© Copyright, The Joint Commission 2014 T HE H EALTHCARE E NVIRONMENT John Maurer, SASHE, CHFM, CHSP...

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2014

THE HEALTHCARE ENVIRONMENT

John Maurer, SASHE, CHFM, CHSP

Engineering Department

The Joint Commission

Engineering Department 2014- 2

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2013/2014 CHALLENGING STANDARDS

THE TOP 20 ISSUES

Department of Engineering 2014 - 3

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Standard/NPSG 2014 Non Compliance, First 6 months

2013 Non Compliance

EC.02.05.01 53% 47%

LS.02.01.20 52% 52%

EC.02.06.01 51% 39%

EC.02.03.05 50% 45%

IC.02.02.01 50% 46%

LS.02.01.10 49% 48%

RC.01.01.01 49% 52%

LS.02.01.30 46% 45%

LS.02.01.35 44% 36%

EC.02.02.01 36% 34%


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Standard/NPSG 2014 Non Compliance, First 6 months

2013 Non Compliance

MM.03.01.01 32% 35%

PC.01.03.01 29% 27%

EC.02.05.09 27% 21%

PC.02.01.03 27% 18%

MM.04.01.01 24% 22%

PC.03.01.03 24% 20%

LD.01.03.01 23% 19%

LD.04.01.05 22% 14%

EC.02.05.07 21% 23%

MM.05.01.01 20% 16%


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TOP 10 CITED STANDARDS: 2011 – 2014 (YTD)

Standard 2014 2013 2012 2011

EC.02.05.01: Utility Systems Risks #1 #4 #10 #13

LS.02.01.20: Means of Egress #2 #1 #2 #2

EC.02.06.01: Built Environment #3 #8 #7 #11

EC.02.03.05: Fire Safety Systems #4 #7 #5 #5

LS.02.01.10: General Bldg Req’s #6 #3 #3 #3

LS.02.01.30: Protection #8 #6 #6 #4

LS.02.01.35: Extinguishment #9 #9 #9 #10

EC.02.02.01: HazMat & Waste #10 #11 #11 #15


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#18 LD.4.01.05

The hospital effectively manages its programs, services, sites, or departments Problematic EP: EP 4: Staff are held accountable for their

responsibilities Used when leadership has allowed non compliance

to exist without correction Sometimes used when situation is serious but does

not warrant a “decision rule”


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WHAT IS YOUR APPROACH TO ESC?

Do you have a team approach or is one person responsible?

Do you do what you need to do to “make it go away” or are the issues analyzed to determine why the non compliance is present?

Do you use this standard ESC response: “We have re-educated the “Fill In The Blank”?”

Have you looked at patient safety events and near misses/close calls in relation to non compliance identified during your survey?

Have you considered what the short term and long term impact will be if you are unsuccessful in correcting the RFIs?


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WHAT IS YOUR APPROACH TO ESC?

Do you develop generic ESC or are your ESC specific to the root causes of the RFIs?

Does the safety culture in your organization encourage staff and medical staff to identify system and process problems so they can be addressed quickly or do you wait until something happens or a surveyor finds it?

When you develop your ESC do you find a way to incorporate it into daily activities and processes or do you lay it on top of everything else staff have to do?

Is the culture in your organization one that allows the importance of the ESC to fade after a few months or is patient safety and compliance embedded in your mission/vision?


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Bottom Line!If you don’t address the issues

the first time you will be continually be doing rework

and patient safety and quality suffer!


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SOME THINGS TO CONSIDER…

Do you have the right people at the table to address the issues identified?

Are you focusing on systems and processes and how to improve them?

Have you had an issue with this requirement on previous surveys?

What kind of follow up monitoring have you planned to determine whether or not the ESC has been effective over the long term?

If you find that your ESC hasn’t worked how do you go about fixing that?

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2014

THE HEALTHCARE ENVIRONMENT

STANDARDS UPDATE


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RISK ICON

Integrated into the Manuals, E-dition, AMP, & FSA Tool All products will display a single icon at the EP level

for three risk-focused categories:1. National Patient Safety Goals2. Accreditation program-specific risk area standards3. Selected direct/indirect impact standards

In addition, the FSA Tool will use the R icon to identify the fourth risk category:

4. RFI standards from current cycle survey events.

Risk• Proximity to patient• Probability of harm• Severity of harm• Number of patients at risk


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TIME RE-DEFINED

The Joint Commission EC chapter defines time as: Daily, weekly, monthly are calendar references Quarterly is once every three months +/- 10 days

effective January 1, 2014 Semi-annual is 6 months from the last scheduled event

month +/- 20 days Annual is 12 months from the last scheduled event

month +/- 30 days 3 years is 36 months from the last scheduled event

month +/- 45 daysNOTE 1: The above does not apply to required frequenciesNOTE 2: An alternative of developing either a unique, written policy or adopting

NFPA definitions when available is acceptable


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Quarterly: +/- 10 daysSemiannual: +/- 20 daysAnnual: +/- 30 days

Due Date

Due Date

Scheduled Month

Scheduled Month20 202020

30 303030

July Sept OctAug NovJune Dec

Jan F M A J J O N

Semiannual

Annual

+ +

JanM A S D

Frequencies required by Code may not be modified (e.g. EC.02.05.07 EP 4 & 7)

10 10 10 10

Jan February March AprQuarterly


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Changes to Elements of Performance Effective 7/1/2014

EC.02.03.03, EP 3 When quarterly fire drills are required, at

least 50% are unannounced. Fire drills are held at unexpected times and under varying conditions.

Added: “Fire drills are held at unexpected times and under varying conditions.”


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Changes to Elements of Performance Effective 7/1/2014

EC.02.03.03, EP 4

Staff who work in buildings where patients are housed or treated participate in drills according to the hospital’s fire response plan. Note: When drills are conducted between 9:00 p.m. and 6:00 a.m., the hospital may use alternative methods to notify staff instead of activating audible alarms.

Replaced: “…the buildings fire alarm system.”


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EC.02.02.01 EP 18Effective July 2, 2014

For hospitals that use Joint Commission for deemed status purposes: Radiation workers are checked periodically, by use of exposure meters or badge tests, for the amount of radiation exposure


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EC.02.02.01 EP 19Effective July 2, 2014

For hospitals that use Joint Commission for deemed status purposes: The hospital has procedures for the proper routine storage and prompt disposal of trash.


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EC.02.03.03 EP 3

When quarterly fire drills are required, at least 50% are unannounced. Fire drills are held at unexpected times and under varying conditions.

Added: “Fire drills are held at unexpected times and under varying conditions.”


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EC.02.03.03 EP 4

Staff who work in buildings where patients are housed or treated participate in drills according to the hospital’s fire response plan. Note: When drills are conducted between 9:00 p.m. and 6:00 a.m., the hospital may use alternative methods to notify staff instead of activating audible alarms.

Replaced “building’s fire alarm system.” See NFPA 101-2000, 19.7.1.2 “…a coded

announcement shall be permitted to be used instead of audible alarms.”


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Clinical Alarms – Brief History

In 2004 there was a NPSG on clinical alarms Goal retired, survey the issue under Environment of Care

EC.02.04.01 EC.02.04.03 CoP Physical Environment 482.41

Clinical Alarm Device Summithttp://www.aami.org/hottopics/alarms/AAMI/2011_Alarms_Summit_publication.pdf http://www.aami.org/publications/AlarmHorizons/index.html Healthcare Technology Safety Institute (HTSI)

Plan, Do, Check, Act: Using Action Research to Manage Alarms, Signals, and Responses

http://www.aami.org/htsi/safety_innovation.html

http://www.aami.org/hottopics/alarms/AAMI/2011_Alarms_Summit_publication.pdf

http://www.aami.org/hottopics/alarms/AAMI/2011_Alarms_Summit_publication.pdf

http://www.aami.org/publications/AlarmHorizons/index.html

https://bl2prd0811.outlook.com/owa/redir.aspx?C=kXsbgIYsTkO_9xWW2M573aXb-16AxM8I2y08S8s0W8aQ9QyyQ7zs2r-tiEgIODt6nS7zZmYjH_c.&URL=http://www.aami.org/htsi/safety_innovation.html


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Number 1 on ECRI top 10 for 2013 and 2014 Incidents of alarms being silenced or shut off

Default settings Incidents of inadequate staffing to support

No mechanisms for monitoring/responding Incidents of “alarm fatigue”

Overuse, too many types of alarms, etc. Patient deaths have occurred


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PC.02.01.11: Resuscitation services are available throughout the hospital

PC.02.01.19: The hospital recognizes and responds to changes in the patient’s condition

LD.03.06.01 EP3: Leaders provide for a sufficient number and mix of individuals to support safe, quality care, treatment and services. CoP 482.23 (b) Nursing Services

HR.01.06.01: Staff are competent to perform their responsibilities. CoP 482.23 (b)(5) Nursing Services


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EC.02.04.01: Equipment Management EP 2 Inventory EP 3 maintenance, inspection and testing activities

EC.02.04.03: Equipment Reliability EP 2 Life support devices EP 3 Non-life support devices

EC.04.01.01: Monitoring & Reporting Continually monitoring medical equipment problems or

failures. CoP 482.13(c)(2) Patient Rights


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The Alarming Problem

More and more devices and alarms More patients connected to alarms or alarm-

based devices 150-400+ alarms per patient per day in a typical

critical care unit Alarm-based devices are not standardized in

many organizations Inconsistent use of alarms due to flexible alarm

setting features


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NPSG on Alarm Mgmt

In Phase I (beginning January 2014) Hospitals will be required to:

(by 7/14) establish alarms as an organization priority (during 2014) identify the most important alarms to

manage based on their own internal situations. Input from medical staff and clinical depts Risk to patients due to lack of response, malfunction Are specific alarms needed or contributing to

noise/fatigue Potential for patient harm based on internal incident

history Published best practices/guidelines


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NPSG on Alarm Mgmt In Phase II (as of January 2016) Hospitals will be expected to:

develop and implement specific components of policies and procedures that address at minimum: Clinically appropriate settings When they can be disabled When parameters can be changed Who can set and who can change parameters and who

can set to “off” Monitoring and response expectations Checking individual alarm signals for accurate settings,

proper operation and detectability educate those in the organization about alarm system

management for which they are responsible


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Questions to Consider Have you identified clinical alarm safety as

a priority? Who is on the team addressing the NPSG? How far along are you in identifying the

most important alarm signals to manage? What is your biggest challenge? Remember that the entire goal must be

fully implemented by January of 2016!


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What’s in a Name?

HTM: Healthcare Technology Management is the department name, which indicates that technology that impacts patient care is managed.

CE: Clinical Engineer. 4 year Engineering degree with emphasis in Clinical Engineering.

BME: BioMedical Engineer: 4 year degree, typically working in Research and Manufacturing for Healthcare

BMET: BioMedical Equipment Technologist. Typically has a 2 or 4 year degree (or military equivalent), working directly in a healthcare setting. CBET: Certified Biomedical Equipment Technician. A formal

certification by the International Certification Commission (ICC) for the BMET who achieve this certification

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EQUIPMENT MANAGEMENT

MEDICAL EQUIPMENT: EC.02.04.01, EC.02.04.03

UTILITY SYSTEMS: EC.02.05.01, EC.02.05.05

APPLIES ONLY TO HOSPITAL & CRITICAL ACCESS HOSPITAL

PROGRAMS


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S&C 14-07-HOSPITAL

S&C 12-07-Hospital Superceded A hospital may adjust its maintenance, inspection, and

testing frequency and activities for facility and medical equipment from what is recommended by the manufacturer, based on a risk-based assessment by qualified personnel, unless: Other Federal or state law; or hospital Conditions of

Participation (CoPs) require adherence to manufacturers’ recommendations and/or set specific requirements. • For example, all imaging/radiologic equipment must be

maintained per manufacturers’ recommendations; or The equipment is a medical laser device; or New equipment without a sufficient amount of

maintenance history has been acquired.


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S&C 14-07-HOSPITAL The organization inspects, tests & maintains New

medical equipment or operating components of utility systems in accordance with manufacturers’ recommendations with insufficient maintenance history to support the use of alternative maintenance strategies. Maintenance history may be gathered from

documented evidence such as Provided by the organization’s contractors Available publically from nationally recognized

sources Through the organization’s experience over time


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EC.02.04.01

Standard EC.02.04.01The hospital manages medical equipment risks

EC.02.04.01 EP 1The hospital solicits input from individuals who operate

and service equipment when it selects and acquires medical equipment.


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EC.02.04.01 EP 2EFFECTIVE JULY 2, 2014

For hospitals that do not use Joint Commission accreditation for deemed status purposes: The hospital maintains either a written inventory of all medical equipment or a written inventory of selected equipment categorized by physical risk associated with use (including all life-support equipment) and equipment incident history.

The hospital evaluates new types of equipment before initial use to determine whether they should be included in the inventory.


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MAINTAINING MEDICAL EQUIPMENT

Inventory is populated based on one of two strategies: All equipment inclusion Physical risk based process

For example, evaluating:• Function• Risk Levels• Maintenance Requirement

Utilize resources, i.e. the FDA MAUDE report All life support equipment is included All new types of equipment evaluated for inclusion


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EC.02.04.01 EP 2CONTINUED

For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital maintains a written inventory of all medical equipment.


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INVENTORY DEFINITIONS Medical equipment—Fixed and portable equipment used for the

diagnosis, treatment, monitoring, and direct care of individuals. Life-support equipment—Any device used for the purpose of

sustaining life and whose failure to perform its primary function, when used according to the manufacturer’s instructions and clinical protocol, will lead to patient death in the absence of immediate intervention (for example, ventilators, anesthesia machines, heart-lung bypass machines, defibrillators).

High-risk equipment—Any device or components of building utility systems for which there is a risk of serious injury or death to a patient or staff member if the device or component fails. High-risk equipment includes life support equipment.

Source: Glossary from the Comprehensive Accreditation Manual for Hospitals, The Joint Commission.See also September 2014 Perspectives


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EC.02.04.01 EP 3EFFECTIVE JULY 2, 2014

The hospital identifies high-risk medical equipment on the inventory for which there is a risk of serious injury or death to a patient or staff member should the equipment fail.

Note: High-risk medical equipment includes life-support equipment


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HIGH-RISK MEDICAL EQUIPMENT High-risk equipment

Includes Life Support Heart/lung bypass machine Anesthesia equipment Circulatory Assist Equipment

• IABP • LVAD

Ventilations• Adult; Infant; MRI-Compatible

Other High-risk equipment Defibrillators Robotic surgery devices


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JOINT COMMISSION MEDICAL EQUIPMENT

Medical equipment includes equipment used in for monitoring, such asBedside monitors Telemetry monitors


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JOINT COMMISSION MEDICAL EQUIPMENT

Treatment, such as Electro-surgery Lasers Diathermy

Diagnostic, such as Laboratory analyzers Radiology equipment Endoscopes

Patient support, such as Patient beds Specialty beds Lifts

Taken from the Environment of

Care Handbook

Chapter 5 (page 73) 3rd edition


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CMS INVENTORY

Medical Equipment includesBiomedical equipmentRadiological equipmentPatient beds, stretchersIV infusion equipmentVentilators Laboratory equipmentEtc.


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SCOPES

Number 6 on ECRI Top 10 for 2014, #8 in 2013 Score at IC. For infection control issues, and will

result in follow-up survey under COP §482.42 IC.02.02.02 EP 1 &2 hi/lo level disinfection IC.01.03.01 EP 1 – 5 risk assess & surveillance IC.01.05.01 EP 1 for policy issues

Score at EC.02.05.01 EP 6 for ventilation issues, will result in follow-up survey under COP §482.42


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EC.02.04.01 EP 4

The hospital identifies the activities and associated frequencies, in writing, for maintenance, inspecting, and testing all medical equipment on the inventory. These activities and associated frequencies are in accordance with manufacturers’ recommendations or with strategies of an alternative equipment maintenance (AEM) program.

Note: The strategies of an AEM program must not reduce the safety of equipment and must be based on accepted standards of practice.

An example of standards for a medical equipment program is ANSI/AAMI EQ56:2013, Recommended Practice for a Medical Equipment Management Program


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EC.02.04.01 EP 5

For hospitals that use Joint Commission for deemed status purposes: The hospital’s activities and frequencies for inspecting, testing, and maintaining the following items must be in accordance with manufacturers’ recommendations

Equipment subject to federal or state law or Medicare Conditions of Participation in which inspecting, testing, and maintaining be in accordance with manufacturers’ recommendations, or otherwise establishes more stringent maintenance requirements


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Medical laser devices Imaging and radiologic equipment (whether used for

diagnostic or therapeutic purposes) New medical equipment with insufficient maintenance

history to support the use of alternative maintenance strategies

Note: Maintenance history includes any of the following documented evidence:

Records provided by the hospital’s contractors Information made public by nationally recognized sources Records of the hospital’s experience over time


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EC.02.04.01 EP 6

For hospitals that use Joint Commission for deemed status purposes: A qualified individual(s) uses written criteria to support the determination whether it is safe to permit medical equipment to be maintained in an alternative manner that includes the following:

How the equipment is used, including the seriousness and prevalence of harm during normal use


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Likely consequences of failure or malfunction, including seriousness of and prevalence of harm

Availability of alternative or back-up equipment in the event the equipment fails or malfunctions

Incident history of identical or similar equipment Maintenance requirements of the equipment

(For more information on defining staff qualifications, refer to Standard HR.01.02.01)


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EC.02.04.01 EP 7

For hospitals that use Joint Commission for deemed status purposes: The hospital identifies medical equipment on its inventory that is included in an alternative equipment maintenance program.


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EC.02.04.03

Standard EC.02.04.03The hospital inspects, tests, and maintains medical

equipment


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MEDICAL EQUIPMENT TESTING

EC.02.04.03 The hospital inspects, tests, and maintains medical equipmentEP 1: For hospitals that do not use Joint

Commission accreditation for deemed status purposes: Before initial use of medical equipment on the inventory the organization performs safety, operational, and functional checks.


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EP 1 (continued): For hospitals that use Joint Commission accreditation for deemed status purposes: Before initial use and after major repairs or upgrades of medical equipment on the medical equipment inventory, the hospital performs safety, operational, and functional checks.


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EC.02.04.03 The hospital inspects, tests, and maintains medical equipmentEP 2. The hospital inspects, tests, and

maintains all life support high-risk equipment. These activities are documented.

Note: High-risk medical equipment includes life support equipment


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EP 3: The hospital inspects, tests, and maintains non-life support non-high-risk equipment identified on the medical equipment inventory. These activities are documented.

EP 4: The hospital conducts performance testing of and maintains all sterilizers. These activities are documented.


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EP 5: The hospital performs equipment maintenance and chemical and biological testing of water used in hemodialysis. These activities are documented.

EP 14: For hospitals that use Joint Commission accreditation for deemed status purposes: Qualified hospital staff inspect, test, and calibrate nuclear medicine equipment annually. The dates of these activities are documented.


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EP 17: For hospitals in California that provide computed tomography (CT) services: A qualified medical physicist measures actual radiation dose produced by each CT imaging system at least annually.

Verifies dose displayed for adult brain, adult abdomen, and pediatric brain protocols is within 20 percent of actual dose delivered.

Dates of the verifications are documented


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EQUIPMENT SURVEY PROCESS

Documentation is completed for High-risk, life support and non-high-risk devices on the inventory Accuracy of Inventory

All High-risk and Life Support equipment must be on the inventory and identified

Preventive maintenance frequencies must be clearly defined in writing

Confirm work done as per scheduled activities Ensure appropriate work is scheduled based on

maintenance strategies Evaluate equipment failure and scheduled actions


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SURVEY PROCESS: STAFF INTERVIEWS

Department LeaderEvaluate the qualifications of the leader

Review appropriate documentationEvaluate how the inventory was created If an alternative maintenance program is in use,

evaluate the inclusion process Evaluate the Monitoring processesEvaluate the effectiveness of the program

What criteria is used to evaluate Evaluate the Completion rate of maintenance

activities


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SURVEY PROCESS: STAFF INTERVIEWS

Equipment MaintainersEvaluate their understanding of the

maintenance process/strategiesEvaluate staff knowledge related to the

alternative maintenance programEvaluate assignment of maintenance activities Evaluate competencies based on repeat work

ordersEvaluate work scheduled against completed


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SURVEY PROCESS: STAFF INTERVIEW

Users of the Equipment Evaluate equipment reliability Evaluate response time when equipment fails

Evaluate emergency response process Evaluate “Culture of Safety”

Appropriate training of staff related to equipment use Customer satisfaction with department

Contract Services Evaluate the process used to ensure contractors use

qualified personnel Evaluate reliability of equipment serviced Evaluate integration of the process


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EVALUATING PROGRAM EFFECTIVENESS

The equipment management programs must have written policies & procedures

Evaluating the program: How is equipment evaluated to ensure no degradation

of performance? Consider miscalibration of equipment Consider test equipment calibration confirmation

How are equipment-related incidents investigated? Could the malfunction have been avoided? Did the alternative maintenance strategy contribute

to the malfunction? How to sequester equipment deemed unsafe?


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EVALUATING PROGRAM EFFECTIVENESS

Is there a performance process to evaluate if modifications to the maintenance strategy are needed?

Evaluate the accuracy of the inventory High-risk equipment segregated in the inventory? Equipment in an alternative maintenance program

segregated? Grouping of like equipment is acceptable Are imaging/radiologic equipment and medical

laser devices exempt from the alternative maintenance program?


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EVALUATING PROGRAM EFFECTIVENESS: MISCELLANEOUS TOPICS

Survey should focus on High-risk equipmentAre appropriate operation manuals and

maintenance schedules available? Verify the inspection, testing & maintaining

activities and frequencies are documented Evaluate the various maintenance strategies used

Are they appropriate?Are they effective? Is the equipment reliable?


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EQUIPMENT NOT FOUND OR IN USE If a device is not available because it is not found or in use

Manage the situation Create policy describing how the device will be

looked for • How will the users be involved• How it impact the users

If the device was looked for “on time” then the PM Completion rate will not be impacted• The device must be reconciled• Surveyors will be reviewing those “equipment not

found” or “in use” for reconciliation− Example: during the next month if 500 scheduled, 10 not

found the total activities should be 510


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EQUIPMENT NOT FOUND OR IN USE

If the device was looked for “on time” then the PM Completion rate will not be impactedThe device must be reconciled

Surveyors will be reviewing those “equipment not found” or “in use” for reconciliation• Example:

− Each month 500 activities are scheduled− One month 10 devices are “not available” − Next month the 500 scheduled devices will be

done plus the missed 10 devices


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DIAGNOSTIC IMAGING

Three phases of implementation for hospitals, critical access hospitals, and ambulatory care organizations Includes ambulatory care organizations that have achieved

Advanced Diagnostic Imaging certification Phase 1 Deferred to January 1, 2015

Exceptions: not applicable to dental cone beam CT radiographic imaging studies performed for diagnosis of conditions affecting the maxillofacial region or to obtain guidance for the treatment of such conditions.

Phase 1.5: minimum qualifications for radiologists performing CT scans

Phase 2: fluoroscopy qualifications for non-radiologists performing imaging exams and cone beam CT, and for dental or oral surgical procedures


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DIAGNOSTIC IMAGING

Phase 1: Deferred to January 1, 2015 Computed tomography (CT), nuclear medicine (NM),

positron emission tomography (PET), and magnetic resonance imaging (MRI)

Minimum competency for radiology technologists, including registration and certification by July 1, 2015

Annual performance evaluations of imaging equipment by a medical physicist

Documentation of CT radiation dose in the patient’s clinical record

Meeting the needs of the pediatric population through imaging protocols and by considering patient size or body habitus when establishing imaging protocols


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DIAGNOSTIC IMAGING

Phase 1: Deferred to January 1, 2015 Management of safety risks in the MRI environment Collection of data on incidents during which identified

radiation dose limits have been exceeded Minimum quarterly review of staff dosimetry results

New, replacement or modification to rooms Medical physicist to perform structural shielding

design New equipment or rooms where ionizing radiation is

emitted or radioactive material is stored Medical physicist to perform radiation protection

survey


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DIAGNOSTIC IMAGING STANDARDS COMMENTS OPEN TO OCTOBER 24, 2014

We are interested in your comments on standards changes that address the following areas: Minimum qualifications for radiologic and nuclear

medicine technologists that perform computed tomography (CT) exams.

Orientation of technologists on safe practices related to the provision of diagnostic imaging

Documentation of CT radiation dose http://www.jointcommission.org/standards_information/field_reviews.aspx?StandardsFieldReviewId=C9K2vcyLB3mFHMTk7hiBm7aLRzbz3AxdZHBivEICNzc%3d for more information

http://www.jointcommission.org/standards_information/field_reviews.aspx?StandardsFieldReviewId=C9K2vcyLB3mFHMTk7hiBm7aLRzbz3AxdZHBivEICNzc=







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RELOCATABLE POWER TAPS (RPTS)

Healthcare Interpretation Task Force (12/2007) stated NFPA 70, NFPA 99 and NFPA 101 all have regulations that control the electrical components and equipment in a patient room. It appears that it is the intent of these documents to restrict RPT use so that it is not used in conjunction with medical equipment

CMS 3/2014: “RPT’s are not to be used with medical equipment in

patient care areas. This includes critical areas such as operating rooms,

recovery areas, intensive care areas, and non-critical patient care areas such as patient rooms, diagnostic areas, exam areas, etc.”


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RELOCATABLE POWER TAPS

RPTs may be used in anesthetizing locations if they are part of the equipment assembly. See NFPA 99-1999 7-5.1.2.5(2)

Ceiling drops are acceptable. See NFPA 99-1999 7-5.1.2.5(3) RPTs may be used for non-patient care equipment such as

computers/monitors/printers, and in areas such as waiting rooms, offices, nurse stations, support areas, corridors, etc.

Precautions needed if RPT’s are used include: ensuring they are never “daisy-chained” preventing cords from becoming tripping hazards installing internal ground fault and over-current protection

devices using power strips that are adequate for the number and types

of devices used


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S&C: 14-46-LSC 9/26/2014

CMS is permitting a categorical waiver to allow for the use of power strips in existing and new health care facility patient care areas, if you are in compliance with all applicable 2012 LSC power strip requirements and with all other 2000 LSC electrical system and equipment provisions.

The organization must follow all requirements of the categorical waiver processThis includes identifying where they are located at

the unit level


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CATEGORICAL WAIVER PROCESS

If the organization decides to use this categorical waiver they must1. Ensure full compliance with the appropriate code reference2. Document the decision to adopt the categorical waiver

The Relocatable Power Tap is not a LSC issue but an Environment of Care issue• For Environment of Care items document by Minutes

in discussion at the Environment of Care Committee (or equivalent)

3. Declare the decision at the beginning of any survey See also November 2013 Perspectives


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DEFINITIONS FROM NFPA 99-2012

Patient bed location is defined in section 3.3.136 as the location of a patient sleeping bed, or the bed or procedure table of a critical care area.

Patient-care-related electrical equipment is defined in section 3.3.137 as electrical equipment that is intended to be used for diagnostic, therapeutic, or monitoring purposes in the patient care vicinity;

Patient care room is defined in section 3.3.138 as any room of a health care facility wherein patients are intended to be examined or treated. Note that this term replaces the term “patient care area” used in the 1999 NFPA 99, but the definition has not changed.

Patient care vicinity is defined in section 3.3.139 as a space, within a location intended for the examination and treatment of patients (i.e., patient care room) extending 6 ft. beyond the normal location of the bed, chair, table, treadmill, or other device that supports the patient during examination and treatment and extends vertically 7 ft. 6 in. above the floor.


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REQUIREMENTS

Power strips may be used in a patient care vicinity to power rack-, table-, pedestal-or cart-mounted patient care-related electrical equipment assemblies, provided all of the following conditions are met, as required by section 10.2.3.6: The receptacles are permanently attached to the equipment assembly. The sum of the ampacity of all appliances connected to the receptacles

shall not exceed 75 percent of the ampacity of the flexible cord supplying the receptacles.

The ampacity of the flexible cord is suitable in accordance with the current edition of NFPA 70, National Electric Code.

The electrical and mechanical integrity of the assembly is regularly verified and documented through an ongoing maintenance program.

Means are employed to ensure that additional devices or nonmedical equipment cannot be connected to the multiple outlet extension cord after leakage currents have been verified as safe.


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REQUIREMENTS

Patient bed locations in new health care facilities, or in existing facilities that undergo renovation or a change in occupancy, shall be provided with the minimum number of receptacles as required by section 6.3.2.2.6.2.

Power strips providing power to rack-, table-, pedestal-, or cart-mounted patient care-related electrical equipment assemblies are not required to be an integral component of manufacturer tested equipment. Power strips may be permanently attached to mounted equipment assemblies by personnel who are qualified to ensure compliance with section 10.2.3.6.


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REQUIREMENTS

Power strips may not be used in a patient care vicinity to power non-patient care-related electrical equipment (e.g., personal electronics).

Power strips may be used outside of the patient care vicinity for both patient care-related electrical equipment & non-patient-care-related electrical equipment.

Power strips providing power to patient care-related electrical equipment must be Special-Purpose Relocatable Power Taps (SPRPT) listed as UL 1363A or UL 60601-1.

Power strips providing power to non- patient-care-related electrical equipment must be Relocatable Power Taps (RPT) listed as UL 1363.


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DEPARTMENT OF ENGINEERING630 792 5900

George Mills, MBA, FASHE, CEM, CHFM, CHSP, Green Belt

Director

Anne Guglielmo, CFPS, LEED, A.P., CHSP, CHFM

Engineer

John Maurer, SASHE, CHFM, CHSP

Engineer

Kathy Tolomeo, CHEM Engineer

James Woodson, P.E., CHFM

Engineer


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These slides are current as of 10/1/2014. The Joint Commission reserves the right to change the content of the information, as appropriate.

These slides are only meant to be cue points, which were expounded upon verbally by the original presenter and are not meant to be comprehensive statements of standards interpretation or represent all the content of the presentation. Thus, care should be exercised in interpreting Joint Commission requirements based solely on the content of these slides.

These slides are copyrighted and may not be further used, shared or distributed without permission of the original presenter or The Joint Commission.

THE JOINT COMMISSION DISCLAIMER

© Copyright, The Joint Commission 2014 T HE H EALTHCARE E NVIRONMENT John Maurer, SASHE, CHFM, CHSP...

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