The Compliance Puzzle: Putting the Pieces Together - PowerPoint PPT Presentation

Loading...

PPT – The Compliance Puzzle: Putting the Pieces Together PowerPoint presentation | free to download - id: 7665c-ZDA3M



Loading


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation
Title:

The Compliance Puzzle: Putting the Pieces Together

Description:

H2E JCAHO Environmental Compliance and Improvement Guide. JCAHO Update ... Click on teal link: HERC Reference. Refers directly to other areas of the H2E website ... – PowerPoint PPT presentation

Number of Views:174
Avg rating:3.0/5.0
Slides: 52
Provided by: LauraB88
Learn more at: http://www.sbeap.org
Category:

less

Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: 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
2
Todays Objectives
  • The Status of Environmental Compliance in
    Healthcare
  • JCAHO Survey vs. EPA Inspections
  • H2E JCAHO Environmental Compliance and
    Improvement Guide

3
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

4
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
5
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
6
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/
7
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.

8
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.

9
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.

10
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.

11
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
12
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.

13
Hazardous Materials
14
Regulated Medical Waste

15
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.

16
10 Steps to Reducing RMW
http//www.h2e-online.org/pubs/tensteps/Rmw10steps
.pdf
Sample Tools 10 Step Guides
17
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

18
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

19
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).

20
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)

21
Environmental Compliance Violations found in
Region 2 Primarily NY and NJ
22
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.

?
?
23
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

24
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.

25
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.
26
Symbols in JCAHO Guide
Compliance
Environmental Improvement
Tools and Resources
27
ENVIRONMENTAL COMPLIANCE AND IMPROVEMENT GUIDE
28
(No Transcript)
29
Choose a Standard.
30
"Clip Board" Versions
31
Standards and Elements of PerformanceFull
Versions 3.10.3
32
Compliance Language
Pollution Prevention Language
33
Understand the Links
Click on blue link EPA Reference
34
Takes you straight to CFR citation for that
requirement!
35
Understand the Links
Click on teal link HERC Reference
36
Refers directly to other areas of the H2E website
37
Understand the Links
Click the green link JCAHO Reference (Topic
Locator)
38
TOPIC LOCATOR
39
Leadership Standard Compliance Counts
40
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

41
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.

42
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

43
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

44
Hazardous materials and waste not identified (EC
3.10 EP 3)
45
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

46
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
47
Feedback on the Guide!
  • Continuous Quality Improvement - its a work in
    progress
  • Is it useful?
  • Is it confusing?
  • Suggestions for additional tools and resources?

48
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.

49
H2E JCAHO Guidance
  • Introduction
  • Table of Contents
  • JCAHO standards
  • http//www.h2e-
  • online.org/regsandstandards/jcahointro.html

50
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

51
Toll Free Hotline 800-727-4179E-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
About PowerShow.com