Biggest Pitfalls and Best Practices in EC

1. Biggest Pitfalls and Best Practices in EC The Environment of Care Chapter Healthcare Engineering Consultants

2. The Survey Planning Session What Should Be Included in the Management Plans? Healthcare Engineering Consultants

3. The Management Plans • Best Practices Include: • Provide a description, not a rewrite of the program! • Be consistent in format; place in a labeled, tabbed binder • Include a list of applicable facilities to avoid multiple plans • Describe how each “element of performance” is achieved • Describe responsibilities from governing body to staff • Include performance improvement and training information • Reference applicable policies and procedures • Review by the safety committee annually *Note: Emergency Management requires an Emergency Operations Plan (EOP), not a management plan Healthcare Engineering Consultants

4. Safety Management • Issue: Proactive Risk Assessments for Safety • Biggest Pitfall: Risk assessing regulatory issues • Best Practices: • Create a “HVA” for prioritizing safety risks (refer to sample chart) • Be sure to include areas with behavioral health patients • Prioritize the risks, from highest to lowest • Appoint a multi-disciplinary group of “stakeholders” to evaluate changes necessary to minimize probability and impact • Seek approval for budget and recommended changes • Implement changes; track and document progress Healthcare Engineering Consultants

5. Documenting Risk Assessments Healthcare Engineering Consultants

6. Example Global Safety Risk Assessment Healthcare Engineering Consultants

7. Example Global Security Risk Assessment Healthcare Engineering Consultants

8. Example Behavioral Health Risk Assessment Healthcare Engineering Consultants

9. Safety Management • Issue: How to enforce the smoking policy? • Biggest Pitfall: Impractical policy or non-compliance • Best Practice: • Create a practical policy • Incorporate smokeless tobacco and electronic cigarettes into the policy • Recognize the “citation priority” • Monitor smoking compliance • Provide realistic discipline for non-compliant staff, vendors and contractors Healthcare Engineering Consultants

10. Security Management • Issue: Violence in the Workplace (JC PSG #45) • JC Recommended “Best Practice” • Audit facility risk of violence • Identify improvements in the violence protection program • Provide extra security precautions in the ED • Thoroughly pre-screen job applicants • Work with HR to minimize chances of violent reactions from employees who are disciplined or fired • Provide staff training regarding potentially violent family members • Ensure violence response procedures are in place Healthcare Engineering Consultants

11. Security Management • Issue: Violence in the Workplace (continued) • JC Recommended “Best Practice” • Encourage staff to report incidents of violent activity or perceived threats of violence • Educate supervisors to be aware of and thoroughly investigate suspicious behavior, or threats • Ensure counseling programs are in place for employees who become victims of violent behavior or crime • If violence occurs, respond accordingly: • 1. Report the crime to law enforcement authorities • 2. Recommend counseling for those affected • 3. Take action to prevent future occurrence Healthcare Engineering Consultants

12. Hazardous Materials and Wastes • Issue: Minimizing Risks With Hazardous Energy • Best Practices: • Provide clear signage for Zones 1 - 4 in MRI areas • Ensure that emergency responders have been trained with regard to entering MRI areas • Verify that fire and other emergencies in the MRI area address quenching the magnet (yes or no) • Appoint a Laser Safety Officer (LSO) if lasers are used • Create and follow all written safety guidelines for MRI’s and lasers • Follow all arc flash protection/ PPE/ signage guidelines • Continue to follow all safety procedures for ionizing radiation Healthcare Engineering Consultants

13. Hazardous Materials and Wastes • Issue: Proper Disposal of Hazardous Medications • Biggest Pitfall: Usingsharps containers for hazardous medications • Best Practices: • Meet federal RCRA (or possibly tougher state) regulations • Be prepared for a visit from EPA, DOT or DEA • Create RCRA “P”, “U” and “D” pharmaceutical inventories and use color-coded labels to assist clinical staff in identification • Create a separate waste stream for disposal of partially-used and unused hazardous medications • Supply color-coded collection containers with sponges in clinical units • Track the manifest forms to verify proper incineration • Check Federal Guidelines at: www.whitehousedrugpolicy.gov/publications/pdf/prescrip_disposal.pdf Healthcare Engineering Consultants

14. Hazardous Materials and Wastes • Issue: Compressed Cylinder Storage • Code Requirements: • Enclosures are not required forstored gases <300 cubic feet per smoke compartment (NFPA 99, section 9.4.3) • For stored gases >300 but <3,000 cubic feet: - Outdoors: enclosed space with doors or gates (9.4.2.1) - Indoors: an enclosure with minimum ½ hour protection (9.4.2.3) • For stored gases >3,000 cubic feet: - Walls, floors, ceilings, doors at least 1-hour rated (5.1.3.3.2) - Racks, chains or fastenings to secure all cylinders (5.1.3.3.2) - Continuous powered ventilation within 1 foot of floor (5.1.3.3.3) • FULL and EMPTY signage required for cylinders • Storage requires stands, racks or fastening devices, such as chains Healthcare Engineering Consultants

15. Hazardous Materials and Wastes • Issue: Compressed Cylinder Storage • Interpretations: • Requirements for stored gas only, notin-usetanks! • In-use gas includes: - Tanks on code carts - Tanks on wheelchairs - Tanks on gurneys - 30-minute rule if patients are not present in wheelchairs, gurneys • Empty tanks do not count toward the total (be careful of AHJ!) • Use of fire-rated cabinets can be used on floors Healthcare Engineering Consultants

16. Hazardous Materials and Wastes • Issue: Alcohol-Based Hand Rub Units Requirements • Code Requirements: • 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 sprinkled 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

17. Hazardous Materials and Wastes • Issue: Eyewashes and Showers • Biggest Pitfall: Failure to test eyewash according to policy • Best Practices: • Use risk assessment to determine placement • ANSI standards have not been officially adopted by the Joint Commission, but JC can reference OSHA • Tepid water between 60 and 100 degrees F will be expected • Testing policy is required – specify test intervals (weekly for eyewash units, monthly for showers recommended) • Documentation of test results is required • Differentiate between eyewash station and “first aid” station, such as mounted bottles Healthcare Engineering Consultants

18. Fire Prevention Issue: Unobstructed access to exits Biggest Pitfall: Believing that providing clear egress isn’t required in a “business occupancy” Code Requirement: The 2011 “Fire Risk” standard (EC.02.03.01 - EP4), describes that the “hospital must maintain free and unobstructed access to all exits”. However, this requirement refers only to business occupancies, since healthcare and ambulatory occupancy egress requirements are specified in the Life Safety chapter Healthcare Engineering Consultants

19. Fire Prevention • Issue: Fire Drills • Biggest Pitfall: Missing specific fire drills required by AHJ • Best Practices: • Consider healthcare facilities as “three shifts”, even if many clinical staff work 12-hour shifts • Clearly define specific fire response roles and responsibilities for all staff in the hospital, including privileged physicians • Perform and document at least one drill annually in the OR • Use the fire drills as an opportunity to: - document magnetic door releases for smoke and fire doors - document the time from fire alarm initiation to receiving station • Document the fire drill on a form with numerical values to track improvement of staff response and knowledge over time Healthcare Engineering Consultants

20. Medical Equipment Management • Issue: Equipment Test Scoring • Biggest Pitfall: Not tracking PM completion rate • Code Requirements: • 100% PM completion for “life support” devices, based on “A” scoring Note: JC considers defibrillators “life support” devices, even AED’s • 90% PM completion for “non-life support” devices (C) • Determine test interval and procedures by “PM effectiveness” and MTBF data (accepted now by CMS) • Test tags with due dates are recommended, but not required! What aboutOngoing PM vs. initial test only? • Flexible and rigid endoscopes are now required to be on the medical equipment inventory for monitoring purposes Healthcare Engineering Consultants

21. Medical Equipment Management • Issue: Incoming Equipment Tests • Biggest Pitfall: Not performing incoming equipment tests on patient-owned equipment • Code Requirements: • Patient-owned equipment (NFPA 99, section 8.5.2.1.2.2) Diagnostic and therapeutic (example: CPAP) Personal use (iPods, smart phones, laptops, iPads) • Rental devices • Demo, loaner and trial equipment Healthcare Engineering Consultants

22. Utility Systems Management • Issue: Airborne Pathogens • Biggest Pitfall: No air exchange data in pharmacy or clinical laboratory areas • Best Practice: • Create an airborne pathogens policy that describes how often air filters are changed, and air exchange and pressure relationships are measured in operating rooms, delivery rooms, special procedure rooms, patient isolation rooms, clinical laboratories, sterile supply rooms and pharmacies • Nominal test frequencies are annual, but can define other • Note: Refer to 2010 FGI document for requirements (new for 2011) • Note: “Grandfathering” permitted for air handlers Healthcare Engineering Consultants

23. Utility Systems Management • Issue:Temperature and Humidity in the Operating Rooms Code Requirements: • NFPA 99, section 6.4.1.1 requires control of humidity >35% • FGI 2010 Guidelines document lists control from 30% to 60% in Table 7-1 • CMS requires humidity above 35% • JC expects temperature and humidity monitoring/ documentation • Policy is needed for monitoring and control range, including clinical procedures when the actual readings are outside the range • Changes to ASHRAE 170 (in FGI document) to lower humidity level requirements to 20% have been approved by the Joint Commission! Healthcare Engineering Consultants

24. Utility Systems Management • Issue: Utility System Test Scoring • Biggest Pitfall: PM not tracked for required categories • Best Practices: • Create three different utility system inventory categories: 1. Critical utility life support 2. Critical utility infection control 3. Critical utility non-life support • Track and maintain “on-time” PM completion rates for the “critical life support” and “critical infection control” components based on “A” scoring: 100% • Track and maintain “on-time” PM completion rates for “critical non-life support” components based on “C” scoring: 90% Healthcare Engineering Consultants

25. FunctionalEnvironment • Issue: The JC “General Duty Clause” • Biggest Pitfall: Surveyor interpretation • Patient areas are safe, clean, free of odors and suitable • Lighting is suitable • Ventilation, temperature and humidity are suitable • Locks and restraints per regulation • Emergency access for locked spaces is provided Healthcare Engineering Consultants

26. Functional Environment Issue: Pre-Construction Risk Assessment (PCRA) Biggest Pitfall: Only ICRA and ILSM are evaluated Best Practice: Include allseven of the items listed below in the PCRA evaluation ● Noise ● Emergency procedures ● Vibration ● Utility failures ● Air quality ● Interim life safety measures ● Infection control Healthcare Engineering Consultants

27. Infection Control Risk Assessment (ICRA) – Best Practice Grid Risk Criteria for Infection Control ConstructionType Patient Risk Healthcare Engineering Consultants

28. Functional Environment • Issue: Documentation of PCRA • Best practices: • Evaluatemeasures to reduce risk and minimize the impact of the construction activities • Perform daily monitoring in all construction areas • Use a monitoring checklist • Post required permits, such as hot work, ICRA, above-the-ceiling work, ILSM, etc. on door entrance to construction area Healthcare Engineering Consultants

29. Functional Environment Issue:Pre-Construction Risk Assessment (PCRA) Best Practice:IncludePCRA changes during the project Healthcare Engineering Consultants

30. Information Collection and Monitoring What is the most effective method to provide EC monitoring and reporting? Healthcare Engineering Consultants

31. Measurement and Improvement What Measurements are Required in 2011? Patient and visitor injuries Occupational illnesses and staff injuries Incidents of damage to hospital or others property Patient, staff or visitor security incidents Hazmat spills and exposures Fire safety management problems, deficiencies and failures Medical equipment management problems, failures, and user errors Utility system management problems, failures and user errors Healthcare Engineering Consultants

32. Monitoring Regulatory Requirements Healthcare Engineering Consultants

33. Monitoring Regulatory Requirements Healthcare Engineering Consultants

34. Measurement and Improvement • What Performance Improvement Measures are Required for each “EC” area? • No longer any minimum number in 2011! • Should be numerical • No maximum number of numerical measures • Should measure performance improvement • Adopt goals, objectives and benchmarks • At least one performance improvement initiative from “EC” is required to be performed, documented and reported to leadership annually • Regular reporting and tracking of PI to the Safety Committee Healthcare Engineering Consultants

35. Reporting of “EC” PI Indicators Healthcare Engineering Consultants

36. Annual Evaluations • “Best Practice”Guidelines for the Evaluations • Demonstrate that the program has improved • Provide numerical data • Demonstrate “effectiveness” rather than “busyness” • Document evaluations for every “EC” area, including Emergency Management • Create the evaluations as soon as possible at the end of the fiscal or calendar year • Re-read the annual evaluations before the survey Healthcare Engineering Consultants

37. Annual Evaluations The Annual Evaluations must include: SCOPE - What is being evaluated? OBJECTIVES - What are the numerical goals/ benchmarks? PERFORMANCE - What does the data show? EFFECTIVENESS - How does the performance (data) compare to the objectives? WHAT NEXT? - What objectives do we define for next year, based on this year’s performance? Healthcare Engineering Consultants

38. Annual Evaluations • Best Practice:Each annual evaluation should include a review of: • The management plan • Regulatory compliance • Performance improvement • Other issues to take credit for Healthcare Engineering Consultants

39. Annual Evaluations Note: This matrix is not intended to be used for the actual annual evaluation format, but provides a guide to what should be included in the evaluation Healthcare Engineering Consultants

40. The Safety Committee • Best Practices Include: • Leadership representative (VP) present at every meeting • Multi-disciplinary membership • Attendance of standing members at least 70% • Meet often enough to limit meeting time to 1 hour or less • Document and distribute meeting minutes within two weeks of the meeting and use the C-R-A-F format • Use dashboards or spreadsheets to track regulatory and performance improvement data • Track the resolution of issues with a monitoring chart • Use the meeting time to solve problems, not to review data or information that does not require any action Healthcare Engineering Consultants

41. Safety Committee Issue Monitoring Healthcare Engineering Consultants

42. Biggest Pitfalls and Best Practices in EC Questions? Healthcare Engineering Consultants