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What’s New for 2008?. Does the Joint Commission Manual Have Major Changes for 2008?. Healthcare Engineering Consultants. Organization of the 2008 Accreditation Manual. Section 1 - Patient Focused Functions Ethics, Rights and Responsibilities (RI)

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what s new for 2008
What’s New for 2008?

Does the Joint Commission Manual Have Major Changes for 2008?

Healthcare Engineering Consultants

organization of the 2008 accreditation manual
Organization of the 2008 Accreditation Manual
  • Section 1 - Patient Focused Functions
  • Ethics, Rights and Responsibilities (RI)
  • Provision of Care, Treatment and Services (PC)
  • Medication Management (MM)
  • Surveillance, Prevention and Control of Infection (IC)
  • Section 2 - Organization-Focused Functions
  • Improving Organization Performance (PI)
  • Leadership (LD) - (includes previous governing body)
  • Management of the Environment of Care (EC)
  • Management of Human Resources (HR)
  • Management of Information (IM)
  • Section 3 - Clinical Functions
  • Medical Staff (MS)
  • Nursing (NR)

No Major Change!

Note: Standards rewrite in 2009

Healthcare Engineering Consultants

what s new for 20081
What’s New for 2008?

What Will the Survey Process be Like in 2008?

Healthcare Engineering Consultants

unannounced surveys in 2008
Unannounced Surveys in 2008
  • Typical Surveys Include:
  • Two to five days “on-site”
  • Two, three or more surveyors (usually nurses
  • and physicians - includes a “Life Safety Specialist”
  • for all hospitals in 2008; multiple days for >750K
  • square feet
  • Review of documents (survey planning meeting)
  • Life safety-focused facility tour
  • Three-part “EC” interview
  • Questions to staff based on tracer methodology
  • Summary conference to present tentative findings

Healthcare Engineering Consultants

unannounced surveys in 20081
Unannounced Surveys in 2008
  • Can Occur Due To:
  • Regular unannouncedsurvey
  • Random off-cycle selection (5%)
  • Sentinel event follow-up
  • Adverse media coverage of specific issue
  • Complaint from the public
  • Note: All new applicants for the accreditation process as well as changes to a new classification (example: critical access designation) will now have unscheduled surveys

Healthcare Engineering Consultants

what s new for 20082
What’s New for 2008?

What Scoring Rules Apply for 2008?

Healthcare Engineering Consultants

joint commission scoring guidelines
Joint Commission Scoring Guidelines
  • No major scoring changes for 2008, except SOC:
  • “EP’s” scored 0, 1 or 2
  • 0 = insufficient compliance
  • 1 = partial compliance
  • 2 = satisfactory compliance
  • Scoring categories have been continued for each
  • EP: A, B or C (B may be eliminated later!)
  • Standards are scored “compliant” or “non-
  • compliant”
  • No grid score calculation
  • Rationale is not scored

Healthcare Engineering Consultants

joint commission scoring for ep s
Joint Commission Scoring for EP’s
  • Category A: usually used forpolicies and procedures
  • or the presence or absence of a requirement
  • Scored either “0” or “2”
  • A “2” may become a “1” or “0” if the track record is

insufficient

  • Category B: used for process requirements
  • If requirement exists, then process design and
  • track record is scored (may be eliminated during 2008!)
  • Category C: instances of non-compliance
  • Score “2”: 1 or no instances of non-compliance
  • Score “1”: 2 instances of non-compliance
  • Score “0”: 3 or more instances of non-compliance

Healthcare Engineering Consultants

joint commission scoring for ep s1
Joint Commission Scoring for EP’s
  • If any “EP” is scored “0”, the standard is
  • not compliant
  • If 65% of the EP’s are scored “2”, then

the standard is considered “compliant”,

unless any other EP is scored “0” (up to

  • 35% of the EP’s may be scored a “1”!)

Healthcare Engineering Consultants

special scoring for soc deficiencies
Special Scoring for SOC Deficiencies
  • “X” is considered a minor deficiency Example: a fire door does not latch properly (item 1C2) – Score 1
  • “Y” is considered a midrange deficiency Example: the same fire door above is missing hardware (item 1C2) – Score 2
  • “Z” is considered a major deficiency Example: the building is not of an allowable type of construction (item 1A1) or each floor does not have at least two approved exits (item 5A) – Score 4

Note 1: Use the scoring grid and key to determine the X, Y and Z scores; 1-5 total score is partial compliance; 6 or greater is non-compliance, or a “Z” score!

Note 2: Use of the BMP “caps” scores for each category at “1”

Healthcare Engineering Consultants

joint commission scoring decisions
Joint Commission Scoring Decisions
  • Accreditation Decision Rules for 2008
  • Accredited (same)
  • Provisional Accreditation (same)
  • Conditional Accreditation (change)
  • 10 or more non-compliant standards (< 100 ADC)
  • 14 or more non-compliant standards (>100 ADC)
  • Preliminary Denial of Accreditation (change)
  • 14 or more non-compliant standards (<100 ADC)
  • 18 or more non-compliant standards (>100 ADC)
  • Denial of Accreditation (same)
  • Preliminary Accreditation (same)

Healthcare Engineering Consultants

ec related scoring rules
“EC”-Related Scoring Rules
  • Preliminary Denial of Accreditation (PDA)
  • PDA01 - Immediate threat to health or safety
  • PDA03 - Falsification of documentation
  • PDA06 - Non-compliant standards 3 standard
  • deviations above the mean (14 or 18 RFI’s)
  • Conditional Accreditation (CON)
  • CON01 - Non-compliant standards count 2 standard
  • deviations above the mean (10 or 14 RFI’s)
  • Note: In 2008, will be 1.5 deviations above the mean
  • CON03 - Failure to clear repeat non-compliant
  • standards
  • CON04 - Delayed PFI or no ILSM’s when required

Healthcare Engineering Consultants

what s new for 20083
What’s New for 2008?

Which Areas Have Historically Been the Lowest Scoring?

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lowest scoring jc areas
Lowest Scoring JC Areas

Percent Scored Not Compliant for Hospitals

IM.3.10 (44%) – Information management

MM.2.20 (36%) – Medications storage

PC.13.20 (29%) – Operative procedure planning

EC.5.20 (19%) – Compliance with the Life Safety Code

MM.3.20 (19%) – Clear medication orders

IM.6.50 (15%) – Transcription of verbal orders

IM.6.10 (15%) – Complete and accurate medical record

PC.8.10 (14%) – Pain assessment and treatment

PC.2.120 (13%) – Definition of initial assessment time frame

EC1.10 (12%) – Safety management risk assessment

Healthcare Engineering Consultants

lowest scoring ec areas
Lowest Scoring “EC” Areas

Percent Scored Not Compliant for Other Facilities

Assisted Living – EC.1.5 (33%) Fire prevention planning

Assisted Living – EC.2.2 (33%) Security planning

Assisted Living – EC.2.5 (33%) Fire prevention implementation

Assisted Living – EC.1.4 (33%) Emergency planning

Ambulatory Care – EC.4.10(19%) Emergency management

Behavioral Health Care – EC.4.10(10%) Emergency management

Behavioral Health Care – EC.4.20(5%) Emergency drills

Critical Access Hospital – EC.1.10(10%) Safety risk management

Critical Access Hospital – EC.7.10(4%) Utility management

Healthcare Engineering Consultants

lowest scoring ec areas1
Lowest Scoring “EC” Areas

Percent Scored Not Compliant for Other Facilities

Laboratory – EC.6.20 (11%) Equipment testing and inspection

Long Term Care – EC.4.10 (18%) Emergency management

Long Term Care – EC.9.10 (14%) Monitoring the environment

Office Based Surgery – EC.4.20 (13%) Emergency drills

Office Based Surgery – EC.1.20(8%) Safe environment

Office Based Surgery – EC.5.40(8%) Fire equipment maintenance

Home Care – EC.4.10(20%) Emergency management

Home Care – EC.4.20(10%) Emergency management drills

Home Care – EC.6.60(7%) Medical equipment testing

Healthcare Engineering Consultants

what s new for 20084
What’s New for 2008?

What will be the Other Major EC Changes for 2008?

Healthcare Engineering Consultants

possible change for 2008
Possible Change for 2008
  • 2006 AIA Document:
  • Approval voted June, 2005
  • May be adopted by JCAHO in the future
  • Available for purchase now! (AIA.org or ASHE.org)
  • Multiple changes for single rooms, expanded
  • ICRA, space revisions, HVAC changes, patient
  • safety language, surge capacity information in
  • Appendix

Healthcare Engineering Consultants

other changes for 2008
Other Changes for 2008
  • Electronic SOC Document
  • All BBI’s and PFI’s must be electronically entered into

the Joint Commission Connect site

  • Deadlines: BBI’s: 1/1/07 PFI’s: 9/1/07
  • Annual submission of SOC with PPR delayed!
  • Entered data will be “frozen” after approval by surveyor
  • PFI entries should be continuous
  • Password for organization will be required for data entry
  • Actual completion dates must be entered as they occur
  • Be sure to fill out forms, even if “No Deficiencies” on PFI
  • Download the data and put “hard copy” in notebook

Healthcare Engineering Consultants

other changes continued for 2008
Other Changes Continued for 2008
  • Electronic SOC Document
  • PPR process will now include questions about the e-SOC
  • No longer “busted plan” – now termed “Non-Compliant”
  • e-SOC will track when completion dates are changed prior

to approval by surveyor

  • PFI’s completed beyond 6 months of intended date may be

cited under: EC.5.20, LD.2.20, LD.3.80 or LD.4.50

  • Can delete buildings on BBI, but not sites!
  • PFI summary uses the following colors:

- Yellow for 4 months beyond intended completion date

- Orange when beyond the 6-month grace period

- Salmon when PFI completed after 6 months of intended date

Healthcare Engineering Consultants

other changes continued for 20081
Other Changes Continued for 2008
  • Generator Run Tests (EC.7.40)
  • 4-hour run at greater than 30% of nameplate load every three years; first due 7/1/07
  • Load test should be dynamic (actual hospital load), although the Joint Commission will accept load bank tests
  • Any 4-hour @ 30% load test since July 1, 2004 will count and the next test will not be required until the 3-year anniversary date
  • Test failure requires interim measures until repairs are completed; successful retest is required after initial failure
  • All other existing generator tests still required; reference NFPA 110, 2005 edition
  • Simultaneous monthly, annual load bank and trienniel tests will count, as long as first 30 minutes are at 30%, rather than 25% of load (NFPA 70 panel does not yet agree!)

Healthcare Engineering Consultants

expectations for 2008
Expectations for 2008
  • Sentinel Event Alert #37 Recommendations
  • Perform emergency power system gap analysis
  • Maintain complete, labeled, accurate inventory of loads served by the emergency power system (EPS)
  • Ensure competency training of staff who are responsible for the testing and maintenance of the EPS
  • Test generator fuel oil on an annual basis and filter or replace, as necessary
  • Communicate EPS capabilities and limitations to clinical staff and hospital management
  • Establish clinical contingency plans in the event of brief or prolonged failure of the EPS

Healthcare Engineering Consultants

other changes for 20081
Other Changes for 2008
  • Operational Damper Tests
  • Re-inspection now every six rather than four years in hospitals; other occupancies still four years per NFPA
  • Change effective January 1, 2008
  • Result of move from NFPA 90A to NFPA 80 (fire dampers) and NFPA 105 (smoke dampers), the 2007 editions
  • For smoke dampers, the inspection shall occur one year after installation and then on a six-year basis
  • Inaccessible dampers should be placed on the PFI form and given a 6-year time period for completion; completion date can be extended after the 6-year period has expired

Healthcare Engineering Consultants

slide24

Emergency Management

  • What are the Newly-Adopted Changes for 2008?
  • EC.4.11: Plans for managing emergencies
  • EC.4.12: Development of emergency operations plan
  • EC.4.13: Emergency communications strategies
  • EC.4.14: Management of resources and assets
  • EC.4.15: Strategies for managing safety and security
  • EC.4.16: Management of staff roles and responsibilities
  • EC.4.17: Strategies for managing utilities
  • EC.4.18: Management of clinical and support activities
  • EC.4.20: Implementation of emergency drills 2X per year

Note: One drill requires external “non-support” simulation

Healthcare Engineering Consultants

top ec focus areas for 2008
Top “EC” Focus Areas for 2008
  • Patient Safety
  • Infection Control
  • Emergency Management

(Katrina impact – 2008 changes)

  • Life Safety (life safety specialist

surveyor change)

  • Risk Assessment

Healthcare Engineering Consultants

ec related patient safety goals for 2008
“EC”-Related Patient Safety Goals for 2008

For Ambulatory, Behavioral Health, Home Care and Hospital Facilities

Add Goal #13:Encourage patient’s active involvement in their own care as a patient safety strategy (define and communicate the means for patients and families to report safety concerns)

Add Goal #15:The organization identifies safety risks inherent in its patient population (identify suicide risk – relates to patients being treated for emotional and behavioral disorders)

Healthcare Engineering Consultants

what s new for 20085
What’s New for 2008?

What Other Chapters in the Manual Will Impact EC in 2008?

Healthcare Engineering Consultants

organizational function overview
Organizational Function Overview
  • Human Resources (HR)
  • Staff training, competency and performance
  • Leadership (LD)
  • Compliance, resources, patient safety (LD.3.50,
  • oversight of contracts/ services; 7/1/07)
  • Performance Improvement (PI)
  • Data collection, aggregation, analysis , action
  • Information Management (IM)
  • Data collection, aggregation, security
  • Infection Control (IC)
  • Measurement and reduction of infections

Healthcare Engineering Consultants

what s new for 2009
What’s New for 2009?

What will the EC Chapter look like in 2009?

Healthcare Engineering Consultants

the 2009 ec chapter
The 2009 EC Chapter
  • What will be the major EC changes?
  • Mostly editorial changes
  • Emergency management and life safety (not fire safety) will have their own chapters
  • Staff competency (including for clinical staff) will be returned to the EC chapter
  • Safety and security will be combined into one standard
  • An entirely new numbering system will be used

Healthcare Engineering Consultants

numbering the ec standards
Numbering the EC Standards
  • EC.1.01 – Management Plan Requirements
  • EC.2.01, 2.03 – Safety and Security
  • EC.3.01 – Hazardous Materials and Wastes
  • EC.4.01 through 4.04 – Fire Safety
  • EC.5.01, 5.02 – Medical Equipment
  • EC.6.01 through 6.05 – Utilities Management
  • EC.7.01, 7.03 – Other Physical Environment
  • EC.8.01 – Staff Competency
  • EC.9.01 through 9.03 – Monitoring, Improvement

Healthcare Engineering Consultants

understanding the four ec vulnerabilities
Understanding the Four “EC” Vulnerabilities

What are the Four Survey Points of EC Vulnerability for 2008?

Healthcare Engineering Consultants

the four survey points of vulnerability
The Four Survey Points of Vulnerability
  • The Survey Planning Session
  • LSC Facility Tour
  • The “EC” Interview Session
  • Involves all seven EC areas
  • Documents and staff must be available
  • Consists of three phases
  • “EC” Tracers

Healthcare Engineering Consultants

the four ec vulnerabilities
The Four “EC” Vulnerabilities

What is the Expectation Triad?

Healthcare Engineering Consultants

slide35

The Expectation Triad

Regulatory Compliance

Performance

Improvement

Risk Assessment

Healthcare Engineering Consultants

slide36

The Expectation Triad

Regulatory Compliance:

“Ensuring that all of the required

standards are being met”

Healthcare Engineering Consultants

slide37

The Expectation Triad

Performance Improvement:

“Attempting to measure and

improve performance on an

ongoing basis in the

Environment of Care”

Healthcare Engineering Consultants

slide38

The Expectation Triad

Risk Assessment:

“Prioritization and management

of resources through an

assessment of probability

and impact”

Healthcare Engineering Consultants