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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

H2E ANDJCAHO COMPLIANCE

Susan B. McLaughlin

Barrington, Illinois

health care finance administration
Health Care Finance Administration
  • Deemed status
  • Medicare reimbursement
  • Go-behind surveys
  • OIG report, 1999
occupational safety health administration osha
Occupational Safety & Health Administration (OSHA)
  • Worker safety
  • Applicable law and regulation
jcaho osha partnership
JCAHO/OSHA PARTNERSHIP
  • Established 1996
  • Educational
    • Surveyors and Inspectors
    • Health care organizations
  • Reduce duplicative compliance activities
relationship
RELATIONSHIP

ENVIRONMENT

OF

CARE

ENVIRONMENT

OF

WORK

OSHA

JCAHO

status
STATUS
  • Renewed for 3 years in 2000
  • “Hammer Award”
  • Remains educational
  • Additional examples of compliance
moving forward
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
surveyor focus
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
epa issues
EPA ISSUES
  • Storage > 180 days
    • Toxic waste storage facility
jcaho epa relationship
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
dot issues
DOT ISSUES
  • Department of Transportation
  • Hazardous materials
  • Regulated medical waste
  • Shipping papers
  • Training
  • Home care
jcaho dot
JCAHO / DOT
  • No formal relationship
  • “Applicable law and regulation”
remember
REMEMBER
  • Always comply with the strictest authority having jurisdiction (AHJ)
  • JCAHO frequently asked question (FAQ) related to hazmat, www.jcaho.org
environment of care
ENVIRONMENT OF CARE®
  • Seven management plans
    • Safety
    • Security
    • Hazardous Materials & Waste
    • Emergency Management
    • Fire Prevention
    • Medical Equipment
    • Utilities
ec requirements
EC REQUIREMENTS
  • Written plans
  • Implementation of plans
  • Risk assessment
  • Staff knowledge and skill
  • Maintenance, testing, inspection activities
  • Monitoring and evaluation
  • Annual evaluation
risk assessment
RISK ASSESSMENT
  • All management plans
  • Specific to organization
  • Non-prescriptive standards
performance monitoring
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
performance monitoring20
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
survey process
SURVEY PROCESS
  • Size of organization determines:
    • Length of survey
    • Number of surveyors
      • Administrator - Nurse - Physician
      • Nurse - Physician
  • Surveyor cross-training
closed document review
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
building tour
Participants

Administrator or Nurse Surveyor

Safety Officer

Engineering Director

Etc.

Function

Validation of SOC

Assessment of Implementation

Staff Interviews

BUILDING TOUR
ec document review
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
ec 1 1 safety management
EC.1.1 SAFETY MANAGEMENT
  • Policies distributed, practiced, enforced
  • Policies reviewed at least every 3 years
ec 1 1 1 worker safety
EC.1.1.1 WORKER SAFETY
  • Occupational illness
  • Personnel injury
  • Safety orientation and training
ec 1 3 hazmat waste
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

ec 1 3 cradle to grave
EC.1.3 “CRADLE TO GRAVE”

A) 1. Selection

-What is to be purchased

-Supplier

-Screening Process

2. Handling

  • Receipt
  • Documentation
ec 1 3 cradle to grave29
EC.1.3 “CRADLE TO GRAVE”

3. Storage

-Chemical type

-Medical gas

4. Transportation

-Chemicals

-Cylinders

-Intra- and inter-facility

ec 1 3 cradle to grave30
EC.1.3 “CRADLE TO GRAVE”

5. Use

-Training

6. Disposal

-Chemicals

-Potentially infectious medical waste

-Empty gas cylinders

-Waste anesthetic gas

b applicable law regulation
B) APPLICABLE LAW & REGULATION

1. OSHA

2. EPA

3. DOT

“Includes but not limited to. . .”

b 1 osha issues
Bloodborne Pathogens

Hazard Communication

Hazardous Drugs

Formaldehyde

Ethylene Oxide

Tuberculosis

Respiratory Protection

Personal Protective Equipment (PPE)

Etc.

B) 1. OSHA ISSUES
b 2 3 epa dot other
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
b 2 managing waste
B) 2. MANAGING WASTE
  • Chemical
  • Chemotherapeutic
  • Radioactive
  • Regulated medical
    • Sharps
b 2 managing waste35
B) 2. MANAGING WASTE
  • Intra-facility tracking
  • Disposal methods
  • Training
  • Documentation
c space equipment
C) SPACE & EQUIPMENT
  • Adequate
  • Appropriate
  • Segregation
reporting and investigating
REPORTING and INVESTIGATING
  • Problems, failures, user errors
  • Information collection and evaluation system (ICES)
  • Input into Safety Committee
e gases vapors
E) GASES & VAPORS

1. Formaldehyde

2. Ethylene Oxide

3. Waste Anesthetic Gas

4. Glutaraldehyde

5. Xylene

orientation education
ORIENTATION & EDUCATION
  • Personnel who use or have contact with hazmat
    • Procedures & Precautions
    • Emergency Procedures
      • Spills and exposures
    • Health Hazards
    • Reporting Procedures
      • Spills or exposures
emergency procedures
EMERGENCY PROCEDURES
  • Spills
    • Chemical
      • Mercury
    • Potentially infectious
    • Chemotherapy
  • Major clean-up operations
    • OSHA Hazardous Waste Operations (HAZWOPR)
    • Fire department
emergency procedures41
EMERGENCY PROCEDURES
  • Radiation Exposure
  • Personal Protective Equipment
d performance monitoring
D) PERFORMANCE MONITORING
  • Examples:
    • Waste volume
      • Solid waste
      • Hazardous waste
    • Waste disposal costs
    • Staff knowledge and skill
    • Monitoring of gases & vapors
    • Etc.
documentation
DOCUMENTATION
  • EC.2.3: Implementation
    • Permits
    • Licenses
    • Manifests
ec 1 4 emergency management
EC.1.4 EMERGENCY MANAGEMENT
  • Facilities for chemical and radioactive decontamination
frequently asked surveyor questions
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?
waste reduction
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)
chemical waste minimization
CHEMICAL WASTE MINIMIZATION
  • Demonstrated performance improvement
  • Reduced need for:
    • Storage
    • Training
    • PPE
    • MSDS
chemical waste minimization49
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
mercury virtual elimination
MERCURY VIRTUAL ELIMINATION
  • Demonstrated performance improvement
  • Eliminate need for spill clean-up procedure
  • Eliminate specialized disposal
  • Reduce regulatory compliance
  • Worker / patient safety improved
the bottom line
THE BOTTOM LINE
  • If you have less to manage. . .
    • Less waste
    • Fewer chemicals
    • No mercury
  • . . .you will streamline your process