H2E AND JCAHO COMPLIANCE

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H2E ANDJCAHO COMPLIANCE

• Susan B. McLaughlin
• Barrington, Illinois

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JCAHO AND THEGOVERNMENT
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Health Care Finance Administration

• Deemed status
• Medicare reimbursement
• Go-behind surveys
• OIG report, 1999

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Occupational Safety Health Administration
(OSHA)

• Worker safety
• Applicable law and regulation

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JCAHO/OSHA PARTNERSHIP

• Established 1996
• Educational
• Surveyors and Inspectors
• Health care organizations
• Reduce duplicative compliance activities

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RELATIONSHIP
ENVIRONMENT OF CARE
ENVIRONMENT OF WORK
OSHA
JCAHO
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STATUS

• Renewed for 3 years in 2000
• Hammer Award
• Remains educational
• Additional examples of compliance

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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

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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

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EPA ISSUES

• Storage gt 180 days
• Toxic waste storage facility

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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

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DOT ISSUES

• Department of Transportation
• Hazardous materials
• Regulated medical waste
• Shipping papers
• Training
• Home care

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JCAHO / DOT

• No formal relationship
• Applicable law and regulation

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REMEMBER

• Always comply with the strictest authority having
  jurisdiction (AHJ)
• JCAHO frequently asked question (FAQ) related to
  hazmat, www.jcaho.org

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ENVIRONMENT OF CAREREQUIREMENTS
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ENVIRONMENT OF CARE

• Seven management plans
• Safety
• Security
• Hazardous Materials Waste
• Emergency Management
• Fire Prevention
• Medical Equipment
• Utilities

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EC REQUIREMENTS

• Written plans
• Implementation of plans
• Risk assessment
• Staff knowledge and skill
• Maintenance, testing, inspection activities
• Monitoring and evaluation
• Annual evaluation

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RISK ASSESSMENT

• All management plans
• Specific to organization
• Non-prescriptive standards

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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

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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

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SURVEY PROCESS

• Size of organization determines
• Length of survey
• Number of surveyors
• Administrator - Nurse - Physician
• Nurse - Physician
• Surveyor cross-training

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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

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BUILDING TOUR

• Participants
• Administrator or Nurse Surveyor
• Safety Officer
• Engineering Director
• Etc.

• Function
• Validation of SOC
• Assessment of Implementation
• Staff Interviews

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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

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EC.1.1 SAFETY MANAGEMENT

• Policies distributed,
  practiced, enforced
• Policies reviewed at least every 3 years

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EC.1.1.1 WORKER SAFETY

• Occupational illness
• Personnel injury
• Safety orientation and training

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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

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EC.1.3 CRADLE TO GRAVE

• A) 1. Selection
• -What is to be purchased
• -Supplier
• -Screening Process
• 2. Handling
• Receipt
• Documentation

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EC.1.3 CRADLE TO GRAVE

• 3. Storage
• -Chemical type
• -Medical gas
• 4. Transportation
• -Chemicals
• -Cylinders
• -Intra- and inter-facility

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EC.1.3 CRADLE TO GRAVE

• 5. Use
• -Training
• 6. Disposal
• -Chemicals
• -Potentially infectious medical waste
• -Empty gas cylinders
• -Waste anesthetic gas

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B) APPLICABLE LAW REGULATION

• 1. OSHA
• 2. EPA
• 3. DOT
• Includes but not limited to. . .

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B) 1. OSHA ISSUES

• Bloodborne Pathogens
• Hazard Communication
• Hazardous Drugs
• Formaldehyde

• Ethylene Oxide
• Tuberculosis
• Respiratory Protection
• Personal Protective Equipment (PPE)
• Etc.

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B) 2. 3. EPA, DOT, other

• EPA
• Clean Air Act
• Clean Water Act
• Federal Insecticide, Fungicide, Rodenticide Act
• Incinerators
• Generators (proposed)
• Boilers (proposed)
• Etc.

• DOT
• Medical Waste
• Hazardous Materials

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B) 2. MANAGING WASTE

• Chemical
• Chemotherapeutic
• Radioactive
• Regulated medical
• Sharps

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B) 2. MANAGING WASTE

• Intra-facility tracking
• Disposal methods
• Training
• Documentation

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C) SPACE EQUIPMENT

• Adequate
• Appropriate
• Segregation

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REPORTING and INVESTIGATING

• Problems, failures, user errors
• Information collection and evaluation system
  (ICES)
• Input into Safety Committee

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E) GASES VAPORS

• 1. Formaldehyde
• 2. Ethylene Oxide
• 3. Waste Anesthetic Gas
• 4. Glutaraldehyde
• 5. Xylene

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ORIENTATION EDUCATION

• Personnel who use or have contact with hazmat
• Procedures Precautions
• Emergency Procedures
• Spills and exposures
• Health Hazards
• Reporting Procedures
• Spills or exposures

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EMERGENCY PROCEDURES

• Spills
• Chemical
• Mercury
• Potentially infectious
• Chemotherapy
• Major clean-up operations
• OSHA Hazardous Waste Operations (HAZWOPR)
• Fire department

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EMERGENCY PROCEDURES

• Radiation Exposure
• Personal Protective Equipment

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D) PERFORMANCE MONITORING

• Examples
• Waste volume
• Solid waste
• Hazardous waste
• Waste disposal costs
• Staff knowledge and skill
• Monitoring of gases vapors
• Etc.

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DOCUMENTATION

• EC.2.3 Implementation
• Permits
• Licenses
• Manifests

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EC.1.4 EMERGENCY MANAGEMENT

• Facilities for chemical and radioactive
  decontamination

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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?

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H2E IMPACT ONJCAHO COMPLIANCE
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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)

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CHEMICAL WASTE MINIMIZATION

• Demonstrated performance improvement
• Reduced need for
• Storage
• Training
• PPE
• MSDS

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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

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MERCURY VIRTUAL ELIMINATION

• Demonstrated performance improvement
• Eliminate need for spill clean-up procedure
• Eliminate specialized disposal
• Reduce regulatory compliance
• Worker / patient safety improved

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THE BOTTOM LINE

• If you have less to manage. . .
• Less waste
• Fewer chemicals
• No mercury
• . . .you will streamline your process

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AND JCAHO WILL HAVE LESS TO QUESTION AND LOOK AT
ON SURVEY!