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Environment of Care, Emergency Management & Life Safety

Environment of Care, Emergency Management & Life Safety. Changing Expectations & Surveyor Approaches Marty Piepoli December 10, 2009. Disclosures.

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Environment of Care, Emergency Management & Life Safety

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  1. Environment of Care, Emergency Management & Life Safety Changing Expectations & Surveyor Approaches Marty Piepoli December 10, 2009

  2. Disclosures • “Courtemanche & Associates Healthcare Synergists is an Approved Provider of continuing nursing education by the North Carolina Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation.” • Continuing Education Contact Hours will be awarded upon full attendance of the program and receipt of the participant course evaluations. • There are no influencing financial relationships or commercial support relating to this activity. • Participation in an accredited activity does not imply endorsement by the provider or NCNA of any commercial products displayed in conjunction with this activity. • Courtemanche & Associates does not discuss any products for use for a purpose other than that for which they were approved by the Food and Drug Association. www.courtemanche-assocs.com

  3. Session Objectives • At the conclusion of this session, learner will be able to: • Describe the importance of assessing risk as it relates to Life Safety and Emergency Management preparation. • Identify at least two challenging standards & potential solutions. • Identify the impact of the disparity in findings for the Environment of Care regarding TJC and CMS surveys. www.courtemanche-assocs.com

  4. Glossary of Terms • AIA – American Institute of Architects • ASHE – American Society for Healthcare Engineering • CMS – Centers for Medicare & Medicaid Services • CoP – Conditions of Participation • EC – Environment of Care • EM – Emergency Management • e-PFI – Electronic Plan for Improvement • EPA – Environmental Protection Agency • ESC – Evidence of Standards Compliance • HAI – Healthcare Acquired Infections • HAP – Hospital Accreditation Program www.courtemanche-assocs.com

  5. Glossary of Terms • HCO – Healthcare Organization • ICC – Incident Command Center • ILSM – Interim Life Safety Measures • LS – Life Safety • LSC – Life Safety Code • NFPA – National Fire Protection Agency • OSHA – Occupational Safety Health Administration • PARA – Pro-active Risk Assessment • SA – State Agency • TJC – The Joint Commission www.courtemanche-assocs.com

  6. CMS Driving TJC Expectations www.courtemanche-assocs.com

  7. CMS Deeming Application • TJC-accredited hospitals = 4,153 • 82 percent of all hospitals participating in the Medicare program • The CMS validation program assures accredited hospitals are in compliance with statutory requirements in 42 CFR Part 482 www.courtemanche-assocs.com

  8. CMS Validation Surveys • FY 2007*, 4164 CMS surveys were performed • 55 Look-back surveys were done (1.3%) • 4,109 Allegation (complaint) surveys were completed (98.7%) • Look-back surveys demonstrated: • 55 of 1,451 (3.8%) hospitals surveyed by TJC in 2007 • 40% disparity rate between TJC and SA ability to detect CoP deficiencies • 29% of the disparities relate to physical environment • * CMS 2008 Annual Report to Congress, November 2008 www.courtemanche-assocs.com

  9. By the Numbers – CMS Survey Activity • Increase in the disparity rate from 2006 (14.6%) • In 2007, 73% of Physical Environment findings by TJC were not cited at the Condition Level • Lack of detailed emphasis on the conditions of the physical plant/building safety www.courtemanche-assocs.com

  10. CMS/TJC Disparity • With high disparity seen in the physical environment, TJC changes include: • Completion of the Statement of Conditions by Qualified Personnel • Set Minimum Standards for the Statement of Conditions/Plans for Improvement • Submission of the Statement of Conditions and Plans for Improvement to TJC prior to survey • Incorporating a Life Safety Surveyor into the process www.courtemanche-assocs.com

  11. CMS Deeming Application • Open dialogue between TJC & CMS • Onsite visits • Working through outstanding issues such as telemedicine, environment of care. • Announcement in Federal Register November 27, 2009: approval of a deeming application from TJC for continued recognition as a national accreditation program for hospitals that request participation in the Medicare or Medicaid programs. • Effective July 15, 2010 through July 15, 2014 www.courtemanche-assocs.com

  12. Top EC/EM/LS Findings 2009 www.courtemanche-assocs.com

  13. Challenging Standards % Non-Compliance www.courtemanche-assocs.com

  14. EC.02.01.01 – Safety & Security Risks • Findings: • Identification of risks not evident – proactive risk assessment, etc. • Secure areas accessible • Strategies: • EC or Safety Committee to charter and guide annual (more frequent as needed) risk assessment process; assure results & follow-up activities identified & implemented • Implement secure access to high risk areas – i.e., pharmacy, mother/baby, hazardous storage rooms and assure staff adhere to security measures • Change keypad codes regularly www.courtemanche-assocs.com

  15. EC.02.03.05 – Maintaining Fire Equipment & Fire Safety • Findings: • Inspecting, testing, etc.: • Fire alarms, sprinklers • Fire extinguishers • Tamper switches • Strategies: • Assure that vendor testing & maintenance documentation is maintained onsite • Testing logs should include all required elements (i.e., tamper switches) • Assure systems are fully functional and tied to local Fire Department www.courtemanche-assocs.com

  16. CMS Update – Dampers • Option for Damper Testing Interval • Hospitals permitted to apply the NFPA 6-year damper testing interval for fire and smoke dampers. • Testing system must conform to the testing requirements under the 2007 edition of NFPA 80 and NFPA 105. • At the time of a CMS onsite life-safety code survey, hospital must notify survey team it has elected to operate under this waiver. • S&C-10-04-LSC 10/30/09 www.courtemanche-assocs.com

  17. EC.02.05.07 – Inspect & Test Emergency Power Systems • Findings: • Testing of battery powered lights, generators, automatic transfer switches • Strategies: • Assure that vendor testing & maintenance documentation is maintained onsite • Testing logs should include all required elements (i.e., automatic transfer switches) • Once issues are fixed, test the system again www.courtemanche-assocs.com

  18. EC.02.05.09 – Inspect, Test & Maintain Medical Gas & Vacuum • Findings: • Defined timeframes not met • Shutoff valves not accessible or clearly labeled • Strategies: • Have testing and maintenance timeframes approved by EC or Safety Committee who will require status checks • Assure shut-off valves are on an inventory, labeled and checked periodically www.courtemanche-assocs.com

  19. EC.02.06.01 – Safe, Functional Environment • Findings: • Furnishings & equipment not safe/in good repair • Space inadequate for care • Strategies: • Conduct regular EC rounds (particularly behavioral health and pediatric areas) to identify hazardous (safety and infection control issues) equipment and furniture; then remove/repair • Where space is an identified issue, document Leadership knowledge and understanding and future plans; if a Life Safety issue – place on e-PFI www.courtemanche-assocs.com

  20. LS.02.01.10 – Minimize Fire, Smoke, Heat Effects • Findings: • Fire/Smoke door integrity • Penetrations!!! • Strategies: • Use a building maintenance program to check doors regularly • Institute an “above the ceiling” process to assure penetrations are filled when they happen • “Red line” badges of vendors who work in the ceiling – so they can be easily identified www.courtemanche-assocs.com

  21. LS.02.01.20 – Maintaining Egress • Findings: • Hallway clutter • Stairwell storage • Exit signs not visible • Strategies: • “Garage” sale days – remove all broken, obsolete equipment • Only what is in immediate use should be in halls • Create docking areas for computers on wheels • Use several vehicles for rounding – including Leadership Rounds www.courtemanche-assocs.com

  22. LS.02.01.30 – Maintaining Buildings from Fire Hazards • Findings: • Issues in boiler rooms, flammable storage areas, labs, etc. • Dampers inaccessible or inoperable • Corridor door integrity • Strategies: • Assure these areas are secure from public access • Clutter patrol! Engage folks from outside the area - you don’t see the cobwebs in your own home • Evaluate dampers – identify those that are inaccessible or inoperable and fix them or place on the e-PFI www.courtemanche-assocs.com

  23. LS Document Review and EC/EM Tracer • Document Review occurs the morning of Day 1 followed by building tour unless LSS arrives later. • Provides additional observations for the surveyor directing the EC/EM tracer. • The EC/EM session combined into one session in 2009. • This session has three parts: • EC Discussion • EM Discussion • EC Tracer www.courtemanche-assocs.com

  24. Getting Ready • Know What Surveyors Review • Annual evaluations of the Environment of Care (EC) management plans (EC.04.01.03) • EC multidisciplinary team meeting minutes for the previous 12 months (EC.04.01.03) • Hazard Vulnerability Analysis (EM.01.01.01) • ILSM Policy (LS.01.02.01) www.courtemanche-assocs.com

  25. Getting Ready • Know What Surveyors Review • EC-related issues observed in previous survey activities by other survey team members • Note identified risk points as possibilities for tracer observation www.courtemanche-assocs.com

  26. What to Expect – Emergency Management • Surveyor Discussion Points • Proactive Risk Assessment (HVA) • Emergency Operations Plan • Involvement of various organizational disciplines and the community • Approaches for educating staff • Organizational communication and notification plans www.courtemanche-assocs.com

  27. Surveyor Approaches 2009 www.courtemanche-assocs.com

  28. Emergency Management Tracer • Selection • Consider your top three vulnerabilities on your HVA • Let’s consider recent concerns: • Influx of H1N1 • Miracle on the Hudson • Floods in the Midwest • Tornados everywhere! www.courtemanche-assocs.com

  29. Who, What and When • Some Practical Tips • Print out the standard survey agenda for your organization to see when the EC/EM tracer will be conducted. • Check the backgrounds of your survey team • Does the Life Safety Specialist come on the first day or later during the survey? www.courtemanche-assocs.com

  30. Some Results from the Field • Example #1 Conducted by the physician • Heavy focus on the specific items on the HVA • Majority of discussion on the top 3 items • Preparation to address these items • Framework of mitigation, preparedness, response & recovery • How the “Big 6” were addressed • Chose to focus on Utilities Disruption of Water which was identified on proactive risk assessment related to planned well. www.courtemanche-assocs.com

  31. Some Results from the Field • Example #2 Life Safety Specialist • Arrived on day 3 of the 3.5 day survey. • Conducted review of all of the EC Mgmt Plans and the EOP. • In his review of the EC Management Plans, he tied in the Big 6 as they related to each of the plans. • Very consultative and educational. www.courtemanche-assocs.com

  32. Some Results from the Field • Example #3 Life Safety Specialist • Arrived on day 4 of the 5 day survey. • Conducted his review standard by standard from EC and EM. • In his review of EM, focus was on the HVA methodology and sustainability. • Emphasis on Communication, Assets and approach to drill critiques. www.courtemanche-assocs.com

  33. Surveyor Findings • No specific scoring of the EM chapter thus far: only 3 direct impact EP’s in the EM chapter. • EM.02.01.01 EP#8 In an actual emergency, the hospital implements its response procedures related to patient care, treatment, and services. • EM.02.02.13/02.02.15 EP#5 that addresses volunteer disaster privileges to LIP and non-LIP volunteers. www.courtemanche-assocs.com

  34. EM and Other Tracer Activity • Surge Capacity related to the Infection Control tracer. • Availability of emergency medications in the medication management tracer. • Patient Flow tracer/discussions in the ED related to Surge and same level of care. www.courtemanche-assocs.com

  35. Use of Pro-active Risk Assessment in the Environment of Care www.courtemanche-assocs.com

  36. Risk Assessments • Risk Assessment is a method for identification of potential harm to a patient population using quantifiable approaches. • Objectively determining the potential for a negative outcome based on: • Severity of outcome • Frequency of event • Likelihood of detection www.courtemanche-assocs.com

  37. Proactive Risk Assessments • To correct process issues or barriers and reduce the potential for experiencing adverse events • To evaluate processes to see how they could fail • To understand the potential impact of such a failure • To identify components of the process that need improvement www.courtemanche-assocs.com

  38. Process Examples • Clinical: • Surgical Procedures • Medication Administration • Central Line Insertion • Environmental and Other Non-Clinical: • Maintenance of building fire prevention features • Maintenance of medical gas systems www.courtemanche-assocs.com

  39. Risk Assessment Cycle www.courtemanche-assocs.com

  40. Environmental Risks • EC.01.01.01 The hospital works to assess and minimize risks in the environment of care. Can be managed by one or more individuals. • Managing these risks through a systematic, proactive approach to evaluating potential harm and mitigating opportunities for harm is key. www.courtemanche-assocs.com

  41. Environmental Risks • Potential for environmental risks • Safety and security for people, equipment, and other material; • The handling of hazardous materials and waste; • Fire; • The use of medical equipment; • Utility systems. www.courtemanche-assocs.com

  42. Environmental Risks • EC.02.06.05 - Experts, i.e., AIA, TJC, ASHE, recommend including at least the following in your pre-construction risk assessment • Air quality requirements, • Infection control, • Utility requirements, • Noise, • Vibration, • Other hazards • Also refer to LS.01.02.01 related to interim life safety measures www.courtemanche-assocs.com

  43. Environmental Risks • IC.01.03.01 • EP#1Tells us that we should identify our risks for spread of infection by considering geographic location, community, and population served. • EP#2 And always includes concerns related to the care, treatment, and services it provides for patients and the community. www.courtemanche-assocs.com

  44. TJC – What to Expect in the Future www.courtemanche-assocs.com

  45. TJC – Evolving to Drive Sustained Improvement • Standards & NPSGs focused on contributing to improved health outcomes. Attributes: • Relates to quality & safety • Has a positive impact on outcomes • Has a ROI for safety & quality • Can be measured or surveyed • More in depth analysis of adverse events to identify sustainable improvement initiatives • Improved internal operations - while maintaining integrity of survey process www.courtemanche-assocs.com

  46. Resources • 2009 Comprehensive Accreditation Manual for Hospitals (CAMH): The Official Handbook. Published by: Joint Commission Resources, Inc., Oak Brook, IL. • TJC Hospital Executive Briefings – September 2009. Presented by: Joint Commission Resources, Inc., Oak Brook, IL. • CMS S&C-10-04-LSC. http://www.cms.hhs.gov/SurveyCertificationGenInfo/downloads/SCLetter10_04.pdf. Published: October 30, 2009. Accessed: December 8, 2009. www.courtemanche-assocs.com

  47. Resources • Environment of Care News, February 2009, Volume 12, Number 2. Published by: Joint Commission Resources, Inc., Oak Brook, IL. • Environment of Care News, March 2009, Volume 12, Number 3. Published by: Joint Commission Resources, Inc., Oak Brook, IL. • CMS 2008 Annual Report to Congress, November 2008. http://www.cms.hhs.gov/CFOReport/Downloads/2008_CMS_Financial_Report.pdf. Published: November 2009. Accessed: December 8, 2009. www.courtemanche-assocs.com

  48. Questions? Contact Us At: Info@courtemanche-assocs.com (704) 573-4535

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