Post on 23-Dec-2015
UTILITIES MANAGEMENT
CSHE Los Angeles Chapter2013 Annual
Devin J Hugie, SASHE, CHFM, CHSP-FSM, CHEP
Criticality
Criticality defined as “the immediacy of risk to patient safety or quality of care as a result of noncompliance with a joint commission requirement.”
4 levels of Criticality: 1. Immediate Threat to Life (ITL) *PDA Until Resolved2. Situational Decision Rules * Based on Specific
situations at time of Survey.3. Direct Impact Requirements * Noncompliance may
create an immediate risk to patient safety or quality of care.
4. Indirect Impact Requirements * Based on planning and evaluation or care processes
What Triggers ITL(Immediate Threat To Life)
Significantly compromised fire alarm system Significantly compromised fire sprinkler
system Significantly compromised emergency
power supply system Significantly compromised medical gas
master alarm panel Significantly compromised exits Other situations that place patients, staff or
visitors at extreme danger
Criticality of Findings & Immediacy of Risk
The amount of time for submitting the ESC (Evidence of Standards Compliance) is based on the criticality of the finding and the immediacy of risk as follows
Direct Impact Within 45 Days Indirect Impact Within 60 Days D- Documentation is required C- “C” Standards, All others are “A”
standards
EC.02.05.01 Manages Utility Systems Risks
1) Design/Installs systems that meet pt care / op needs2) Written inventory of components D3) Identifies inspection / maintenance activities D C4) Identifies intervals for inspecting, testing, maintain componentsD⑤ Minimizes pathogenic biological agents in cooling towers, etc⑥ Pressure relationships; air-exchanges, filtration efficiencies (the ventilation
systems provides appropriate pressure relationships, air-exchange rates, and filtration efficiencies)
7) The hospital maps distribution of utility systems D8) The hospital Labels emergency shut downs9) The hospital has written procedures for responding to utility system disruptions
D10) The hospitals’ procedures address shutting off the malfunctioning systems and
notifying staff in affected areas.11) The hospitals procedures address performing emergency clinical interventions
during utility systems disruptions. 12) The hospitals procedures addresses the following: How to obtain emergency
repair services.13) The hospital responds to utility system disruptions as described in its
procedures
EC.02.05.03 Emergency Electrical Power
Provides Emergency power for① Alarm systems per LSC (NFPA 99)② Exit route and exit sign illumination③ Emergency communication system4) Elevators (at least 1 for non-ambulatory pts)⑤ Equipment that could cause harm if fails⑥ Areas where loss of power cause result in PT
harm (Or’s)
EC.02.05.05 Maintain Utility Systems
1) Tests components before initial use D C③ Inspects/tests/maintains Life Support
Utility Systems D④ Inspects/tests/maintains inf Cont utility
system components D5) Inspects/tests/maintains Non-Life Support
Utility components D C
EC.02.05.07 Maintains Emergency Power Systems
1) 30 day intervals, test battery-powered lights for 30 seconds (if required for egress) D C
2) 12 months, tests battery-powered lights for 1.5 HRS or replace all batteries @ 12 months/random tests 10% (if required for egress) D C
3) SEPSS tested for 5 min monthly/annual full load D④ 12/year tests emergency generator for 30 minutes D⑤ Emergency generator tested @ 30% or exhaust temp or annual
load bank: 25% for 30 min, 50% for 30 min, 75% 60 min⑥ 12/yr tests all automatic transfer switches D⑦ 36 months, generator tested for 4 continuous hours D⑧ 36 month test uses 30% nameplate rating or temp⑨ Per Occurrence: If test fails, implements measures to protect
pts until repaired10) Perform retest after repairs
EC.02.05.09 Maintains Medical Gas and Vacuum Systems
① Inspects, tests, maintains critical components per defined timeframes D
② Tests for purity, correct gas, pressure when installed, modified, repaired D
3) Shutoff valves accessible and clearly identifies control areas
EC.02.05.09 Monitors conditions in environment
11) Utility systems management problems, failure, use errors C
EM.02.02.09 Utility Disruption
Emergency Operations Plan identifies alternative means of providing:
② Electricity③ Water needed for consumption and essential care
activities④ Water needed for equipment and sanitary purposes⑤ Fuel required for building operations or essential
transport activities⑥ Medical gas/vacuum systems⑦ Utility systems defined as essential, such as
Vertical & horizontal transport Heating & cooling systems Steam for sterilization
⑧ Utility needs identified in the HVA
New Areas of Focus
On the increase are observations related to: Electrical Panel Schedules Room Pressure relationships Fire Sprinkler lines used for support Battery back up lighting in Generator
rooms Eyewash Stations
Questions
Thank You