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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 ANDJCAHO COMPLIANCE Susan B. McLaughlin Barrington, Illinois
Health Care Finance Administration • Deemed status • Medicare reimbursement • Go-behind surveys • OIG report, 1999
Occupational Safety & Health Administration (OSHA) • Worker safety • Applicable law and regulation
JCAHO/OSHA PARTNERSHIP • Established 1996 • Educational • Surveyors and Inspectors • Health care organizations • Reduce duplicative compliance activities
RELATIONSHIP ENVIRONMENT OF CARE ENVIRONMENT OF WORK OSHA JCAHO
STATUS • Renewed for 3 years in 2000 • “Hammer Award” • Remains educational • Additional examples of compliance
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 • 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 • Storage > 180 days • Toxic waste storage facility
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 • Department of Transportation • Hazardous materials • Regulated medical waste • Shipping papers • Training • Home care
JCAHO / DOT • No formal relationship • “Applicable law and regulation”
REMEMBER • Always comply with the strictest authority having jurisdiction (AHJ) • JCAHO frequently asked question (FAQ) related to hazmat, www.jcaho.org
ENVIRONMENT OF CARE® • Seven management plans • Safety • Security • Hazardous Materials & Waste • Emergency Management • Fire Prevention • Medical Equipment • Utilities
EC REQUIREMENTS • Written plans • Implementation of plans • Risk assessment • Staff knowledge and skill • Maintenance, testing, inspection activities • Monitoring and evaluation • Annual evaluation
RISK ASSESSMENT • All management plans • Specific to organization • Non-prescriptive standards
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 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 • Size of organization determines: • Length of survey • Number of surveyors • Administrator - Nurse - Physician • Nurse - Physician • Surveyor cross-training
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
Participants Administrator or Nurse Surveyor Safety Officer Engineering Director Etc. Function Validation of SOC Assessment of Implementation Staff Interviews BUILDING TOUR
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 • Policies distributed, practiced, enforced • Policies reviewed at least every 3 years
EC.1.1.1 WORKER SAFETY • Occupational illness • Personnel injury • Safety orientation and training
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” A) 1. Selection -What is to be purchased -Supplier -Screening Process 2. Handling • Receipt • Documentation
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 GRAVE” 5. Use -Training 6. Disposal -Chemicals -Potentially infectious medical waste -Empty gas cylinders -Waste anesthetic gas
B) APPLICABLE LAW & REGULATION 1. OSHA 2. EPA 3. DOT “Includes but not limited to. . .”
Bloodborne Pathogens Hazard Communication Hazardous Drugs Formaldehyde Ethylene Oxide Tuberculosis Respiratory Protection Personal Protective Equipment (PPE) Etc. B) 1. OSHA ISSUES
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 • Chemical • Chemotherapeutic • Radioactive • Regulated medical • Sharps
B) 2. MANAGING WASTE • Intra-facility tracking • Disposal methods • Training • Documentation
C) SPACE & EQUIPMENT • Adequate • Appropriate • Segregation
REPORTING and INVESTIGATING • Problems, failures, user errors • Information collection and evaluation system (ICES) • Input into Safety Committee
E) GASES & VAPORS 1. Formaldehyde 2. Ethylene Oxide 3. Waste Anesthetic Gas 4. Glutaraldehyde 5. Xylene
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 • Spills • Chemical • Mercury • Potentially infectious • Chemotherapy • Major clean-up operations • OSHA Hazardous Waste Operations (HAZWOPR) • Fire department
EMERGENCY PROCEDURES • Radiation Exposure • Personal Protective Equipment
D) PERFORMANCE MONITORING • Examples: • Waste volume • Solid waste • Hazardous waste • Waste disposal costs • Staff knowledge and skill • Monitoring of gases & vapors • Etc.
DOCUMENTATION • EC.2.3: Implementation • Permits • Licenses • Manifests
EC.1.4 EMERGENCY MANAGEMENT • Facilities for chemical and radioactive decontamination
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 • 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 • Demonstrated performance improvement • Reduced need for: • Storage • Training • PPE • MSDS
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 • Demonstrated performance improvement • Eliminate need for spill clean-up procedure • Eliminate specialized disposal • Reduce regulatory compliance • Worker / patient safety improved