently cited requirements are displayed in decreasing frequency for each program. Please note that surveyors review compliance with all standards in manuals. This list is provided only to help organizations recognize potential trouble spots. If you have questions about these requirements, please review the Standards Frequently Asked Questions at jointcommission.org/ Standards/ FAQs. Questions not addressed on this site may be directed to the Standards Interpretation Group through its online question form, at Standards/OnlineQuestionForm. Copyright 2015 The Joint Commission Environment of Care News, May 2015, Volume 18, Issue Joint Commission Resources 7 of 35

8 Take a Walk-Through Make an environmental tour part of your spring cleaning In spring, an environmental manager s attention turns to tidiness. It s the season for spring cleaning of all types, and what better time to conduct an environmental tour of your facility? This tour is required at least once a year anyway for business occupancies and twice a year for health care occupancies. An environmental tour is essentially a routine comprehensive inspection of your organization s physical milieu, conducted as a walk-through event. Its purpose is to assess environment of care safety; identify environmental weaknesses, hazards, and unsafe practices; and evaluate how effective and knowledgeable staff are at managing safety and security risks. An environmental tour is not synonymous with a patient safety tour, and it s not focused on aesthetics like paint colors or decor. Instead, it s a carefully planned checkup of the factors affecting the patient care environment and those working in it. The tour s goal is for the organization to take a hard, honest look at itself and determine where it s struggling with environmental safeguarding so that it can improve those areas, says John Maurer, SASHE, CHFM, CHSP, engineer, Department of Engineering, The Joint Commission. The first of these tours should be conducted closer to the early part of the year, so it can be used to help your organization monitor whatever expectations and goals it has set in its annual evaluation from the prior year, he notes. When, where, and who Each tour event usually takes a few hours and is scheduled to visit all nursing units and departments. An environmental tour is required: EC Standards and Environmental Tours Joint Commission accredited facilities are required to conduct environmental tours, per the following Environment of Care standards: EC , which states that the organization must: Manage safety and security risks Identify safety and security risks associated with the environment of care that could affect patients, staff, and other people coming to the organization s facilities Take action to minimize or eliminate identified safety and security risks in the physical environment Maintain all grounds and equipment EC , which states that the organization must: Collect information to monitor conditions in the environment Conduct environmental tours every six months in patient care areas to evaluate the effectiveness of previously implemented activities intended to minimize or eliminate environment of care risks Conduct annual environmental tours in non-patient care areas to evaluate the effectiveness of previously implemented activities intended to minimize or eliminate risks in the environment Use its tours to identify environmental deficiencies, hazards, and unsafe practices Evaluate each environment of care management plan every 12 months, including a review of the plan s objectives, scope, performance, and effectiveness EC , which states that the organization must: Analyze identified environment of care issues Use the results of data analysis to identify opportunities to resolve environmental safety issues At least twice a year (once every six months) in patient care areas At least once annually in non-patient care areas, including public waiting areas, doors, walkways, stairs, elevators, parking lots, sidewalks, and garages See EC Standards and Environmental Tours, above. Scheduling to repeat these tours at approximately the same time every year at consistent intervals allows you to compare data and track progress or lack thereof. Extra tours can be added if desired, and a tour can be moved up sooner to accelerate the schedule, but a tour cannot be delayed. For instance, six-month tours normally slated for June and December can be bumped up to occur every April and October instead; but if the first occurs in April, the second cannot occur any later than six months after that date. Many organizations break these up into shorter, easier-to-manage monthly tours, during which different designated departments are scheduled to be investigated. This reduces the burden of trying to cover so much ground twice a year, Maurer says Joint Commission Resources 8 of 35

9 The actual walk-through tour is best performed by a multidisciplinary group consisting of the assigned safety officer and members of various departments (see Tour Teammates, below). To efficiently structure the touring process, these groups often create forms or checklists to scrutinize various areas and keep the steps organized. Staying organized is important, as an environmental tour usually involves several components, each necessary to thoroughly evaluate the environment of care and weed out any safety deficiencies that could lead to accidents, security breaches, and/or harm to staff and patients. These tour components include the following: Visual observations Random staff interviews Review of relevant documents Eyes on the safety prize During the visual observation phase, aim to keep an eye out for red flags in the physical environment, including any of the following: Clutter in halls, corridors, and heavily trafficked rooms Soiled and clean laundry that is mixed/bundled together Incorrect storage, such as medication that s not securely stored or that s not in its recommended climate; lack of or improper placement of a sharps container; supplies storage areas that are not clean or sterile; blood products that aren t clearly labeled; or cleaning products accidentally mixed in with clinical supplies Fire hazards, such as equipment that uses flammable gases or oxygen that is not safely secured or stored On your EC tour, keep an eye out for hallway clutter that might endanger patients or staff. Workarounds shortcuts taken by workers to save time but that can lead to exposure to risk such as a disabled door latch, which could allow unauthorized personnel into restricted areas Lack of needed safety signage in key areas See the October 2014 issue of EC News for additional problem areas to watch for. What you can learn from staff and their records During the tour, conducting random interviews of personnel is highly recommended, as these queries can help gauge staff awareness of and compliance with procedures and policies related to safety and security. Several key topics can be broached during these interviews from the practices involved in reporting defective equipment, to the availability and use of safety data sheets (SDS), to fire safety protocols. In addition to learning worker practices, this is a great opportunity to educate staff about crucial safety matters, says Maurer. Tour Teammates An environmental tour should include a team of assigned personnel from different disciplines in the health care organization. Joint Commission engineer John Maurer recommends that you try to include staff members from as many of the following departments as possible: Safety Clinical/nursing Infection control Security Risk management Quality assurance Performance improvement Administration Facilities management Engineering Clinical engineering Environmental services Housekeeping Laundry distribution Materials management 2015 Joint Commission Resources 9 of 35

10 Reviewing documents during your tour is worthwhile as well, to ensure that items are adequately logged and inventoried and processes are being correctly followed. Items of documentation to review may include the following: Training records Is staff training documented properly? Identification badges Are they worn and displayed as required? Policies/procedures Are they appropriately posted and accessible? Annual competencies Are they conducted on time? Chemical, medication, and supply inventories Is the paperwork effectively managed and updated? A review of all six required Management Plans (See EC , EPs 3 8), including a review of the plan s objectives, scope, performance, and effectiveness Once the tour is completed, your organization is required to review the data gathered, document and analyze the problems and areas of improvement identified, and take action to resolve or improve those issues. When it conducts its survey of your facility every three years, The Joint Commission will inquire about the environmental tours you performed over this period and may ask to see the data, which it will use to gauge compliance and improvement, says Maurer. Spring ahead, don t fall behind Maurer says there are several additional reasons why the spring season can be an ideal time to carry out an environmental tour. If the tour is conducted in the early part of the year, it can be scheduled to be completed prior to an annual inspection by fire officials and local authorities, he notes. Moreover, a spring tour can be advantageous for facilities in colder climates, as they can carefully examine the building perimeter, parking lots, and other external areas that may have been affected by freezing, thawing, and other weather events. These problems could have been obscured while snow and ice were present. For example, an upheaved sidewalk that could create a tripping hazard outside an organization exit may not have been visible before the snow covering it melted. Finally, slating a springtime tour can also possibly better address the Environment of Care, Emergency Management, and Life Safety standards that are most frequently cited for the highest incidence of noncompliance. This list, published every year in EC News (see the table on page 8 [not included in this document] of this issue), can be checked against during the tour to ensure that the facility is meeting these key standards, says Maurer. Copyright 2015 The Joint Commission Environment of Care News, May 2015, Volume 18, Issue Joint Commission Resources 10 of 35

11 Remaining Vigilant: Key Safety Issues to Watch For on EC Tours With The Joint Commission s Director of Engineering: George Mills The Joint Commission requires hospitals and critical access hospitals to conduct environment of care (EC) tours every six months in patient care areas and every year in non-patient care areas. Not only do these tours allow organizations to identify long-term improvement opportunities, but they also help EC professionals spot existing safety hazards that require immediate attention and ensure that the organization consistently maintains a safe and hazard-free environment. While no two EC tours are exactly alike, there are a number of issues that commonly come up during these exercises. Some hazards such as a ripped carpet or a leaking water fountain will be obvious, while others may be more subtle, such as the proper personal protective equipment used in an area or the space heaters found throughout the building. The following sections discuss a few frequently occurring safety hazards organizations may encounter during EC tours or on other walks through the facility, and they also provide compliance strategies. Staff should be aware of these issues and look out for them. Moreover, EC professionals should be familiar with the compliance nuances involved with these topics so they can address any staff questions or concerns along the way. Take a tour an environmental tour to find safety issues before they cause accidents. Propped-open doors To help with air flow, ventilation, and/or temperature, staff may prop a room door open with a chair, a wood block, or another object. If the room opens onto a corridor, however, the door should not be kept open in this manner. With one exception patient room doors all corridor doors must be self-closing and remain closed at all times to separate the corridor from the room in case of fire. If organizations seek to keep certain doors open, they can install on a door a magnetic holdopen interfaced with the fire alarm system. In case of fire, the magnetic connection is severed, and the door closes automatically, protecting the room s occupants. If you find doors propped open, make sure you look for the cause. If it is related to temperature, you may want to evaluate the effectiveness of the heating, ventilating, and air conditioning (HVAC) system. Affirm that the system is functioning as designed. It is possible that the system needs additional controls to meet the occupants needs. Space heaters The Joint Commission prohibits the use of portable space heaters in patient sleeping and treatment areas because of the increased fire risk associated with this equipment. If a piece of paper, gauze, or other combustible material inadvertently falls onto a space heater, it could start a fire, compromising the safety of patients sleeping or being treated in the area. In this context, a nurse s station is considered a treatment area and, thus, a space heater is prohibited. However, an office such as a nurse manager s office or an admitting area, which is separated from all sleeping and treatment areas by a door or wall, can have a space heater. As with the door situation described previously, if your organization uses a large number of space heaters, you may want to perform a detailed evaluation of your heating system to see if you can enhance performance and improve the flow of warm air throughout the facility. This could eliminate the need for some or all space heaters; avoiding space heater use altogether is the safest course of action. Appropriate personal protective equipment Every hospital has policies about personal protective equipment (PPE) that delineate when it should be worn and what kind of PPE is necessary for particular tasks and situations. During the EC tour, you should verify that practice follows policy and staff understand and consistently comply with the rules. For example, in maintenance areas where there are saws, grinders, vapors, and fumes, staff should be using eye, ear, and respiratory protection, as well as foot protection and helmets when warranted. Organizations should have proper signage indicating when PPE is necessary. For more information on the proper PPE for specific situations, see the Occupational Safety and Health Administration (OSHA) guidelines (for example, 29 CFR ). Note that, while The Joint Commission does not survey for OSHA compliance per se, if a surveyor sees an obvious OSHA violation such as not wearing the correct PPE in the maintenance shop he or she will cite the organization under Leadership (LD) Standard LD , element of performance (EP) 2, which addresses the need to comply with outside rules and regulations Joint Commission Resources 11 of 35

12 In addition to checking for appropriate PPE use, organizations should verify that PPE is in good working order. For example, you should periodically evaluate lead aprons to ensure that there is no cracking or shielding material displacement. Don t forget to look at items used to protect patients, such as the collars placed on individuals during an X-ray. This type of equipment is often overlooked and yet is crucial to keep patients safe. Proper lighting While it may seem like a little thing, a burned-out light bulb in an exit sign can be a significant safety hazard. The Joint Commission requires organizations to have two-bulb exit fixtures so that the loss of one bulb will not leave an area in total darkness. When staff members see a burned-out bulb, they should report the outage immediately so the bulb can be replaced as soon as possible. Appropriate lighting is also important for patient care areas to ensure that staff can correctly read identification badges, charts, and information supporting proper patient care and treatment. Organizations should assess lighting conditions at various times of day to gauge whether lighting is suitable for the activities taking place in the area. If lighting levels are not sufficient, the organization will need to explore effective means of adding lighting. This may include adding fixtures or changing existing fixtures or bulbs. Asking staff members about their perceptions of lighting can be beneficial to see if there are any concerns about light level and intensity. Sufficient cleaning Routine environmental cleaning is necessary to maintain a standard of overall organizational cleanliness. Accumulation of dust, dirt, and potential microbial contaminants on and under environmental surfaces is visually unattractive and also serves as a potential reservoir for microorganisms. There are requirements, established by government regulation and by guidelines issued by the Centers for Disease Control and Prevention (CDC), for maintaining the cleanliness of the health care environment. Each health care organization must have and follow written policies and procedures for environmental cleaning. Organizations should also address the presence of strong and offensive odors in the environment. Sometimes these odors can be tied to trash in the area, which may need to be emptied more frequently or at different times. Strong smells can also come from cleaning products, which may have potent odors that are offensive to patients and staff. Organizations should have processes in place for limiting and managing odors. EC professionals should double-check that these processes are consistently followed. Routine environmental cleaning is necessary to maintain a standard of overall organizational cleanliness. Another sometimes overlooked matter involves returning the environment to a ready state after cleaning. When housekeeping staff clean an area, they may raise alarm pulls, display wet floor signs, open drawers, or in other ways alter the clinical environment to clean the space. While this is appropriate, the housekeeping staff must return the environment to a ready position to fully support clinical use. One area of concern is in an exit enclosure such as a stair, where housekeeping may have cleaned the floor and left a wet floor sign. The problem occurs when the floor is dry and the sign remains. It s more than just an EC responsibility The EC tour is a logical time to identify hazards that could have a negative impact on the safety and functionality of the environment. However, it is not the only time staff should be on the lookout for safety hazards. Standard EC , EPs 1 3, requires organization staff and licensed independent practitioners to remain vigilant about physical risks and take responsibility for addressing them. In other words, a staff person or licensed independent practitioner should not just walk by a spill, hoping someone else will deal with it; instead, he or she should take ownership for notifying the proper personnel to respond to the issue. Ensuring a safe environment requires commitment from all staff and licensed independent practitioners. When such a commitment is present, an organization can foster an environment that supports the best possible care for patients. About this column: The Joint Commission has identified the need to increase the field s awareness and understanding of the Life Safety Code * as well as other key environment of care concepts. To address this need, Environment of Care News publishes the column Clarifications and Expectations, authored by George Mills, MBA, FASHE, CEM, CHFM, CHSP, director, Department of Engineering, The Joint Commission. This column clarifies standards expectations and provides strategies for challenging compliance issues, primarily in life safety and the environment of care but also in the vital area of emergency management. You may wish to share the ideas and strategies in this column with your organization s leadership. * Life Safety Code is a registered trademark of the National Fire Protection Association, Quincy, MA. Copyright 2014 The Joint Commission Environment of Care News, October 2014, Volume 17, Issue Joint Commission Resources 12 of 35

13 What the CMS Life Safety Code Waivers Mean for You Getting Your Questions Answered The Joint Commission has identified the need to increase the field s awareness and understanding of the Life Safety Code.* To address this need, The Joint Commission Perspectives publishes the column Clarifications and Expectations, authored by George Mills, MBA, FASHE, CEM, CHFM, CHSP, director, Department of Engineering, The Joint Commission. This column clarifies standards expectations and provides strategies for challenging compliance issues, primarily in life safety and the environment of care, but also in the vital area of emergency management. You may wish to share the ideas and strategies in this column with your facility s leadership. The Centers for Medicare & Medicaid Services (CMS) has recently granted a series of categorical waivers for requirements in the 2000 edition of the National Fire Protection Association s (NFPA s) Life Safety Code * (LSC). These waivers were announced in a memorandum released by CMS on August 30, 2013 (Survey and Certification, S&C LSC). The Joint Commission was instrumental in helping CMS to identify the need for and content of these waivers. Overall, the waivers are designed to protect the physical environment while preserving hospital resources and maintaining life safety. The Joint Commission was asked by CMS to identify requirements in the Life Safety Code that would have an immediate benefit to patient care and safety. In addition, The Joint Commission also requested that four earlier actions, named originally in S&C LSC, now be classified as categorical waivers. Categorical waivers differ from conventional waivers in that initiating a categorical waiver is not related to a survey event but may be elected at any time. To satisfy CMS s conditions related to categorical waivers, organizations are required to do the following: 1. Document their decision to use a categorical waiver(s). If a waiver involves a specific requirement in the Joint Commission s Life Safety (LS) standards chapter, an organization must annotate the Additional Comments field of the Basic Building Information (BBI) in the electronic Statement of Conditions * Life Safety Code is a registered trademark of the National Fire Protection Association, Quincy, MA. In a conventional waiver, if CMS identifies a noncompliant life safety condition during a survey and writes a citation, the organization is then required to implement corrective action. At this point, if an organization feels it will have a difficult time implementing corrective action (or for other reasons), it may request a conventional waiver. However, in a categorical waiver, permission is received outside of any survey activity. (E-SOC). However, if the requirements involve the Environment of Care (EC) standards chapter, an organization must document the decision in its EC committee minutes or an equivalent place. 2. Notify Joint Commission and CMS surveyors at the beginning of a survey that they have chosen to declare a categorical waiver. This is critical. It is not acceptable for an organization to wait until after it receives a Life Safety Code citation to notify the surveyor that it wishes to declare a categorical waiver. While categorical waivers are straightforward, organizations should be aware of a few nuances. The following paragraphs answer organizations frequently asked questions. Why is this set of categorical waivers significant? These particular CMS categorical waivers apply to specific requirements found in the Life Safety Code. Both The Joint Commission and CMS require compliance with the 2000 edition of the Life Safety Code as well as with other NFPA standards associated with that edition. In some cases, compliance with the 2000 edition is costly to organizations, whereas later editions of the Code have aligned requirements with those that are more cost effective while still ensuring patient safety. CMS issued a Survey and Certification (S&C) letter on August 30, 2013, declaring that these categorical waivers could be implemented immediately. What topics do the waivers address? The waivers relate to seven distinct topic areas, with specific waivers targeted to various requirements in each area. The topics are shown in the sidebar on this page and discussed as follows. Openings in exit enclosures. Many existing buildings have mechanical rooms or spaces (such as penthouses) that only open directly into an exit enclosure, such as an exit stair. To bring these spaces into compliance with the 2000 edition of the Life Safety Code, an organization would need to construct a new exit enclosure that provides exiting from the unoccupied spaces. Building a compliant exit enclosure would typically be cost prohibitive, and, in many cases, not even possible. The CMS waiver tied to this topic permits organizations to keep existing openings in exit enclosures for mechanical equipment spaces, if those spaces are protected by fire-rated door assemblies. Note that organizations can only use the mechanical spaces cited by the waiver for non fuel-fire 2015 Joint Commission Resources 13 of 35

14 mechanical equipment, and the spaces must not house any combustible materials. In addition, the spaces must be located in a fully sprinklered building. (See Standard LS , EP 32.) Emergency generators and standby power systems. Another CMS categorical waiver reduces the time an organization must annually test any diesel-powered emergency generator that does not meet monthly load level requirements. The NFPA 110 Technical Committee has determined that a 1.5-hour test (as opposed to the 2-hour test required by NFPA as cited in the 2000 edition of the LSC) is sufficient to detect problems with a generator and adequately test its reliability. By reducing the test time, it is estimated that an organization reduces emissions by at least 25% thus helping to preserve the environment. The total cost of the load bank test may also be reduced by approximately 25%, based on fuel savings and duration of the exercise. (See Standard EC , EP 5) Doors. Two CMS categorical waivers address the topic of doors. One allows for door locking arrangements in areas where patients a) have specific clinical needs (such as on a psychiatric or Alzheimer s unit); b) pose a security risk (such as a potentially violent patient in the emergency department); or c) require certain protective measures to ensure their safety (such as patients in a neonatal unit). Specifically acknowledging patient safety as associated with allowed locking arrangements is a change from the 2000 edition of the Life Safety Code. The second waiver permits more than one delayed egress lock to be installed in the path of egress. This is significant because an organization can now lock more than one exit access door along the egress path, allowing, for example, more than one unit to be secured. (See Standard LS , EP 1.) Suites. Suites are room and space groupings that function more efficiently than individual rooms off a corridor. To facilitate the use of suites, later editions of the Life Safety Code allow larger sleeping suites, up from 5,000 square feet in the 2000 edition to 7,500 square feet (and in certain conditions to 10,000 square feet). Suites are required to have one exit into an egress corridor in the 2000 Life Safety Code, but in later editions, one exit may be to an exit stair and the second required exit may be into a second compliant suite. From a patient care perspective, allowing the suite-to-suite configuration provides the patient with consistent care, as patient care equipment would be available in the second suite (rather than having to relocate the patient into the egress corridor to access equipment, for instance). The categorical waiver provides clarifying language specific to allowing the suite-to-suite separation, which is equivalent to a corridor separation. (See Standard LS , EP 18.) Seven CMS Waiver Topics (Plus Four) The seven topics below are the subject of the new CMS categorical waivers. In addition, four other topics are listed that existed before but are now classified as categorical. Openings in exit enclosures Emergency generators and standby power systems Doors Suites Extinguishing requirements Clean waste and patient record recycling containers Medical gas alarms Plus four... Wheeled equipment in the egress corridor One alternative kitchen cooking arrangement open to the egress corridor per smoke compartment Direct vent gas fireplaces and solid fuel-burning fireplaces Combustible decorations on walls, doors, and ceilings Extinguishing requirements. Another CMS categorical waiver reduces the required testing frequency for sprinkler system alarm devices and electric motor-driven fire pump assemblies. The 2000 Life Safety Code requires organizations to inspect, test, and maintain all automatic sprinkler and standpipe systems in accordance with the 1998 edition of NFPA 25, Standard for the Inspections, Testing, and Maintenance of Water-Based Fire Protection Systems. This document requires quarterly testing of vane-type and pressure switch waterflow alarm devices and weekly testing of electric motor-driven pump assemblies. The waiver allows organizations to return testing frequency to the previous Joint Commission requirement of semiannual for vane-type and pressure switch type waterflow alarm devices, for an estimated savings of 50% (reduction from 4 tests per year to 2). Electric motor-driven pump assemblies may now be tested monthly rather than weekly, for an estimated 77% reduction of testing costs and time. This will reduce both the labor and testing cost burden without negatively impacting the equipment s reliability. (See Standard EC , EPs 2 and 6.) 2015 Joint Commission Resources 14 of 35

15 Clean waste and patient record recycling containers. Another CMS categorical waiver permits organizations to use 96-gallon containers for recycling clean waste for example, paper and cans and patient records awaiting destruction. The goal of this waiver is to reduce the number of trash containers an organization must use, thus reducing the cost burden. (See Standard LS , EP 2.) Medical gas alarms. An additional CMS categorical waiver permits organizations to substitute a centralized computer system for one of the medical gas master alarms required by the 1999 edition of NFPA Health Care Facilities, which is referenced in the 2000 edition of the Life Safety Code. The provision requires that the computer system meet the requirements outlined in section of the 2012 edition of NFPA 99. Using a centralized computer system may result in a one-time savings, and in most cases will be a more efficient means to monitor the status of piped medical gas systems. (See Standard EC , EP 1.) What other topics are included? Four previous Life Safety Code waivers, originally issued in a March 2012 S&C letter, are now addressed in the categorical waiver granted in S&C LSC. The previous S&C waivers were only granted on a case-by-case basis. By including that S&C in the current S&C LSC, the previously required CMS case-by-case action is nullified.these are the four topics: Wheeled equipment such as lifts (with certain provisions and restrictions see NFPA / (6)) is allowed in the egress corridor provided that at least 5 feet clearance remains and the fire plan includes management of the lift in a fire condition. Other wheeled equipment would include crash carts, transport carts (including wheelchairs), and isolation carts. Fixed seating with at least 6 feet clearance and other restrictions (see NFPA / (5)) is also allowed. (See Standard LS , EPs 12 and 13.) One alternative kitchen cooking arrangement (per NFPA / ) open to the egress corridor per smoke compartment is allowed, following the requirements at 18/ (See Standard LS , EP 25.) The installation of direct vent gas fireplaces in smoke compartments containing patient sleeping rooms and the installation of solid fuel-burning fireplaces in areas other than patient sleeping areas is allowed, with certain restrictions as defined in LSC 2012 section 18/ Heating, Ventilating, and Air Conditioning. (See Standard LS , EP 1.) The installation of combustible decorations is allowed on walls, doors, and ceilings, with very specific restrictions as required in the 2012 Life Safety Code 18/ (See Standard LS , EP 1.) Are the waivers mandatory? No. An organization must decide whether to invoke the categorical waivers or not. Because of this, The Joint Commission will not be adjusting the standards and elements of performance related to these topics. Before electing to use a waiver, an organization should fully educate itself on the waiver s requirements and make sure that the waiver s approach aligns with its operations. How do I ensure compliance with the waivers? For an organization to apply a categorical waiver, it must comply with all of the requirements in the Life Safety Code edition cited in the waiver. For example, if an organization has suite-to-suite exiting, the organization must ensure that both suites are fully compliant with the 2012 edition of the Life Safety Code. What if an organization forgets to document the waiver decision? If an organization neglects to document the waiver decision or forgets to tell the surveyor at the beginning of survey, the surveyor will assess compliance with the applicable requirements found in the 2000 edition of the Life Safety Code. Any areas of noncompliance as a result of not documenting the decision to apply the categorical waiver, or failing to declare that decision at the beginning of survey, will result in a finding. Where can I get more information? Joint Commission accredited organizations that need more information should feel free to contact the Joint Commission Department of Engineering ( ). For more information about the CMS S&C LSC, please go to Enrollment-and-Certification/SurveyCertificationGenInfo/ Downloads/Survey-and-Cert-Letter pdf. This month s column, which also appears in the November 2013 issue of Environment of Care News, discusses Life Safety Code waivers from the Centers for Medicare & Medicaid Services. Next month s column will discuss maintaining fire equipment and building features. Joint Commission Perspectives, November 2013, Volume 33, Issue 11 Copyright 2013 The Joint Commission 2015 Joint Commission Resources 15 of 35

16 The Top Five Hot Button Issues in EC Joint Commission Life Safety Code Surveyors name the most common compliance problems Joint Commission Life Safety Code * 50 square feet, The Joint Commission Surveyors (LSCS) met in January to has no problem with items being discuss hot button issues in the stored there. Reducing the amount of environment of care (EC). Based on unused equipment in corridors is also field experience and 2013 survey extremely helpful. Take C-arms back information,1 there are five common to the x-ray department, or with problem areas in hospitals and health appropriate permission, place them in care facilities that need to be better a seldom-used space. Returning these addressed. Here s the lowdown on kinds of items to their original what Joint Commission LSCS will be locations or placing them in focusing on in the coming year and alternative spots will keep them from what you can do to make your piling up in corridors. Educating or buildings safer for patients and staff. reminding staff about corridor safety on a regular basis is also a good way to help prevent clutter. 1. Corridor clutter In the event of an emergency, clutter can not only make it difficult to move patients, it can hinder emergency responders who need to access parts of your building quickly. Keeping corridors unobstructed also happens to be standard and regulation. The National Fire Protection Agency (NFPA) 101: Life Safety Code * requires a corridor to be free of items and equipment to the original design width, which is typically 8 feet. Some equipment such as crash, chemo, and isolation carts is allowed in corridors at all times, as long as it is in use. The Joint Commission defines in use as being used at least every 30 minutes. Unfortunately, LSCS typically find a variety of items, like C-arms and laundry carts, which sit untouched by staff for much longer. Advance thinking and strategy go a long way toward maintaining clutterfree corridors. Designating a team to walk around and identify alternative storage locations in your building, such as storage rooms or dead-end spaces, should be a priority. As long as these storage areas do not exceed * Life Safety Code is a registered trademark of the National Fire Protection Association, Quincy, MA. NFPA 101: Life Safety Code (Section 18.2) offers guidelines for corridor clutter. See life-safety-code-handbook-roncote-8th/chapter-18/section-18-2-means-of-egress. 2. Penetrations Penetrations are literally holes in the wall. They are typically found above the drop-in ceiling tiles that transverse fire or smoke walls. These walls (or barriers) support compartmentation that is, the division of a health care facility into compartments to limit the spread of fire and restrict the movement of smoke. Holes in the smoke or fire walls lining these compartments can allow smoke, and potentially flames, to shoot through to adjacent areas that would otherwise be safe areas of refuge. According to Joint Commission standards compliance data, nearly half of the hospitals surveyed in 2013 did not have adequate building and fire protection designed and maintained to minimize the effects of fire, smoke, and heat. 1 So this is a serious problem that needs to be solved at many facilities. Preventing penetrations and ensuring the integrity of walls can be achieved by simply having a quality barrier management program (see EC News, July 2012, pages 5 7). A good program will do the following: Have qualified staff who are trained to recognize unsealed penetrations and know how to apply the appropriate firestopping system. Take into consideration the firestopping system being used. The type, size, and conduit used in penetrating the wall should all contribute to your selection of firestopping material. Materials used to plug holes should be Factory Mutual (FM) or Underwriters Laboratories (UL). Document where penetration repairs are made. Have the contractor annotate penetrations on life safety drawings or take photographs of repaired penetrations. This will allow you to follow up on any work done by an external contractor. You can more easily check to see if the right material was used and whether it was applied correctly, according to the manufacturer s recommendations. Limit access to barriers. If you notice somebody up above a ceiling with a ladder, check to see if that person has a barrier management permit usually a tag hanging on the ladder with the current day s date on it. If not, report the encounter so it can be investigated Joint Commission Resources 16 of 35

17 Consult NFPA 101: Life Safety Code (Section 8.3) for information on smoke barriers and penetrations. See life-safety-code-handbook-roncote-8th/chapter-8/section-8-3-s moke-barriers. 3. Door issues (latches, closures, and gaps) Door issues go hand-in-hand with penetrations, since they both fall under your barrier management program. If your building has fire and smoke walls, it typically has fire and smoke doors. Doors that fail to close and latch can be dangerous in the event of a blaze. A door that has inappropriate clearances between the door leaves or underneath the door will be ineffective against smoke. Some common problems include staff removing closers to keep doors open and the removal of other hardware to accommodate a newly carpeted floor. Maintaining latches, closures, and gaps starts with staff education on the importance of properly working doors and the safety they provide. Having an inventory of doors in your building will help make sure you have the right protection in place. Door type should be based on the type of fire or smoke barrier in the room or corridor. For example, if you have a one-hour fire barrier wall, you need a door with a ¾-hour fire protection level (a ¾-hour fire-rated door). See the article Ensuring Full Compliance with the Life Safety Code (EC News, July 2013, pages 5, 6, 9) at ingentaconnect.com/content/jcaho/ ecn/2013/ / /art000 03/ for more information. Performing door inspections on a regular basis will help mitigate problems. Inspections should be based on your inventory and the level of risk associated with barrier levels. The Life Safety Code 2000 and the 1999 edition of NFPA 80 (Chapter 15, Care and Maintenance, Paragraph ) state, Hardware shall be examined frequently and any parts found to be inoperative shall be replaced immediately. The Joint Commission recommendation is that annual inspections should be considered for doors that are critical to protecting occupants and for doors in high-traffic areas. It s also a good idea to keep a record of your door repair history. This can help you determine how often you need to make inspections. A guide to door inspections (including a checklist) is available from the Firestop Contractors International Association at org/articles/keybiscaynenov09 /documents/dhifiremarshal PrintVersionSept1.pdf/. For more information on fire door requirements, take a look at NFPA 80: Standard for Fire Doors and Other Protective Opening Protectives at -standards/document-informatio n-pages?mode=code&code= Ventilation Maintaining proper ventilation is extremely important in certain critical areas because you want air to move from clean to less clean areas. This keeps spaces that must be sterile, like operating rooms (ORs) or sterile processing areas, free of possible contaminants that could potentially cause infection. The flow of air from one room to another is based on pressure relationships: The air in the clean area should have positive pressure so it moves out to the adjacent area where the pressure is less positive. When LSCS visit a facility, they refer to the Facility Guidelines Institute s (FGI s) 2010 Guidelines, which recommend what rooms should have positive, negative, or neutral pressure. LSCS often use a simple tissue test to start a discussion regarding the appropriate pressure relationships. By placing the tissue in front of a door, they can immediately see if the tissue is sucked in or blown out. It s a good idea for you to perform this same test at your health care facility at the time of a Joint Commission visit specifically, when the overhead announcement is made, welcoming The Joint Commission to your organization. Ensuring a correct pressure relationship means making sure your ventilation systems are operating as designed and that all the components, such as filters and Variable Air Volume (VAV) boxes, are working well. Many organizations have an HVAC company or internal staff perform routine balance tests. Over time, any number of problems can occur that affect the ventilation system. For instance, vibration might close a VAV, something could block an area intake on the roof, or a fan belt might break. As with the first three hot button issues, it is important to establish a regular process of inspection to minimize problems and to service any components that do break down. Keep in mind that LSCS will use the code and year in which the space was built to determine the appropriate pressure relationship. The same 2010 FGI Guidelines for Ventilation that LSCS use are available as a free, read-only document at guidelines.org/guidelines2010. php Joint Commission Resources 17 of 35

18 5. Documentation issues with fire alarm systems The fifth and final hot button issue concerns missing documentation of an installed fire alarm system. Many organizations lack an inventory, miss annual tests, or fail to record the results of testing based on the requirements provided with the system. Proper documentation of your fire alarm system should include the following: The manufacturer s instructions covering all system equipment Life safety drawings that depict the installed system. In most cases, the way the system is installed in your building is not exactly the same as the original designs. Make sure your drawings match what you actually have installed. Keep an accurate set of drawings on site. You should also share the information with your local fire department. A record of completion by the installing contractor. The document should state that the system has been installed as designed and has been tested. Documented inspections and testing, along with a written plan that covers both per NFPA 72 requirements. For more information on fire alarm documentation requirements, take a look at NFPA 72: National Fire Alarm and Signaling Code at tandards/document-informationpages?mode =code&code=72. As you can see, addressing these top five issues is very doable. Simply taking the time to create a plan that addresses these concerns at your hospital or health care organization goes a long way toward securing your facility and protecting everyone in it. Contributed by Jim Kendig, CHSP, CHCM, HEM, field director for the Life Safety Code Surveyors, The Joint Commission Reference 1. The Joint Commission. Top Standards Compliance Issues for Joint Commission Perspectives. 2014;34(4):1, 3 8. Copyright 2014 The Joint Commission Environment of Care News, May 2014, Volume 17, Issue Joint Commission Resources 18 of 35

19 a Clarifications Expectations n d With The Joint Commission s Director of Engineering: George Mills EC Dashboard Keeps Compliance Front and Center Step-by-step tips for creating and using valuable dashboard tools The phrase history repeats itself certainly rings true when it comes to the most frequently scored survey findings. The list of Joint Commission standards with which organizations struggle is nearly identical from year to year, although the order differs slightly. Once again, several Environment of Care (EC) and Life Safety (LS) LS standards made the list (see, Most-Cited EC/LS Hospital Standards, right). Similar issues face health care organizations in all accreditation programs. For instance, according to scoring trends, organizations are still wrestling with how to reliably sustain proper ventilation in high-risk areas, eliminate corridor clutter, and maintain fire safety equipment to name a few. The reality is that most people in health care know what they need to do; they don t need a repeat of the tips and strategies shared so many times before. But consistently doing the work and documenting it is what many find challenging. Compliance starts with accountability and transparency, from the process owner to the facility manager to senior leadership. A robust dashboard reporting process can be used to introduce accountability for ensuring compliance with the EC and LS standards. The Joint Commission EC standards require this kind of accountability and documentation, via, among other things, (continued on page 3) Most-Cited EC/LS Hospital Standards Standard First half 2014 % Noncompliance 2013 % Noncompliance EC % 47% LS % 52% EC % 39% EC % 45% LS % 48% LS % 45% LS % 36% EC % 34% These standards are often repeat offenders for noncompliance. Page 1 Copyright 2015 The Joint Commission Environment of Care News, February 2015, Volume 18, Issue 2

20 EC Dashboard Keeps Compliance Front and Center (continued from page 1) an annual evaluation of the effectiveness of EC components (EC , EP 15). Using a dashboard is one option for collecting data (EC ), analyzing data (EC ), and providing regular reports to an EC committee that are understandable and actionable (EC , EP 3). To tackle this problem head on, organizations should consider taking a more strategic approach to ensuring compliance, which keeps the work active and on top of the to-do pile. Please note: Using a dashboard will not influence survey results. This article simply presents one as a way to introduce transparency, accountability, and long-lasting compliance in these EC and LS areas. What is a dashboard? Inspired by a car s instrument panel, a dashboard is a management tool that provides a real-time snapshot of performance, helping users quickly see the status of current work and areas that require attention. At its most basic level, a dashboard is a report that shows an organization s progress toward a goal and points toward the necessary next steps. Continuing the analogy, although a mechanic (or process owner) needs to know what s happening under the hood with each individual system, the driver (or senior leadership) only monitors the gauges and indicator lights on the dashboard. A car dashboard displays key performance indicators (KPIs) such as the speedometer, fuel gauge, oil pressure, and engine temperature. Careful monitoring of these KPIs ensures successful motoring. Similar KPIs in business, clinical, and environmental areas can be monitored to ensure success in these areas. For example, in the care environment, KPIs include barrier integrity, egress reliability, and air exchange and pressure differentials. Although dashboard reports can be quite complex (such as featuring four-color graphics to illustrate the current state), they do not have to be. Dashboards can be easy to understand and easy to update and still provide all the information a reader would need. Organizations can even create these tools internally, using word processing or spreadsheet software. EC professionals shouldn t overlook the resources they already have. Many organizations use clinical dashboarding to meet CMS requirements, and clinical colleagues can be a great resource in adapting a dashboard to help monitor and maintain a successful environment. Using a dashboard to address EC and LS risks This article features a dashboard, supported by two worksheets, that EC professionals can adapt to help their organization monitor current, real-time activity in their environment. Standards Analysis Worksheet The Standards Analysis Worksheet is a tool that can be used to capture the compliance status of the elements of performance (EPs) that are included in the desired dashboard. The worksheet is flexible and could be used to overview the entire EC and LS chapters, monitor the top 10 Joint Commission compliance issues, or focus on the organization s specific Requirements for Improvement. (See page 5 for a snapshot of this worksheet; the entire completed tool can be found at /1/7/ ECN0215_dash_completed.xls, and a blank tool is available at jcrinc.com/assets/1/7/ecn0215_dash_ blank.xls.) For EPs that require a simple yes/no response, this worksheet is sufficient; for more complex EPs that require data analysis, the In-depth Data Analysis Worksheet also needs to be completed. In-depth Data Analysis Worksheet This tool can be used to capture data Writable Dashboard Forms Available The sample worksheets and dashboard presented in this article are available at com/assets/1/7/ecn0215_dash_ completed.xls. They are also available as blank forms, which the user can populate with organization-specific data. These are provided with the hope that using them will result in improved patient safety and reduced findings during your organization s survey. You can access these writable forms at assets/1/7/ecn0215_dash_blank.xls. for multiple-issue, data-driven EPs, which require detailed analysis before determining compliance status. The results from this worksheet are fed into the Standards Analysis Worksheet to prepare data for the dashboard. (See page 6 for a snapshot of this worksheet; the entire completed tool can be found at /1/7/ECN0215_ dash_completed.xls, and a blank tool at ECN0215_dash_blank.xls.) KPI Summary Dashboard The KPI Summary Dashboard provides an overview of the KPIs for the EPs the organization has chosen to include in the analysis. (See page 6 for a snapshot of this dashboard; the entire completed dashboard can be found at jcrinc.com/assets /1/7/ECN0215_dash_ completed.xls, and a blank dashboard at ECN0215_dash_blank.xls.) The next sections of this article explain each of these tools in more detail. Simple standards analysis EC professionals can use the Standards Analysis Worksheet to perform an active compliance assessment of all EPs within a single standard. This evaluation is usually done by the process owner who is (continued on page 4) Page 3 Copyright 2015 The Joint Commission Environment of Care News, February 2015, Volume 18, Issue 2

21 EC Dashboard Keeps Compliance Front and Center (continued from page 3) familiar with the EP requirements. As staff members examine the various EPs within the standard, they will find those that comprise single issues, multiple issues, or data-driven issues. Most EPs address a single issue; for example, EC , EP 9, states the hospital has a written fire response plan. Either an organization has a written fire response plan or it does not. This is a simple yes/no or pass/fail analysis. For these single-issue EPs, the Standards Analysis Worksheet can quickly record the compliance status, keeping noncompliant EPs at the forefront until the organization achieves compliance. Other EPs may have a simple yes/no response but represent multiple issues. For example, EC , EP 9, states the hospital has written procedures for responding to utility system disruptions. Although this is a yes/no question (either an organization has the written procedures or it does not), it encompasses many factors, such as electricity, gas, air, and so forth. So, the worksheet should display each utility system separately to confirm that each is represented with a pass/fail status. Though this is not data driven, it does require more than a single yes/no response. The need for in-depth data analysis Some EPs have multiple requirements that would have more than one measurable factor or that are data driven. For example, Standard LS , EP 5, states: Doors required to be fire rated have functioning hardware, including positive latching devices and self-closing or automatic-closing devices. Gaps between meeting edges of door pairs are no more than 1/8 inch wide, and undercuts are no larger than ¾ inch. For these multiple-issue EPs that are data driven and require measurement, a separate, detailed analysis would be Building Your Own Environmental Dashboard Step 1. Identify the scope of your monitoring project. It could be a single standard, your most recent Requirements for Improvement, the top 10 Joint Commission compliance issues, or the entire Environment of Care (EC) or Life Safety (LS) chapter. Step 2. Build your Standards Assessment Worksheet(s). For each standard within the scope of your monitoring project, create an individual worksheet. All of the standards can be included in a single file, with individual tabs for each standard, or each standard could be in a standalone file. Starter files (and directions) are available online at dash_blank.xls. Be sure to include on each worksheet the standard number and language, each element of performance (EP), and compliance results. For multiple-issue EPs, you can list the individual factors that require a compliance assessment, such as each utility system that requires a written procedure for responding to a disruption. You should note on your Standards Assessment Worksheet which EPs require an additional In-depth Data Analysis Worksheet(s) to capture the data used to determine compliance status. Step 3. Build your In-depth Data Analysis Worksheet(s). Each In-depth Data Analysis Worksheet will be different because each EP requires unique assessment. Be sure to include what you are analyzing, the frequency of analysis, and other appropriate factors. In some cases, a single EP might require more than one In-depth Analysis Worksheet (for example, air pressure relationships, air-exchange rates, and filtration efficiencies from EC , EP 15). Step 4. Update the Standards Analysis Worksheet. The Standards Analysis Worksheet should include the summary data for all EPs in the standard, including those that needed an In-depth Data Analysis Worksheet. Once each EP in a particular standard is scored, determine your overall compliance with that standard. Step 5. Populate the KPI Summary Dashboard. Build your dashboard with the overall compliance information identified in your Standards Analysis Worksheets. The dashboard should list each standard included in the monitoring project for leadership s review. Consider using line graphs or pie charts to provide an at-aglance summary of the compliance status of each standard, and clearly label each entry. Step 6. Monitor compliance and stay accountable. With the worksheets, process owners will have the tools they need to improve how they monitor the environment and the information they need to approach improvements. With the dashboard, leaders can efficiently monitor key indicators of environmental compliance and be prepared to implement needed improvements. conducted for each factor. The In-depth Data Analysis Worksheet provides a practical way to organize and calculate the organization s performance on the individual factors in the EP that ultimately drive overall compliance with the EP. Summarizing data in a dashboard Whereas a standard defines the performance expectations and/or structures or processes that must be in place, the standard s EPs detail those expectations and/ or structures or processes. EPs are scored and determine an organization s overall compliance with a standard. Once each EP is scored in the worksheet, EC professionals can determine their organization s overall compliance with the standard which is the information that feeds the KPI Summary Dashboard. The standards-level information from Page 4 Copyright 2015 The Joint Commission Environment of Care News, February 2015, Volume 18, Issue 2

22 Figure 1. Standards Analysis Worksheet Standards Analysis Worksheet Example EC the Standards Analysis Worksheet populates the KPI Summary Dashboard. This high-level summary is similar to a score card in that it only indicates whether the organization is compliant with each standard. The intent is to display for the organization s leadership a global view of EC and LS compliance. For example, the dashboard may list the top 10 standards identified as noncompliant nationally and display the organization s own level of compliance for any of them that are related to EC and LS. Specific noncompliant EPs identified in the Standard Analysis and In-depth Data Analysis Worksheets should be assigned for correction to the process owner (for example, a contractor for life safety, the mechanic who services the HVAC system, or the nursing supervisor who ensures that corridors are kept unobstructed). This process owner should keep the worksheet and the resultant dashboard on his or her desk and should refer to it frequently to make sure compliance is being achieved or maintained. Periodically, the process owner should report to organization leaders on the trended status shown by the individual standards worksheets. As performance on each EP is brought into compliance, the KPI Summary Dashboard can be updated. Doing this keeps the organization leaders aware of successes and improvements. Ongoing monitoring may be required to ensure sustained compliance. Everyday attention to compliance data can drive ultimate and lasting change. Knowledge of exactly what is causing noncompliance allows a team to identify targeted actions and long-lasting solutions. For example, if the nurse supervisor identifies a chronic issue with medical equipment storage on one unit, it may highlight the need to create more storage on that unit. A dashboarding example To help readers better understand the dashboarding process, this article looks at a specific example using Standard EC ( the organization manages risks associated with its utility systems ). Historically, this has been a challenging standard for all organizations. See ECN0215_dash_blank.xls for simple instructions about using the worksheets and dashboard. The first step in the dashboarding process for Standard EC would be to populate the Standards Analysis Worksheet with the standard s 16 EPs and begin rating compliance (see Figure 1, left). For many of the EPs, compliance can be quickly rated as pass/fail. For example, EP 9 has multiple issues, but they can quickly be answered as pass/fail. However, EP 15 presents a more complex compliance question and requires that the ventilation system in areas designed to control airborne contaminants provide appropriate pressure relationships, air-exchange rates, and filtration efficiencies. This EP requires staff to rate multiple factors and requires that data on those factors accurately score compliance. The three main factors of EP 15 include appropriate pressure relationships, air exchanges, and filtration. An In-depth Data Analysis Worksheet would be created for each factor. This example follows only the appropriate pressure relationships issue; in practice, similar in-depth analysis should also occur for air exchanges and filtration. The organization designs an In-depth Data Analysis Worksheet to capture data on areas served by each specific air handling unit (AHU) and whether appropriate pressure relationships are being maintained. The data used in the worksheet (as shown in the example in Figure 2, page 6) include the following information: Each AHU (shown in column A) and the specific operating rooms, critical care units, corridors, storage areas, isolation rooms, patient rooms, and other areas supplied under the unit (column B) Compliance measurements at scheduled intervals that roll up to a quarterly percentage (columns C and D for Quarter 1, for example) and then feed an overall compliance rate (column Q) The process owner in this case facility engineering staff would measure (continued on page 6) Page 5 Copyright 2015 The Joint Commission Environment of Care News, February 2015, Volume 18, Issue 2

23 EC Dashboard Keeps Compliance Front and Center (continued from page 5) air-pressure relationships at every access point to that room and note whether the measurement is in or out of target. Identifying the appropriate measurement frequency depends on several factors that EC professionals will need to identify. Once they have identified measurement frequencies and the target rate, they need to capture data and identify whether the data fall within acceptable limits. If measurements fall outside acceptable limits, EC professionals need to document it, make repairs and adjustments, and continue monitoring. In the example shown in Figure 1, recent monitoring of the ventilation system revealed an unacceptable 73.14% compliance rate (row 27, column Q), which moves EP 15 to a high-risk category of noncompliance. The overall compliance of EP 15 is then transferred as noncompliant to the In-depth Data Analysis Worksheet, which informs the KPI Summary Dashboard. Leadership is apprised of the noncompliance by the dashboard, which identifies EC as one of the top 10 national standards being monitored and shows that the organization is out of compliance with this standard (see Figure 3, right). The process owners responsible for the noncompliant EP begin taking corrective actions. They report the compliance status, if appropriate, via an In-depth Data Analysis Worksheet. Once corrective actions have produced an acceptable rate of compliance, the EP s status is changed to compliant on each worksheet, and the dashboard is updated. The next step is to determine how the compliance will be monitored to ensure ongoing consistency. The monitoring system should be designed with need, experience, and frequency in mind. In this example, this AHU and its affected areas will be closely monitored until a trend of compliance is established. Figure 2. In-depth Data Analysis Worksheet In-depth Data Analysis Worksheet Example EC , EP 15 Figure 3. KPI Summary Dashboard KPI Summary Dashboard Example Accountability Accountability is critical to successful dashboarding. If monitoring efforts are embedded into the workflow, staff members know what they are responsible for checking and how often it should be done. An organization may find that (continued on page 9) Page 6 Copyright 2015 The Joint Commission Environment of Care News, February 2015, Volume 18, Issue 2