D28 ENVIRONMENT OF CARE GUIDE.pdf

i

Table of Contents

PREFACE

Disclaimer Statements .............................................................................................. vii

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

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

Update Listing .............................................................................................................. x

1 What's New in the Guidebook?

1.1. Introduction

1.2. What’s New

National Patient Safety Goals (NPSGs)

Life Safety

VHA Smoking Policy

The Joint Commission Top Ten Most-Cited Standards in 2019

VHA-Joint Commission Clarification Document Changes

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, Effect on the Life Safety Plans for Improvement (PFI)

2018 Review Project Changed 300 Hospital Requirements

2.3. Enclosure

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

Accreditation Services & Programs

3.1. Survey Readiness

3.2. The Joint Commission Field Tracker Report

3.3. Environment of Care Most Challenging Standards

4 Management Plans

4.1. Management Plans Introduction and Overview

4.2. Enclosures

5 Implement

5.1. Safety and Security Management

Introduction ii

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

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 iii

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.02.05.03

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

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

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

iv

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

7.3. Enclosures

8 Patient Safety

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

National Patient Safety Goal (NPSG) Changes:

8.1.1.a. NPSG 03.05.01

8.1.1.b. NPSG 15.01.01

Goal 6: Reduce the Harm Associated with Clinical Alarm Systems

8.1.2.a. NPSG.06.01.01

8.1.2.b. References and Resources

Goal 7: Reduce the Risk of Health Care Associated Infections

8.1.3.a. NPSG.07.01.01

8.1.3.b. References and Resources

Goal 15: The Organization Identifies Safety Risks Inherent in its

[Patient] Population

8.1.4.a. NPSG.15.01.01

8.1.4.b. References and Resources

8.2. Sentinel Event Alerts

8.3. Patient Safety Tools and Topics

Patient Safety Assessment Tool (PSAT)

VHA Patient Safety Alerts and Advisories v

Root Cause Analysis (RCA)

Healthcare Failure Mode and Effect Analysis (HFMEA)

General Patient Safety Links

Patient Safety Topics

8.4. Preventing Surgical Fires

Background

Guidance

References and Resources

8.5. Alcohol-Based Hand Cleaner

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

9.4. Compliance Tips

vi

LS.01.01.01

LS.01.02.01

9.5. Enclosure

10 Environment of Care News

10.1. Environment of Care News

10.2. Healthcare Interpretations Task Force (HITF)

11 Community-Based Outpatient Clinics (CBOCs) and Leased Facilities

11.1. VA-Operated CBOCs

11.2. Contractor-Operated CBOCs

11.3. Environment of Care Compliance

11.4. CBOC Facility Design Requirements

11.5. References and Resources

11.6. Enclosure

Enclosures

Appendix

Acronyms and Abbreviations vii

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 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.

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 2020 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, at (314) 894-6100, extension 66081, or by email at

Jeff.Vaughn@va.gov.

/default 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 2020 update to this guidebook. The guidebook was developed and published based on the expertise of numerous Environment of Care professionals across several Veterans Integrated Service Networks (VISNs) and medical centers, to include the staff from the VHA Healthcare Environment and Facilities

Programs (HEFP), St. Louis, Missouri.

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

Louis, MO

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

Antonio, TX

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

Center, Columbia, SC

Diane Kroll, B.A., M.S., MT-ASCP, RN-BSN, Area Emergency Manager, VHA

Office of Emergency Management, Richfield, MN

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

Office, Washington, DC

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

Cynthia Paterson, RN, BSN, MS, Ph.D., VISN 11 Patient Safety Officer and VA

Ann Arbor Healthcare System Patient Safety Manager, Ann Arbor, MI

*Denotes Chairpersons

HEFP Publishing Staff

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

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/ x

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

June 2019 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

See Chapter 1 for a brief overview of The Joint Commission updates from January 2019 to January 2020.

Added link to the “VHA-Joint Commission Clarification

Document”, which replaced the document “George Mills

Concurrence on 23 Clarification Issues

1.2.5

Updated the Joint Commission’s ten most-cited standards to those published in 2019.

Added VA’s new smoking policy.

5.1.3.c

Revised the National Patient Safety Goals (NPSGs) with new elements of performance added to NPSGs 03.05.01 and

15.01.01.

Added Sentinel Alerts, Safety Alerts, and Advisories 8.2

Updated Joint Commission Life Safety Standards.

2 July

Added Enclosures:

2-1 Sample Statement of Conditions Management Memo

5-3. Smoke/Smokeless Tobacco Products and Electronic

Nicotine Delivery System (ENDS) Free Policy

5-4 Attachment B: Sample Detailed Fire Plan

Updated Enclosures:

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

4-3. Sample Fire Safety Management Plan

4-4. Sample Hazardous Materials and Waste Management

Plan

4-5. Sample Medical Equipment Management Plan

4-6. Sample Safe and Functional Environment Management

Plan

/resources/2-1-statement-conditions-management-memo /resources/5-3-smokesmokeless-tobacco-products-and-electronic-nicotine-delivery-systems-ends-free /resources/5-3-smokesmokeless-tobacco-products-and-electronic-nicotine-delivery-systems-ends-free http://vaww.hefp.va.gov/resources/5-4-attachment-b-detailed-fire-plan /resources/4-1-sample-overview-environment-care-life-safety-and-emergency-management-operations /resources/4-1-sample-overview-environment-care-life-safety-and-emergency-management-operations /resources/4-3-sample-fire-safety-management-plan /resources/4-4-sample-hazardous-materials-and-waste-management-plan /resources/4-4-sample-hazardous-materials-and-waste-management-plan /resources/4-5-sample-medical-equipment-management-plan /resources/4-6-sample-safe-and-functional-environment-management-plan /resources/4-6-sample-safe-and-functional-environment-management-plan xi

4-7. Sample Safety Management Plan

4-8. Sample Security Management Plan

4-9. Sample Safety and Security Management Plan

4-10. Sample Utility Systems Management Plan

5-4. Sample Fire Prevention Management Program

Memorandum

Attachment A: Sample Fire Plan (Code Red)

9-1. Sample Interim Life Safety Measures Memorandum

/resources/4-7-sample-safety-management-plan /resources/4-8-sample-security-management-plan /resources/4-9-sample-safety-and-security-management-plan http://vaww.hefp.va.gov/resources/4-10-sample-utility-systems-management-plan http://vaww.hefp.va.gov/resources/5-4-sample-fire-prevention-management-program-memorandum http://vaww.hefp.va.gov/resources/5-4-sample-fire-prevention-management-program-memorandum http://vaww.hefp.va.gov/resources/5-4-attachment-sample-fire-plan-code-red http://vaww.hefp.va.gov/resources/9-1-sample-interim-life-safety-measures-memorandum

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 2020 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 National Patient Safety Goals (NPSGs) following the July 2019 update. Changes affecting Hospital, Ambulatory, and

Behavioral Health Programs occurred. In January 2020, a change to the Life

Safety Standard resulted in the reemergence of the Basic Building Information requirement. Also included in this update is the new VA Smoking Policy and the

2019 Joint Commission top ten most-cited standards. 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 Healthcare Environment and Facilities

(HEFP) website. The Joint Commission Manual via E-dition, which contains all

The Joint Commission Standards, can be accessed online via the VHA Office of

Quality, Safety & Value (OQSV) website.

1.2. What’s New

In July 2019, five new Elements of Performance (EP) were added to NPSG

03.05.01, and seven new EPs were added to NPSG 15.01.01. In January 2020, one new EP was added to Life Safety (LS) 01.01.01. 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”).

National Patient Safety Goals (NPSGs)

Changes were made to two of the National Patient Safety Goals in July 2019.

NPSG 03.05.01 was updated to reduce the likelihood of patient harm associated with the use of anticoagulant therapy. Five new EPs were developed for this chapter to support this goal.

NPSG 15.01.01 was changed to reduce the risk for suicide. Seven new EPs were developed to support this change.

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

Life Safety

January 2020 saw the return of the Basic Building Information (BBI) in the

Statement of Conditions (SOC). EP 7 was added to LS.01.01.01, requiring hospitals to maintain current BBI within the SOC.

VHA Smoking Policy

On March 5, 2019, the Department of Veterans Affairs published a revised version of VHA Directive 1085, Smoke Free Policy for Patients, Visitors, Contractors, Volunteers, and Vendors at VA Health Care Facilities. This updated

VHA directive implements a smoke-free policy at all VA health care facilities.

The Joint Commission Top Ten Most-Cited Standards in 2019

Annually, The Joint Commission publishes the top ten most-cited standards. The

2019 top ten is included in Chapter 3.

VHA-Joint Commission Clarification Document Changes

Effective January 31, 2020, the VHA-Joint Commission Clarification Document was updated and approved. Concurrence has been provided by The Joint

Commission (Jeff Conway, Director, CMS & Government Programs, The Joint

Commission) on updated clarifications regarding VHA implementation of The Joint

Commission (TJC) Environment of Care (EC) and Life Safety (LS) standards.

This document supersedes the previous clarification document titled, “George

Mills Concurrence on 23 Clarification Issues”, effective 4-Sept-2017 (rev. 1).

Updated clarifications include modifications to Issues 4, 7, 9, 14, 16, 17, 18, and

19, as well as the addition of three new issues: 24, 25, and 26.

The updated clarification document is: VHA-Joint Commission Clarification

Document, effective 31-Jan-2020 (Rev 0).

1.3. References and Resources

The Joint Commission E-dition Emergency Management, Environment of Care, and Life Safety Chapters.

Environment of Care News, The Source, and Joint Commission Perspectives.

Newsletters available via the OQSV website.

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

The Joint Commission Standards for Veterans Affairs Community Living Centers

(CLCs) standards.

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

https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=8242 /resources/vha-joint-commission-clarification-document-effective-31-jan-2020-rev-0 /sites/default/files/files/2020-01/VHA-Joint%20Commission%20Clarification%20Document%2C%20effective%2031-Jan-2020%20%28Rev%200%29.pdf#page=12 /sites/default/files/files/2020-01/VHA-Joint%20Commission%20Clarification%20Document%2C%20effective%2031-Jan-2020%20%28Rev%200%29.pdf /sites/default/files/files/2020-01/VHA-Joint%20Commission%20Clarification%20Document%2C%20effective%2031-Jan-2020%20%28Rev%200%29.pdf http://vaww.oqsv.med.va.gov/functions/integrity/accred/accredNewsletters.aspx /default 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, 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

/resources/2-1-statement-conditions-management-memo

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:

• Joint Commission Survey Activity Guide.

• Joint Commission Corporate Orientation for Surveys

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

Program Office Overviews.

• “Facility TJC Experience Report” shared aspects of The Joint Commission survey visit such as programs reviewed, survey findings, tips, and lessons learned.

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

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

• The Joint Commission Monthly Newsletters.

3.2. The Joint Commission Field Tracker Report

The Joint Commission Field Tracker Report is prepared by the VHA OQSV and summarizes The Joint Commission findings of less than full compliance for VA facilities. The report provides data on the following items:

• User dashboard.

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

http://vaww.oqsv.med.va.gov/functions/integrity/accred/JCRContinuousSurvey.aspx https://www.jointcommission.org/assets/1/6/2019_All_Programs_Organization_Survey_Activity_Guide.pdf http://vaww.oqsv.med.va.gov/functions/integrity/accred/jointcommission.aspx http://vaww.oqsv.med.va.gov/functions/integrity/accred/jointcommissionorientation.aspx http://vaww.oqsv.med.va.gov/functions/integrity/accred/jointcommissionorientation.aspx http://vaww.oqsv.med.va.gov/functions/integrity/accred/jointcommission.aspx http://vaww.oqsv.med.va.gov/functions/integrity/accred/jointCommissionSIGFAQs.aspx http://vaww.oqsv.med.va.gov/functions/integrity/accred/jointcommission.aspx http://vaww.oqsv.med.va.gov/functions/integrity/accred/accredNewsletters.aspx

• Total findings by program.

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

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

Calendar Year 2018,” has been updated and now provides findings referenced to the elements of performance (EP) in addition to findings based on The Joint

Commission standards. This information should help facilities prepare for their accreditation survey.

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

3.3. Environment of Care Most Challenging Standards

Annually, The Joint Commission publishes the top ten most-cited EC standards, with the percentage of surveyed facilities that were cited for each. The top ten most-cited standards for 2019 were:

1. EC.02.06.01, EP 1: Safe, functional environment-interior spaces

2. EC.02.05.05, EP 6: Utility system components, non-high-risk

3. EC.02.05.01, EP 9: Utility system controls, labeling

4. EC.02.02.01, EP 5: Hazardous chemicals-handling, disposal

5. EC.02.05.01, EP 15: Ventilation, critical care areas

6. EC.02.03.03, EP 3: Quarterly fire drills-unannounced, varied times

7. EC.02.05.09, EP 11: Piped medical gas shut-off valves

8. EC.02.05.09, EP 12: Medical gas cylinders policy

9. EC.02.05.01, EP 16: Ventilation, non-critical areas

10. EC.02.04.03, EP 3: High-risk medical equipment-inspection, testing

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 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, http://vaww.hefp.va.gov/resources/4-10-sample-utility-systems-management-plan 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

4-10. Sample Utility Systems Management Plan

/resources/4-1-sample-overview-environment-care-life-safety-and-emergency-management-operations /resources/4-1-sample-overview-environment-care-life-safety-and-emergency-management-operations /resources/4-1-sample-overview-environment-care-life-safety-and-emergency-management-operations /resources/4-2-sample-emergency-operations-plan /resources/4-3-sample-fire-safety-management-plan /resources/4-4-sample-hazardous-materials-and-waste-management-plan /resources/4-5-sample-medical-equipment-management-plan /resources/4-6-sample-safe-and-functional-environment-management-plan /resources/4-7-sample-safety-management-plan /resources/4-8-sample-security-management-plan /resources/4-9-sample-safety-and-security-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.

Prior to the 2009 edition of the EC Standards, safety and security management were two separate standards (EC 1.10 and EC 2.10). Environmental round requirements, previously found within EC.1.20, were relocated to EC.04.01.01.

Standards

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

Administration (VHA) Office of Quality, Safety & Value (OQSV) website (click on

“Joint Commission Manual via E-dition”).

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

5.1.2.a. Standard EC.01.01.01

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

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

5.1.2.b. Standard EC.02.01.01

The hospital manages safety and security risks.

5.1.2.c. Standard EC.02.01.03

The hospital prohibits smoking except in specific circumstances.

Compliance Tips

5.1.3.a. Standard EC.01.01.01

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

(see Enclosure 5-1 for a sample Safety Officer designation letter). EC.01.01.01, EPs 4-8 require written management plans for safety and security, hazardous materials and waste, fire safety, medical equipment, and utility management.

January 1, 2018, EP 3 was added, requiring the hospital to have a library of information regarding inspection, testing, and maintenance of its equipment and systems.

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

Care Committee (EOCC), and the review should be documented in the EOCC minutes (see Enclosure 5-2 for a sample Environment of Care annual report).

Sample management plans are provided in Chapter 4, Management Plans.

5.1.3.b. Standard EC.02.01.01

The hospital manages safety and security risks.

This standard has remained unchanged since the 2017 updates.

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

http://vaww.hefp.va.gov/resources/5-1-sample-safety-officer-designation http://vaww.hefp.va.gov/resources/5-2-sample-environment-care-annual-report

Risk assessments may be global and address a large area within the environment of care, or they may be specific and address a specific issue. They may be identified from internal sources, such as ongoing monitoring, results of root cause analyses, results of proactive risk assessments of high-risk processes, and from credible external sources, such as Sentinel Event Alerts. Specific risk assessment topics may include:

• Locking of clean supply room doors.

• Equipment test tags.

• Refrigerator temperature tests.

• Nurse call systems.

• Infant/pediatric abduction measures.

• Safe environment for mental health.

• Defibrillator testing.

• Use of cardboard boxes in the facility.

• Tubing connections.

On June 3, 2010, The Joint Commission issued Sentinel Event Alert Issue 45, Preventing violence in the health care setting [available online at The Joint

Commission website (click on “View More” inside the “Sentinel Event Alert” box)].

(Addendum, February 2017). Once considered safe havens, health care institutions today are confronting steadily increasing rates of crime, including violent crimes such as assault, rape, and homicide. Resources have been added to the Workplace Violence Prevention Resources Portal. The Sentinel Event Alert suggested the following actions be taken to prevent violent acts from occurring in a health care setting:

• Audit the risk of violence in the medical center.

• Evaluate the medical center’s Violence Prevention Program.

• Discuss issues with Human Resources.

• Provide appropriate employee training.

• Ensure that practical response procedures are in place.

• Provide counseling and other services, as required.

• Report violent acts to local authorities when appropriate.

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

16, Sentinel Event Alert 59: Physical and verbal violence against health care workers, was published, followed on July 31 by Sentinel Event Topic Workplace

Violence Prevention: Implementing Strategies for Safer Healthcare Organizations webinar. Both Sentinel Events focused on either the risk to staff, patients, or visitors.

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

5.1.3.c. Standard EC.02.01.03

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

EC.02.01.03 does allow patients of specific circumstances to smoke within buildings, and these exceptions are covered in the Provision of Care (PC)

Chapter of The Joint Commission Manual, though not explicitly.

On March 5, 2019, the Department of Veterans Affairs published a revised version of VHA Directive 1085, Smoke Free Policy for Patients, Visitors, Contractors, Volunteers, and Vendors at VA Health Care Facilities . This updated

VHA directive implements a smoke-free policy at all VA health care facilities. This directive defines health care facilities under the authority of this policy as any property assigned to VHA that is under the charge and control of VA (no GSA facilities) and includes VISNs, VA Medical Facilities, VHA Health Care Systems, Community Based Outpatient Clinics (CBOCs), Vet Centers, and VHA Research

Centers of Excellence.

VHA implemented this policy with guidance from a National VHA Smoke-Free

Implementation Plan and Toolkit, available at https://www.va.gov/health/smokefree.

VHA Directive 1057, Smoking Cessation Benefit for VHA Employees: No-Cost

Provision of Nicotine Replacement Therapy, dated August 10, 2017, was published to encourage creation of smoking cessation programs and identification of individuals to manage the program locally. In addition, whenever a medical center’s policy allows patients to smoke by either written authorization by a physician or in a designated area in a long-term care setting, appropriate fire safety precautions are necessary. The 2018 edition of the Life Safety Code (LSC) does not allow patients classified as not responsible to smoke unless under direct supervision. Additional requirements for smoking regulations in existing healthcare occupancies can be found in NFPA® 101, 19.7.4.

VA recently provided more guidance on electronic cigarette (or e-cigarette) use within VA hospitals. Information Letter (IL) 10-2013-005, Under Secretary for

Health’s Information Letter - Electronic Cigarettes (Enclosure 5-3), clarified that e-cigarettes should not be used for cessation purposes, and facility smoking policy restrictions should be applied in the same manner as conventional tobacco leaf-based cigarettes.

Executive Order (EO) 13058, Protecting Federal Employees and the Public from

Exposure to Tobacco Smoke in the Federal Workplace, signed August 9, 1997, addresses limitations on smoking at federal facilities.

References and Resources

7 Easy Steps to Risk Assessments: How You Can Do It and Why You Need To, EC News, March 2013.

https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=8242 https://www.va.gov/health/smokefree https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=5445…