D.10 Attachment - Environment of Care Guidebook 2019.pdf

Research Laboratory Safety Guidebook Volume 1:

Managing Chemical Safety

Environment of Care

Guidebook

Published by

VHA Center for Engineering & Occupational Safety and Health (CEOSH)

St. Louis, Missouri vaww.ceosh.med.va.gov i

Table of Contents

PREFACE

Disclaimers ................................................................................................................ vii

Executive Summary ................................................................................................. viii

Acknowledgements .................................................................................................... ix

Update Listing ............................................................................................................. xi

Acronyms and Abbreviations .................................................................................. xii

1 What's New in the Guidebook?

1.1. Introduction

1.2. What’s New

1.2.1. Emergency Management (EM)

1.2.2. Environment of Care (EC)

1.2.3. Life Safety

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

2.2.1. Effect on the Life Safety Plans for Improvement (PFI)

2.2.2. 2018 Review Project Changed 300 Hospital Requirements

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 and Life Safety Chapters Most Challenging Standards 12

4 Management Plans

4.1. Management Plans Introduction and Overview

4.2. Enclosures

5 Implement

5.1. Safety and Security Management

5.1.1. Introduction

5.1.2. Standards

5.1.2.a. Standard EC.01.01.01 ii

5.1.2.b. Standard EC.02.01.01

5.1.2.c. Standard EC.02.01.03

5.1.3. 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

5.1.4. References and Resources

5.1.5. Enclosures

5.2. Hazardous Materials and Waste

5.2.1. Standard

5.2.1.a. Standard EC.02.02.01

5.2.2. Compliance Tips

5.3. Fire Safety

5.3.1. Introduction

5.3.2. 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

5.3.3. Compliance Tips

5.3.3.a. Door Testing

5.3.3.b. Documentation of Inspection Testing and Maintenance

5.3.4. Enclosures

5.4. Medical Equipment Management

5.4.1. Standards

5.4.1.a. Standard EC.02.04.01

5.4.1.b. Standard EC.02.04.03

5.4.2. Compliance Tips

5.4.2.a. Standard EC.02.04.01

5.4.2.b. Standard EC.02.04.03

5.4.3. 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 iii

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

5.4.3.i. Surveyor Questions and Findings

5.4.3.j. Surveyor interaction

5.4.4. References and Resources

5.4.5. Enclosures

5.5. Utilities Management

5.5.1. Standards

5.5.1.a. Standard EC.02.05.01

5.5.1.b. Standard EC.02.05.03

5.5.1.c. Standard EC.02.05.05

5.5.1.d. Standard EC.02.05.07

5.5.1.e. Standard EC.02.05.09

5.5.2. Compliance Tips

5.5.2.a. EC.02.05.01

5.5.2.b. EC.02.05.03

5.5.2.c. EC.02.05.05

5.5.2.d. EC.02.05.07

5.5.2.e. EC.02.05.09

5.5.3. Enclosures

5.6. Other Physical Environment Requirements

5.6.1. Standards

5.6.1.a. Standard EC.02.06.01

5.6.1.b. Standard EC.02.06.05

5.6.2. Compliance Tips

5.6.2.a. Standard EC.02.06.01

5.6.2.b. Standard EC.02.06.05

5.6.3. References and Resources

5.6.4. Enclosures

6 Staff Competency for Environment of Care

6.1. Standards

6.1.1. Standard EC.03.01.01

6.1.1.a. Related Standards

6.2. Compliance Tips

iv

6.3. References and Resources

7 Monitor and Improve

7.1. Standards

7.1.1. Standard EC.04.01.01

7.1.2. Standard EC.04.01.03

7.1.3. Standard EC.04.01.05

7.1.4. Standard EM.03.01.01

7.1.5. Standard EM.03.01.03

7.2. Compliance Tips

7.2.1. Standard EC.04.01.01

7.2.2. Standard EC.04.01.03

7.2.3. Standard EC.04.01.05

7.2.4. Top Standards Compliance Issues for 2015

7.3. Enclosures

8 Patient Safety

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

8.1.1. Goal 6: Reduce the Harm Associated with Clinical Alarm Systems

8.1.1.a. NPSG.06.01.01

8.1.1.b. References and Resources

8.1.2. Goal 7: Reduce the Risk of Healthcare Associated Infections

8.1.2.a. NPSG.07.01.01

8.1.2.b. References and Resources

8.1.3. Goal 15: The Organization Identifies Safety Risks Inherent in its

[Patient] Population

8.1.3.a. NPSG.15.01.01

8.1.3.b. References and Resources

8.2. Sentinel Event Alerts

8.3. Patient Safety Tools and Topics

8.3.1. Patient Safety Assessment Tool (PSAT)

8.3.2. VHA Patient Safety Alerts and Advisories

8.3.3. Root Cause Analysis (RCA)

8.3.4. Healthcare Failure Mode and Effect Analysis (HFMEA)

8.3.5. General Patient Safety Links

8.3.6. Patient Safety Topics

8.4. Preventing Surgical Fires

v

8.4.1. Background

8.4.2. Guidance

8.4.3. References and Resources

8.5. Alcohol-Based Hand Cleaner

8.5.1. Background

8.5.2. Installation

8.5.3. References and Resources

9 Life Safety Standards

9.1. Introduction

9.2. Standards

9.2.1. Standard LS.01.01.01

9.2.2. Standard LS.01.02.01

9.2.3. Standard LS.02.01.10

9.2.4. Standard LS.02.01.20

9.2.5. Standard LS.02.01.30

9.2.6. Standard LS.02.01.34

9.2.7. Standard LS.02.01.35

9.2.8. Standard LS.02.01.40

9.2.9. Standard LS.02.01.50

9.2.10. Standard LS.02.01.70

9.2.11. Standard LS.03.01.10

9.2.12. Standard LS.03.01.20

9.2.13. Standard LS.03.01.30

9.2.14. Standard LS.03.01.34

9.2.15. Standard LS.03.01.35

9.2.16. Standard LS.03.01.40

9.2.17. Standard LS.03.01.50

9.2.18. Standard LS.03.01.70

9.3. Compliance Tips

9.3.1. LS.01.01.01

9.3.2. LS.01.02.01

9.4. Enclosures

10 Environment of Care News

10.1. Environment of Care News

10.2. Healthcare Interpretations Task Force (HITF)

vi

10.3. References

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 vii

Disclaimers

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) Center for Engineering & Occupational Safety and Health (CEOSH) website, electronic media, or printed media.

Guidance

VHA CEOSH guidebooks are “BEST PRACTICE” resources designed to assist health care facilities implement and enhance programs and more effectively comply with current VA/VHA policy and external regulatory standards. CEOSH guidebooks are NOT OFFICIAL POLICY. In accordance with VHA Directive 6330(1), Controlled National Policy/Directives Management System, official policy documents include: (1) Directives, which carry the authority to mandate Department- or Administration-wide policies, and (2) Handbooks, which carry the authority to mandate procedures or operational requirements implementing policies contained in directives.

https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=4310 https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=4310 viii

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 2019 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 Center for Engineering & Occupational Safety and Health (CEOSH) 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, Center for Engineering &

Occupational Safety and Health (CEOSH), St. Louis, Missouri, at (314) 894-6100, extension 66081, or by email at Jeff.Vaughn@va.gov.

http://vaww.ceosh.med.va.gov/ mailto:Jeff.Vaughn@va.gov ix

Acknowledgements A special thank you is extended to Jeff Vaughn, Safety Data Sheet

(SDS)/Chemical Inventory Service Program Manager, for his commitment in providing the 2019 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 Center for Engineering & Occupational

Safety and Health (CEOSH), St. Louis, Missouri.

*Howrey Ferguson, CHMM, CHEC, Chief, Safety & Health Technical Services, CEOSH, St. Louis, MO

*Jeff Vaughn, Program Manager, SDS/Chemical Inventory Services, CEOSH, 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

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

CEOSH Publishing Staff

Tina Beckner, Lead Technical Information Specialist, St. Louis, MO

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

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

Connie Young, Chief, Publishing Services, St. Louis, MO x

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/ xi

Update Listing The following listing identifies online updates since the initial publication of the

June 2017 edition of this guidebook. It is designed to assist the reader in verifying the most current information available.

Update

Number Date Updated Remarks Chapter/Section

1 January 2019 See Chapter 1 for a brief overview of The Joint Commission updates from January 2018 to January

2019.

Updated Project REFRESH information.

Added The Joint Commission’s ten most-cited standards.

3.3.

Updated Joint Commission standards and compliance tips to delete old information and add new information regarding The Joint

Commission updates.

5, 6, 7, 9

The revised document, “Joint

Commission Concurrence on 23

Clarification Issues (Revised

September 4, 2017)” was included as a reference on the CEOSH website.

5.3.2.c.

Updated information regarding patient alarms.

5.4.3.h.

Updated National Patient Safety

Goals (NPSGs) and added

Sentinel Alerts and Safety Alerts and Advisories. .

Added five Healthcare

Interpretations Task Force (HITF)

Decisions.

10.2.

http://vaww.ceosh.med.va.gov/01HP/Pages/JC_References.shtml xii

Acronyms and Abbreviations

ACRONYM/

ABBREVIATION

DEFINITION

A&MM Acquisition and Materiel Management

A/E Architect/Engineer

AAMI Association for the Advancement of Medical Instrumentation

AAR After Action Report

AC Alternate Current

ACGIH® American Conference of Governmental Industrial Hygienists

ACR American College of Radiology

AED Automated External Defibrillator

AEM Area Emergency Manager

AEM Alternative Equipment Maintenance

AEMS/MERS Automated Engineering Management System/Medical Equipment Reporting System

AER Automatic Endoscope Reprocessor

AHCA American Health Care Association

AHJ Authority Having Jurisdiction

AHRQ Agency for Healthcare Research and Quality

AIA American Institute of Architects

AMA American Medical Association

ANSI American National Standards Institute

AOD Administrative Officer of the Day

AORN Association of periOperative Registered Nurses

APIC Association for Professionals in Infection Control and Epidemiology

APR Accreditation Participation Requirements

ARMS Alerts and Recalls Management System

ARS Acute Radiation Syndrome

ASHE American Society for Healthcare Engineering

ASHRAE American Society of Heating, Refrigeration, and Air- Conditioning Engineers

ASISTS Automated Safety Incident Surveillance and Tracking System

ATC Above-the-Ceiling

ATS Automatic Transfer Switch

AWE Annual Workplace Evaluation

BBI Basic Building Information xiii

BCMA Bar Code Medication Administration

BESS Biomedical Equipment Support Specialist

BME Biomedical Engineering

BME Biomedical Engineer

BMET Biomedical Engineering Technician

BMP Building Maintenance Program

BSL Biosafety Level

CAA Clean Air Act

CAAA Clean Air Act Amendments

CAI Computer Assisted Instruction

CAMH Comprehensive Accreditation Manual for Hospitals

CAP College of American Pathology

CAP Combined Assessment Program

CARF Commission on Accreditation of Rehabilitation Facilities

CBOC Community-Based Outpatient Clinic

CCTV Closed-Circuit Television

CDC Centers for Disease Control and Prevention

CEAB Chief Engineers Advisory Board

CEM Comprehensive Emergency Management

CEMP Comprehensive Emergency Management Plan

CEO Chief Executive Officer

CEOC Comprehensive Environment of Care

CEOSH Center for Engineering & Occupational Safety and Health

CFM Office of Construction and Facilities Management

CFR Code of Federal Regulations

CHFM Certified Healthcare Facility Manager

CHG Chlorhexidine Gluconate

CIO Chief Information Officer/Office

CIS/ARK Clinical Information Systems/Anesthesia Record Keeping

CLC Community Living Center

CMS Centers for Medicare and Medicaid Services

CNO Chief Nurse Operator

CNH Community Nursing Home

CO Contracting Officer

COOP Continuity of Operations Plan

CoP Condition of Participation

COR Contracting Officer’s Representative

CSEPP Clinical Stockpile Emergency Preparedness Program

CSO Construction Safety Officer xiv

CSR Continuous Survey Readiness

CT Computerized Tomography

CWA Clean Water Act

CY Calendar Year

DASHO Designated Agency Safety Health Official

DCO Disaster Coordinating Officer

DEC Department of Environmental Conservation

Decon Decontamination

DEMPS Disaster Emergency Medical Personnel System

DER Department of Environmental Research

DFO Disaster Field Office

DHHS Department of Health and Human Services

DME Durable Medical Equipment

DoD Department of Defense

DOL Department of Labor

DOT Department of Transportation

DUSHOM Deputy Under Secretary for Health for Operations & Management e-BBI Electronic Basic Building Information

EC Environment of Care

ECRI Emergency Care Research Institute

EES Employee Education System

EFECT Employee Functional Education and Competency Team

EIL Equipment Inventory Listing

ELB Executive Leadership Board

EM Emergency Management

EMCAP Emergency Management Capability Assessment Program

EMI Electro-Magnetic Interference

EMP Emergency Management Program

EMPG Emergency Management Program Guidebook

EMS Environmental Management Service

EMSC Emergency Management Safety Coordinator

ENT Ear, Nose, & Throat

EO Executive Order

EOCC Environment of Care Committee

EOP Emergency Operations Plan

EP Elements of Performance

EPA Environmental Protection Agency

EPC Emergency Planning Committee e-PFI Electronic Plan for Improvement xv

EPS Emergency Power System

ER Emergency Room

ESC Evidence of Standards Compliance

ESC Executive Safety Committee

ESEM Environmental Safety and Equipment Management

ESF Emergency Support Function e-SOC Electronic Statement of Conditions

EtO Ethylene Oxide

FAQ Frequently Asked Question

FAR Federal Acquisition Regulations

FBI Federal Bureau of Investigation

FCO Federal Coordinating Officer

FDA Food and Drug Administration

FGI Facility Guidelines Institute

FMS Facilities Management Service

FRC Facility Recall Coordinator

FRP Federal Response Plan

FRRA Fire Resistance Rated Assembly

FSA Focused Standards Assessment

FSES Fire Safety Evaluation System

FSO Facility Safety Officer ft3 Cubic Feet

FY Fiscal Year

GEMS Green Environmental Management System

GHS Globally Harmonized System of Classification and Labeling of Chemicals

GI Gastrointestinal gpm Gallons per Minute

GPMRC Global Patient Movement Requirements Center

GSA General Services Administration

HAI Healthcare-Associated Infection

HAP Hospital Accreditation Program

HAS Hospital Accreditation Services

HazMat Hazardous Materials

HAZWOPER Hazardous Waste Operations and Emergency Response

HBPC Home-Based Primary Care

HEPA High-Efficiency Particulate Air

HCFA Health Care Financing Administration

HFMEA Healthcare Failure Mode and Effect Analysis

HICS Hospital Incident Command System xvi

HIPAA Health Insurance Portability and Accountability Act

HITF Healthcare Interpretations Task Force

HLD High-Level Disinfection

HR Human Resources

HTM Healthcare Technology Management

HVA Hazard Vulnerability Analysis

HVAC Heating, Ventilation, and Air Conditioning

IACW Immunization Action Coalition of Washington

IC Infection Control

ICES Information Collection and Evaluation System

ICRA Infection Control Risk Assessment

ICS Incident Command System

ICU Intensive Care Unit

IDLH Immediately Dangerous to Life and Health

ICC Infection Control Committee

IFMA International Fire Marshals Association

IFU Instructions for Use

IH Industrial Hygienist

IHI Institute for Healthcare Improvement

IL Information Letter

ILSM Interim Life Safety Measures

IM Intracycle Monitoring

IPM Integrated Pest Management

IRM/IT Information Resource Management/Information Technology

IRMS Information Resource Management Service

ISMP Institute for Safe Medication Practices

ISO International Organization for Standardization

ITL Immediate Threat to Life

ITM Inspection, Testing, and Maintenance

JCR Joint Commission Resources kg Kilogram kW Kilowatt

L Liter

LD Leadership

LIM Line Isolation Monitors

LIP Licensed Independent Practitioner

LPN Licensed Practical Nurse

LS Life Safety

LSA Life Safety Assessment

LSC Life Safety Code xvii

LSCS Life Safety Code Surveyor

LSS Life Safety Standard

LTC Long Term Care

MAA Medical Administrative Assistant

MC Medical Center

MCM Medical Center Memorandum

MDNS Medical Device Nomenclature System

MEC Minimal Effective Concentration

MEMP Medical Equipment Management Plan

MG Medical Gas

MGAVS Medical Gas and Vacuum System

MHRC Management of Human Resources Committee

MHz Megahertz mm Millimeter

MM Medication Management

MMR Measles, Mumps, and Rubella

MOS Measurement of Success

MOU Memorandum of Understanding

MR Magnetic Resonance

MRI Magnetic Resonance Imaging

NAVFAC Naval Facilities Engineering Command

NCPS National Center for Patient Safety

NCRP National Council for Radiation Protection & Measurements

NFPA® National Fire Protection Association®

NHCU Nursing Home Care Unit

NHPP National Health Physics Program

NIMS National Incident Management System

NIOSH National Institute for Occupational Safety and Health

NM Nuclear Medicine

NP Nurse Practitioner

NPSF National Patient Safety Foundation

NPSG National Patient Safety Goals

NQF National Quality Forum

NRC Network Recall Coordinator

NRC Nuclear Regulatory Commission

NRM Non-Recurring Maintenance

NWS National Weather Service

OAL Office of Acquisition and Logistics

OB Obstetrics

OCS Off-site Care Site xviii

OIG Office of Inspector General

OQSV Office of Quality, Safety & Value

OR Operating Room

OSH Occupational Safety and Health

OSHA Occupational Safety and Health Administration

OWCP Office of Workers’ Compensation Programs oz Ounce

P2 Pollution Prevention

PA Public Address

PAG Professional Advisory Group

PAPR Powered Air-Purifying Respirator

PC Provision of Care

PCB Polychlorinated Biphenyl

PCRA Pre-Construction Risk Assessment

PDA Preliminary Denial of Accreditation

PDF Portable Document Format

PET Positron Emission Tomography

PFA Priority Focus Area

PFI Plan for Improvement

PFP Priority Focus Process

PI Performance Improvement

PIMS Performance Improvement Management System

PIO Public Information Officer

PM Preventive Maintenance

PM Property Management

PPE Personal Protective Equipment

PPR Periodic Performance Review

PS Patient Safety

PSAT Patient Safety Assessment Tool psi Pounds per Square Inch

PTSM Plant Technology and Safety Management

Q&A Question and Answer

QM Quality Management

QR Quick Response

RA Risk Assessment

RAC Risk Analysis Code

RACE Rescue/Remove, Alarm/Activate, Confine, Extinguish

RCA Root Cause Analysis

RCN Report Control Number

RCRA Resource Conservation and Recovery Act

RE Resident Engineer xix

RFI Requirement for Improvement

RFP Request for Proposal

RFQ Request for Quotation

RI Rights and Responsibilities of the Individual

RM Risk Management

RME Reusable Medical Equipment

RPM Revolutions per Minute

SAC Safety Assessment Code

SAFE Safety Automated Facility Evaluation

SARA Superfund Amendments and Reauthorization Act

SCBA Self-Contained Breathing Apparatus

SDS Safety Data Sheet

SEPSS Stored Emergency Power Supply System

SES Senior Executive Service

SFO Solicitation for Offers

SICU Surgical Intensive Care Unit

SIG Standards Interpretation Group

SII Standards Improvement Initiative

SITREP Situation Report

SMDA Safe Medical Devices Act

SME Subject Matter Expert

SOARS System-Wide Ongoing Assessment and Review Strategy

SOC™ Statement of Conditions™

SOI Service Operating Instructions

SOP Standard Operating Procedure

SPFI Survey-related Plan for Improvement

SPS Sterile Processing Service

SRF Survey Report Form

SRMC Safety and Risk Management Committee

TB Tuberculosis

TiPS Topics in Patient Safety

TJC The Joint Commission

TLW Time-Limited Waiver

UFAS Uniform Federal Accessibility Standards

UPS Uninterruptible Power Supply

USC United States Code

USP United States Pharmacopeia

VA Department of Veterans Affairs

VA-PAS Department of Veterans Affairs Personnel Accountability System xx

VAAR Veterans Affairs Acquisition Regulation

VACO Department of Veterans Affairs Central Office

VAF Veterans Affairs Form

VHA Veterans Health Administration

VISN Veterans Integrated Service Network

VPC Visco Palliative Care

VSSC VISN Support Service Center webPSAT Web-based Version of the PSAT

WHO World Health Organization

WMD Weapons of Mass Destruction

WOC Without Compensation

WT Waived Testing

Y2K Year 2000

Chapter 1

What's New in the Guidebook?

1 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 2019 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.

A single change was made to the EC standards following the January 2019 update, with a significant number of changes made to The Joint Commission’s EC and Life Safety (LS) standards in 2018. These changes are highlighted in this chapter, with a brief discussion of the 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 Center for Engineering & Occupational

Safety and Health (CEOSH) website. The 2019 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

In January 2019, one new Element of Performance (EP) was added to

EC.02.04.03, following the updates in January, March, and July of 2018, in which

54 new Elements of Performance were added to the Environment of Care, Emergency Management, and Life Safety Standards. 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”).

1.2.1. Emergency Management (EM)

Effective March 11, 2018, The Joint Commission made the following significant changes to the Emergency Management Chapter of the Ambulatory Program:

EM.01.01.01: added EP 10, requiring documentation of potential risk in the community that could impact the organization’s ability to provide care for patients.

EM.02.01.01: added EPs 20-22, adding the requirement for an annual review of the Emergency Management Plan, as well as a description of the patient population served and a continuity of operations strategy.

http://vaww.ceosh.med.va.gov/01HP/Pages/Guidebooks.shtml http://vaww.ceosh.med.va.gov/01HP/Pages/Guidebooks.shtml http://vaww.oqsv.med.va.gov/functions/integrity/accred/jointcommission.aspx

EM.02.02.01: added EPs 30-34, describing how the organization will communicate with suppliers and third parties; maintain contact information for staff, physicians, volunteers, and others; and maintain documentation of completed and attempted contact with emergency preparedness officials.

EM.02.02.07: added EPs 18-20, adding the requirements that staff be trained in their emergency response roles and receive ongoing training relevant to their emergency response roles, and that a system be developed to track the location of on-duty staff.

EM.02.02.11: added EPs 15 and 16, requiring the organization to have a system to track patients sheltered on site and procedures for patient evacuation.

EM.03.01.03: added EP 22, requiring organizations to monitor management of staff roles and responsibilities during exercises.

EM.04.01.01: added EPs 5-7, requiring facilities that are part of a health care system to demonstrate participation in the development of the health care system’s integrated emergency preparedness program.

The VHA Emergency Management Program Guidebook (EMPG) provides best practices and information regarding the development and maintenance of a VHA Comprehensive Emergency Management Program (CEMP). The

EMPG combines key concepts and requirements from both national and VHA preparedness policies and doctrine. The EMPG is congruent with the

Emergency Management Capability Assessment Program (EMCAP) in supporting compliance with Directives, Handbooks, policies, and the standards of accreditation organizations. EMCAP materials can be accessed online via the VHA Performance Improvement Management System (PIMS) website in the VHA Resources section found under the User Support tab.

Note: access to the PIMS website is password controlled; contact your organization's Emergency Manager to be granted access to VHA PIMS.

1.2.2. Environment of Care (EC)

EC.02.04.03: EP 34 was added on January 1, 2019. This EP requires hospitals that provide fluoroscopic service to conduct performance equipment evaluations.

Effective January 1, 2018, a significant number of changes occurred to the EC chapter:

EC.01.01.01: EP 3 was added, requiring hospitals to have a library of information regarding inspection, testing, and maintenance of its equipment and systems.

EC.02.01.03: EP 4 was added, addressing the removal of smoking materials from patients receiving respiratory therapy.

EC.02.03.01: EPs 11-13 were added, addressing potential fire hazards during surgical procedures, requiring written fire prevention and response http://vaww.ceosh.med.va.gov/01HP/Pages/guidebooks.shtml https://vhapims.orau.org/ https://vhapims.orau.org/ procedures for the use of flammable germicides or antiseptics, and requiring compliance with NFPA® 99-2012 fire protection requirements.

EC.02.03.05: added EP 27, requiring monthly testing for elevators used for fire fighter operations.

EC.02.04.03: added EPs 8, 10, 26, and 27, adding labeling requirements for equipment listed for use in oxygen-enriched atmospheres; requiring facilities with hyperbaric chambers to comply with the NFPA® 99 requirements; adding requirement to perform equipment maintenance on anesthesia apparatus, and to require compliance with NFPA® 99 for all electrical equipment requirements.

EC.02.05.01: EPs 2 and 20-26 were added, requiring building systems to meet NFPA® 99’s category 1-4 requirements, classifying Operating Rooms as wet locations to be protected by either isolated power or ground fault circuit interrupters; categorizing electrical distribution as one of three categories (critical care, general care, basic care); providing testing requirements for hospital-grade receptacles; requiring limitations on usage of power strips in patient rooms; prohibiting the use of extension cords as a substitute for fixed wiring; requiring areas designated for administration of general anesthesia using medical gases to comply with NFPA® 101-2012:

8.7; and adding requirements for locating zone valves, area alarm panels, and alarm sensors, as well as the essential electrical systems critical branch supplies power.

EC.02.05.03: EPs 4, 11, 12, 14, and 15 were added. These EPs provide requirements for new buildings to be equipped with (or requiring) the use of life support systems to have illumination of means of egress, emergency lighting equipment, exit and directional signs; emergency power within 10 seconds of power loss for emergency lighting at emergency generator locations; the emergency power system (EPS) has a remote manual stop and is located outside of the EPS location; equipment designated to be powered by emergency power supply is energized by the hospitals design;

and the hospital implements a policy to provide emergency backup power for essential medication dispensing equipment and refrigeration of medications.

EC.02.05.05: added EPs 7 and 8, with line isolation monitors testing requirements and the requirement to meet NFPA® 99-2012 requirements related to electrical systems and heating, ventilation, and air conditioning

(HVAC) systems.

EC.02.05.09: EPs 1-6, 8, 9,12,13, and 14 were added regarding the hospital inspection, testing, and maintenance of medical gas and vacuum systems and the reference for hospitals to meet all other NFPA® 99-2012 Health Care

Facility Code requirements related to gas and vacuum systems. This chapter does not require hospitals to have medical gasses and vacuum systems, but provides inspection, testing, and maintenance requirements when these systems are used. The new EPs provide requirements to categorize medical gas cylinders and provide for design, fabrication, testing, and marking of cylinders, including the labeling of storage areas and the “empty” cylinders classification requirements. Requirements were also added for emergency oxygen supply connections to be installed so that a temporary auxiliary connection source is available. Finally, a hospital policy was added for all cylinders, prohibiting transfilling of cylinders in any patient care room and providing a designated area for transfilling cylinders that is remote from any section of the hospital where patients are housed, treated, or examined.

EC.03.01.01: added EP 1, requiring staff responsible for the maintenance, inspection, testing, and use of medical equipment, utility systems and equipment, fire safety systems and equipment, and safe handling of hazardous materials and waste are competent and receive continuing education and training.

On March 11, 2018, two changes occurred to the EC standard:

EC.02.05.01: EP 27 was added to requiring areas designated for administration of general anesthesia (specifically, inhaled anesthetics) using medical gases or vacuum to meet specific heating, cooling, and ventilation requirements prescribed by The American Society of Heating, Refrigeration, and Air Conditioning Engineers (ASHRAE) 170. Medical supply and equipment manufacturers’ instructions are considered before reducing humidity levels to those allowed by ASHRAE.

EC.02.03.05: EP 25 was updated to clarify annual inspections and testing is for fire door assemblies, previously listed simply as door assemblies. Two new notes were added to reflect that nonrated doors are not subject to annual inspection and testing requirements and that deemed-status hospitals should inspect and maintain nonrated doors per the facility’s maintenance program. Note: VA facilities are not considered deemed-status hospitals and will comply with the most current edition of all codes and standards.

1.2.3. Life Safety

March 11, 2018, the Life Safety(LS) Chapter LS.02.01.30 added EP 13, requiring in existing buildings that all corridors be constructed to resist the passage of smoke and constructed of 1 3/4 inch or thicker solid-bonded wood core or constructed to resist fire for not less than 20 minutes. The doors are not to have ventilation louvers or transfer grills, with minor exceptions. Positive latching hardware is also required; roller latches are prohibited (reference: NFPA® 101, 19.3.6.3.1-5).

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.

http://vaww.oqsv.med.va.gov/functions/integrity/accred/accredNewsletters.aspx

Reference Materials and Environment of Care pages on the CEOSH website

[click on the “Accreditation (TJC and CARF)” tab].

The Joint Commission Standards for Veterans Affairs Community Living Centers

(CLCs) standards. Available online via the CEOSH website.

VHA Directive 1608, Comprehensive Environment of Care (CEOC) Program.

https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=3171

Chapter 2

Environment of Care Survey Process and Scoring

2 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 multiphased 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.

The next chapters that were reviewed include Care, Treatment, and Services

(Behavioral Health Care); Medication Management; Nursing; and 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 and C scoring designations, and direct and indirect impact Elements of Performance (EPs).

Surveyors will perform a real-time, on-site evaluation of deficiencies, placing each one within the SAFER 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 activities

Opportunities for Improvement (single observations of noncompliance at Category C EPs) will no longer exist.

Also, Measures of Success (MOS) will no longer be required.

All observations of noncompliance will be documented within the SAFER Matrix™ and will require follow-up activity based on placement within the matrix. Immediate 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 for Evidence of Standards Compliance (ESC)

EPs will no longer be identified as direct impact (with 45 days for submission) or indirect impact (with 60 days for submission).

All cited deficiencies will be assigned a single time frame of 60 days for corrective action. For deficiencies of a higher risk 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,

2.2.1. 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 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.

Joint Commission leadership, after reviewing the restrictions being placed on the

SOC, has determined that the Basic Building Information and PFI components of the SOC no longer fit the quality assessment program it was originally designed as, and will become an optional management program and will not be a part of the survey process. Post survey, the CMS Time-Limited Waiver and equivalency components of the SOC will be used to manage survey-related deficiencies. All questions should be directed to The Joint Commission Standards Enterpretation

Center at 630-792-5900.

2.2.2. 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 has 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.

Chapter 3

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

3 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:

• 2019 Joint Commission Survey Activity Guide.

• Joint Commission Corporate Orientation for 2017 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.

• The Joint Commission Continuous Readiness Message/Discussion Board.

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 compliance for VA facilities. The report provides data on the following items:

• User dashboard.

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/filedownload.ashx?fid=10084 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/facTJCExpRpts.aspx http://vaww.oqsv.med.va.gov/functions/integrity/accred/jointCommissionSIGFAQs.aspx http://vaww.oqsv.med.va.gov/filedownload.ashx?fid=10207 http://vaww.oqsv.med.va.gov/functions/integrity/accred/accredNewsletters.aspx

• 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 and Life Safety Chapters 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. The top ten most-cited standards for 2017 were:

1. LS.02.01.35 (86 percent)

EP 4: Manage systems for extinguishing fire, including the integrity (nothing supported by sprinkler piping, missing escutcheons) (59 percent).

EP 5: Sprinkler heads are not damaged. They are free of corrosion, foreign materials, paint, and have necessary escutcheon plates installed (41 percent).

EP 14: Other issues, including: blocked access to fire extinguishers

(34 percent).

2. EC.02.05.01 (73 percent)

EP 8: Labels utility system controls to facilitate partial or complete emergency shutdowns (45 percent).

EP 15: In critical areas the organization manages risk associated with utility systems, including pressure relationships, filtration, air exchanges (ach), and temperature and humidity (40 percent).

EP 16: In non-critical areas, the organization manages risk associated with utility systems, including pressure relationships, temperature, and humidity

(25 percent).

3. IC.03.03.01 (72 percent)

4. LS.02.01.30 (72 percent)

EP 3: Building and fire protection features: Existing Hazardous Areas

(38 percent).

EP 18: Smoke barrier integrity (32 percent).

EP 11: Corridor doors (30 percent).

EP 19: Smoke barrier doors (20 percent).

5. EC.02.06.01 (70 percent)

EP 1: Safe environment, including ligature risks, stained ceiling tiles, mismanaged pull cords (66 percent).

EP 26: Furniture and equipment (13 percent).

6. LS.02.01.10 (66 percent)

EP 7: Building and fire protection general requirements; fire-rated door

(39 percent).

EP 10: Building and fire protection general requirements: Barrier Penetrations

(38 percent).

7. EC.02.02.01 (63 percent)

EP 5: Minimize risks with hazardous chemicals (42 percent).

EP 12: Hazardous materials and waste labeling (26 percent).

8. EC.02.05.05 (62 percent)

EP 6: Inspection, testing, and maintenance (ITM) of non-high-risk utility equipment (52 percent).

EP 5: ITM of infection control utility equipment (12 percent).

9. LS.02.01.20 (62 percent)

EP 1: Locking arrangements (18 percent).

EP 11: Means of egress clear and unobstructed (32 percent).

10. EC.02.05.09 (59 percent)

EP 6: Medical gas cylinder management (37 percent).

EP 5: Medical gas shut-off valves labeled and accessible (25 percent).

Chapter 4

Management Plans

4 Management Plans

4.1. Management Plans Introduction and Overview

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.