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Part 7: Meeting the Standards Challenges

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Title: Part 7: Meeting the Standards Challenges


1
Part 7 Meeting the Standards Challenges
Strategies for the Standards Challenges
Healthcare Engineering Consultants
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Safety Management
Issue Proactive Risk Assessments for Safety
Tip for Compliance Think of risk
assessments as simply prioritizing potential
problems
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Documenting Risk Assessments
Risk Assessment Prioritization and
management of resources though an assessment of
probability and impact
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Why Perform Risk Assessments?
Not enough time! Not enough staff! Not enough
money!
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Calculating Risk Assessments
Risk Probability X Impact
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Global Risk Assessments
Whats a Global Risk Assessment and What is its
Purpose?
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Performing a Global Risk Assessment
Step 1 Identify a Global Area to Assess Step
2 Select a Team of Stakeholders Step 3
Brainstorm and List the Risk Elements Step 4
Assign Probability and Impact to the Risk
Elements Step 5 Prioritize the Risk
Elements Step 6 Perform the Specific Risk
Assessments
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Documenting Risk Assessments
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Example Global Safety Risk Assessment
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Example Global Security Risk Assessment
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Specific Risk Assessments
Whats a Specific Risk Assessment and What is
its Purpose?
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Performing a Specific Risk Assessment
Step 1 Identify Issues and Select a Team Step 2
Analyze Factors Step 3 Make a Decision Step 4
Document the Evaluation and Decision Step 5
Make the Necessary Changes Step 6 Monitor and
Reassess
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Specific Risk Assessment Examples
  • Lock clean supply room doors?
  • Infant/ pediatric abduction measures
  • Safe environment for mental health
  • Medical equipment test tags
  • Utility system PM intervals
  • Security sensitive areas
  • Other?

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Understanding RCAs and FMEAs
Whats the Difference Between an FMEA and an
RCA? Are They Both Risk
Assessments?
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Safety Management
Issue What about
recurring operational deficiencies?
Tip for Compliance You cant improve what you
cant measure!
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How Do We Solve This Problem?
Steps required to reduce operational
deficiencies 1. Determine how to measure the
problem severity 2. Establish a numerical
baseline score 3. Explain measurement
system to area staff 4. Let staff determine an
improvement goal 5. Re-measure scores at
unscheduled times 6. Provide numerical feedback
to staff 7. Celebrate achievement of goal 8.
Continue measurement until the culture changes
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Solving the Hallway Clutter Problem
Step 1 Determine how to measure the problem
severity Solution and Procedure Assign points
to various types of egress corridor deficiencies,
based on severity of violation
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Solving the Hallway Clutter Problem
Point Score Examples
Description of Deficiency Point Score (per occurrence)
Small medical device on wheels (NIBP unit), against wall, charging, not blocking shut-offs 1
Equipment or furniture, not in use, one side of corridor only, not blocking shut-off or fire alarm 3
Large furniture or equipment, on both sides of corridor, not in use, not blocking shut-off/ alarm 5
Large furniture or equipment, in corridor, not in use, blocking emergency shut-off or fire alarm 8
Large furniture or equipment, in corridor, preventing fire or smoke door from closing 10
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Solving the Hallway Clutter Problem
Step 2a Establish a numerical baseline score for
a specific hospital area (4 West) Procedure Use
the point values for deficiencies that have been
assigned and determine total scores by randomly
inspecting the area once per day for at least one
week
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Solving the Hallway Clutter Problem
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Solving the Hallway Clutter Problem
Point Score Results of Daily Inspections
Day Mon. Tues. Wed. Thurs. Fri.
Points 34 27 39 42 28
Cum. Average 34 32 33 36 34
This is the baseline number for 4 West
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Solving the Hallway Clutter Problem
Graphical Results
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Solving the Hallway Clutter Problem
Graphical Results
New goal 25 points
Daily Scores
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Safety Management
  • Issue
  • How to solve the smoking dilemma?
  • Tips for Compliance
  • Create a practical policy
  • Recognize the citation priority
  • Monitor smoking compliance

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Smoking Monitoring

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Security Management
  • Issue Security Responsibility Appointment
  • Tips for Compliance
  • Letter provided by leadership
  • Identify security responsibility
  • Include
  • Coordination
  • Development and implementation
  • Monitoring

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Security Management
  • Issue Security Risk Assessment
  • Tips for Compliance
  • Include security sensitive areas
  • ED, OB/ Gyn, Pharmacy, Infectious
    waste
  • Other areas?
  • Evaluate facility access control
  • Provide training for staff in sensitive areas

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Security Management
  • Issue Security Special Cases
  • Tips for Compliance Consider the following
  • Use of firearms or other means of force
  • Mental health areas
  • Medication and infectious waste security
  • Infant/ child abduction prevention and drills
  • Cell phones with cameras/ privacy issues
  • Access to unauthorized areas
  • Security in construction areas

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Hazardous Materials and Wastes
  • Issue MSDS Sheets
  • Tips for Compliance
  • Ensure an accurate inventory
  • Provide staff training
  • Consider MSDS options
  • Binder with data sheets
  • 1-800 Fax-on-Demand
  • Internet or intranet access

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Hazardous Materials and Wastes
  • Issue Chemical Waste Stream
  • Tips for Compliance
  • Ensure disposal procedures for
  • Chemicals
  • Chemotherapeutics
  • Radioactive materials
  • Medical waste and sharps
  • Waste phamaceuticals
  • Per applicable laws (OSHA, EPA, NRC, DOT)

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Hazardous Materials and Wastes
  • Issue Compressed Cylinder Storage
  • Tips for Compliance
  • For stored gases lt300 cubic feet in smoke
    compartment
  • - Enclosures not required (NFPA 99, section
    9.4.3)
  • For stored gases gt300 but lt3,000 cubic feet
  • - Outdoors enclosed space with doors or
    gates (9.4.2.1)
  • - Indoors an enclosure with minimum ½
    hour protection (9.4.2.3)
  • For stored gases gt3,000 cubic feet
  • - Walls, floors, ceilings, doors at least
    1-hour rated (5.1.3.3.2)
  • - Racks, chains or fastenings to secure
    all cylinders (5.1.3.3.2)
  • - Continuous powered ventilation within 1
    foot of floor (5.1.3.3.3)

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Hazardous Materials and Wastes
  • Issue Compressed Cylinder Storage
  • Tips for Compliance
  • Requirements for stored gas only, not in-use
    tanks!
  • In-use gas includes
  • - Tanks on code carts
  • - Tanks on wheelchairs
  • - Tanks on gurneys
  • Empty tanks do not count toward the total
  • Use of fire-rated cabinets can be used on floors

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Hazardous Materials and Wastes
  • Issue Alcohol-Based Hand Rub Units Requirements
  • Tips for Compliance
  • Patient safety goal 7 requires CDC compliance
    with Category I recommendations, suggests
    Category II compliance!
  • When no soiling is present, ABHR units are
    recommended (Cat I)
  • ABHR is permitted in a corridor at least 6 feet
    in width, at least 4 feet apart, and not directly
    over electrical outlets (6 inches from dispenser)
  • ABHR dispensers can be used over carpeted
    surfaces only in sprinklered smoke compartments!
  • ABHR permissible volumes
  • - 10 gallons in dispensers/ 5 gallons in
    storage per smoke compartment
  • - Maximum individual dispenser capacity .3
    gallons
  • - Maximum dispenser size per suite of rooms
    .5 gallons

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Hazardous Materials and Wastes
  • Issue Eyewashes and Showers
  • Tips for Compliance
  • Use risk assessment to determine placement
  • ANSI standards have not been officially adopted
    by the
  • Joint Commission
  • Testing policy is required specify test
    intervals
  • Documentation of test results is required
  • Differentiate between eyewash station and first
    aid
  • station, such as mounted bottles

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Hazardous Materials and Wastes
Issue Hazardous Vapor Monitoring Tips for
Compliance Clinical lab formaldehyde and
xylene Central supply ethylene oxide
ORs nitrous oxide, methyl-methacrylate
Respiratory glutaraldehyde Sleep lab
collodion Monitor and document per OSHA
requirements!
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Approved Changes for 2009
  • The organization of the standards
  • EM.01.01.01 Plans for managing emergencies
  • EM.02.01.01 Develops an emergency operations
    plan
  • EM.02.02.01 Establishes emergency
    communication strategies
  • EM.02.02.03 Establishes strategies for
    managing resources
  • EM.02.02.05 Establishes strategies for
    managing safety and security
  • EM.02.02.07 Defines and manages staff roles
    and responsibilities
  • EM.02.02.09 Identifies an alternative means
    for providing utilities
  • EM.02.02.11 Identifies strategies for patient
    management
  • EM.02.02.13 Privileges to LIPs
  • EM.02.02.15 Privileges to volunteer staff
  • EM.03.01.01 Annual effectiveness review
  • EM.03.01.03 Regularly tests the emergency
    operations plan

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Emergency Management
  • EM.01.01.01 The organization plans for managing
    the consequences of emergencies
  • Medical and clinical staff participate in
    planning
  • A Hazard Vulnerability Analysis (HVA) is
    performed and documented
  • The hazards are prioritized
  • Communication of emergency plan with community
    responders
  • Mitigation, Preparedness, Response, Recovery
  • Assets and resources are inventoried and
    documented (CAP)
  • Asset and resource inventories are monitored
    during emergencies (CAP)
  • The emergency management program is evaluated
    annually (S,O,P,E)

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Emergency Management
  • Tips for Compliance with EM.01.01.01
  • Appoint a physician and administrative
    representative to actively participate on the
    emergency management planning committee
  • Perform and document the Hazard Vulnerability
    Analysis (HVA) for all geographically separate
    facilities review annually!
  • Be ready to describe the Mitigation,
    Preparedness, Response and Recovery procedures
    in the EOP
  • Ensure that emergency resources are inventoried
    (PPE, utility and medical supplies and
    pharmaceuticals) and monitored
  • Evaluate the emergency management program
    annually (S,O,P,E) and report the results to the
    safety committee

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Emergency Management
  • EM.02.01.01 The organization develops and
    maintains an Emergency Operations Plan (EOP)
  • Written EOP includes an all hazards command
    structure
  • An incident command structure (ICS) is
    established and is consistent with the community
    plan
  • The ICS identifies a reporting structure
  • Activation of ICS is identified
  • Activation of ICS phases is identified
  • The EOP identifies the organization response
    when community non-support may occur for up to 96
    hours (CAP)
  • Alternative care sites are identified

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Emergency Management
  • Tips for Compliance with EM.02.01.01
  • Create a written emergency operations plan
    (EOP) that describes the incident command
    structure and process that is in use (HICS 4?) as
    well as how ICS integrates into the six critical
    core areas
  • 1. Emergency communications
  • 2. Resources and assets
  • 3. Safety and security
  • 4. Staff roles and responsibilities
  • 5. Management of utilities
  • 6. Clinical and support activities
  • The EOP can either describe the ICS and core
    area integration in detail or reference existing
    documents

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Emergency Management
HICS Organizational Chart
Incident Commander
Public Info Officer
Safety Officer
Liaison Officer
Med/ Tech Specialist(s)
Operations Section Chief
Planning Section Chief
Logistics Section Chief
Finance/ Admin Section Chief
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Emergency Management
  • Tips for Compliance with EM.02.01.01
  • Create two color-coded timeline charts the
    indicate how long utilities will be operational
    and how long consumable supplies will be
    available in the event of an emergency in which
    no re-supply is possible
  • Ensure that decisions are made to determine
    whether any utility or supply changes will be
    implemented to extend green zones
  • Create two 96-hour plans that assume the
    following scenarios
  • PLAN A Supplies are available and are
    ordered and received
  • PLAN B Internal supply shortages or
    utility failures require partial or
  • total patient evacuation
  • PLAN C Shortages and/ or utilities are
    not sufficient to continue
  • normal patient care,
    although evacuation is not possible

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Emergency Management
  • Critical Utilities and Supplies Timeline
  • Assume external help is not available
  • Create timeline for utilities and critical
    supplies, such as food and medications
  • Determine time-dependent status
  • - Green Continue all services as usual
  • - Yellow Transition to conservation mode
  • - Red Discontinue patient treatment,
    evacuate

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Emergency Management
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Emergency Management
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Emergency Management
  • EM.02.02.01 The organization establishes
    emergency communications strategies
  • Staff notification procedures are created
  • Provisions for ongoing staff communication
    during the emergency
  • Process to notify external authorities
  • Communication with patients and their families
  • Communication with the community and media
  • Communication with vendors and suppliers (CAP)
  • Sharing information with other health care
    providers
  • Providing information about patients to
    third-parties (FEMA, CDC, etc.)
  • Communication with alternative care sites
  • Establishment of back-up communication systems
    and technologies

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Emergency Management
  • Tips for Compliance with EM.02.02.01
  • Create notification charts with phone numbers,
    email addresses, etc.
  • Include for staff, external authorities,
    community, media, vendors
  • Determine what information will be shared with
    other health care providers in the area
  • Ensure that liaisons are established with
    government agencies
  • Verify that MOUs for alternative care sites
    are updated
  • Establish and check operation of back-up
    communication systems, such as the internet, cell
    phones, two-way radios, emergency land lines, and
    amateur radio operators

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Emergency Management
  • EM.02.02.03 The organization establishes
    strategies for managing resources and assets
    during emergencies
  • Plans for obtaining medications and
    non-clinical supplies
  • Replenishing medical supplies and equipment
    during the emergency
  • Replenishing pharmaceutical supplies
  • Replenishing non-medical supplies (food, water,
    fuel, linens, etc.)
  • Managing staff and family support activities
  • Sharing of resources with other health care
    organizations in and outside of the local
    community (CAP)
  • Horizontal, vertical and total evacuation
    (CAP), including transportation of patients,
    medications, equipment, staff and medical record
    information

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Emergency Management
  • Tips for Complying with EM.02.02.03
  • Plans should be in place to stockpile and
    reorder critical clinical and non-clinical
    supplies
  • Written procedures should describe how the
    needs of staff and families of staff will be met
    during an emergency
  • A plan to share community resources and assets
    should be in place
  • A practical patient evacuation plan that
    includes horizontal and vertical movement within
    the facility as well as partial or total
    evacuation outside of the facility is required
  • Logistics for evacuation should include 1)
    transportation 2) staffing 3) medications 4)
    equipment, and 5) the medical record

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Emergency Management
  • EM.02.02.05 The organization establishes
    strategies for managing safety and security
    during emergencies
  • Internal safety and security measures are
    established
  • Role of community security agencies is
    established with the healthcare organization and
    means of coordination is identified (CAP)
  • Processes for handling hazardous materials and
    waste are developed (CAP)
  • Plans are developed for radioactive,
    biological, chemical decontamination
  • Patients susceptible to wandering are
    identified (CAP)
  • Access into and out of the facility are
    controlled
  • Movement of staff and patients is controlled
    within the facility
  • Traffic accessing the facility is controlled

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Emergency Management
  • Tips for Complying with EM.02.02.05
  • Security staffing plans during emergencies must
    be established
  • Expectations with outside police agencies
    should be identified
  • Plans to dispose of infectious and hazardous
    waste must be created
  • Procedures to treat contaminated patients must
    be written (radioactive, biological and chemical)
  • Methods to lock down the facility to prevent
    entry must be provided
  • Methods to minimize staff and patients from
    leaving the facility must be planned
  • Plans must be in place to control traffic
    accessing the facility

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Emergency Management
  • EM.02.02.07 The organization defines and manages
    staff roles and responsibilities
  • Staff roles and responsibilities are defined
    for the critical areas (communications, resources
    and assets, safety and security, utilities,
    clinical activities)
  • Staff are trained relative to their
    responsibilities (CAP)
  • Roles of LIPs are specifically defined (CAP)
  • Care providers and command center staff are
    identified (ID badges, vests, caps, etc.)

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Emergency Management
  • Tips for Complying with EM.02.02.07
  • Review and update as necessary, the ICS
    organizational chart and job action sheets (check
    after each drill)
  • Ensure that hospital staff have participated in
    NIMS training
  • Discuss emergency expectations with the
    independent physicians who have privileges at the
    hospital
  • Select the primary and back-up command center
    locations
  • Have a method to identify incident command
    staff (ID badges, vests, caps, etc.)

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Emergency Management
  • EM.02.02.09 The organization establishes
    strategies for managing utilities during
    emergencies, such as
  • Electricity
  • Potable and non-potable water
  • Fuel for building operations or transport
    vehicles (CAP)
  • Other essential utility needs, such as
  • - HVAC equipment
  • - Medical gas and vacuum systems
  • - Fire systems
  • - Sewer

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Emergency Management
  • Tips for Complying with EM.02.02.09
  • Complete the utility 96-hour timeline chart
  • Determine which utilities require additional
    supplies, especially water and fuel
  • Determine the feasibility of redundant systems
    or supplies
  • Examples Water on-site well, water tower
    or nearby lake
  • Electricity additional
    generators installed
  • Boilers portable boiler
    on a truck
  • Medical gas low
    pressure external connection, manifold

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Emergency Management
  • EM.02.02.11 The organization establishes
    strategies for managing clinical and support
    activities during emergencies, including
  • Patient scheduling, triage, assessment,
    treatment admission, transfer, discharge and
    evacuation
  • Clinical services for vulnerable patients, such
    as pediatric, geriatric, disabled or serious
    chronic conditions or addictions
  • Personal hygiene and sanitation
  • Mental health needs (CAP)
  • Mortuary services (CAP)
  • Tracking and documenting patient information
    (CAP)

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Emergency Management
  • Tips for Complying with EM.02.02.11
  • Identify which patients in the hospital are
    considered vulnerable
  • (neonatal intensive, pediatric, geriatric,
    dementia, behavioral health)
  • Plan for patient and staff hygiene and
    sanitation without water or sewer
  • Determine mortuary needs in the event of a
    pandemic
  • Evaluate back-up methods to track patient
    information in the event that
  • the electronic information system fails

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Emergency Management
  • EM.02.02.13 During disasters, the organization
    may grant privileges to licensed independent
    practitioners
  • Privileges granted only when EOP has been
    activated
  • Medical staff bylaws indicate to who and how to
    grant privileges, and policies will indicate how
    performance will be evaluated
  • Minimum privileging requirements include
  • 1. Current picture ID and license to
    practice
  • 2. Must be a member of a recognized
    disaster response group
  • 3. Proof of government authority to
    provide services during a disaster
  • Hospital determines within 72 hours if
    privileges should continue

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Emergency Management
  • EM.02.02.15 During disasters, the organization
    may assign disaster responsibilities to volunteer
    practitioners
  • Hospital assigns responsibilities only when EOP
    has been activated
  • Hospital identifies in writing who is eligible
    and how to assign disaster responsibilities to
    non-LIPs
  • Minimum requirements to assist during disasters
    include
  • 1. Current picture ID and license to
    practice professional specialty
  • 2. Must be a member of a recognized
    disaster response group
  • 3. Confirmation by hospital staff the
    individual is qualified
  • Hospital determines a method to evaluate
    performance and decide within 72 hours if
    responsibilities should continue

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Emergency Management
  • EM.03.01.01 The organization evaluates the
    effectiveness of its emergency management
    planning activities
  • The Hazard Vulnerability Analysis (HVA) is
    evaluated annually to determine if revisions are
    necessary
  • The Emergency Operations Plan (EOP) is
    evaluated annually with regard to the Scope,
    Objectives, Performance and Effectiveness of the
    program
  • The hospital conducts an annual review of the
    inventory process with regard to emergency
    supplies, and documents the results

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Emergency Management
  • EM.03.01.03 The organization regularly tests its
    emergency operation plan
  • Twice over 12 months, either as a drill or
    actual emergency
  • Once per year in a business occupancy
  • One influx of patient drill per year
  • One escalation per year to test community
    non-support
  • One community-wide drill per year
  • Drills are realistic and based on the HVA
  • A dedicated, trained individual must evaluate
    the drill

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Emergency Management
  • EM.03.01.03 The organization regularly tests its
    emergency operation plan (continued)
  • The six critical areas are monitored 1)
    Communication 2) Resource mobilization 3)
    Safety and security 4) Staff roles and
    responsibilities 5) Utility systems, and 6)
    Patient clinical and support activities
  • Exercises are critiqued with a
    multi-disciplinary group, including leadership,
    physician and support staff and evaluate
    deficiencies
  • The operations plan is revised based on the
    drill findings
  • Subsequent exercises evaluate the improvements
    to the EOP
  • Drill evaluations are reported to the hospital
    safety committee

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Emergency Management
  • Tips for Compliance with EM.03.01.03
  • Two drills per rolling 12-month period should
    be performed, based on the HVA
  • At least one drill per 12 months in a business
    occupancy
  • At least one influx drill for a disaster
    receiving station
  • Community-wide and influx drills can be
    performed concurrently
  • The community 96-hour non-support drill can
    be a tabletop
  • Trained staff, including a physician and
    leadership, must evaluate the drill and must
    document the six core areas in the evaluation
  • Infant abduction (EC.2.10) and patient surge
    (IC.6.10) drills are highly recommended

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Fire Prevention
  • Issue Fire Drills
  • Tips for Compliance
  • Healthcare and ambulatory
  • 1 drill per shift per quarter
  • Business occupancy
  • 1 drill per shift per year
  • Drill monitoring as defined in the plan
  • Evaluate effectiveness annually in written
    report

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Fire Prevention
  • Issue Interim Life Safety Measures
  • Tips for Compliance
  • A policy must describe the program
  • Document whether ILSM is or is not required
  • Determine ILSM applicability for PFIs!
  • Document which measures are applicable
  • Document required inspections
  • Failure to meet ILSM provisions CON04!

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Medical Equipment Management
  • Issue Equipment Test Scoring
  • Tips for Compliance
  • 100 PM completion for life support devices,
    based on scoring (A)
  • 90 PM completion for non-life support
    devices (C)
  • Determine test interval by PM effectiveness
    and MTBF data
  • Test tags with due dates recommended, but not
    required! What about Ongoing PM vs. initial test
    only?

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Medical Equipment Management
  • Issue Other Medical Equipment Issues
  • Tips for Compliance
  • Patient-owned equipment
  • Diagnostic and therapeutic (example CPAP)
  • Personal use (iPods, cell phones,
    blackberries)
  • Rental devices
  • Demo, loaner and trial equipment
  • Radio-frequency interference

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Utility Systems Management
Issue Waterborne Pathogens Tips for
Compliance Waterborne pathogens policy must
include 1. Patient risk assessment for
pathogen vulnerability 2.
Operational description of measures to reduce
waterborne pathogens 3. Remediation
procedures if hospital-acquired
waterborne infection is determined
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Utility Systems Management
Issue Airborne Pathogens Tips for Compliance
An airborne pathogens policy must exist that
describes Air filter maintenance, room air
exchange rate and pressure relationships for
operating rooms, delivery rooms, special
procedure rooms, patient isolation rooms,
clinical laboratories, sterile supply rooms and
pharmacies Note Refer to AIA document for
requirements Note Grandfathering permitted for
air handlers
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Utility Systems Management
  • Issue Utility System Test Scoring
  • Tips for Compliance
  • All devices included in the utility systems
    management program must be at least initially
    tested
  • Expected PM completion rate for critical life
    support and critical infection control
    components based on A scoring 100
  • Expected PM completion rate for critical
    non-life support components based on C
    scoring 90
  • Non-critical components are not scored

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Appropriate Environment
  • Issue The General Duty Clause
  • Tips for Compliance
  • Patient areas are safe, clean, comfortable
  • Lighting is suitable
  • Ventilation provides for acceptable temperature
  • Locks and restraints per regulation
  • Emergency access for locked spaces

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Appropriate Environment
  • Issue New Construction
  • Tips for Compliance
  • AIA document, 2001 edition (2006 soon?)
  • Applicable federal, state or local
  • guidelines
  • Equivalent design criteria

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Appropriate Environment
Issue Pre-Construction Risk Assessment
(PCRA) Tips for Compliance Include all of the
items listed below in the PCRA evaluation
Noise Vibration Air quality Infection
control Emergency procedures Utility failures


Interim life safety measures
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Infection Control Risk Assessment (ICRA)
  • Risk Criteria for Infection Control

Type A Type B Type C Type D
Group 1 (lowest) I II II III
Group 2 (medium) I II III IV
Group 3 (medium high) II III III IV
Group 4 (highest) III III IV IV
Construction Type
Patient Risk
Healthcare Engineering Consultants
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Appropriate Environment
  • Issue Ongoing Monitoring
  • Tips for Compliance
  • Controls include measures to reduce risk and
    minimize the impact of the construction
    activities
  • Daily monitoring checklist is recommended
  • Consider posting required PCRA permits, such as
    hot work, ICRA, above-the-ceiling work, etc. on
    door entrance to construction area

Healthcare Engineering Consultants
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