D.6 EOC 2022 02.pdf

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Table of Contents

PREFACE

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

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

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

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

Acronyms and Abbreviations .......................................................... xiii

1 What's New in the Guidebook?

1.1. Introduction

1.2. What’s New

Environment of Care

Life Safety

Sentinel Events

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 and Patient Safety, Office of External

Accreditation Services and 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

D.6 EO C2022

36C25923R0040 ii

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

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

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 Policy 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

vi

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

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 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 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.

x

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 2022 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 mailto:Jeff.Vaughn@va.gov xi

Acknowledgements

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.

Robert Cornell, VISN 6 Engineer, Asheville, NC

*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

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

*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 2021 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 and July 2022.

January

Updated Enclosures:

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

4-10. Sample Utility Systems Management Plan

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 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 xiii

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, Refrigerating 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

BCMA Bar Code Medication Administration

BESS Biomedical Equipment Support Specialist xiv

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 xv

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 xvi e-PFI Electronic Plan for Improvement

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

ESS Enterprise Support Services (formerly CEOSH)

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

HEFP Healthcare Environment and Facilities Programs

(10NA5)

xvii

HEPA High-Efficiency Particulate Air

HCFA Health Care Financing Administration

HFMEA Healthcare Failure Mode and Effect Analysis

HICS Hospital Incident Command System

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

INR International Normalized Ratio

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 xviii

LIM Line Isolation Monitors

LIP Licensed Independent Practitioner

LPN Licensed Practical Nurse

LS Life Safety

LSA Life Safety Assessment

LSC Life Safety Code

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 Goal

NQF National Quality Forum xix

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

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 xx

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

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 xxi

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

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 2022 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 2022. 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 and Patient Safety website.

1.2. What’s New

Effective January 2022, two new Elements of Performance (EPs) were added: one in the Environment of Care (EC) chapter and one in the Life

Safety (LS) chapter. Effective July 2022, eight new EC EPs were added.

Finally, the Sentinel Events were renamed the Sentinel Event Policy (SE).

A complete list of updates to The Joint Commission Standards can be accessed online via the Office of Quality and Patient Safety website (click on “TJC Manual via E-dition”).

Environment of Care

Effective January 2022, The Joint Commission added one EP to EC 02.01.01, adding a requirement for the hospital to conduct an annual worksite analysis related to its Workplace Violence Prevention Program.

In July 2022, The Joint Commission added eight new EPs to the following

EC Chapters:

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

• EC.02.03.03,The hospital conducts fire drills: EPs 3, 7 and 8 were added.

• EC.02.03.05, The hospital maintains fire safety equipment and fire safety building features: EPs 11 and 14 were added.

• EC.02.04.01, The hospital manages medical equipment risks: EP 11 was added.

• EC.02.05.01, The hospital manages risks associated with its utility systems: EP 27 was added.

• EC.02.05.07, The hospital inspects, tests and maintains emergency power systems: EP 11 was added.

Life Safety

In January 2022, EP 7 was added to LS chapter LS.03.01.35, requiring at least six spare sprinkler heads that correspond to the types and temperature rating of the hospital's sprinkler heads, with associated wrenches, are kept in a cabinet that will not exceed 100°F.

Sentinel Events

In January 2022, the Sentinel Event chapter was renamed Sentinel Event

Policy (SE), with a general reorganization of the content in the policy to flow in a more logical order and connect related content.

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 Office of Quality and Patient

Safety 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.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

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 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.

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, 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 and Patient Safety, Office of External Accreditation Services and Programs Services & Programs

3 The Office of Quality and Patient

Safety, Office of External

Accreditation Services and

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 Office of Quality and Patient

Safety website provides valuable resources, including presentations, guides, tools and reports on various environment of care topics. As of June

2022, the following list provides a sample of topics that might interest the user of this guidebook:

• Joint Commission All Accreditation Programs Survey Activity Guide

– January 2022.

• The Joint Commission (TJC) VHA Program Office Overviews for

TJC Survey Team Leaders.

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

FAQs.

• The Joint Commission Corporate Summation Presentation.

• The Joint Commission Monthly Newsletters.

3.2. The Joint Commission Field Tracker Report

The Joint Commission Field Tracker Report is prepared by the VHA Office of Quality and Patient Safety 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/-/media/tjc/documents/accred-and-cert/survey-process-and-survey-activity-guide/2022/2022-all-programs-organization-sag.pdf https://www.jointcommission.org/-/media/tjc/documents/accred-and-cert/survey-process-and-survey-activity-guide/2022/2022-all-programs-organization-sag.pdf https://vaww.qps.med.va.gov/divisions/qm/ea/jointcommissionorientation.aspx https://vaww.qps.med.va.gov/divisions/qm/ea/jointcommissionorientation.aspx https://vaww.qps.med.va.gov/divisions/qm/ea/jointCommissionSIGFAQs.aspx https://vaww.qps.med.va.gov/divisions/qm/ea/jointCommissionSIGFAQs.aspx https://vaww.qps.med.va.gov/divisions/qm/ea/jointcommissionsummation.aspx https://vaww.qps.med.va.gov/divisions/qm/ea/accredNewsletters.aspx https://vaww.qps.med.va.gov/divisions/qm/ea/jointcommission.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 Office of Quality and Patient Safety 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.

https://vaww.qps.med.va.gov/divisions/qm/ea/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/

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. 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

Chapter 5

Implement

5 Implement

5.1. Safety and Security Management

Introduction

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 and Patient Safety website

(click on “Joint Commission Manual via E-dition”).

5.1.2.a.