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