The Preliminary Planning Session

1. The Preliminary Planning Session How Should I Prepare for the Preliminary Planning Session? Healthcare Engineering Consultants

2. The Preliminary Planning Session • Occurs on the morning of the first survey day • Will be performed by the surveyors “alone” • Will create strong first impressions (“Blink!”) • Will impact the rest of the survey! • Will be document-based (documents should always be up-to-date and ready) • Hospital must be prepared for this! • Should trigger the “Rapid Response Team” • The Life Safety Surveyor may come at a later time Healthcare Engineering Consultants

3. The Preliminary Planning Session • Documents to be reviewed include: • The six required management plans plus the “EOP” • Safety committee minutes from the last 12 months • The most recentannual effectiveness evaluations from each “EC” area and Emergency Management • Statement of Condition documents (reviewed by the LSS) • Fire plans and fire drill evaluations • Interim life safety measures policy • Safety officer signed appointment letter with intervention authority statement • Categorical waiver letter, if applicable Healthcare Engineering Consultants

4. The Management Plans • Expectations Include: • A description of the program, not a rewrite of the program! • Consistent format, in a labeled, tabbed binder • A list of applicable facilities to avoid multiple plans • A description of each “element of performance” • Responsibilities from governing body to staff • Performance improvement and training information • Risk assessment and ICES information • An annual review by the safety committee Note 1: Emergency Management requires an Emergency Operations Plan (EOP), not a management plan Note 2: “High Risk” plans include safety, hazmat, biomed, utilities Healthcare Engineering Consultants

5. The Management Plans • Best Practices Include: • Cross-reference or cite supporting policies that already exist • Note when the AHJ has a stricter interpretation or code reference • Reference other related Joint Commission standards (example: HR, LD, PI, IM standards) • Distribute plans to each applicable “off-site” facility • Don’t just list or restate the required standards or EC numbers • Consider the plans to be a “roadmap” to effective EC management • Consider appendix documents that reference applicable policies, define responsibilities and list performance indicators Note:Refer to additional information regarding “EC management Plans” in the June, 2013 issue of Perspectives Healthcare Engineering Consultants

6. The Emergency Operations Plan • Expectations Include: • The Emergency Operations Plan (EOP) is not a management plan, but a robust description of emergency operations procedures and information • At a minimum, the EOP should describe the following: 1. The Hazard Vulnerability Analysis (HVA) 2. Mitigation, Preparedness, Response, Recovery (MPRR) 3. The Incident Command System structure (ICS) 4. The six critical core areas of emergency management, including: communications, resources and assets, safety and security, staff roles and responsibilities, utilities and patient management • Also include a description in the EOP of emergency drills and reference emergency codes, procedures, and other materials that exist and supplement the program Healthcare Engineering Consultants

7. The Safety Committee • Best Practices Include: • Leadership representative (VP-level or equivalent) 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

8. Safety Committee Issue Monitoring Healthcare Engineering Consultants

9. Annual Evaluations The written Annual Evaluations must include the following sections: 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

10. Annual Evaluations • “Best Practice”Guidelines for the Evaluations • Demonstrate that the program has improved • Provide numerical data • Demonstrate “effectiveness” rather than “busyness” • To effectively communicate the report to others, include a narrative explanation, spreadsheets and graphs and charts • Indicate whether the regulatory and performance improvement goals and objectives have been “met” or “not met”, with a clear method of determination • Include goals and objectives for the following year, based on the results of the previous year Healthcare Engineering Consultants

11. Annual Evaluations • Additional “Best Practice”Guidelines • Document evaluations for every “EC” area, and Emergency Management • Create the evaluations as soon as possible at the end of the fiscal or calendar year (within 30 days, if possible) • Review and approve by the Safety Committee (within 60 days) • Review and approve by the Governing Body (within 90 days) • Re-read the annual evaluations before the survey to be prepared for the Physical Environment Interview session • The annual evaluations are a “Direct Impact” score Healthcare Engineering Consultants

12. The Statement of Conditions Review • LS.01.01.01: SOC and Life Safety Code • The SOC completion will be verified through the Joint Commission Connect site (BBI’s and PFI’s) • Have the SOC notebook available for review • The PFI documents from the previous survey may be reviewed to verify completion of deficiencies (have them available, if requested) • The compartmentation drawings will be reviewed to assist in planning the facility tour • Life Safety Code compliance will be verified during the facility tour Healthcare Engineering Consultants

13. The Statement of Conditions • What is the SOC? The Statement of Conditions (SOC) is a document that is required to be completed by every healthcare facility that applies for accreditation by the Joint Commission. It references the *2000 edition of the Life Safety Code and consists of the following sections: • Basic Building Information (BBI) Form – electronic on Connect site • Life Safety Assessment (LSA) Form – not on Connect site • Plan for Improvement (PFI) Form – electronic on Connect site *Note 1: The Joint Commission permits other LSC editions to be selected, but the entire edition must then be followed; CMS also requires compliance with the 2000 Life Safety Code Note 2:It is likely that the 2012 Life Safety Code will be adopted by CMS and the Joint Commission in 2015 Healthcare Engineering Consultants

14. The Statement of Conditions • SOC Notebook (Best Practice) • A SOC notebook is stronglyrecommended to contain “hard copies” of the SOC documents • The notebook should include atleast the following sections: Section 1: The SOC policy and responsibility statement Section 2: Current copies of the downloaded BBI forms Section 3: Accurate, color-coded compartmentation prints Section 4: The latest, completed LSA-type document Section 5: Current and previous, downloaded PFI forms Section 6: Any correspondence with the Joint Commission, including equivalencies, letters and emails Healthcare Engineering Consultants

15. The Statement of Conditions • Why Should I have an SOC Policy? • The SOC policy describes how the Statement of Conditions program is organized for the facility What Should the SOC Policy Include? • Who is responsible for completing and maintaining the SOC • How often the SOC documents are reviewed • Who reviews the SOC documents for timeliness • PFI guidelines (when does a work order become a PFI?) • Whether a BMP is implemented • Whether an above-the-ceiling program is in place • How the SOC documents are organized Healthcare Engineering Consultants

16. The Statement of Conditions Document The current Statement of Conditions “hard copy” document is dated 5/2004 and can still be downloaded as a pdf file from JointCommission.org for the LSA form only (donot use the BBI or PFI “hard copies” – they are obsolete) Note: Most organizations donot use this document at all! Healthcare Engineering Consultants

17. Statement of Conditions Document • Notes About the e-BBI Form • List on the e-BBI cover page every occupancy that will be surveyed, even for business occupancies (make sure that the BBI and survey list match!) • The e-BBI questionnaires are only required for ambulatory and healthcare facilities, not business occupancies • Fill in the e-BBI comments section regarding SOC preparer, location of building drawings, mixed occupancies, equivalencies, special building features or local AHJ requirements, including the CMS “Categorical Waivers” • If multiple occupancies are entered, the greatest percentage defaults to the BBI form, so multiple BBI entries are required • Be sure to print the electronic version of the BBI form at least annually so that a “back-up” is available, and place a copy in the SOC Notebook Healthcare Engineering Consultants

18. Statement of Conditions Document • Compartmentation Requirements • Mixed Occupancies: (LSC sections: 19.1.2.1, 19.1.2.2) • Sections of health care facilities shall be permitted to be classified as other occupancies (such as business), provided that they meet the following conditions: • They are not intended to serve health care occupants for purposes of housing, treatment, or customary access by patients incapable of self-preservation • They are separated from the health care occupancy by a fire rating of at least 2 hours • The facility is not intended to provide services simultaneously for four or more health care patients who are “litterborne” • Separation between ambulatory and business occupancies only requires a 1-hour rating (LSC: 21.1.2.1) Healthcare Engineering Consultants

19. Statement of Conditions Document e-BBI Form – Buildings Be sure to complete for all healthcare and ambulatory facilities Optional for business occupancies, but strongly suggested to include the cover page to indicate “surveyable facilities” Healthcare Engineering Consultants

20. Statement of Conditions Document e-BBI Form – page 3 “Previous inspections” data provides valuable information to the survey team! Be sure to list local or regional requirements (example: limited generator testing due to high pollution days) in the “Comments” section at the bottom of the form as well as other requested information, including: 1) location of the compartmentation drawings; 2) e-SOC preparer; 3) mixed occupancies, and; 4) equivalencies or issued variances, including CMS “Categorical Waivers” Healthcare Engineering Consultants

21. Statement of Conditions Document Life Safety Building Compartmentation Drawings Typical line colors might include: Blue– smoke barrier Green– 1 hour fire wall (typically a hazardous area) Red– 2 hour fire wall • Note 1: A color-coded drawing is “best practice” Note 2: Be sure to indicate the following features on the drawings: • Hazardous areas • Smoke/ fire barriers • Suites w/ sizes, other information • Linen/ waste chutes, shafts, chases • Exits • Sprinkled/ non-sprinkled areas • Approved equivalencies • A legend with fire safety features Healthcare Engineering Consultants

22. Statement of Conditions Document • LSA Form (is not electronic): • Is a voluntary assessment tool, although some assessment is required at least annually • Is not required for “Business Occupancies” • The Joint Commission surveyor normally expects some type of form, document or evaluation to be completed • Dated 5/2004, so a cover sheet that is signed annually is recommended • Can still be downloaded from the Joint Commission home page website JointCommission.org (type “Statement of Conditions” in the search box) • Can use other assessment tools (2011 form) or checklists for the LSA • Comments in LSA must match PFI deficiencies Healthcare Engineering Consultants

23. Statement of Conditions Document • LSA Documentation Options: • Can manually complete the 2004 LSA form available on the Joint Commission home website (JointCommission.org) in Adobe format • Can complete the updated 2011Joint Commission questionnaire form available from the “EC Essentials” book • Can create a new form or process for internal use • Can contract with an outside vendor May, 2004 Form 2011 Form Healthcare Engineering Consultants

24. Statement of Conditions Document • Notes About the PFI Forms • The forms should not be used for “operational deficiencies”, such as exit lights burned out, doors out of minor adjustment or small penetrations that can be easily filled – these should be completed using the routine work order system • The normal “trigger time” from a work order to PFI is 45 days • Document the “PFI’s” on a continuing basis – be sure that the PFI log is up-to-date and ready to be reviewed by the surveyor • Don’t forget to enter the projected start and completion dates and the actual completion date • Be sure to document an ILSM evaluation for every PFI! • Failure to meet the completion dates without a delay approval results in Contingent Accreditation6 monthsaftertheprojected completion date has passed! • If applicable, keep any previously signed PFI copies available Healthcare Engineering Consultants

25. Statement of Conditions Document The second page for the electronic PFI forms is used to indicate the deficiency resolutions Don’t forget to complete all of the requested information, including the proposed action, source of funds and the projected start and completion dates The projected completion dates can be altered until they are “frozen” before or during the actual survey! Be sure to check “YES” on the form to indicate that interim life safety measures (ILSM) have been evaluated for the PFI Healthcare Engineering Consultants

26. Statement of Conditions Document • Changes to the SOC Process – effective 7/1/2014 • Open PFI’s will now be listed in the final decision report, so will be available to anyone who has access to the report • Failure to resolve a PFI beyond the 6-month “grace” period will result in a phone call from the Joint Commission and a possible on-site survey if it is not resolved in a timely basis • Once a delay for a PFI is granted, the 6-month grace period is no longer applicable! • Equivalencies that are requested from the Joint Commission will now be forwarded to the CMS regional (state) office for review and possible approval – the Joint Commission will no longer issue equivalencies unless approved by CMS! Healthcare Engineering Consultants

27. The Safety Officer Appointment • Should be in a letter format • Should identify an individual (or multiple people) by name • Must include an “intervention authority statement” • Should be signed by the organization CEO and CMO if they are on the same organizational level • Can be signed by the Governing Body President to indicate additional organizational support • Only requires a re-issue if any individuals change positions Healthcare Engineering Consultants

28. The Preliminary Planning Session Questions? Healthcare Engineering Consultants