2010

George Mills, Senior Engineer Standard Interpretation Group The Joint Commission

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The Healthcare Environment

Human Factor  Trust

 Report

TRUST

REPORT

IMPROVE

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 Improve

Assessing Risk: EC.02.02.01 EP 1 associated with the environment of care  NOTE: risks are identified from internal sources such as ongoing monitoring of the environment, results of root cause analysis, results of annual proactive risk assessments of high risk processes and from credible external sources such as Sentinel Event Alerts (see also EC.04.01.01 EP 14)  Is there a risk assessment process?  Quality of the risk assessment process SIG Engineering 2010 - 3

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 The hospital identifies safety & security risks

Assessing Risk: EC.02.02.01 EP 3 minimize or eliminate identified safety & security risks in the physical environment Direct impact C category

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 The hospital takes action to

Compliance Strategies clear decision  Educated guess that drives your assumptions  Clearly document the process  Determine when to re-assess the issue  Problem solving approach to determine appropriate response  Preventive strategies to address potential issues SIG Engineering 2010 - 5

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 Use to evaluate any issue that lacks a

Conducting a Risk Assessment 1. Identify the issue

3. 4. 5.

6. 7.

issue Develop arguments against the issue Objectively evaluate both arguments Reach a conclusion Document the process Monitor and reassess the conclusion to ensure it is right conclusion SIG Engineering 2010 - 6

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2. Develop arguments in support of the

Risk Assessment Cycle 1 Identify Issue

Risk Assessment Cycle

3 Disadvantages

4 Objectively evaluate

6 Document

5 Reach a conclusion

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7 Monitor & Re-assess

2 Advantages

Risk Assessment Opportunities  EC Standards

Performance Review is a risk assessment process that affects all seven functional areas of the EC  Safety Management  Review Smoking Effectiveness assessment  Environmental Tours  Process  Environment  Job Hazards

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 Periodic

Risk Assessment Opportunities  Security Management

Security Assessment of potential external issues and outcomes  Security Sensitive Areas  External Environment  Hazardous Materials & Waste  Review inventory and processes associated with hazardous materials handling  MSDS review SIG Engineering 2010 - 9

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 Review

Risk Assessment Opportunities  Proposed Acquisitions

for acquisition of furnishings  Bedding  Draperies  Privacy curtains  Wall coverings  Floor coverings  Decorations

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 Policy

EP 5: Grounds & equipment are maintained EP 7: Identifies individuals entering the facility EP 8: Controls access to and from areas it identifies as security sensitive

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Safety & Security EC.02.01.01

EP 1: maintains a written current inventory  Uses, stores or generates  Only those items addressed by law and regulation  Inventory may be in writing, or other working media, such as  Electronic  Fax back  Phone service • Emergency provision removes access based on catastrophic event SIG Engineering 2010 - 12

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Hazardous Materials & Waste EC.02.02.01

Hazardous Materials & Waste EC.02.02.01 exposures  EP 4: Implements its procedures  EP 11: Law & Regulations  Permits  Licenses  Manifests  MSDS  Labels identify contents and hazard warnings

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 EP 3: Written procedures for spills and

LS.02.01.20 EP 13  Exits, exit access and exit discharge are clear of obstructions or impediments to the public way, such as clutter (for example, equipment, carts and furniture), construction material, snow and ice.  NFPA 101-2000 7.1.10.1

 EC.02.03.01 EP 10  Written fire response plan SIG Engineering 2010 - 14

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Fire Safety

Built Environment EC.02.06.01 the patient population and are safe and suitable to the care, treatment and services provided  EP 18: Interior space accommodates use of equipment  EP 20: Areas used by patients are clean and free of offensive odors  EP 26: The hospital keeps furnishings and equipment safe and in good repair SIG Engineering 2010 - 15

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 EP 1: Interior spaces meet the needs of

Monitoring Conditions: EC.04.01.01

and staff injuries EP 8: Spills and exposures EPs 12 - 14: Environmental Tours Using

Tour results

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EP 4: Occupational illnesses

 Emergency Recovery  Supplies  Staffing issues  Disposal  Containers  Storing  Shipping  Other issues SIG Engineering 2010 - 17

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Emergency Management EM.02.01.01 EP 5

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Questions?

The Joint Commission Disclaimer  These slides are current as of 9/16/2010. The Joint

Commission reserves the right to change the content of the information, as appropriate. were expounded upon verbally by the original presenter and are not meant to be comprehensive statements of standards interpretation or represent all the content of the presentation. Thus, care should be exercised in interpreting Joint Commission requirements based solely on the content of these slides.

 These slides are copyrighted and may not be further

used, shared or distributed without permission of the original presenter or The Joint Commission.

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 These slides are only meant to be cue points, which

SIG Support: 630 792 5900 George Mills, MBA, CEM, CHFM, CHSP Senior Engineer SIG

Michael Chisholm, CPE, CHFM Engineer SIG Anne Guglielmo, CFPS, LEED A.P. Engineer SIG

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Jerry Gervais, CHFM Engineer SIG