D.21 EO C2021.pdf

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D.21 EO C2021

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Table of Contents

PREFACE

Disclaimer Statements ..................................................................... viii

Executive Summary ............................................................................ x

Acknowledgements ............................................................................ xi

Update Listing ................................................................................... xii

1 What's New in the Guidebook?

1.1. Introduction

1.2. What’s New

Environment of Care

1.2.2. Life Safety

Sentinel Events

Early Survey Policy (ESP)

1.3. References and Resources

2 Environment of Care Survey Process and Scoring

2.1. Project REFRESH

2.2. Statement of Conditions (SOC™) Process Changes Effective

August 1, 2016

Effect on the Life Safety Plans for Improvement (PFI)

2018 Review Project Changed 300 Hospital

Requirements

2.3. Enclosure

3 The Office of Quality, Safety & Value (OQSV), Division of

External Accreditation Services & Programs

3.1. Survey Readiness

3.2. The Joint Commission Field Tracker Report

3.3. Environment of Care Most Challenging Standards

4 Management Plans

4.1. Management Plans Introduction and Overview

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4.2. Enclosures

5 Implement

5.1. Safety and Security Management

Introduction

Standards

5.1.2.a. Standard EC.01.01.01

5.1.2.b. Standard EC.02.01.01

5.1.2.c. Standard EC.02.01.03

Compliance Tips

5.1.3.a. Standard EC.01.01.01

5.1.3.b. Standard EC.02.01.01

5.1.3.c. Standard EC.02.01.03

References and Resources

Enclosures

5.2. Hazardous Materials and Waste

Standard

5.2.1.a. Standard EC.02.02.01

Compliance Tips

5.3. Fire Safety

Introduction

Standards

5.3.2.a. Standard EC.02.03.01

5.3.2.b. Standard EC.02.03.03

5.3.2.c. Standard EC.02.03.05

Compliance Tips

5.3.3.a. Door Testing

5.3.3.b. Documentation of Inspection Testing and

Maintenance

Enclosures

5.4. Medical Equipment Management

Standards iii

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5.4.1.a. Standard EC.02.04.01

5.4.1.b. Standard EC.02.04.03

Compliance Tips

5.4.2.a. Standard EC.02.04.01

5.4.2.b. Standard EC.02.04.03

Additional Information

5.4.3.a. Categorizing Equipment

5.4.3.b. Inspection, Testing and Maintenance

Frequencies

5.4.3.c. Inspection Tags and Stickers

5.4.3.d. Incoming Inspections

5.4.3.e. Compliance with EC.02.04.03, EP 2

5.4.3.f. Compliance with EC.02.04.03, EP 5

5.4.3.g. Recalls and Hazard Alerts

5.4.3.h. Patient Safety Issues Related to Environment of

Care Patient Alarms

5.4.3.i. Surveyor Questions and Findings

5.4.3.j. Surveyor Interaction

References and Resources

Enclosures

5.5. Utilities Management

Standards

5.5.1.a. Standard EC.02.05.01

5.5.1.b. Standard EC.02.05.02

5.5.1.c. Standard EC.02.05.03

5.5.1.d. Standard EC.02.05.05

5.5.1.e. Standard EC.02.05.07

5.5.1.f. Standard EC.02.05.09

Compliance Tips

5.5.2.a. EC.02.05.01

5.5.2.b. EC.02.05.03 iv

5.5.2.c. EC.02.05.05

5.5.2.d. EC.02.05.07

5.5.2.e. EC.02.05.09

Enclosures

5.6. Other Physical Environment Requirements

Standards

5.6.1.a. Standard EC.02.06.01

5.6.1.b. Standard EC.02.06.05

Compliance Tips

5.6.2.a. Standard EC.02.06.01

5.6.2.b. Standard EC.02.06.05

References and Resources

Enclosures

6 Staff Competency for Environment of Care

6.1. Standards

Standard EC.03.01.01

6.1.1.a. Related Standards

6.2. Compliance Tips

6.3. References and Resources

7 Monitor and Improve

7.1. Standards

Standard EC.04.01.01

Standard EC.04.01.03

Standard EC.04.01.05

Standard EM.03.01.01

Standard EM.03.01.03

7.2. Compliance Tips

Standard EC.04.01.01

Standard EC.04.01.03

Standard EC.04.01.05 v

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7.3. Enclosures

8 Patient Safety

8.1. The Joint Commission National Patient Safety Goals (NPSGs) ... 67

National Patient Safety Goal (NPSG) Changes:

8.1.1.a. NPSG 03.05.01

8.1.1.b. NPSG 15.01.01

Goal 6: Reduce the Harm Associated with Clinical Alarm

Systems

8.1.2.a. NPSG.06.01.01

8.1.2.b. References and Resources

Goal 7: Reduce the Risk of Health Care Associated

Infections

8.1.3.a. NPSG.07.01.01

8.1.3.b. References and Resources

Goal 15: The Organization Identifies Safety Risks

Inherent in its [Patient] Population

8.1.4.a. NPSG.15.01.01

8.1.4.b. References and Resources

8.2. Sentinel Event Alerts

8.3. Patient Safety Tools and Topics

Patient Safety Assessment Tool (PSAT)

VHA Patient Safety Alerts and Advisories

Root Cause Analysis (RCA)

Healthcare Failure Mode and Effect Analysis (HFMEA) ... 77

General Patient Safety Links

Patient Safety Topics

8.4. Preventing Surgical Fires

Background

Guidance

References and Resources

8.5. Alcohol-Based Hand Cleaner

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Background

Installation

References and Resources

9 Life Safety Standards

9.1. Introduction

9.2. Changes to the LS Standards

9.3. Standards

Standard LS.01.01.01

Standard LS.01.02.01

Standard LS.02.01.10

Standard LS.02.01.20

Standard LS.02.01.30

Standard LS.02.01.34

Standard LS.02.01.35

Standard LS.02.01.40

Standard LS.02.01.50

Standard LS.02.01.70

Standard LS.03.01.10

Standard LS.03.01.20

Standard LS.03.01.30

Standard LS.03.01.34

Standard LS.03.01.35

Standard LS.03.01.40

Standard LS.03.01.50

Standard LS.03.01.70

Standard LS.05.01.10

Standard LS.05.01.20

Standard LS.05.01.30

Standard LS.05.01.34

Standard LS.05.01.35 vii

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9.4. Compliance Tips

LS.01.01.01

LS.01.02.01

9.5. Enclosure

10 Environment of Care News

10.1. Environment of Care News

10.2. Healthcare Interpretations Task Force (HITF)

11 Community-Based Outpatient Clinics (CBOCs) and Leased

Facilities

11.1. VA-Operated CBOCs

11.2. Contractor-Operated CBOCs

11.3. Environment of Care Compliance

11.4. CBOC Facility Design Requirements

11.5. References and Resources

11.6. Enclosure

Enclosures

Appendix

Acronyms and Abbreviations viii

Disclaimer Statements

Endorsement

Reference herein to any specific commercial product, process, or service by trade name, trademark, manufacturer, or otherwise, does not necessarily constitute or imply its endorsement, recommendation, or favoring by the U.S. Government. The views and opinions of authors expressed herein do not necessarily state or reflect those of the U.S.

Government and shall not be used for advertising or product endorsement purposes.

Hyperlinks

The appearance of external hyperlinks does not constitute endorsement by the Department of Veterans Affairs (VA) of the linked websites or the information, products, or services contained therein. For other than authorized VA activities, the Department does not exercise any editorial control over the information you may find at these locations. All links are provided with the intent of meeting the mission of the Department and the

VA website. Please let us know about existing external links that you believe are inappropriate and about specific additional external links that you believe should be included.

Liability

With respect to documents available from this server, neither the U.S.

Government nor any of its employees makes any warranty, expressed or implied, including the warranties of merchantability and fitness for a particular purpose, or assumes any legal liability or responsibility for the accuracy, completeness, or usefulness of any information, apparatus, product, or process disclosed, or represents that its use would not infringe privately-owned rights.

Reference from this website or from any of the information services sponsored by VA to any non-governmental entity, product, service, or information does not constitute an endorsement or recommendation by VA or any of its employees. We are not responsible for the content of any “off-site” websites referenced from the Veterans Health Administration (VHA)

Healthcare Environment and Facilities Programs (HEFP) website, electronic media, or printed media.

Guidance

HEFP guidebooks are “best practice” resources designed to assist VA professionals implement and enhance HEFP programs; the guidebooks do ix

36C25922R0102 not constitute official policy or an interpretation of published statutes or regulations.

Disclaimer Statements have been reviewed by the Department of Veterans

Affairs Office of General Counsel.

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Executive Summary

The purpose of this guidebook is to provide an interpretation of the latest

Joint Commission Environment of Care (EC) Standards for Department of

Veterans Affairs (VA) medical facilities and provide improvement strategies for implementation, measurement and evaluation of EC activities. This guidebook addresses all applicable EC requirements and includes an overview of all medical facility responsibilities stated in the EC standards with an emphasis on continual quality and performance improvement.

This 2021 update of the Veterans Health Administration (VHA)

Environment of Care Guidebook is designed for use by facilities to tailor sample documents to individual facility needs. The entire guidebook is available electronically on the VHA Healthcare Environment and Facilities

Programs (HEFP) website.

A summary of the updates can be found in Chapter 1, What’s New.

Every effort has been made to make the content consistent with the best available information, based on The Joint Commission practices/criteria.

The co-chairs of the guidebook encourage your suggestions and feedback to improve future editions of the VHA Environment of Care Guidebook. For any questions or concerns related to the content, please contact Jeff

Vaughn, Safety Data Sheet (SDS)/Chemical Inventory Service Program

Manager, Enterprise Support Services (ESS), Healthcare Environment and

Facilities Programs (HEFP), St. Louis, Missouri, by email at

Jeff.Vaughn@va.gov.

http://vaww.hefp.va.gov/guidebooks http://vaww.hefp.va.gov/guidebooks mailto:Jeff.Vaughn@va.gov xi

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Acknowledgements

A special thank you is extended to Sue Ellen Myers, VISN 6 Environment of Care Program Manager, and Jeff Vaughn, Safety Data Sheet

(SDS)/Chemical Inventory Service Program Manager, for their commitment in providing the 2021 update to this guidebook. The guidebook was developed and published based on the expertise of numerous Environment of Care professionals across several Veterans Integrated Service Networks

(VISNs) and medical centers, to include the staff from the VHA Healthcare

Environment and Facilities Programs (HEFP), St. Louis, Missouri.

*Jeff Vaughn, Program Manager, SDS/Chemical Inventory Services, HEFP, St. Louis, MO

Agapito Lambert, Jr., CHMM, Chief, Safety Service, VA Medical Center, San Antonio, TX

Michael Henrickson, MPH, CHMM, CFI, VISN 7 Safety Manager, VA

Medical Center, Columbia, SC

Diane Kroll, B.A., M.S., MT-ASCP, RN-BSN, Area Emergency Manager, VHA Office of Emergency Management, Richfield, MN

*Peter A. Larrimer, P.E., Fire Protection Operations Manager, VHA

Central Office, Washington, DC

Sue Ellen Myers, VISN 6 Environment of Care Program Manager, Asheville, NC

Cynthia Paterson, RN, BSN, MS, Ph.D., VISN 11 Patient Safety Officer and VA Ann Arbor Healthcare System Patient Safety Manager, Ann Arbor, MI

*Denotes Chairpersons

HEFP Publishing Staff

Lesley Luscri, Technical Information Specialist, St. Louis, MO

Melody Watts, Technical Information Specialist, St. Louis, MO

Copyright Acknowledgements

Copyrighted documents used in this guidebook were reproduced with permission for VA use only.

The Joint Commission, Oakbrook Terrace, IL 60181, www.jointcommission.org/ http://www.jointcommission.org/ xii

Update Listing

The following listing identifies online updates since the publication of the

January 2020 edition of this guidebook. It is designed to assist the reader in verifying the most current information available.

Date

Updated Remarks

Chapter/

Section

July

See Chapter 1 for an overview of The Joint Commission updates from January 2021 to July 2021.

Updated Enclosure 4-3, Sample Fire Safety Management

Plan

January

Updated Enclosures:

4-4. Sample Hazardous Materials and Waste

Management Plan

4-5. Sample Medical Equipment Management Plan

4-6. Sample Safe and Functional Environment

Management Plan

4-7. Sample Safety Management Plan

4-8. Sample Security Management Plan

4-9. Sample Safety and Security Management Plan

4-10. Sample Utility Systems Management Plan

July

Added Enclosures:

2-1 Sample Statement of Conditions Management Memo

5-3. Smoke/Smokeless Tobacco Products and Electronic

Nicotine Delivery System (ENDS) Free Policy

5-4 Attachment B: Sample Detailed Fire Plan

Updated Enclosures:

4-1. Sample Overview of Environment of Care, Life

Safety and Emergency Management Operations

4-3. Sample Fire Safety Management Plan

4-4. Sample Hazardous Materials and Waste

Management Plan

4-5. Sample Medical Equipment Management Plan http://vaww.hefp.va.gov/resources/4-3-sample-fire-safety-management-plan http://vaww.hefp.va.gov/resources/4-3-sample-fire-safety-management-plan http://vaww.hefp.va.gov/resources/4-4-sample-hazardous-materials-and-waste-management-plan http://vaww.hefp.va.gov/resources/4-4-sample-hazardous-materials-and-waste-management-plan http://vaww.hefp.va.gov/resources/4-5-sample-medical-equipment-management-plan http://vaww.hefp.va.gov/resources/4-6-sample-safe-and-functional-environment-management-plan http://vaww.hefp.va.gov/resources/4-6-sample-safe-and-functional-environment-management-plan http://vaww.hefp.va.gov/resources/4-7-sample-safety-management-plan http://vaww.hefp.va.gov/resources/4-8-sample-security-management-plan http://vaww.hefp.va.gov/resources/4-9-sample-safety-and-security-management-plan http://vaww.hefp.va.gov/resources/4-10-sample-utility-systems-management-plan http://vaww.hefp.va.gov/resources/2-1-statement-conditions-management-memo http://vaww.hefp.va.gov/resources/5-3-smokesmokeless-tobacco-products-and-electronic-nicotine-delivery-systems-ends-free http://vaww.hefp.va.gov/resources/5-3-smokesmokeless-tobacco-products-and-electronic-nicotine-delivery-systems-ends-free http://vaww.hefp.va.gov/resources/5-4-attachment-b-detailed-fire-plan http://vaww.hefp.va.gov/resources/4-1-sample-overview-environment-care-life-safety-and-emergency-management-operations http://vaww.hefp.va.gov/resources/4-1-sample-overview-environment-care-life-safety-and-emergency-management-operations http://vaww.hefp.va.gov/resources/4-3-sample-fire-safety-management-plan http://vaww.hefp.va.gov/resources/4-4-sample-hazardous-materials-and-waste-management-plan http://vaww.hefp.va.gov/resources/4-4-sample-hazardous-materials-and-waste-management-plan http://vaww.hefp.va.gov/resources/4-5-sample-medical-equipment-management-plan xiii

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4-6. Sample Safe and Functional Environment

Management Plan

4-7. Sample Safety Management Plan

4-8. Sample Security Management Plan

4-9. Sample Safety and Security Management Plan

4-10. Sample Utility Systems Management Plan

5-4. Sample Fire Prevention Management Program

Memorandum

Attachment A: Sample Fire Plan (Code Red)

9-1.Sample Interim Life Safety Measures Memorandum http://vaww.hefp.va.gov/resources/4-6-sample-safe-and-functional-environment-management-plan http://vaww.hefp.va.gov/resources/4-6-sample-safe-and-functional-environment-management-plan http://vaww.hefp.va.gov/resources/4-7-sample-safety-management-plan http://vaww.hefp.va.gov/resources/4-8-sample-security-management-plan http://vaww.hefp.va.gov/resources/4-9-sample-safety-and-security-management-plan http://vaww.hefp.va.gov/resources/4-10-sample-utility-systems-management-plan http://vaww.hefp.va.gov/resources/5-4-sample-fire-prevention-management-program-memorandum http://vaww.hefp.va.gov/resources/5-4-sample-fire-prevention-management-program-memorandum http://vaww.hefp.va.gov/resources/5-4-attachment-sample-fire-plan-code-red http://vaww.hefp.va.gov/resources/9-1-sample-interim-life-safety-measures-memorandum

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Chapter 1

What's New in the Guidebook?

What's New in the Guidebook?

1.1. Introduction

This chapter is intended to provide information regarding new updates shown in this edition of the Veterans Health Administration (VHA)

Environment of Care Guidebook. The 2021 edition of the VHA Environment of Care Guidebook attempts to provide the latest Department of Veterans

Affairs (VA) guidance and sample documents needed for compliance with

The Joint Commission Environment of Care (EC) Standards. This guidebook is a current reference source on the latest standards, and this chapter is the starting point to know what has been revised from previous editions of the guidebook.

There were several changes to the Environment of Care and Life Safety

Chapters in 2021. These changes are highlighted in this chapter, with a brief discussion of each change. An explanation of where additional detailed information can be found in other chapters of the guidebook is also provided.

This edition of the VHA Environment of Care Guidebook will be in electronic format only and will be posted on the Healthcare Environment and Facilities Programs (HEFP) website. The Joint Commission Manual via

E-dition, which contains all The Joint Commission Standards, can be accessed online via the VHA Office of Quality, Safety & Value (OQSV) website.

1.2. What’s New

Effective January 2021, revisions were made to two Elements of

Performance (EPs) in the Environment of Care (EC) chapter and two EPs in the Life Safety (LS) chapter. Effective July 2021, two new EC EPs and five new LS Standards were added. Finally, updates to the Safety

Management Plans reflecting the 2020/2021 updates to The Joint

Commission standards were made. The update listings can be found on

The Joint Commission E-dition website.

A complete list of updates to The Joint Commission Standards can be accessed online via the OQSV website (click on “TJC Manual via

E-dition”).

Environment of Care

Effective January 2021, The Joint Commission revised two EC EPs.

http://vaww.hefp.va.gov/guidebooks http://vaww.hefp.va.gov/guidebooks http://vaww.oqsv.med.va.gov/functions/integrity/accred/jointcommission.aspx http://vaww.oqsv.med.va.gov/functions/integrity/accred/jointcommission.aspx http://vaww.oqsv.med.va.gov/functions/integrity/accred/jointcommission.aspx

• EC.02.03.05, EP 14, updating the NFPA cross reference.

• EC.02.04.03, EP 34, changing the assessment criteria for maximum exposure rate from all imaged modes to fluoroscopic mode.

In July 2021, TJC added four new EPs to EC.02.05.02, adding new requirements related to a hospital’s water management program that will be effective January 1, 2022.

1.2.2. Life Safety

In January 2021, updates were made to the LS chapter, revising the measurements conversion and clarifying the requirements related to availability of spare sprinkler heads in LS.02.01.35, EP 7 (note: this has been further updated in the prepublication standards to appropriately align the EP with NFPA 25) and revising the measurement conversion found in

LS.02.01.30, EP 6.

Effective July 2021, TJC updated the definition of a business occupancy, deleted a section of the Building Maintenance Program and added

LS.05.01.10; LS.05.01.20; LS.05.01.30; LS.05.01.34 and LS.05.01.35:

• LS.05.01.10 with EPs 1-7 added new requirements related to minimizing the effects of fire, smoke and heat.

• LS.05.01.20 with EPs 1-9 added new requirements related to maintaining the integrity of the means of egress.

• LS.05.01.30 with EPs 1-4 added new requirements that hospitals protect individuals from fire and smoke hazards.

• LS.05.01.34 with EPs 1-3 added new requirements that hospitals provide and maintain fire alarm systems.

• LS.05.01.35 with EPs 1-6 added new requirements that hospitals provide and maintain fire extinguishing equipment.

Sentinel Events

In January 2021, the definition of a Sentinel Event was updated. “Fall

Event” was added to the list of events considered sentinel to help staff understand whether a fall should be reviewed as a sentinel event. It also clarified that systemic improvements must have measurable outcomes to be considered an appropriate response to a sentinel event. Lastly, it clarified that a credible comprehensive systematic analysis must include a bibliography with evidence-based literature.

https://www.jointcommission.org/standards/prepublication-standards/new-and-revised-sprinkler-head-requirements/?ref=TJCAL21

Effective July 2021, the definition of Sentinel Event was further updated, expanding content addressing assault and homicide into six revised bullets separately addressing sexual abuse/assault, physical assault and homicide of any patient or staff member, licensed independent practitioner, visitor or vendor.

Early Survey Policy (ESP)

In January 2021, NPSG.01.01.01, EP 2 was deleted from the ESP, and effective July 2021, EC.02.05.02, EPs 1-2; LS 05.01.10, EPs 1-7;

LS.05.01.20, EPs 1-9; LS.05.01.30, EPs 1-4; LS.05.01.34, EPs 1-3; and

LS.05.01.35, EPs 1-6 were all added to the ESP.

1.3. References and Resources

The Joint Commission E-dition Emergency Management, Environment of

Care and Life Safety Chapters.

Environment of Care News, The Source and Joint Commission

Perspectives. Newsletters available via the OQSV website.

Reference materials and Environment of Care pages on the HEFP website.

The Joint Commission Standards for Veterans Affairs Community Living

Centers (CLCs) standards.

VHA Directive 1608, Comprehensive Environment of Care (CEOC)

Program.

http://vaww.oqsv.med.va.gov/functions/integrity/accred/accredNewsletters.aspx http://vaww.hefp.va.gov/topics/environment-care-eoc https://www.va.gov/vhapublications/publications.cfm?Pub=1

The next chapters that were reviewed include Care, Treatment and

Services (Behavioral Health Care); Medication Management; Nursing; and

Chapter 2

Environment of Care Survey Process and Scoring

Environment of Care Survey

Process and Scoring

2.1. Project REFRESH

R eal-time information gathering between surveyors and Standards

Interpretation (group during survey)

E nhanced mobile technology (survey accuracy)

F ewer standards

R evised criticality models for standards

E asier and less complex decision process

S treamlined post-survey process

H igher consistency in interpretation of standards

Project REFRESH is a series of interrelated process improvement projects underway that will impact The Joint Commission accreditation programs.

The projects look at various aspects of pre-survey, on-site survey and post-survey activities in an effort to:

• Simplify them.

• Enhance their relevancy to accredited organizations.

• Increase transparency within the accreditation process.

• Utilize innovative approaches and technology to enrich the customer experience.

• Identify and communicate risk levels.

• Help prioritize and focus corrective actions.

The Elements of Performance (EP) Review Project is a multi-phased component of Project REFRESH, a series of interrelated process improvement initiatives The Joint Commission has been conducting. The first chapters for Phase IV were evaluated for streamlining and consolidation at the January 1, 2018 and July 1, 2018 releases. The Joint

Commission’s multi-phase process improvement project includes the

Survey Analysis for Evaluating Risk (SAFER) Matrix™, effective January 1, 2017.

Provision of Care, Treatment and Services. These changes became effective January 2019, and, as with the first set of chapters, the consolidations reduced the number of EPs.

Table 1-1: Changes to Survey Processes

CHANGE NEW PROCESS

Scoring methodology Elimination of Category A Surveyors will perform a and C scoring designations real-time, on-site evaluation and direct and indirect of deficiencies, placing impact Elements of each one within the SAFER Performance (EPs). Matrix™ according to the likelihood of the issue to cause harm to patients, staff or visitors, and according to how widespread the problem is, based on surveyors’ observations (that is, scope).

Post-survey, follow-up Opportunities for All observations of activities Improvement (single noncompliance will be observations of documented within the noncompliance at Category SAFER Matrix™ and will C EPs) will no longer exist. require follow-up activity Also, Measures of Success based on placement within (MOS) will no longer be the matrix. Immediate required. Threats to Life (ITLs) will be noted with the SAFER Matrix™, but the identification and follow-up process for ITLs will not change.

Submission time frame EPs will no longer be All cited deficiencies will be for Evidence of identified as direct impact assigned a single time Standards Compliance (with 45 days for frame of 60 days for (ESC) submission) or indirect corrective action. For impact (with 60 days for deficiencies of a higher risk submission). level in the matrix, additional information will be required within the ESC regarding sustainment of corrective actions.

2.2. Statement of Conditions (SOC™) Process Changes Effective

August 1, 2016

Effect on the Life Safety Plans for Improvement (PFI)

Effective August 1, 2016, changes to the SOC process impacted the Life

Safety (LS) chapter survey requirements. The following changes to the survey occurred:

1. The open PFI items will no longer be reviewed by the survey team.

Any PFI items provided to the surveyor could become findings. The

PFI Program is for facility use only.

2. The open PFI will no longer be imported into the final report.

3. All LS chapter deficiencies identified during survey will become

Requirements for Improvement (RFI) with a 60-day ESC.

For those deficiencies that require more than 60 days, a Time-

Limited Waiver (TLW) process is available. Note: The Joint

Commission recommends that facilities submit TLWs at the 45-day mark to ensure timely feedback.

4. Only equivalency requests related to survey events will be reviewed.

The Joint Commission has had the SOC as part of its accreditation program since 1995. The SOC was originally created to allow organizations a process to develop a plan for improvement to correct deficiencies they self-identified within a justifiable time frame based on budgeting and scheduling needs, with Interim Life Safety Measures (ILSM) to ensure patient safety. Initially, these self-identified actions were not documented during the survey because the SOC already documented the deficiency. The Joint Commission also created the ILSM process to mitigate risk while resolving the deficiencies. This allowed the SOC process to be the method for organizations to create and submit their PFI, with an amount of time to make the correction that the organization could manage, while still providing a safe environment. Occasionally, an organization would need additional time to complete the corrective action, and The Joint Commission granted extension requests. Many of these extension requests occurred during the 6-month automatic extension period.

Centers for Medicare and Medicaid Services (CMS) has identified required changes to the SOC process, including:

• No longer allowing the SOC to document self-identified deficiencies;

instead, taking the self-identified deficiencies and converting those to RFIs by the surveyor.

• No longer allowing more than 60 days for corrective actions unless approved by the CMS regional office.

• The surveyor citing all deficiencies, replacing the extension request component with a Time-Limited Waiver process, using the Survey-related Plan for Improvement (SPFI) process that will be managed and tracked by the CMS regional office.

• Managing the survey-related equivalency process, as defined by

CMS, using Salesforce and the SOC to manage and track the CMS regional office action.

• Removing the 6-month automatic extension.

• No longer granting requested extensions.

The Joint Commission determined that the Basic Building Information (BBI) is to be once again included in the SOC. The addition of EP 7 to

LS.01.01.01 was added effective January 1, 2020 with this change.

2018 Review Project Changed 300 Hospital Requirements

Project REFRESH includes a project first announced in the December 9, 2015 issue of Joint Commission Online - the evaluation of standards and

EPs in order to identify EPs that were no longer considered necessary to assess quality and safety. This effort to modernize and streamline The

Joint Commission requirements resulted in the deletion of 225 EPs from the Comprehensive Accreditation Manual for Hospitals (CAMH). The majority of these deletions were effective July 1, 2016. The other 94 deleted EPs, which relate to duplicative restraint and seclusion standards, became effective in January 2017. None of the deletions are connected to

Medicare Conditions of Participation.

The deleted restraint and seclusion standards were only applicable to organizations that do not use accreditation for Medicare reimbursement purposes. The deleted standards were very similar to other restraint and seclusion requirements (Standards PC.03.05.01 through PC.03.05.19) that address the Conditions of Participation (CoPs). For simplicity and clarity, The Joint Commission decided to use the restraint and seclusion standards that address the CoPs for all organizations, regardless of deemed status.

The deletion of Standards PC.03.02.01 through PC.03.03.31 went into effect in January 2017.

2.3. Enclosure

2-1 Sample Statement of Conditions Management Memo http://vaww.hefp.va.gov/resources/2-1-statement-conditions-management-memo

Chapter 3

The Office of Quality, Safety & Value(OQSV), Division of External Accreditation Services & Programs

The Office of Quality, Safety &

Value (OQSV), Division of External

Accreditation Services &

Programs

3.1. Survey Readiness

The Survey Readiness Program allows the Department of Veterans Affairs

(VA), Veterans Health Administration (VHA) facilities, program offices and

Veterans Integrated Service Networks (VISNs) to participate in a Survey

Readiness Program to continue to improve compliance with The Joint

Commission standards. Joint Commission Standard compliance occurs when an organization, at the time of survey, is found to meet or exceed

The Joint Commission standards.

The survey readiness information on the VHA OQSV website provides valuable resources, including presentations, guides, tools and reports on various environment of care topics. As of June 2017, the following list provides a sample of topics that might interest the user of this guidebook:

• Joint Commission Survey Activity Guide.

• Joint Commission Corporate Orientation for Surveys.

• The Joint Commission (TJC) Survey Team Leader Bio’s and VHA

Program Office Overviews.

• “Facility TJC Experience Report” shared aspects of The Joint

Commission survey visit such as programs reviewed, survey findings, tips and lessons learned.

• The Joint Commission (TJC) Standards Interpretation Group (SIG)

FAQs.

• The Joint Commission Summation Presentation – January 26, 2017.

• The Joint Commission Monthly Newsletters.

3.2. The Joint Commission Field Tracker Report

The Joint Commission Field Tracker Report is prepared by the VHA OQSV and summarizes The Joint Commission findings of less than full http://vaww.oqsv.med.va.gov/functions/integrity/accred/JCRContinuousSurvey.aspx https://www.jointcommission.org/assets/1/6/2019_All_Programs_Organization_Survey_Activity_Guide.pdf http://vaww.oqsv.med.va.gov/functions/integrity/accred/jointcommission.aspx http://vaww.oqsv.med.va.gov/functions/integrity/accred/jointcommissionorientation.aspx http://vaww.oqsv.med.va.gov/functions/integrity/accred/jointcommissionorientation.aspx http://vaww.oqsv.med.va.gov/functions/integrity/accred/jointcommission.aspx http://vaww.oqsv.med.va.gov/functions/integrity/accred/jointCommissionSIGFAQs.aspx http://vaww.oqsv.med.va.gov/functions/integrity/accred/jointCommissionSIGFAQs.aspx http://vaww.oqsv.med.va.gov/functions/integrity/accred/jointcommission.aspx http://vaww.oqsv.med.va.gov/functions/integrity/accred/accredNewsletters.aspx compliance for VA facilities. The report provides data on the following items:

• User dashboard.

• The 25 most-cited and least-cited standards.

• Total findings by program.

• Totals and percentage of facilities cited by standard and elements of performance.

The format of the field tracker report, “TJC Quality Manager Tracker

Report-Calendar Year 2018,” has been updated and now provides findings referenced to the elements of performance (EP) in addition to findings based on The Joint Commission standards. This information should help facilities prepare for their accreditation survey.

The report of “CBOCs Most Challenging TJC Standards in VA” is also available online at the VHA OQSV website.

3.3. Environment of Care Most Challenging Standards

Annually, The Joint Commission publishes the top ten most-cited standards, with the percentage of surveyed facilities that were cited for each. In 2020, due to the COVID-19 Pandemic, a limited number of surveys were conducted, resulting in The Joint Commission publishing the top five most challenging requirements for each Ambulatory Health Care, Behavioral Health Care and Human Services, Hospital, Critical Access

Hospitals, Home Care; Laboratory and Point-of-Care Testing, Nursing Care

Centers, and Office-Based Surgery. We present here the top five hospital most challenging standards; the other categories can be found on the Joint

Commission web site:

1. NPSG.15.01.01, EP 1: Reduce the risk for suicide

2. IC.02.02.01, EP 2: The hospital reduces the risk of infections associated with medical equipment devices and supplies.

3. IC.02.02.01, EP 1: The hospital implements its infection prevention and control plan.

4. MM.06.01.01, EP 3: The hospital safely administers medication.

5. EC.02.05.01, EP 15: The hospital manages risks associated with its utility systems.

http://vaww.oqsv.med.va.gov/functions/integrity/accred/jointcommission.aspx http://vaww.oqsv.med.va.gov/functions/integrity/accred/jointcommission.aspx https://www.jointcommission.org/resources/news-and-multimedia/newsletters/newsletters/joint-commission-online/may-12-2021/top-5-most-challenging-requirements-for-2020/ https://www.jointcommission.org/resources/news-and-multimedia/newsletters/newsletters/joint-commission-online/may-12-2021/top-5-most-challenging-requirements-for-2020/

Management Plans

4.1. Management Plans Introduction and Overview

Chapter 4

Management Plans

The requirement for Environment of Care component management plans is outlined in the Environment of Care (EC) Standard EC 01.01.01. There are eight elements of performance (EPs) that describe the content and objectives of the management plans. Note carefully the second paragraph of the rationale given for the standard that describes the management plans as high-level written management plans designed to help the hospital manage risks. These plans are not the same as operational plans but provide a framework for managing the environment of care. The plans should address the scope and objectives of risk assessment and management, describe the responsibilities of individuals or groups and give time frames for specific activities identified in the plan.

It is not necessary to recreate existing policy or procedure documents to satisfy the management plan requirement. Where appropriate, include the title and number of applicable medical center policies containing the required information and use the management plan as an atlas, showing the relationship between existing policies and procedures and The Joint

Commission Standards. A flow chart or diagram showing the relationships of the various medical center policies, standard operating procedures

(SOPs), departments, individuals and programs can be very useful in demonstrating document relationships and compliance.

Templates for each of the required management plans are provided as enclosures for use in developing the required management plans provided in this chapter. Individual management plans are not required, and a single document can be used. Regardless of the format, ensure that all the required elements are accounted for.

Be sure to distinguish between the management of these program standards at medical centers, community-based outpatient clinics

(CBOCs), or other off-site patient treatment centers. The templates provided outline operations only at medical centers. Language to include the relevant CBOCs (see Enclosure 4-10, Sample Utility Systems

Management Plan) should be addressed, and separate management plans for operations at other locations should be produced if they are not covered in the hospital management plan. Because most medical centers have multiple CBOCs, it is possible to produce a management plan for medical center operations and a separate individual or “umbrella” management http://vaww.hefp.va.gov/resources/4-10-sample-utility-systems-management-plan plan outlining CBOC operations. They should be similar in nature by process, although some specifics might be different. For example, all the

CBOCs might have to call 911 to access local law enforcement and fire services, although the name of the organizations could vary. An additional example might be that the medical center fire plan would reference a fire drill conduct and documentation policy that differs from the policy used for conducting and documenting fire drills at the dependent CBOCs. As an additional example, where hazardous materials are used at the CBOC, the spill response process will likely vary considerably from the hospital response. If similar operational elements between the CBOCs do not exist, then a specific management plan for each dissimilar CBOC operation should be generated. Each off-site patient care location’s environment of care elements must be addressed in a management plan (either medical center or program or site-specific) to include mental health facilities, transition housing, domiciliary and similar operations.

Each template includes descriptive text that must be replaced or deleted in the final document. The suggested position titles (e.g., “Chief, Facilities Management”) provided in each template (typically in bold) must be altered to reflect the actual operations and responsibilities within the medical center. Broad descriptions of responsibility for specific EPs should be used only in a limited number of instances and with a great deal of caution. Performance responsibility should not be assigned to the

Department of Veterans Affairs Medical Center (VAMC) facility alone (i.e., Anywhere VAMC) since the VAMC itself cannot have individual element responsibilities. In addition, be cautious in using terminology such as “all employees” or “all supervisors” for assigning specific responsibilities.

Responsibilities must generally be assigned to a person (e.g., Chief, Engineering) or group of persons (e.g., Environment of Care Committee) specifically.

As the templates are edited, recognize that individual EPs are listed in the same order as outlined in the respective standard and numbered exactly as the EP is numbered in the Hospital Accreditation Program (HAP) so the standard can be referred to when writing the management plan. Do not eliminate entire individual EP paragraphs without providing a clear reference to existing medical center policies or procedures containing the specific requirement. Ensure that the existing documents are carefully read to ensure that the specific requirement is present as outlined by The Joint

Commission.

The templates provided cover each of the Environment of Care Program elements. Emergency Management no longer has a management plan requirement (although a template is provided), but The Joint Commission requires a written Emergency Operations Plan that details the organization’s plans to prepare for, respond to and recover from a disaster.

The writer should distinguish between the operational elements contained in the Fire Safety Management Plan and the construction and features requirements contained in the Life Safety (LS) Standard. A template for the

Fire Safety Management Plan is included.

As in past years, a Safe and Functional Environment template is provided as a management plan template instead of a program appendix, although this management plan is not specifically identified in the EC Standards.

Please see the note at the beginning of this template for guidance on use.

The templates provided include a combined Safety and Security

Management Plan as well as separate plans for both Safety and Security.

Regardless of the approach taken, ensure that all the Environment of Care

EPs are included in a management plan. Where the EPs do not follow the outline provided in the EC Standard, consider providing a crosswalk or

“roadmap” of where they can be found (either as an official policy document or as a cover for the documents provided to the survey team) in the respective management plans to avoid unnecessary surveyor confusion.

An overview template (Enclosure 4-1) is also provided to serve as a cover document for medical centers using a single medical center policy memorandum to contain all Environment of Care policies and procedures

(i.e., the Environment of Care manual approach).

Good luck on the survey!

4.2. Enclosures

4-1. Sample Overview of Environment of Care, Life Safety and

Emergency Management Operations

4-2. Sample Emergency Operations Plan

4-3. Sample Fire Safety Management Plan

4-4. Sample Hazardous Materials and Waste Management Plan

4-5. Sample Medical Equipment Management Plan

4-6. Sample Safe and Functional Environment Management Plan

4-7. Sample Safety Management Plan

4-8. Sample Security Management Plan

4-9. Sample Safety and Security Management Plan http://vaww.hefp.va.gov/resources/4-1-sample-overview-environment-care-life-safety-and-emergency-management-operations http://vaww.hefp.va.gov/resources/4-1-sample-overview-environment-care-life-safety-and-emergency-management-operations http://vaww.hefp.va.gov/resources/4-1-sample-overview-environment-care-life-safety-and-emergency-management-operations http://vaww.hefp.va.gov/resources/4-2-sample-emergency-operations-plan http://vaww.hefp.va.gov/resources/4-3-sample-fire-safety-management-plan http://vaww.hefp.va.gov/resources/4-4-sample-hazardous-materials-and-waste-management-plan http://vaww.hefp.va.gov/resources/4-5-sample-medical-equipment-management-plan http://vaww.hefp.va.gov/resources/4-6-sample-safe-and-functional-environment-management-plan http://vaww.hefp.va.gov/resources/4-7-sample-safety-management-plan http://vaww.hefp.va.gov/resources/4-8-sample-security-management-plan http://vaww.hefp.va.gov/resources/4-9-sample-safety-and-security-management-plan

4-10. Sample Utility Systems Management Plan http://vaww.hefp.va.gov/resources/4-10-sample-utility-systems-management-plan

Implement

5.1. Safety and Security Management

Introduction

Chapter 5

Implement

Risks are inherent in the health care environment because of the types of care provided and the equipment and materials that are necessary to provide high-quality health care. Risks should be managed through an organized approach that involves a proactive assessment of the harm that could occur. Risk assessments and reduction activities should be managed by one or more individuals, and they must have the authority to intervene when any condition that poses an immediate or delayed threat to life or that would cause irreversible adverse health effects exists.

In March 2017, The Joint Commission issued Sentinel Event Alert Issue

57, “The essential role of leadership in developing safety culture” (available online at The Joint Commission website). The issue addresses The Joint

Commission establishing a theoretical framework that emphasizes safety culture, leadership and robust process improvement as three domains that are critical to high reliability within a health care organization. By promoting the core attributes of trust, report and improve, high-reliability organizations create safety cultures in which team members trust peers and leadership;

report vulnerabilities and hazards that require risk-based consideration;

and communicate the benefits of these improvements back to involved staff. Leaders can self-assess performance and improvements relating to high reliability by using the Oro™ 2.0 High Reliability Organizational

Assessment and Resources Tool.

Note: Please refer to Chapter 4, Management Plans, for the discussion on management plans.

Risks in the health care environment affect all individuals in the organization: patients, visitors and those who work in the hospital. It is important to identify these risks in advance so that the hospital can prevent or effectively respond to incidents. It should be noted that safety and security were merged into one Environment of Care (EC) Standard, EC.02.01.01. Facilities may manage safety and security as a single function or separately.

http://www.jointcommission.org/sentinel_event.aspx

Standards

Note: The standards below can be accessed online via the Veterans

Health Administration (VHA) Office of Quality, Safety & Value (OQSV) website (click on “Joint Commission Manual via E-dition”).

5.1.2.a. Standard EC.01.01.01

The hospital plans activities to minimize risks in the environment of care.

Note: One or more persons can be assigned to manage risks associated with the management plans described in this standard.

5.1.2.b. Standard EC.02.01.01

The hospital manages safety and security risks.

5.1.2.c. Standard EC.02.01.03

The hospital prohibits smoking except in specific circumstances.

Compliance Tips

5.1.3.a. Standard EC.01.01.01

EC.01.01.01, EP 1 requires medical facilities to identify an individual(s) to manage risk. An appointment letter should name a specific individual(s) and should be cited by the Facility Director. The appointment letter does not require updating unless another individual is assigned to the task or there is a change in leadership (see Enclosure 5-1 for a sample Safety

Officer designation letter). EC.01.01.01, EPs 4-8 require written management plans for safety and security, hazardous materials and waste, fire safety, medical equipment and utility management. January 1, 2018, EP 3 was added, requiring the hospital to have a library of information regarding inspection, testing and maintenance of its equipment and systems.

Management plans should be a description and not a rewrite of the program. The plans are not the same as operational plans but provide a framework for managing the environment of care. They should be consistent in format, include a list of applicable facilities and describe each of the EPs. The plans should address the scope and objectives of risk assessment and management; describe responsibilities, performance improvement, training, applicable policy/procedures; and provide time frames for specific activities identified in the plan. Lastly, the management plans should be reviewed on an annual basis by the Environment of Care

Committee (EOCC), and the review should be documented in the EOCC minutes (see Enclosure 5-2 for a sample Environment of Care annual http://vaww.oqsv.med.va.gov/functions/integrity/accred/jointcommission.aspx http://vaww.oqsv.med.va.gov/functions/integrity/accred/jointcommission.aspx http://vaww.oqsv.med.va.gov/functions/integrity/accred/jointcommission.aspx http://vaww.hefp.va.gov/resources/5-1-sample-safety-officer-designation http://vaww.hefp.va.gov/resources/5-2-sample-environment-care-annual-report

36C25922R0102 report). Sample management plans are provided in Chapter 4, Management Plans.

5.1.3.b. Standard EC.02.01.01

The hospital manages safety and security risks.

This standard has remained unchanged since the 2017 updates.

Risk Assessments: When an item is identified that introduces a potential risk to the environment that is not explicitly addressed within codes or standards, a risk assessment should be performed to ensure the risk is properly managed. Once a decision has been made determining what action is to be taken, this decision should be properly documented, and efforts should be made to revisit this item to monitor the risk.

Risk assessments may be global and address a large area within the environment of care, or they may be specific and address a specific issue.

They may be identified from internal sources, such as ongoing monitoring, results of root cause analyses, results of proactive risk assessments of high-risk processes and from credible external sources, such as Sentinel

Event Alerts. Specific risk assessment topics may include:

• Locking of clean supply room doors.

• Equipment test tags.

• Refrigerator temperature tests.

• Nurse call systems.

• Infant/pediatric abduction measures.

• Safe environment for mental health.

• Defibrillator testing.

• Use of cardboard boxes in the facility.

• Tubing connections.

In February 2019, The Joint Commission revised Sentinel Event Alert Issue

45, Preventing violence in the health care setting (originally published June

3, 2010, addendum February 2017). Sentinel Event Alert 45 is available online at The Joint Commission website (click on “View More” inside the

“Sentinel Event Alert” box). Once considered safe havens, health care institutions today are confronting steadily increasing rates of crime, including violent crimes such as assault, rape and homicide. Resources have been added to the Workplace Violence Prevention Resources Portal.

http://www.jointcommission.org/sentinel_event.aspx

The Sentinel Event Alert suggested the following actions be taken to prevent violent acts from occurring in a health care setting:

• Audit the risk of violence in the medical center.

• Work with local law enforcement to seek their input on risk issues and potential solutions.

• Evaluate the medical center’s Violence Prevention Program.

• Take extra security precautions in the Emergency Department (ED).

• Discuss issues with Human Resources.

• Provide appropriate employee training.

• Ensure that practical response procedures are in place.

• Provide counseling and other services, as required.

• Report violent acts to local authorities when appropriate.

• Educate supervisors that all reports of suspicious behavior or threats are to be taken seriously.

In 2018, The Joint Commission issued two new Sentinel Events. First, on

April 17, Sentinel Event Alert 59: Physical and verbal violence against health care workers, was published, followed on July 31 with the launch of the webinar titled “Workplace Violence Prevention: Implementing

Strategies for Safer Healthcare Organizations.” Both focused on either the risk to staff, patients or visitors.

5.1.3.c. Standard EC.02.01.03

Smoking Policy: EC.02.01.03 applies to all smoking types, including tobacco, electronic or other. Smoking Cessation Program requirements for patients who smoke within buildings are not specifically addressed in the

EC Standards. EC.02.01.03 does allow patients of specific circumstances to smoke within buildings, and these exceptions are covered in the

Provision of Care (PC) Chapter of The Joint Commission Manual, though not explicitly.

On March 5, 2019, the Department…