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Part 7: Meeting the Standards Challenges

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Part 7: Meeting the Standards Challenges

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  1. Part 7: Meeting the Standards Challenges Strategies for the Standards Challenges Healthcare Engineering Consultants

  2. Safety Management Issue: Proactive Risk Assessments for Safety Tip for Compliance: Think of risk assessments as simply prioritizing potential problems Healthcare Engineering Consultants

  3. Documenting Risk Assessments Risk Assessment: “Prioritization and management of resources though an assessment of probability and impact” Healthcare Engineering Consultants

  4. Why Perform Risk Assessments? Not enough time! Not enough staff! Not enough money! Healthcare Engineering Consultants

  5. Calculating Risk Assessments Risk = Probability X Impact Healthcare Engineering Consultants

  6. Global Risk Assessments What’s a Global Risk Assessment and What is it’s Purpose? Healthcare Engineering Consultants

  7. Performing a Global Risk Assessment Step 1: Identify a “Global” Area to Assess Step 2: Select a Team of Stakeholders Step 3: Brainstorm and List the Risk Elements Step 4: Assign Probability and Impact to the Risk Elements Step 5: Prioritize the Risk Elements Step 6: Perform the Specific Risk Assessments Healthcare Engineering Consultants

  8. Documenting Risk Assessments Healthcare Engineering Consultants

  9. Example Global Safety Risk Assessment Healthcare Engineering Consultants

  10. Example Global Security Risk Assessment Healthcare Engineering Consultants

  11. Specific Risk Assessments What’s a Specific Risk Assessment and What is it’s Purpose? Healthcare Engineering Consultants

  12. Performing a Specific Risk Assessment Step 1: Identify Issues and Select a Team Step 2: Analyze Factors Step 3: Make a Decision Step 4: Document the Evaluation and Decision Step 5: Make the Necessary Changes Step 6: Monitor and Reassess Healthcare Engineering Consultants

  13. Specific Risk Assessment Examples Lock clean supply room doors? Infant/ pediatric abduction measures Safe environment for mental health Medical equipment test tags Utility system PM intervals Security “sensitive areas” Other? Healthcare Engineering Consultants

  14. Understanding RCA’s and FMEA’s What’s the Difference Between an FMEA and an RCA? Are They Both Risk Assessments? Healthcare Engineering Consultants

  15. Safety Management Issue: What about recurring operational deficiencies? Tip for Compliance: You can’t improve what you can’t measure! Healthcare Engineering Consultants

  16. How Do We Solve This Problem? Steps required to reduce operational deficiencies: 1. Determine how to measurethe problem severity 2. Establish a numerical baseline score 3. Explain measurement system to area staff 4. Letstaffdetermine an improvement goal 5. Re-measure scores at unscheduled times 6. Provide numerical feedback to staff 7. Celebrate achievement of goal 8. Continue measurement until the culture changes Healthcare Engineering Consultants

  17. Solving the Hallway Clutter Problem Step 1: Determine how to measure the problem severity Solution and Procedure: Assign points to various types of egress corridor deficiencies, based on severity of violation Healthcare Engineering Consultants

  18. Solving the Hallway Clutter Problem PointScoreExamples Healthcare Engineering Consultants

  19. Solving the Hallway Clutter Problem Step 2a: Establish a numerical baseline score for a specifichospitalarea(4 West) Procedure: Use the point values for deficiencies that have been assigned and determine total scores by randomly inspecting the area once per day for at least one week Healthcare Engineering Consultants

  20. Solving the Hallway Clutter Problem Healthcare Engineering Consultants

  21. Solving the Hallway Clutter Problem Point Score Results of Daily Inspections This is the baseline number for 4 West Healthcare Engineering Consultants

  22. Solving the Hallway Clutter Problem Graphical Results Healthcare Engineering Consultants

  23. Solving the Hallway Clutter Problem Graphical Results Daily Scores New goal: 25 points Healthcare Engineering Consultants

  24. Safety Management • Issue: • How to solve the smoking dilemma? Tips for Compliance: • Create a practical policy • Recognize the “citation priority” • Monitor smoking compliance Healthcare Engineering Consultants

  25. Smoking Monitoring Healthcare Engineering Consultants

  26. Security Management • Issue: Security Responsibility Appointment • Tips for Compliance: • Letter provided by leadership • Identify security responsibility • Include: • Coordination • Development and implementation • Monitoring Healthcare Engineering Consultants

  27. Security Management • Issue: Security Risk Assessment • Tips for Compliance: • Include security sensitive areas: • ED, OB/ Gyn, Pharmacy, Infectious waste • Other areas? • Evaluate facility access control • Provide training for staff in sensitive areas Healthcare Engineering Consultants

  28. Security Management • Issue: Security “Special Cases” • Tips for Compliance: Consider the following – • Use of firearms or other means of force • Mental health areas • Medication and infectious waste security • Infant/ child abduction prevention and drills • Cell phones with cameras/ privacy issues • Access to unauthorized areas • Security in construction areas Healthcare Engineering Consultants

  29. Hazardous Materials and Wastes • Issue: MSDS Sheets • Tips for Compliance: • Ensure an accurate inventory • Provide staff training • Consider MSDS options: Binder with data sheets 1-800 “Fax-on-Demand” Internet or intranet access Healthcare Engineering Consultants

  30. Hazardous Materials and Wastes • Issue: Chemical Waste Stream • Tips for Compliance: • Ensure disposal procedures for: • Chemicals • Chemotherapeutics • Radioactive materials • Medical waste and sharps • Waste phamaceuticals • Per applicable laws (OSHA, EPA, NRC, DOT) Healthcare Engineering Consultants

  31. Hazardous Materials and Wastes • Issue: Compressed Cylinder Storage • Tips for Compliance: • For stored gases <300 cubic feet in smoke compartment: - Enclosures not required (NFPA 99, section 9.4.3) • For stored gases >300 but <3,000 cubic feet: - Outdoors: enclosed space with doors or gates ( - Indoors: an enclosure with minimum ½ hour protection ( • For stored gases >3,000 cubic feet: - Walls, floors, ceilings, doors at least 1-hour rated ( - Racks, chains or fastenings to secure all cylinders ( - Continuous powered ventilation within 1 foot of floor ( Healthcare Engineering Consultants

  32. Hazardous Materials and Wastes • Issue: Compressed Cylinder Storage • Tips for Compliance: • Requirements for stored gas only, notin-usetanks! • In-use gas includes: - Tanks on code carts - Tanks on wheelchairs - Tanks on gurneys • Empty tanks do not count toward the total • Use of fire-rated cabinets can be used on floors Healthcare Engineering Consultants

  33. Hazardous Materials and Wastes • Issue: Alcohol-Based Hand Rub Units Requirements • Tips for Compliance: • Patient safety goal 7 requires CDC compliance with Category I recommendations, suggests Category II compliance! • When no soiling is present, ABHR units are recommended (Cat I) • ABHR is permitted in a corridor at least 6 feet in width, at least 4 feet apart, and not directly over electrical outlets (6 inches from dispenser) • ABHR dispensers can be used over carpeted surfaces only in sprinklered smoke compartments! • ABHR permissible volumes: - 10 gallons in dispensers/ 5 gallons in storage per smoke compartment - Maximum individual dispenser capacity: .3 gallons - Maximum dispenser size per suite of rooms: .5 gallons Healthcare Engineering Consultants

  34. Hazardous Materials and Wastes • Issue: Eyewashes and Showers • Tips for Compliance: • Use risk assessment to determine placement • ANSI standards have not been officially adopted by the Joint Commission • Testing policy is required – specify test intervals • Documentation of test results is required • Differentiate between eyewash station and “first aid” station, such as mounted bottles Healthcare Engineering Consultants

  35. Hazardous Materials and Wastes Issue: Hazardous Vapor Monitoring Tips for Compliance: Clinical lab: formaldehyde and xylene Central supply: ethylene oxide OR’s: nitrous oxide, methyl-methacrylate Respiratory: glutaraldehyde Sleep lab: collodion Monitor and document per OSHA requirements! Healthcare Engineering Consultants

  36. Approved Changes for 2009 • The organization of the standards : • EM.01.01.01: Plans for managing emergencies • EM.02.01.01: Develops an emergency operations plan • EM.02.02.01: Establishes emergency communication strategies • EM.02.02.03: Establishes strategies for managing resources • EM.02.02.05: Establishes strategies for managing safety and security • EM.02.02.07: Defines and manages staff roles and responsibilities • EM.02.02.09: Identifies an alternative means for providing utilities • EM.02.02.11: Identifies strategies for patient management • EM.02.02.13: Privileges to LIP’s • EM.02.02.15: Privileges to volunteer staff • EM.03.01.01: Annual effectiveness review • EM.03.01.03: Regularly tests the emergency operations plan Healthcare Engineering Consultants

  37. Emergency Management • EM.01.01.01:The organization plans for managing the consequences of emergencies • Medical and clinical staff participate in planning • A Hazard Vulnerability Analysis (HVA) is performed and documented • The hazards are prioritized • Communication of emergency plan with community responders • Mitigation, Preparedness, Response, Recovery • Assets and resources are inventoried and documented (CAP) • Asset and resource inventories are monitored during emergencies (CAP) • The emergency management program is evaluated annually (S,O,P,E) Healthcare Engineering Consultants

  38. Emergency Management • Tips for Compliance with EM.01.01.01: • Appoint a physician and administrative representativetoactivelyparticipate on the emergency management planning committee • Perform and document the Hazard Vulnerability Analysis (HVA) for all geographically separate facilities – review annually! • Be ready to describe the Mitigation, Preparedness, Response and Recovery procedures in the EOP • Ensure that emergency resources are inventoried (PPE, utility and medical supplies and pharmaceuticals) and monitored • Evaluate the emergency management program annually (S,O,P,E) and report the results to the safety committee Healthcare Engineering Consultants

  39. Emergency Management • EM.02.01.01:The organization develops and maintains an Emergency Operations Plan (EOP) • Written EOPincludes an “all hazards” command structure • An incident command structure (ICS) is established and is consistent with the community plan • The ICS identifies a reporting structure • Activation of ICS is identified • Activation of ICS phases is identified • The EOP identifies the organization response when community non-support may occur for up to 96 hours (CAP) • Alternative care sites are identified Healthcare Engineering Consultants

  40. Emergency Management • Tips for Compliance with EM.02.01.01 • Create a written emergency operations plan (EOP) that describes the incident command structure and process that is in use (HICS 4?) as well as how ICS integrates into the six critical core areas: 1. Emergency communications 2. Resources and assets 3. Safety and security 4. Staff roles and responsibilities 5. Management of utilities 6. Clinical and support activities • The EOP can either describe the ICS and core area integration in detail or reference existing documents Healthcare Engineering Consultants

  41. Emergency Management HICS Organizational Chart Incident Commander Public Info Officer Safety Officer Liaison Officer Med/ Tech Specialist(s) Operations Section Chief Planning Section Chief Logistics Section Chief Finance/ Admin Section Chief Healthcare Engineering Consultants

  42. Emergency Management • Tips for Compliance with EM.02.01.01 • Create two color-coded timeline charts the indicate how long utilities will be operational and how long consumable supplies will be available in the event of an emergency in which no re-supply is possible • Ensure that decisions are made to determine whether any utility or supply changes will be implemented to extend “green zones” • Create two 96-hour plans that assume the following scenarios: PLAN A:Supplies are available and are ordered and received PLAN B: Internal supply shortages or utility failures require partial or total patient evacuation PLAN C: Shortages and/ or utilities are not sufficient to continue normal patient care, although evacuation is not possible Healthcare Engineering Consultants

  43. Emergency Management • Critical Utilities and Supplies Timeline • Assume external help is not available • Create timeline for utilities and critical supplies, such as food and medications • Determine time-dependent status: - Green: Continue all services as usual - Yellow: Transition to conservation mode - Red: Discontinue patient treatment, evacuate Healthcare Engineering Consultants

  44. Emergency Management Healthcare Engineering Consultants

  45. Emergency Management Healthcare Engineering Consultants

  46. Emergency Management • EM.02.02.01:The organization establishes emergency communications strategies • Staff notification procedures are created • Provisions for ongoing staff communication during the emergency • Process to notify external authorities • Communication with patients and their families • Communication with the community and media • Communication with vendors and suppliers (CAP) • Sharing information with other health care providers • Providing information about patients to third-parties (FEMA, CDC, etc.) • Communication with alternative care sites • Establishment of back-up communication systems and technologies Healthcare Engineering Consultants

  47. Emergency Management • Tips for Compliance with EM.02.02.01 • Create notification charts with phone numbers, email addresses, etc. • Include for staff, external authorities, community, media, vendors • Determine what information will be shared with other health care providers in the area • Ensure that liaisons are established with government agencies • Verify that MOU’s for alternative care sites are updated • Establish and check operation of back-up communication systems, such as the internet, cell phones, two-way radios, emergency land lines, and amateur radio operators Healthcare Engineering Consultants

  48. Emergency Management • EM.02.02.03:The organization establishes strategies for managing resources and assets during emergencies • Plans for obtaining medications and non-clinical supplies • Replenishing medical supplies and equipment during the emergency • Replenishing pharmaceutical supplies • Replenishing non-medical supplies (food, water, fuel, linens, etc.) • Managing staff and family support activities • Sharing of resources with other health care organizations in and outside of the local community (CAP) • Horizontal, vertical and total evacuation (CAP),including transportation of patients, medications, equipment, staff and medical record information Healthcare Engineering Consultants

  49. Emergency Management • Tips for Complying with EM.02.02.03 • Plans should be in place to stockpile and reorder critical clinical and non-clinical supplies • Written procedures should describe how the needs of staff and families of staff will be met during an emergency • A plan to share community resources and assets should be in place • A practical patient evacuation plan that includes horizontal and vertical movement within the facility as well as partial or total evacuation outside of the facility is required • Logistics for evacuation should include: 1) transportation; 2) staffing; 3) medications; 4) equipment, and; 5) the medical record Healthcare Engineering Consultants

  50. Emergency Management • EM.02.02.05:The organization establishes strategies for managing safety and security during emergencies • Internal safety and security measures are established • Role of community security agencies is established with the healthcare organization and means of coordination is identified (CAP) • Processes for handling hazardous materials and waste are developed (CAP) • Plans are developed for radioactive, biological, chemical decontamination • Patients susceptible to wandering are identified (CAP) • Access into and out of the facility are controlled • Movement of staff and patients is controlled within the facility • Traffic accessing the facility is controlled Healthcare Engineering Consultants