Upload
others
View
3
Download
0
Embed Size (px)
Citation preview
Environment of Care
COMPLIANCE MANUAL
Thomas J. Huser, MS, CHSP
A Guide to the Joint Commission Standards
FOURTH EDITION
Environment of Care COMPLIANCE MANUAL
Thomas J. Huser, MS, CHSP
A Guide to the Joint Commission Standards
FOURTH EDITION
Environment of Care Compliance Manual: A Guide to the Joint Commission Standards, Fourth Edition, is published by HCPro, Inc.
Copyright © 2008 HCPro, Inc.
All rights reserved. Printed in the United States of America. 5 4 3 2 1
ISBN: 978-1-60146-293-0
No part of this publication may be reproduced, in any form or by any means, without prior written consent of HCPro, Inc., or the Copyright Clearance Center (978/750-8400). Please notify us immediately if you have received an unauthorized copy.
HCPro, Inc., provides information resources for the healthcare industry.
HCPro, Inc., is not affiliated in any way with The Joint Commission, which owns the JCAHO and Joint Commission trademarks.
Thomas J. Huser, MS, CHSP, AuthorOwen W. MacDonald, Senior Managing EditorBob Croce, Group PublisherSusan Darbyshire, Cover DesignerMichael Roberto, Layout ArtistMike Mirabello, Senior Graphic ArtistAudrey Doyle, CopyeditorLauren Rubenzahl, ProofreaderDarren Kelly, Books Production SupervisorSusan Darbyshire, Art DirectorJean St. Pierre, Director of Operations
Advice given is general. Readers should consult professional counsel for specific legal, ethical, or clinical questions.
Arrangements can be made for quantity discounts. For more information, contact:
HCPro, Inc.P.O. Box 1168Marblehead, MA 01945Telephone: 800/650-6787 or 781/639-1872Fax: 781/639-2982E-mail: [email protected]
Visit HCPro at its World Wide Web sites:www.hcpro.com and www.hcmarketplace.com
08/200821517
Environment of Care Compliance Manual, Fourth Edition iii© 2008 HCPro, Inc.
List of figures ..........................................................................................................................................vi
Dedication ............................................................................................................................................ viii
About the author .................................................................................................................................... ix
Preface .................................................................................................................................................... xi
Chapter 1: Strategies for the Environment of Care ............................................................................ 1
A Brief History of PTSM and EC Function ......................................................................................................2
The Joint Commission Today: What to Expect in the Upcoming Year.........................................................3
The Key to EC Compliance: Strong Team, Strong Plan ..................................................................................5
Chapter 2: Safety and Security ............................................................................................................. 7
2009 Environment of Care Scoring ...................................................................................................................8
EC.01.01.01: Minimizing EC Risks ..................................................................................................................10
EC.02.01.01: Managing Safety and Security Risks .........................................................................................12
EC.02.01.03: Smoking Prohibitions .................................................................................................................18
Survey Hot Spots ...............................................................................................................................................20
Chapter 3: Hazardous Materials and Waste ..................................................................................... 41
Definitions of “Hazardous Chemicals” and “Hazardous Waste” ..................................................................41
EC.02.02.01: Managing Hazardous Material and Waste ...............................................................................42
Survey Hot Spots ...............................................................................................................................................52
Contents
iv Environment of Care Compliance Manual, Fourth Edition© 2008 HCPro, Inc.
Contents
Chapter 4: Fire Prevention ................................................................................................................... 87
Survey Focus on Fire Safety, Buildings, Equipment, and Emergency Power ..............................................88
EC.02.03.01: Managing Fire Risks ...................................................................................................................89
EC.02.03.03: Conducting Fire Drills ...............................................................................................................93
EC.02.03.05: Maintaining Fire Safety Equipment, Features ..........................................................................96
Survey Hot Spots .............................................................................................................................................103
Chapter 5: Medical Equipment .......................................................................................................... 111
Documentation Must Be Detailed and Managed Well ...............................................................................112
EC.02.04.01: Managing Medical Equipment Risks ......................................................................................113
EC.02.04.03: Testing, Maintaining, and Inspecting Medical Equipment .................................................119
Survey Hot Spots .............................................................................................................................................121
Chapter 6: Utilities Management ...................................................................................................... 131
Utilities Management: Purpose and Scope ...................................................................................................131
EC.02.05.01: Managing Utility Risks .............................................................................................................132
EC.02.05.03: Emergency Power Sources .......................................................................................................139
EC.02.05.05: Testing, Inspecting, and Maintaining Utility Systems ..........................................................142
EC.02.05.07: Inspection, Testing, and Maintenance of Emergency Power ...............................................144
EC.02.05.09: Maintaining, Testing, and Inspecting Medical Gas, Vacuums .............................................149
Survey Hot Spots .............................................................................................................................................151
Chapter 7: Functional Environment .................................................................................................. 163
EC.02.06.01: A Safe and Functional Environment .......................................................................................163
EC.02.06.05: Design and Construction ........................................................................................................169
Survey Hot Spots .............................................................................................................................................171
Environment of Care Compliance Manual, Fourth Edition v© 2008 HCPro, Inc.
Contents
Chapter 8: Staff Competency ............................................................................................................. 173
EC.03.01.01: Responsibilities and Roles in the EC ......................................................................................173
Survey Hot Spots .............................................................................................................................................175
Chapter 9: Demonstrating Implementation of Care ....................................................................... 177
Leadership’s Role in EC ...................................................................................................................................177
EC.04.01.01: Organizational Monitoring ......................................................................................................178
EC.04.01.03: Recognizing and Resolving Areas of Concern ......................................................................185
EC.04.01.05: Improving the EC ......................................................................................................................186
Survey Hot Spots .............................................................................................................................................187
Chapter 10: Updated Survey Hotspots ............................................................................................. 195
Hot Spots Checklist .........................................................................................................................................196
Appendix: Using the Files on Your Environment of Care CD-ROM ............................................. 199
Management Plans ...........................................................................................................................................199
Chapter Files ....................................................................................................................................................200
vi Environment of Care Compliance Manual, Fourth Edition© 2008 HCPro, Inc.
Chapter 2
Figure 2.1: The SOA Form ................................................................................................................................21
Figure 2.2: Blank Witness Statement Form.....................................................................................................21
Figure 2.3: Blank Supplement Report ..............................................................................................................22
Figure 2.4: Injury Information Sheet ...............................................................................................................23
Figure 2.5: Fall/Injury Report ...........................................................................................................................24
Figure 2.6: Security Activity Log ......................................................................................................................26
Figure 2.7: Elopement/AWOL Report Form ..................................................................................................28
Figure 2.8: Security Incident Report Form .....................................................................................................30
Figure 2.9: Plans and Policies for Worker Safety ............................................................................................31
Figure 2.10: Smoking Intervention Form ........................................................................................................32
Figure 2.11: Security Department Statement of Purpose ..............................................................................33
Figure 2.12: Firearms and Weapons Policy .....................................................................................................35
Figure 2.13: Forensic Patient Policy/Procedure..............................................................................................37
Figure 2.14: Extra Patrol Sign-In Form ...........................................................................................................39
Figure 2.15: Narcotics Discrepancy Report Form ..........................................................................................40
Chapter 3
Figure 3.1: Chemical Response Plan ...............................................................................................................55
Figure 3.2: Hazard Communication Program ................................................................................................65
Figure 3.3: Asbestos Management Policy ........................................................................................................67
Figure 3.4: Hazardous Waste Policy.................................................................................................................71
Figure 3.5: Infectious Waste Policy ..................................................................................................................75
Figure 3.6: DOT Hazmat Transportation Security Plan ................................................................................78
Figure 3.7: Alarm/Odor Response Form.........................................................................................................85
List of figures
Environment of Care Compliance Manual, Fourth Edition vii© 2008 HCPro, Inc.
List of figures
Chapter 4
Figure 4.1: Life Safety System Preventative Maintenance Grid ..................................................................104
Figure 4.2: Fire Alarm Response Record ......................................................................................................105
Figure 4.3: Fire Drill Evaluation Form ..........................................................................................................106
Figure 4.4: Fire Watch Log ..............................................................................................................................108
Figure 4.5: Fire Watch Report Form ..............................................................................................................109
Figure 4.6: Life Safety Systems Shutdown Advisory Form ..........................................................................110
Chapter 5
Figure 5.1: Medical Equipment Safety Policy ...............................................................................................123
Figure 5.2: Preventive Maintenance of Electronic Equipment ...................................................................124
Figure 5.3: Vendor Representatives Policy ....................................................................................................126
Figure 5.4: Safe Medical Device Reporting Policy .......................................................................................127
Chapter 6
Figure 6.1: Construction Risk Assessment Form .........................................................................................153
Figure 6.2: Risk Criteria for Individual Types of Equipment .....................................................................160
Figure 6.3: Sample Emergency Generator Test Log/Report ........................................................................161
Chapter 9
Figure 9.1: Employee Environment of Care Survey .....................................................................................188
Figure 9.2: Hazard Surveillance Discrepancy Checklist ..............................................................................189
Figure 9.3: Hazard Surveillance Discrepancy Report ..................................................................................191
Figure 9.4: Safety Inspection Report .............................................................................................................192
Figure 9.5: Annual EOC Committee Reporting Grid .................................................................................193
viii Environment of Care Compliance Manual, Fourth Edition© 2008 HCPro, Inc.
To Ray, gone but not forgotten;
and to my wife, Linda, for her support and understanding
T.J.H.
Dedication
Environment of Care Compliance Manual, Fourth Edition ix© 2008 HCPro, Inc.
Thomas J. Huser, MS, CHSP
Thomas J. Huser, MS, CHSP, brings more than 23 years of experience to bear on his position as safety coor-
dinator, Emergency Management and Hazardous Materials, with Clarian Health in Indianapolis. With expe-
rience ranging from hospital management to emergency preparedness planning to fire safety instruction,
Huser brings both administrative and real-world knowledge to his work in healthcare safety.
A certified master-level Certified Healthcare Safety Professional (CHSP), Huser is well versed in Environ-
ment of Care chapter sections, including safety, security, hazardous materials and wastes, fire prevention,
medical equipment, and the functional environment. Huser also has expertise in Emergency Management
and Life Safety chapters of The Joint Commission’s (formerly JCAHO) Comprehensive Accreditation Manual
for Hospitals.
Before joining Clarian Health, Huser worked for St. Vincent’s Hospital in Indianapolis as the manager of
health and safety for the hospital’s organizational safety department and was a consultant for the St. Vincent
Health affiliated facilities. A volunteer firefighter for the past 25 years, Huser is a certified National Fire
Protection Association (NFPA) fire instructor II/III and a state-certified hazardous materials instructor. He
is the healthcare representative on the Marion County, IN, Local Emergency Planning Committee and
serves as a hospital representative on numerous other planning groups.
Huser writes for Briefings on Hospital Safety (HCPro, Inc.) and the Journal of Healthcare Security. He has
given presentations at such gatherings as the Ascension Health Safety Conference, the NFPA World Fire and
Safety Conference, and the National Earthquake Conference.
Huser holds a master’s degree in health and safety management from Indiana State University, a bachelor’s
degree in business administration from Indiana Wesleyan University, and an associate’s degree in applied
fire science from Ivy Tech State College of Indiana.
About the author
Environment of Care Compliance Manual, Fourth Edition xi© 2008 HCPro, Inc.
In 2002, when I set out to write the first edition of this book, my goal was to help safety directors, plant
managers, security managers, accreditation managers, The Joint Commission (formerly JCAHO) survey
coordinators, operations managers, and others in facility management to assess where they stood in compli-
ance with the Environment of Care (EC) chapter set out by The Joint Commission. I wanted to help you
better understand The Joint Commission’s expectations and to obtain support for fulfilling these obligations.
I reviewed all of the sections of the EC, including safety, security, hazardous materials and wastes, fire pre-
vention, medical equipment, utilities, and the functional environment, a relatively new chapter requiring
that facilities prove they have put into practice all of the aforementioned sections and that they are working
for continuous improvement. To comply with the EC, responsible personnel also must be familiar with rec-
ommendations and regulations from the National Fire Protection Association (NFPA) and the Occupational
Safety and Health Administration (OSHA). As such, the book also discussed how the NFPA and OSHA
requirements have become part of The Joint Commission requirements. I talked about the history of the EC
and how it had evolved since 1995, and I structured the book so that it was as easy to read and understand
for the veteran safety officer as for the novice newly involved with the EC.
I set out plans and tools meant not only to help you improve your compliance but also to help you attain
compliance in areas where your facility might be deficient. In writing the book, I called upon experiences I
gained in the military and in the fields of firefighting, law enforcement, and healthcare.
With this fourth edition, my goals are the same. I will:
• Deliver a plain-English interpretation of The Joint Commission requirements for the EC
• Provide sample management plans for each of the six sections (available on the accompanying
CD-ROM, courtesy of Safety Management Services, Inc.)
• Update information to reflect changes in 2009
Preface
xii Environment of Care Compliance Manual, Fourth Edition© 2008 HCPro, Inc.
Preface
The Purpose of this Book
The intent of this manual is to assist the leaders of an organization, as well as those who are responsible for
compliance with the EC chapter. Depending upon the size of your organization, this audience could include
anyone from the CEO to any employee responsible for compliance. This manual is to be shared among
members of the organization to help them both understand the expectations of The Joint Commission and
obtain support in procuring funds to fulfill those obligations.
As you review this manual, you will notice that aspects of this chapter affect everyone within the facility.
The safety of patients, visitors, and employees rests upon compliance with this section. Indeed, compliance
with this chapter can be a matter of life and death.
Remember, the foundation of each program is the management plan discussed in Chapter 1.
How to Use this Book
As a safety officer, I know that managers need a guide to The Joint Commission standards that will serve as
a sourcebook for up-to-date EC information while also functioning as a signpost toward future changes.
Today, this preparation must be done as the facility also prepares for unannounced surveys. The EC process
is a team effort that requires support from everyone, from the board of directors to the employees. The EC
also extends past the walls of the hospital to all locations the hospital owns, including those that do not
involve inpatient care.
As I present commentary on the revisions to the management plans, I also talk about what I think The Joint
Commission expects facilities to do regarding management drills and, if the changes are approved, I offer
advice on how the changes will affect facilities.
Chapter 1 offers an overview of the EC.
Chapters 2–6 detail each EC management plan, from planning through implementation.
Chapter 7 discusses the environment in which the patient actually stays. The Joint Commission is taking a
more subjective look at this area to ensure that patient care extends beyond just medical aspects to include
the environment in which patients will be staying.
Environment of Care Compliance Manual, Fourth Edition xiii© 2008 HCPro, Inc.
Preface
Chapter 8 details the requirements for compliance as they relate to your staff and licensed independent
practitioners who work within your EC.
Chapter 9 reviews methods for providing documentation that your organization has implemented the five
management plans. This chapter also discusses how your organization can measure outcomes and use this
information to show continuous performance improvement.
Chapter 10 assesses the latest “hot spots” in the EC chapter, including the pitfalls suffered by other organi-
zations and what surveyors will be looking for when they call. This chapter, as well as the “survey hot spots”
listed at the end of each chapter, has been updated to reflect changes in survey emphasis.
Your challenge: Create a solid EC program, facilitywideCreating an effective EC program can be challenging. Given that, it should not be undertaken by just one
or two staff members.
My hope is that this book will make the EC process easier to understand so that you can comply with
The Joint Commission’s standards. I wish you the best of luck with your next survey.
Those of you who read the earlier editions of this book may note a similarity in wording.
As this is a guidebook, such similarity is expected; however, do not assume that the
information is unchanged. Facts and conditions regarding the standard or news may have
been altered slightly, and it is up to you to note every detail (your surveyor will!).
TIP
Environment of Care Compliance Manual, Fourth Edition �© 2008 HCPro, Inc.
In the evolution of the Environment of Care (EC) chapter, The Joint Commission is taking a closer look at
methods of survey preparation and reporting, as well as the integration of personnel in meeting accredita-
tion imperatives. Recent changes affect standards for patient safety, peer and performance reviews, and staff
competency. In this fourth edition, I have renamed this chapter to include the word strategies to acknowl-
edge how The Joint Commission’s (formerly JCAHO) changes to the EC serve as a strong function in help-
ing readers create a plan of action.
The goal of EC management, according to The Joint Commission, is to “provide a safe, functional, support-
ive, and effective environment” to ensure quality, safety, and care of buildings, equipment, and people. As
you read through this manual, you will see that this is the most aggressive overhaul of the EC chapter since
its creation in 1995. Not only has the numbering changed to reflect that used by other code organizations,
but the life safety portion of the fire safety section has been removed from the EC chapter, as has emergency
management. Both have been placed into their own chapters within the accreditation manual to demon-
strate their importance to leadership. These chapters are covered in HCPro, Inc.’s upcoming Life Safety
Compliance Manual and Emergency Management Compliance Manual, respectively. You will note that there is
still a fire prevention section of the EC manual; however, compliance also will be tied to elements of the new
life safety chapter.
CH
APT
ERStrategies for the Environment of Care1
Chapter 1
� Environment of Care Compliance Manual, Fourth Edition© 2008 HCPro, Inc.
A Brief History of PTSM and EC Function
Before 1995, The Joint Commission separated the Plant Technology Safety Management (PTSM) require-
ments into four sections: utilities and preventive maintenance; fire prevention; disaster preparedness (now
known as emergency management); and safety, which included the subcategory of hazardous materials and
infectious waste. These standards were independent of each other and could function in silos, or indepen-
dent units. Thus, the person in charge of the utility program did not necessarily have to share information
with the person heading the safety program.
This changed in 1995, under the new direction of Ode Keil, The Joint Commission’s PTSM director. Keil’s
responsibilities involved overseeing and creating surveys and standards, which comprised standards devel-
opment, survey process development, and surveyor education. Under Keil, The Joint Commission imple-
mented a radical change: the alteration of the PTSM to the EC chapter. The changes included the following:
Expansion of EC sectionsThe four PTSM chapters were expanded to eight sections: safety, security, hazardous materials and wastes,
emergency management (formerly disaster preparedness), fire prevention, medical equipment, utilities man-
agement, and the newest section, functional environment (formerly appropriate environment). That final
chapter requires facilities to document adherence to the aforementioned requirements and demonstrate
efforts toward continuous improvement. This would include employee orientation and education, drills (to
ensure knowledge and readiness), and testing and maintenance of operational components. The new section
requires regular reporting, such as a comprehensive annual report to the board of directors, and the board’s
approval of performance improvement (PI) initiatives.
Continued emphasis on emergency managementThe EC’s continued emphasis on emergency management came at a time when these issues were brought to
mainstream attention. Although it is generally understood that hurricanes Katrina and Rita did not initiate
the revision of EC.4.20—the prevailing belief is that changes were in development for years—the catastrophic
damage and subsequent controversy surrounding response certainly contributed to a new examination of
the emergency management section and, to a lesser degree, utilities management. Because of the increasing
importance of emergency preparedness in our world today, The Joint Commission has completely removed
the emergency management section from the EC chapter and placed it in its own chapter of the compliance
manual. Because of this change, I will not discuss the expectations for emergency management in this manual.
Strategies for the Environment of Care
Environment of Care Compliance Manual, Fourth Edition �© 2008 HCPro, Inc.
Continued emphasis on patient safetyThe hurricanes also brought to the fore concerns about patient safety from all sides and from all sources—
from extreme natural disasters to the more common train derailments, bus crashes, and subway fires.
Adding to these enduring threats are threats of infectious diseases that were thought to have been either
eliminated or reduced, such as tuberculosis (in 2005, a surgical intern at a Boston hospital treated patients
for months after testing positive for tuberculosis); community-acquired methicillin-resistant Staphylococcus
aureus (CA-MRSA) infections; healthcare-associated infections (HAI); recent outbreaks of mumps; and the
fear of avian flu. The increase in domestic manufacturing of illegal drugs has resulted in injuries and fires
related to the manufacturing of methamphetamine. The new imperative is safety. Its corollary is constant
improvement, which is one reason for the creation of the fourth edition of this manual.
Changes in method of surveyWith the implementation of the EC in 1995, a major shake-up occurred in the way hospitals were surveyed.
Higher expectations were placed on medical facilities to meet EC demands. Cooperation with other areas of
the hospital became necessary to ensure that the required training was completed and to determine the com-
petency of the staff. Traditional requirements, such as fire drills, disaster drills, and compliance with stan-
dards and codes set out by the Occupational Safety and Health Administration (OSHA) and the National
Fire Protection Association (NFPA), remained in place. Added to the new and updated requirements is a
new treatment of “voluntary” as mandatory, in areas involving, for example, workplace antiviolence pro-
grams and the filing of the Statement of Conditions (SOC). The SOC requires hospitals to conduct a thor-
ough inventory regarding their compliance with the NFPA Life Safety Code®, as well as documentation of
their deficiencies and repairs. Both the NFPA and OSHA codes and standards have become part of The Joint
Commission’s requirements.
The Joint Commission Today: What to Expect in the Upcoming Year
With the 2009 overhaul of the EC chapter and the addition of the life safety and emergency management
chapters, there is a lot to keep an eye on in the coming year, including the following:
Change in requirements for emergency generator tests: EC.6.04.07 (previously EC.7.40), which deals with test-
ing of emergency power systems, underwent revisions on January 1, 2007. The big change was a new
requirement that hospitals test their generators for a four-hour run at least once every 36 months.
Chapter 1
� Environment of Care Compliance Manual, Fourth Edition© 2008 HCPro, Inc.
Surveyors’ continued crackdown on EC.2.01.04 (previously EC.1.10): Last year, according to The Joint Com-
mission, one out of every 10 hospitals received a citation under the old EC.1.10, the standard mandating
that hospitals should respond to safety risks.
Expansion of The Joint Commission’s National Patient Safety Goals: The addition of this section will affect the
EC directly. It is important for the safety committee to remain up to date on these goals and to coordinate
with other departments to ensure continuous compliance. Look for this section to change as The Joint
Commission continues to add new requirements to this program.
Continuation of unannounced surveys established in 2006: Facilities received no notice of their survey date
prior to the start of the survey, as The Joint Commission said in the 2006 Comprehensive Accreditation
Manual for Hospitals. Exceptions included initial surveys (for organizations undergoing their first Joint
Commission survey) and locations in which it would not be logical or feasible to conduct an unannounced
survey, such as prisons and Department of Defense facilities.
Tracer surveying: The last change in the current evolutionary trail is the advent of the tracer method of sur-
veying. Previously, units were surveyed methodically and individually. In 2004, however, surveys began to
use the tracer method, in which the surveyors chose patient records and traced a patient’s stay through the
facility. If a patient arrived in the emergency department (ED), had surgery, and was then admitted, the sur-
veyor would begin in the ED and follow the data flow right on through to the facility’s discharge of the
patient. During the tracer, the surveyor also would look for other problems—including any that were part of
the EC. With the new tracer method, you never know where a surveyor will go, so it is vital that the entire
facility be prepared for a visit. However, patient care is not the only place tracers can be used; for example,
tracers can also track a system, such as tracing hazardous materials from the loading dock, through staff
use, and then disposal.
Performance improvement: PI is the cornerstone of The Joint Commission survey, including the EC. The
Joint Commission wants to see not only that you are meeting the basic requirements of the chapter but also
that you are improving upon them. The entire PI section in The Joint Commission accreditation manual
guides you through what is required. (Read more on how this is done in Chapter 9 of this manual.)
Strategies for the Environment of Care
Environment of Care Compliance Manual, Fourth Edition �© 2008 HCPro, Inc.
The Key to EC Compliance: Strong Team, Strong Plan
Successful EC compliance hinges on a well-planned, well-executed team approach that has the support of
the administration and the staff.
The planEach section of the EC requires a management plan, which gives the surveyor an overview of the way the
facility is addressing the requirements of each standard. All management plans need to be identical in format
to show the surveyor that the people responsible for the EC chapter perform as a team and communicate
well with each other. This also shows the surveyor what processes your facility uses to ensure compliance
with each section of the EC chapter. On the CD-ROM accompanying this manual are completely updated
management plans for each of the sections.
The teamThe EC chapter should not be administered by only one or two people, especially with the advent of the
unannounced survey. One facility I know of has chapter facilitators who are responsible for ensuring com-
pliance with the chapter. The facility also has support personnel who assist in ensuring compliance. For
example, the director of facilities and security is responsible for the utilities management section. He has
support from various managers and supervisors and is also co-facilitator for the chapter. Another example
is the director of clinical engineering. Numerous staff members support the reporting and activities in the
maintenance of this section. Because of the size of this facility, 15 people directly assist the chapter facilita-
tors. And this overview does not begin to encompass members of the support staff, who conduct the day-
to-day activities related to the EC.
The number of people on your team will vary depending upon the size of your facility. Some suggested team
members might include people from senior management, facilities/engineering services, safety, security (if
applicable), clinical engineering/biomedical, infection control, nursing administration, and off-site loca-
tions, along with any “facilities” within your facility.
Make sure that all players come together on a regular basis, not just before a survey. They must be familiar
with their roles during a survey and be comfortable discussing issues and processes with the surveyor.
Holding regular meetings also allows new members to become familiar with the survey process and to see
how your facility responds to survey questions. The week before a survey is not the time to get everyone
together for the first time—rather, such meetings should be part of the ongoing EC process.
Chapter 1
� Environment of Care Compliance Manual, Fourth Edition© 2008 HCPro, Inc.
The supportThe team can’t make it happen without support from the top brass. The success of the EC program depends
upon the support of senior management, up to and including the board of directors. This support is needed
for many reasons, the most important being financial support—when compared with other Joint Commission
chapters, the EC chapter is likely the most expensive with which to comply. However, it is not an overstate-
ment to say that lives depend upon compliance with this chapter.
If you have any doubts as to the potential for disaster if compliance is not maintained, simply look at recent
history. People are still dying in fires in healthcare facilities; people still die from inhalation of improper
gases through the central gas distribution system. Imagine what would happen to patients on life support if
your facility lost power and the emergency generators failed. Likewise, the ramifications of improper main-
tenance of a defibrillator could be devastating. The Joint Commission requires that the board of directors be
informed of all such deficient areas and of all actions being taken to correct them.
It is sometimes difficult to garner the support of leadership, especially in today’s healthcare environment.
Funds are tight, and it is often difficult to justify spending money for a new generator when you have never
had one fail—especially when a physician requests funding for a revenue-producing project.
The EC chapter deals in the area of “what-ifs”—what if something goes wrong? You might have a plan in
place to deal with the what-ifs of the world, but such projects are extremely hard to get approved—even if
your facility has experienced similar failures or disasters. The “lightning never strikes twice” mindset shows
itself here.
There is no clear-cut formula that will guarantee funding for your projects. It takes a time-proven, well-
established working relationship between senior management and your EC team working on all levels to
make your program succeed.