The Compliance Puzzle: Putting the Pieces Together

1
The Compliance PuzzlePutting the Pieces
Together
H2E

• A Guide to comply with JCAHO, EPA, OSHA, DOT,
  H2E and beyond.

JCAHO
EPA
Janet Brown, H2E Partner Program Mgr. Ph
413/253-0254 E-mail janet.brown_at_h2e-online.org ww
w.h2e-online.org
DOT/ OSHA
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Todays Objectives

• The Status of Environmental Compliance in
  Healthcare
• JCAHO Survey vs. EPA Inspections
• H2E JCAHO Environmental Compliance and
  Improvement Guide

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JCAHO Update

• Rewriting all EOC Standards for 2009
• Field Review
• Life Safety Chapter welcoming feedback right now.
• Emergency Management Standard will be pulled into
  its own chapter in 2008.
• So there will be 1. eoc, 2. emergency mgmt and 3.
  life safety

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JCAHO Definition/Background

• The Joint Commission for the Accreditation of
  Healthcare Organizations
• Sets standards for care and quality improvement
• Minimum standards are set by Center Medicare and
  Medicaid Services (CMS)
• JCAHO accredited organizations meet and exceed
  CMS standards
• Other accreditation organizations
• E.g. Institute for Healthcare Improvement
• Also, state licensure
• Methodology
• Healthcare processes divided into areas, e.g.
  Environment of Care, Leadership, Treatment, Human
  Resources, Patient Rights
• Each area has a set of standards
• The standard is the goal
• Rationale explains why important to reach the
  goal.
• Elements of Performance are the steps necessary
  to reach the goal.

JCAHO
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Joint Commission

• http//www.jointcommission.org/

Top Stories Tell Us What You Think About The
Proposed Standard Revisions to The Joint
Commissions Standards - Patient Rights
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Joint Commission

• NEW!  Safe by DesignDesigning Safety in Health
  Care Facilities, Process, and Culture by John
  Reiling.   Learn the latest design trends and how
  they can enhance patient safety in health care
  environments.  Read about health care
  organizations that have succeeded in designing
  and constructing safe environments.  Discover the
  value of involving nurses, physicians, patients,
  and others in health care facility design. 

http//www.jcrinc.com/26632/
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Standards Improvement Initiative
http//www.jointcommission.org/Standards/SII/

• The Joint Commission has launched a Standards
  Improvement Initiative (SII) to
• Clarify standards language
• Ensure that standards are program-specific
• Delete redundant or non-essential standards
• Consolidate similar standards
• As additional benefits to users, the manuals will
  be reorganized and the scoring and decision
  process will be refined.
• Improvementsboth format and language editsare
  targeted to go into effect January 2009 for the
  ambulatory, critical access hospital, home care,
  hospital, and office-based surgery programs.
  Beginning in 2008, The Joint Commission will seek
  feedback on standards for the behavioral health
  care, laboratory and long term care accreditation
  programs. 
• Questions can be sent to standardsimprovement_at_join
  tcommission.org.

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JCAHOs Environment of Care

• Goal
• To provide a safe, functional, supportive and
  effective environment for patients, staff and
  others in the facility. This is crucial to
  providing quality patient care, achieving good
  outcomes and improving patient safety.
• Effective management of EC includes activities
  and processes for
• Reduce control environmental hazards and risks
• Prevent accidents and injuries
• Maintain safe conditions for patients, staff
  visitors
• Maintain an environment that minimizes
  unnecessary environmental stresses for patients,
  staff and visitors.
• Crosswalk of 2003 Management of the Environment
  of Care Standards to 2004 Management of
  Environment of Care Standards for Hospitals,
  JCAHO, 2005.

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JCR - www.jcrinc.com/26632/

• The environment in which care is provided can
  make a differenceNumerous studies demonstrate
  that factors in the physical and social
  environment can impact patients for better or
  worse.  Let JCR help you take a fresh look at
  your existing facility, or provide best practices
  in maintenance and design for a building
  prototype.  Our Environment of Care products and
  services provide organizations with the tools to
  build a safer environment for patients, staff,
  and visitors.

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JCAHO Performance Improvement

• Is a continuous process
• Involves measuring importance processes and
  services and identifying changes that enhance
  performance
• These changes are incorporated into new or
  existing processes
• Performance is monitored to ensure the
  improvements are sustained.
• Crosswalk of 2003 Improving Organization
  Performance Standards for Hospitals to 2004
  Improving Organization Performance Standards for
  Hospitals, JCAHO, 2005.

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Hospitals for a Healthy Environment

• Born out of a partnership between the US EPA,
  American Hospital Assn, American Nurses Assn
  and Healthcare without Harm, 1998.
• Provides assistance to healthcare industry
• Memorandum of Understanding setting goals for
  environmental improvement in healthcare
• Elimination of mercury
• Total waste reduction
• Minimize persistent, bioaccumulative pollutants
  such as dioxins, heavy metals and others.
• Awards program for facilities meeting and
  exceeding goals.

H2E
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JCAHO Leadership

• Leaders provide framework for planning, directing
  , coordinating, providing and improving care,
  treatment and services to respond to community
  and patient needs and improve healthcare
  outcomes.
• Effective leadership depends on
• Governance
• Management-enables the hospital to fulfill its
  mission and meet/exceed its goals
• Planning
• Improving safety and quality of care
• Use of clinical practice guidelines
• Teaching and coaching staff.
• Crosswalk of 2003 Leadership Standards for
  Hospitals to 2004 Leadership Standards for
  Hospitals, JCAHO, 2005.

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Hazardous Materials
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Regulated Medical Waste

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JCAHO Hazardous Materials and Waste

• Materials whose handling, use and storage are
  guided or regulated by local, state or federal
  regulation
• Examples
• EPA
• Chemicals waste
• DOT
• Hazardous materials, including infectious agents
• transportation requirements
• OSHA
• Hazardous substances
• Blood borne pathogens
• Ionizing radiation, hazardous energy sources
• Nuclear Regulatory Commission
• Radioactives
• NIOSH
• Hazardous drugs
• State defined infectious waste
• Crosswalk of 2003 Management of the Environment
  of Care Standards to 2004 Management of
  Environment of Care Standards for Hospitals,
  JCAHO, 2005.

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10 Steps to Reducing RMW
http//www.h2e-online.org/pubs/tensteps/Rmw10steps
.pdf
Sample Tools 10 Step Guides
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Regulatory Compliance in Healthcare

• Healthcare has flown under the regulatory radar
  for years
• Mid 1990s EPA had focus on Colleges and
  Universities -- overlapped with university
  hospitals
• What they found
• 1 out of 2 hospitals has a penalty violation
• Compared to 1 out of 30 in general industry

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OUR TOXIC HOSPITALS

• January 18, 2004 -- New York City hospitals are
  flouting environmental laws - spewing toxic fumes
  into the air and mishandling medical waste, The
  Post has learned.
• recent violations by 10 private and public city
  hospitals, which led to fines as high as 500,000
  for polluting.
• "With all we know about air pollution and its
  health effects, it's troubling that health-care
  institutions would be contributing to the
  problem," said a spokesman for the American Lung
  Association of New York State.
• The problem is so bad that the federal EPA began
  stepping up hospital inspections in 2002 because
  of "systemic problems" in meeting environmental
  codes.
• "We are focusing on them as an industry that
  needs extra attention," said EPA spokeswoman

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EPA Enforcement - Top Ten Violations

• Hazardous materials and waste not identified (EC
  3.10.2, 3, 5)
• Illegal disposal of waste (LD 1.30, EC
  3.10.3)
• Waste not properly labeled (EC 3.10.3, 9)
• Staff not trained (EC 3.10.3, HR 2.20, HR
  3.10)
• Appropriate authorities not notified (EC
  3.10.2, 3, 7).

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EPA Top Ten Violations (cont.)

• Manifest records lacking (EC 3.10.8)
• Hazardous waste containers not kept closed
• (EC 1.20.4, EC 3.10.3, HR 2.20, HR 3.10)
• Containers not inspected
• (EC.2.10.6, EC 3.10.3)
• Waste not stored to prevent leaks, spills or
  breakage (EC 3.10.3, 4, 6).
• Wastewater authorities not notified regarding
  sewer disposal of waste/permits not obtained (EC
  3.10.3, 7)

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Environmental Compliance Violations found in
Region 2 Primarily NY and NJ
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What does that have to do with Joint Commission?
Inspected hospitals expressed confusion that
despite just passing JCAHO, they still had
significant compliance violations under EPA

• Shouldnt JCAHO have told us or cited us?
• It must not be that important since JCAHO didnt
  survey on environmental compliance.
• Confusing maze of who regulates what.

?
?
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Compliance

• Is not optional
• Compliance is a term used for both JCAHO and
  other regulatory requirements -- JCAHO is
  typically reliant on other regulatory statutes
  for its elements of performance.
• BUT JCAHO Surveyors are not expected to be
  defacto inspectors for other regulatory agencies,
  like EPA

• OSHA Bloodborne Pathogens, HazCom
• RCRA

• EPCRA
• CAA
• CWA

• SPCC
• DOT
• HIPAA

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Comprehensive Approach to ALL Compliance Issues

• While preparing for Joint Commission incorporate
  environmental requirements.
• Use JCAHOs emphasis on Environment of Care (EOC)
  and environmental requirements to leverage
  resource support for environmental compliance and
  pollution prevention programs.
• Use environmental programs as performance
  improvement initiatives for the Joint Commission.

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How does the JCAHO Guide Work?
JCAHO standards address an organizations
performance in key functional areas. Each
standard is presented as a series of "Elements of
Performance" (EP) -- expectations that establish
the broad framework that JCAHO surveyors use to
evaluate a facility's performance. Many of the
environmentally relevant Elements of Performance
fall under the Environment of Care (EC) standard,
but others are included in the Human Resources
(HR) and Leadership (LD) standards. The Guide
relates each JCAHO Element of Performance to
specific federal regulations, to help facilities
be in compliance with both.
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Symbols in JCAHO Guide
Compliance
Environmental Improvement
Tools and Resources
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ENVIRONMENTAL COMPLIANCE AND IMPROVEMENT GUIDE
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(No Transcript)
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Choose a Standard.
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"Clip Board" Versions
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Standards and Elements of PerformanceFull
Versions 3.10.3
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Compliance Language
Pollution Prevention Language
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Understand the Links
Click on blue link EPA Reference
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Takes you straight to CFR citation for that
requirement!
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Understand the Links
Click on teal link HERC Reference
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Refers directly to other areas of the H2E website
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Understand the Links
Click the green link JCAHO Reference (Topic
Locator)
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TOPIC LOCATOR
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Leadership Standard Compliance Counts
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JCAHO Performance Improvement

• Write up Environmental Programs as Performance
  Improvement Initiatives
• H2E has sample write-ups for Performance
  Improvement Initiatives on
• Regulated Medical Waste Reduction
• Mercury Elimination
• Glutaraldehyde Elimination
• Please let us know your experiences

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Evidence of Comprehensive Programs

• Three lists
• 1. Facility infrastructure that fundamentally
  addresses environmental compliance and
  improvement programs
• 2. Current top compliance violation issues in
  healthcare
• 3. Overall comprehensive environmental program
  management - priority issues.

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Infrastructure

• Institutional
• Environment of Care Standard 3.10 The
  organization manages hazardous materials and
  waste risks
• e.g., comprehensive environmental management
  policy
• Leadership
• LD 1.20 - Staff resources - Is there enough
  staff and resources to appropriately manage and
  respond
• e.g., written commitment and policy from all
  levels within organization includes roles of
  Safety Committee and staff
• HR Competencies 2.10, 2.20 - Staff appropriately
  respond

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Violations - Hazardous materials and waste not
identified

• EC 3.10 The organization manages hazardous
  materials and waste risks (EP 3. Implementation)
• EC 3.10 EP 8 - Hazardous Waste Manifests -
  Manifest records lacking
• A RCRA hazardous waste determination has
  been made, and documented, for all solid waste
  that is generated.
• Manifest and other records are comprehensive and
  up-to-date.
• Staff shows core competency in proper management
  and minimization based on proper determination
• How to do it! --- JCAHO Guide and the HERC
  Hazardous Waste Determination Page

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Hazardous materials and waste not identified (EC
3.10 EP 3)
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Comprehensive Programs

• Mercury Management, for example
• Surveyors might look for evidence of
• a Plan,
• an Inventory, 
• Implementation program and results including
  staff competency,  
• Emergency and Safety plan - spill policy and
  competency,
• Leadership - mercury elimination commitment
  statement
• MMMF Award
• How to do it! --- www.h2e-online.org

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The Fit!
DOT/ OSHA
EPA

• EPA
• Environmental regulations
• Waste, water, air, land
• DOT
• Hazardous materials in transportation
• OSHA
• Environment affects workers
• Hazardous materials/substances
• JCAHO
• Environment affects patients, visitors and
  healthcare staff
• H2E
• Goals for improving environmental performance in
  healthcare

H2E
JCAHO
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Feedback on the Guide!

• Continuous Quality Improvement - its a work in
  progress
• Is it useful?
• Is it confusing?
• Suggestions for additional tools and resources?

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Summary

• JCAHO standards cover all environmental
  regulations
• H2E JCAHO guidance tool to assist with compliance
  and improvement
• Tool is free and online. Use is easy especially
  with practice.
• For comments or suggestions on the tool or
  training, contact Laura Brannen of H2E.

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H2E JCAHO Guidance

• Introduction
• Table of Contents
• JCAHO standards
• http//www.h2e-
• online.org/regsandstandards/jcahointro.html

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Where to Get More Information

• Laura Brannen, H2E Executive Director
• Laura.Brannen_at_H2E-online.org
• 603/795-9966
• Catherine Zimmer, MnTAP
• zimme053_at_umn.edu
• 612/624-4635
• www.mntap.umn.edu
• Hospitals for a Healthy Environment
• www.h2eonline.org

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Toll Free Hotline [phone]E-mail
h2e_at_h2e-online.orgwww.h2e-online.org
H2E Program Contacts

• Cecilia DeLoach, State Partnership Programs
  CoordinatorCecilia.DeLoach_at_H2E-online.org
• 800-727-4179

• Laura Brannen, DirectorLaura.Brannen_at_H2E-online.o
  rg
• 603-795-9966
• Janet Brown, Partner Program Mgr.Janet.Brown_at_H2E-
  online.org
• 413/253-0254