© Copyright, The Joint Commission 2013 T HE H EALTHCARE E NVIRONMENT U PDATE Anne M. Guglielmo Engineering Department The Joint Commission

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2013

THE HEALTHCARE ENVIRONMENT

UPDATE

Anne M. Guglielmo

Engineering Department

The Joint Commission

Department of Engineering 2013 - 2

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RISK ICON

Integrated into the Manuals, E-dition, AMP, & FSA Tool All products will display a single icon at the EP level

for three risk-focused categories:1. National Patient Safety Goals2. Accreditation program-specific risk area standards3. Selected direct/indirect impact standards

In addition, the FSA Tool will use the R icon to identify the fourth risk category:

4. RFI standards from current cycle survey events.

Risk• Proximity to patient• Probability of harm• Severity of harm• Number of patients at risk


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RANKING RESULTS: 11 OUT OF 21 IN 2012

Top 20

RankStandard

2012 RFIs

2011 RFIs Subject

2 LS.02.01.20 51% 56% Means of Egress

3 LS.02.01.10 46% 52% General LSC Requirements

5 EC.02.03.05 40% 40% Features of Fire Safety

6 LS.02.01.30 39% 45% Life Safety Protection

7 EC.02.06.01 35% 31% Built Environment

9 LS.02.01.35 34% 29% Fire Suppression Systems

10 EC.02.05.01 33% 23% Utility Systems (Ventilation)

11 EC.02.02.01 30% 25% Hazardous Materials & Waste

15 EC.02.05.09 23% 22% Medical Gases

17 EC.02.05.07 22% 26% Emergency Power

21 EC.02.03.01 19% 21% Fire Safety


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#2: LS.02.01.20 51%

The hospital maintains the integrity of the means of egress.EP 13 Corridor Clutter

Also scoredEPs 16 – 21 Suites issues

Boundaries & Size defined• Sleeping Suite <5000 sq ft• Non-sleeping suite <10,000 sq ft

EP 22: Patient sleeping room is not locked


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CORRIDOR STORAGE

“If the corridor looks cluttered…it probably is”

Carts Allowed:Crash Carts Isolation CartsChemo Carts

Anything in the egress corridor more than 30 minutes is storage

Dead end corridors may be used for storage Less than or equal to 50sqft space


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SUITES

Not identified on drawings BoundariesDimensionsExits


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LS DRAWING INFORMATION A legend that clearly identifies features of fire safety Areas of the building that are fully sprinklered (if the

building is partially sprinklered) Locations of all hazardous storage areas Locations of all rated barriers Locations of all smoke barriers Suite boundaries, including the size of the identified suites

—both sleeping (max 5,000 sq ft) and non-sleeping (max 10,000 sq ft)

Locations of designated smoke compartments Locations of chutes and shafts Any approved equivalencies or waivers


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#3: LS.02.01.10 46%

Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat.EP 9 Fire Barrier PenetrationsEPs 5 – 7 Door issuesEPs 1 & 2 Building Type issuesEP 8 Duct issues


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#5: EC.02.03.05 40%

The hospital maintains fire safety equipment and fire safety building features.Features of fire protection Risk Icons: EP4: Audio/Visual AlarmsEP11: Water flow alarm to fire pump flow testEP19: Automatic shutdown of AHU


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NEED FOR INVENTORY EC.02.03.05 EP 1 – 20:

Each device that is required to be tested must be documented in an inventory If x devices were tested last year, and x-1 were tested

this year, which device was missed?• Each device must be on the inventory to identify

which device was missed• Total number of devices (quantity) is not adequate

Lack of an inventory (written, electronic or other) results in a finding at the EP Findings solely for lack of inventory is not scored at

EC.02.03.05 EP 25


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EC.02.03.05

During survey specific documentation is reviewed

If the documentation for a specific EP is not available a finding is written as non-compliant for that EPThe documentation should be readily available

If the organization clarifies after survey:Joint Commission Engineers will review and

evaluate complianceLD.04.01.05 EP 4 remains


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EC.02.03.05EPs 1 -20: Missing documentation: score the EP as non-

compliant Also write a finding at EP 25 for documentation

not being readily available to the AHJ• If acceptable documentation appears, finding

at EP 1 – 20 might be removed during survey• EP 25 remains

LD.04.01.05 EP 4: Staff held accountable If 3 or more findings at EC.02.03.05 EP 1 – 20


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EC.02.03.05 EP 25

For hospitals that use Joint Commission accreditation for deemed status purposes:Documentation of maintenance, testing, and

inspection activities for fire alarm and water-based fire protection systems includes the following:

Below for ContentsNote: For additional guidance on documenting activities:

NFPA 25, 1998 edition (Section 2-1.3) NFPA 72, 1999 edition (Section 7-5.2)


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EC.02.03.05 EP 25

Name of the activity Date of the activity Required frequency of the activity Name and contact information, including

affiliation, of the person who performed the activity

NFPA standard(s) referenced for the activity

Results of the activity


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#6: LS.02.01.30 39%

The hospital provides and maintains building features to protect individuals from the hazards of fire and smoke.EPs 16 – 23 Smoke Barriers & DoorsEP2 Hazardous Areas


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#7: EC.02.06.01 35%

EP 1 Interior spaces meet the needs of the patient population and are safe and suitable to the care, treatment and services providedThe organization must provide a safe

environment Unsecured oxygen cylinders Outdoor safety is scored at

EC.02.01.01 EP 5


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EC.02.06.01 EP 13 The organization maintains ventilation,

temperature and humidity levels suitable for the care, treatment and services provided

Ventilation: • i.e. doors held open by air pressure; odors

Temperature: • Hot / Cold calls

Humidity• Primary concern is for areas >60%RH

− Mold growth is possible EP 20: Patient care areas are clean and free of

offensive odors


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#9: LS.02.01.35 34%

Risk Icon:EP 1: monitor authorized automatic sprinkler systemEP 2: water flow alarm

There are 18” or more of open space maintained below the sprinkler deflector to the top of storage.

NOTE: Perimeter wall and stack shelving may NFPA 13-1999, 5-6.6


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18” RULE

18”18”

OK OK OKWrong

Wall Wall

Ceiling

Perimeter Shelving Perimeter

Shelving


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#11: EC.02.05.01 33%

EC.02.05.01 EP 1: Improper system designInability of the mechanical system to

achieve required results EC.02.05.01 EP 4: Lack of written inspection,

testing & maintaining frequenciesContinuous monitoring by a building

automation system (BAS) is acceptable


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EC.02.05.01 EC.02.05.01 EP 6: Ventilation system is unable to provide

appropriate pressure relationships, air-exchange rates and filtration efficiencies Specific areas lack

negative or positive pressures in relationship to adjacent areas • i.e. Endoscopy Processing Room should be negative

to the egress corridor the correct number of air changes per hour Improper filtration

• MERV = minimum efficiency reporting value


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#11: EC.02.02.01 30%

EP’s 3 – 5: Personal Protective Equipment and the process to manage hazardous materials and waste handling and exposures

EP 4 is a RISK ICON EP’s 6 – 7: Hazardous energy sources

Escorts to Hot Lab based on organization policy Perspectives, July 2012 EP 7 is a RISK ICON


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#15: EC.02.05.09 23%

Medical Gas SystemsEP 1: Inspection Testing and MaintainingEP 2: Test when modified, installed or repaired EP 3: ObstructionsEP 3: Labeling

Contents of piping Areas served

• Accuracy


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#17: EC.02.05.07 22%

EPs 4 – 7 Missed Generator & Automatic Transfer

Switch (ATS) Tests12 times per year between 20 & 40 days

Each emergency generator must be tested with a load of at least 30% of nameplate

Each ATS must be tested Missed triennial 4 hour test


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#21: EC.02.03.01 19%

Fire Safety (EP 1) Open junction boxesMore than 300cuft of nonflammable medical

gases (i.e. oxygen) per smoke compartment, open to the egress corridor

Fire Plan (EP 9 & 10)Lack of fire safety training as per fire plan

Surgical site fires


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LIFE SAFETY CODE SURVEYOR

LSCS BackgroundFacilities or Environment of Care basedPrefer CHFM certification

All HAP and CAH will be surveyed for a minimum of 2 days by a LSCSGreater than 1.5 million sq ft will be

surveyed for a third day by the LSCSAn additional day is added for every three

buildings that are classified as healthcare


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LIFE SAFETY CODE SURVEYOR Interfaces with survey team member(s) LSCS Survey Focus

Life Safety Chapter EC.02.03.05 EC.02.05.07 EC.02.05.09

May conduct the EC Session May conduct the EM Session

Other “Observations” May also survey

LD.04.01.05 EP 4 Accountability LD.04.04.01 EP 2 Hi-Priority LD.01.03.01 EP 5 Resources


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WHAT TRIGGERS ITL(IMMEDIATE THREAT TO LIFE)

Significantly compromised fire alarm system Significantly compromised sprinkler system Significantly compromised emergency power

supply system Significantly compromised medical gas master

panel Significantly compromised exits Other situations that place patients, staff or

visitors at extreme danger


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WHAT TRIGGERS ITL(IMMEDIATE THREAT TO LIFE)

PDA01An Immediate Threat to Health or Safety exists for patients or the public within the hospital.

CONT01The Immediate Treat to Health or Safety has been successfully abated and verified through the direct observation or other determining method.


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AFS 10 IS RELATED TO THE SOC AND PFIS

Failure to make sufficient progress on previously accepted PFIs (LS.01.01.01 EP 2)

Failure to develop ILSM policy and implement appropriate ILSMs (LS.01.02.01 EP 3)

Failure to manage previously accepted PFIs affects the Joint CommissionBoth organizations are aware of deficiencies that

have been managed using the PFI process


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DEFICIENCY RESOLUTION Resolution to a deficiency:

Resolve it immediately Correct it within 45 days:

Management process that documents the deficiency and actions to resolve

ILSM must be considered Plan For Improvement located in the Statement

of Conditions™ Corrected within 6 months of the Projected

Completion Date ILSM must be considered


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45 DAY CORRECTIVE ACTION Documented

Origination date Completion date Kept available for rolling 3 years

Life Safety deficiencies Must not exceed 45 days If greater than 45 days create a Plan For Improvement

(PFI)If originally a work order, close out as complete and

generate the PFI Must be made available to the Joint Commission

During survey to confirm management of the deficiency Upon request by the Joint Commission


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HOW MANY OPEN PFIS ARE TOO MANY?

The PFI process was created to allow organizations to self assess and create a Plan for Improvement

The self disclosure has never defined how many is too many

The ILSM process was created to allow both the organization and The Joint Commission to be aware of Life Safety Code deficiencies

Failure to make progress on previously accepted PFIs, including failure to implement ILSMs results in Conditional Accreditation


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HOW MANY OPEN PFIS ARE TOO MANY?

Survey Process: There is no limit to the number of PFIs Evaluate both closed and currently open PFIs in the

View All screen Spot check during building tour both some closed and

open PFIs to evaluate how well the organization is managing the PFI process

Evaluate the scope of PFI entries Are there life safety deficiencies Are they greater than maintenance items (i.e.

screws missing from a door hinge)


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STATEMENT OF CONDITIONS: PFI PFIs should be related to the LS Chapter PFIs should provide specific information

No blanket statements “…penetrations on 3rd floor”

Specific references to Life Safety Drawings is acceptable 32 penetrations as identified on LS Drawing

3rd Floor, Center Tower dated 3/3/2010 Projected Completion Date is for all listed

items (i.e. “32 penetrations”)


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TWO FORMS OF EQUIVALENCIES Fire Safety Evaluation System (FSES)

A process of calculating the features of life safety and deducting any deficiencies, with the outcome determining if the building is equivalized based on the FSES

Traditional Equivalency A process of field verification identifying alternative

methods of fire safety that off-set the identified deficiency Field verification from one of the following:

Registered Architect Fire Protection Engineer Local AHJ responsible for fire safety


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HISTORY AUDIT TRAIL

The History Audit Trail is used by SIG Engineers when considering extensions or other activities related to an organization

Prior to surveying, the surveyor must preview the History Audit Trail to discover if equivalencies or other actions have occurred by SIG Engineers

When surveying, brief but accurate information entered in the File Room is important

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2012 LIFE SAFETY CODE

Department of Engineering

The Joint Commission


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NFPA 101-2012

1.Means of Egress Enhanced Patient lift & transport equipment may be

stored in the Means of Egress, provided 5ft clear corridor width is maintained Fire plan addresses management of

storage Accommodates current “equipment in

use”


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NFPA 101-2012

2. Fixed seating permitted provided 6ft clear width < 50sqft with 10’ between groupings

Groupings must be on same side of the egress corridor


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NFPA 101-2012 CORRIDOR COOKING

3. Cooking Facilities One cooking area may be open to the egress corridor

per smoke compartment Any additional cooking areas must be in protected

room similar to hazardous areas Provisions:

No deep fat fryers Safety equipment to de-activate fuel supply Grease baffles installed No solid fuel (i.e. charcoal)


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NFPA 101-2012 FIREPLACES

4. Fireplaces in smoke compartments with patient sleeping rooms

Section 18/19.5.2(2), (3) and (4) Allow the installation of direct vent gas

fireplaces In smoke compartments containing patient

sleeping rooms Installation of solid fuel burning fireplaces in

areas other than patient sleeping areas


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NFPA 101-2012 DECORATIONS

5. Allow the use of Furnishings, Mattresses, and Decorations including Section 18/19.7.5

Allows the installation of combustible decorations on Walls Doors Ceilings

LSC Section 18/19.7.5.6

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BUILDING MAINTENANCE PROGRAM (BMP)

The BMP is no longer available to offset findings during survey, but is considered “best practice”

All EPs related to the original ten BMP items are ‘C’ categories

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RISK ASSESSMENT


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EC.02.01.01 EP 1 (A CATEGORY)

The hospital identifies safety and security risks associated with the environment of care that could affect patients, staff and other people coming into the hospital’s facilities. NOTE: Risks are identified from internal sources such as

ongoing monitoring of the environment, results of root cause analysis, results of annual proactive risk assessments of high-risk processes, and from credible external sources such as Sentinel Event Alerts. (See also EC.04.01.01 EP 14).

Is there a risk assessment process? Quality of the risk assessment process


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EC.02.01.01 EP 3 (C CATEGORY)

The hospital takes action to minimize or eliminate identified safety and security risks in the physical environment.

Did the organization respond to the risk assessment and correct the identified risk?


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Identify Safety & Security Risks

Established Process?

NoYes

EC.02.01.01 Risk

Assessment

Identify Risk?

EP 3

NoYes

Resolved?

Yes No

EP 1

EP 1

Unsafe conditions? Consider

EC.02.06.01 EP 1


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EC.02.06.01 EP 1

Interior spaces meet the needs of the patient population and are safe and suitable to the care, treatment and services provided.Unsafe patient care areas

Behavioral Healthcare Unit: Clinical or Physical?• Ensure the risk is not being managed clinically• Does not include non-patient care areas


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WHEN TO CONDUCT A RISK ASSESSMENT

Use to evaluate any issue that lacks a clear decision

Educated guess that drives your assumptions Clearly document the process Determine when to re-assess the issue Problem solving approach to determine

appropriate response Preventive strategies to address potential issues


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CONDUCTING A RISK ASSESSMENT: SEVEN STEPS

1. Identify the issue2. Develop arguments in support of the issue3. Develop arguments against the issue4. Objectively evaluate both arguments5. Reach a conclusion6. Document the process7. Monitor and reassess the conclusion to

ensure it is right conclusion


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ENVIRONMENTAL TOURS

The organization monitors conditions in the environment of care. EP 12 Environmental tours

patient care areas every six months EP 13 Environmental tours

non-patient care areas annually EP 14 Ongoing monitoring of actual / potential risk EP 15 Evaluation of objectives, scope, performance

and effectiveness of all EOC management plans


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PRA EC.02.06.05 EPS 2 & 3

Preconstruction Risk Assessment (PRA)Construction or renovation in occupied

healthcare facilities can result in environmental problems such as:NoiseVibration Creation or spread of contaminantsDisruption of essential servicesEmergency ProceduresAir quality


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INTERIM LIFE SAFETY MEASURES Order of Standards (LS.01.02.01)

EP 1 & 2 regardless of ILSM policyEP 3 must clearly define the ILSM policy

including AFS 10 Process When to implement What to do to protect occupants Both construction related and non-

compliance with the LSCEPs 4 – 14 align with policy and

implementation strategies


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DEPARTMENT OF ENGINEERING630 792 5900

George Mills, MBA, FASHE, CEM, CHFM, CHSP

Director

Anne Guglielmo, CFPS, LEED, A.P., CHSP

Engineer

John Maurer, CHFM, CHSP

Engineer

OPEN Engineer Position

OPEN Engineer Position


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These slides are current as of 5/1/2013. 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.

THE JOINT COMMISSION DISCLAIMER

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© Copyright, The Joint Commission 2013 T HE H EALTHCARE E NVIRONMENT U PDATE Anne M. Guglielmo Engineering Department The Joint Commission