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H2E AND JCAHO COMPLIANCE

H2E AND JCAHO COMPLIANCE. Susan B. McLaughlin Barrington, Illinois. JCAHO AND THE GOVERNMENT. Health Care Finance Administration. Deemed status Medicare reimbursement Go-behind surveys OIG report, 1999. Occupational Safety & Health Administration (OSHA) . Worker safety

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H2E AND JCAHO COMPLIANCE

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  1. H2E ANDJCAHO COMPLIANCE Susan B. McLaughlin Barrington, Illinois

  2. JCAHO AND THEGOVERNMENT

  3. Health Care Finance Administration • Deemed status • Medicare reimbursement • Go-behind surveys • OIG report, 1999

  4. Occupational Safety & Health Administration (OSHA) • Worker safety • Applicable law and regulation

  5. JCAHO/OSHA PARTNERSHIP • Established 1996 • Educational • Surveyors and Inspectors • Health care organizations • Reduce duplicative compliance activities

  6. RELATIONSHIP ENVIRONMENT OF CARE ENVIRONMENT OF WORK OSHA JCAHO

  7. STATUS • Renewed for 3 years in 2000 • “Hammer Award” • Remains educational • Additional examples of compliance

  8. MOVING FORWARD • Cooperative arrangement with Veterans Administration • Some exemplary hospitals will invite OSHA in with JCAHO to survey organization • 10 facilities • Central office • Evaluation of programs • NOT enforcement

  9. SURVEYOR FOCUS • Increased knowledge of OSHA issues • Emphasize areas of overlap in requirements • Example of “applicable law and regulation” in EC.1.3 • Verification vs. inspection • New emphasis in standards • EC.1.1.1: Worker Safety

  10. EPA ISSUES • Storage > 180 days • Toxic waste storage facility

  11. JCAHO / EPA RELATIONSHIP • No formal relationship • Letter to Committee on Healthcare Safety • Cited as an example of “applicable law and regulation” in EC.1.3

  12. DOT ISSUES • Department of Transportation • Hazardous materials • Regulated medical waste • Shipping papers • Training • Home care

  13. JCAHO / DOT • No formal relationship • “Applicable law and regulation”

  14. REMEMBER • Always comply with the strictest authority having jurisdiction (AHJ) • JCAHO frequently asked question (FAQ) related to hazmat, www.jcaho.org

  15. ENVIRONMENT OF CARE®REQUIREMENTS

  16. ENVIRONMENT OF CARE® • Seven management plans • Safety • Security • Hazardous Materials & Waste • Emergency Management • Fire Prevention • Medical Equipment • Utilities

  17. EC REQUIREMENTS • Written plans • Implementation of plans • Risk assessment • Staff knowledge and skill • Maintenance, testing, inspection activities • Monitoring and evaluation • Annual evaluation

  18. RISK ASSESSMENT • All management plans • Specific to organization • Non-prescriptive standards

  19. PERFORMANCE MONITORING • Actual or potential risk • Staff knowledge & skills • Level of staff participation • Monitoring & inspection activities • Emergency & incident reporting • Inspection, PM, & testing of equipment • At least one monitor per management plan

  20. PERFORMANCE MONITORING • Data collection • Report to Safety Committee • At least one annual recommendation for a performance improvement activity in EC made to leadership • Leadership prioritization and decision

  21. SURVEY PROCESS • Size of organization determines: • Length of survey • Number of surveyors • Administrator - Nurse - Physician • Nurse - Physician • Surveyor cross-training

  22. CLOSED DOCUMENT REVIEW • All seven EC management plans • Statement of Conditions™ (SOC) • Safety Officer Documentation • Job Description • Appointment Letter • Intervention Authority • Interim Life Safety Measures (ILSM) policy & documentation

  23. Participants Administrator or Nurse Surveyor Safety Officer Engineering Director Etc. Function Validation of SOC Assessment of Implementation Staff Interviews BUILDING TOUR

  24. EC DOCUMENT REVIEW • All seven EC management plans • Documentation of performance monitoring & performance improvement activities • Hazmat permits, licenses, manifests • Hazard surveillance surveys (12 months) • Safety Committee records

  25. EC.1.1 SAFETY MANAGEMENT • Policies distributed, practiced, enforced • Policies reviewed at least every 3 years

  26. EC.1.1.1 WORKER SAFETY • Occupational illness • Personnel injury • Safety orientation and training

  27. EC.1.3 HAZMAT & WASTE A) Selection, handling, storage, transportation, use, disposal B) Applicable law and regulation C) Space and equipment D) Performance monitoring E) Monitoring & disposing of hazardous gases & vapors

  28. EC.1.3 “CRADLE TO GRAVE” A) 1. Selection -What is to be purchased -Supplier -Screening Process 2. Handling • Receipt • Documentation

  29. EC.1.3 “CRADLE TO GRAVE” 3. Storage -Chemical type -Medical gas 4. Transportation -Chemicals -Cylinders -Intra- and inter-facility

  30. EC.1.3 “CRADLE TO GRAVE” 5. Use -Training 6. Disposal -Chemicals -Potentially infectious medical waste -Empty gas cylinders -Waste anesthetic gas

  31. B) APPLICABLE LAW & REGULATION 1. OSHA 2. EPA 3. DOT “Includes but not limited to. . .”

  32. Bloodborne Pathogens Hazard Communication Hazardous Drugs Formaldehyde Ethylene Oxide Tuberculosis Respiratory Protection Personal Protective Equipment (PPE) Etc. B) 1. OSHA ISSUES

  33. EPA Clean Air Act Clean Water Act Federal Insecticide, Fungicide, & Rodenticide Act Incinerators Generators (proposed) Boilers (proposed) Etc. DOT Medical Waste Hazardous Materials B) 2. & 3. EPA, DOT, other

  34. B) 2. MANAGING WASTE • Chemical • Chemotherapeutic • Radioactive • Regulated medical • Sharps

  35. B) 2. MANAGING WASTE • Intra-facility tracking • Disposal methods • Training • Documentation

  36. C) SPACE & EQUIPMENT • Adequate • Appropriate • Segregation

  37. REPORTING and INVESTIGATING • Problems, failures, user errors • Information collection and evaluation system (ICES) • Input into Safety Committee

  38. E) GASES & VAPORS 1. Formaldehyde 2. Ethylene Oxide 3. Waste Anesthetic Gas 4. Glutaraldehyde 5. Xylene

  39. ORIENTATION & EDUCATION • Personnel who use or have contact with hazmat • Procedures & Precautions • Emergency Procedures • Spills and exposures • Health Hazards • Reporting Procedures • Spills or exposures

  40. EMERGENCY PROCEDURES • Spills • Chemical • Mercury • Potentially infectious • Chemotherapy • Major clean-up operations • OSHA Hazardous Waste Operations (HAZWOPR) • Fire department

  41. EMERGENCY PROCEDURES • Radiation Exposure • Personal Protective Equipment

  42. D) PERFORMANCE MONITORING • Examples: • Waste volume • Solid waste • Hazardous waste • Waste disposal costs • Staff knowledge and skill • Monitoring of gases & vapors • Etc.

  43. DOCUMENTATION • EC.2.3: Implementation • Permits • Licenses • Manifests

  44. EC.1.4 EMERGENCY MANAGEMENT • Facilities for chemical and radioactive decontamination

  45. FREQUENTLY ASKED SURVEYOR QUESTIONS • What chemical are you using? • How did you learn about it? • Where would you go to get more information? • What would you do if you spilled it? • May I see the MSDS? • May I see the mercury spill clean-up procedure?

  46. H2E IMPACT ONJCAHO COMPLIANCE

  47. WASTE REDUCTION • Demonstrated performance improvement • Less expensive to use “environmentally friendly” disposal methods • Decreased waste volume • Decreased hazardous waste • Increased worker safety (i.e., sharps reduction)

  48. CHEMICAL WASTE MINIMIZATION • Demonstrated performance improvement • Reduced need for: • Storage • Training • PPE • MSDS

  49. CHEMICAL WASTE MINIMIZATION • Eliminating some chemicals completely • Reduce number of policies & procedures • Eliminate particular disposal processes • Potentially eliminate some regulatory compliance • Decreased documentation • Improved worker safety

  50. MERCURY VIRTUAL ELIMINATION • Demonstrated performance improvement • Eliminate need for spill clean-up procedure • Eliminate specialized disposal • Reduce regulatory compliance • Worker / patient safety improved

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