S02 ATTACHMENT D.48 1608 EOC Guide.pdf

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Department of Veterans Affairs VHA DIRECTIVE 1608(1) Veterans Health Administration Transmittal Sheet Washington, DC 20420 June 21, 2021

COMPREHENSIVE ENVIRONMENT OF CARE PROGRAM

1. REASON FOR ISSUE: This Veterans Health Administration (VHA) directive establishes the Comprehensive Environment of Care (CEOC) program and policy used to define, standardize, monitor, review, maintain, and improve the environment in which health care services are provided throughout the VHA.

2. SUMMARY OF MAJOR CHANGES: This directive updates responsibilities for the VHA Comprehensive Environment of Care Program.

Amendment dated September 7, 2023 revises:

a. The definitions for Environment of Care and Comprehensive Environment of Care Assessment and Compliance Rounding Tool (see paragraph 3).

b. The Policy Statement (paragraph 4).

3. RELATED ISSUES: None.

4. RESPONSIBLE OFFICE: The Assistant Under Secretary for Health for Support (19) is responsible for the contents of this Directive. Questions may be addressed to Healthcare Environment and Facilities Programs (19HEF) and the Office of Environmental Programs Service (19HEFC).

5. RESCISSION: VHA Directive 1608, Comprehensive Environment of Care (CEOC) Program, dated February 2, 2016, is rescinded.

6. RECERTIFICATION: This VHA directive is scheduled for recertification on or before the last working day of June 2026. This VHA directive will continue to serve as national VHA policy until it is recertified or rescinded.

BY DIRECTION OF THE OFFICE OF

UNDER SECRETARY FOR HEALTH:

/s/ Deborah E. Kramer Acting Assistant Under Secretary for Health for Support

NOTE: All references herein to VA and VHA documents incorporate by reference subsequent VA and VHA documents on the same or similar subject matter.

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AMENDED

September 7, 2023

June 21, 2021 VHA DIRECTIVE 1608(1)

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DISTRIBUTION: Emailed to the VHA Publication Distribution List on June 21, 2021.

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CONTENTS

COMPREHENSIVE ENVIRONMENT OF CARE PROGRAM

1. PURPOSE

2. BACKGROUND

3. DEFINITIONS

4. POLICY

5. RESPONSIBILITIES

6. REQUIREMENTS FOR CEOC PROGRAM

7. RECORDS MANAGEMENT

8. TRAINING

9. REFERENCES

COMPREHENSIVE ENVIRONMENT OF CARE PROGRAM

1. PURPOSE

This Veterans Health Administration directive supports consistent operation of the VHA Comprehensive Environment of Care (CEOC) Program by establishing program oversight, performance, and accountability standards that can be monitored at all levels of VHA. AUTHORITY: 38 U.S.C. § 7301(b).

2. BACKGROUND

VHA is committed to ensuring that all facilities have appropriate systems in place to assure that VHA meets The Joint Commission’s Environment of Care (EC), Life Safety and Infection Control standards, VHA requirements and other regulatory and accrediting bodies ensuring a safe, clean health care environment that provides the highest standards in the health care setting. The scope of CEOC services include:

a. Infection Prevention and Control

b. Patient Safety

c. HIPAA/Privacy Rules

d. Safety

e. Engineering Programs

f. Pest Control

g. Healthcare Technology Management

h. Healthcare Environmental Sanitation

i. VHA Law Enforcement and Security

j. Privacy and Dignity (NOTE: Privacy and Dignity applies to all Veterans) and

k. Supply Chain Management.

3. DEFINITIONS

a. Environment of Care. Environment of Care (EC) is a chapter of The Joint Commission Accreditation Standards Manual, detailing requirements for the built environment, including how it is arranged and the special features that protect patients, visitors, and staff; equipment and systems used to support patient care or to safely operate the building or space; and people, including those who work within the hospital, patients, and anyone else who enters the environment, all of whom have a role in minimizing risks by ensuring that these environments support all Veterans’ dignity, privacy, safety, and security.

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AMENDED

September 7, 2023

b. Comprehensive Environment of Care Rounds. Comprehensive Environment of Care (CEOC) Rounds are recurring facility tours used to manage environmental risk through the pro-active identification of unsafe conditions or non-compliance, and addressing corrective actions while expanding interaction with facility staff.

c. Comprehensive Environment of Care Assessment and Compliance Rounding Tool. The Comprehensive Environment of Care (CEOC) Assessment and Compliance Rounding Tool is a VA intranet-based platform for documenting, reporting, and identifying deficiencies, trends and actions taken for facility CEOC Rounds compliance. NOTE: Multiple programs make use of the CEOC Assessment and Compliance Rounding Tool platform; only those listed in section 6.c(1)-(11) are within the scope of the CEOC Program.

4. POLICY

It is VHA policy that, in order to set standards for a safe, clean and high-quality environment for Veterans, their families, visitors and employees, the VHA Comprehensive Environment of Care (CEOC) Program will be established.

5. RESPONSIBILITIES

a. Under Secretary for Health. The Under Secretary for Health, or designee, is responsible for ensuring overall VHA compliance with this directive.

b. Assistant Under Secretary for Health for Operations. The Assistant Under Secretary for Health for Operations is responsible for:

(1) Communicating the contents and intent of this directive to each Veterans Integrated Service Network (VISN).

(2) Assisting VISN Directors in resolving implementing solutions to compliance challenges in all VA medical facilities within that VISN.

(3) Providing oversight of VISNs to ensure compliance with this directive.

c. Assistant Under Secretary for Health for Support. The Assistant Under Secretary for Health for Support is responsible for establishing policy and providing guidance and oversight as necessary to ensure the timely and successful implementation of this directive.

d. Deputy to the Assistant Under Secretary for Health for Support. The Deputy to the Assistant Under Secretary for Health for Support, is responsible for:

(1) Establishing and co-chairing the CEOC Steering Committee and overseeing the development and implementation of the CEOC Program and policies.

(2) Ensuring that the CEOC Steering Committee is charged with the oversight of the CEOC Program.

(3) Establishing CEOC Program performance standards.

(4) Ensuring that funding and adequate training are provided to ensure an efficient and effective CEOC Program.

(5) Maintaining those elements of the CEOC Program that fall within the purview of the Assistant Under Secretary for Support program offices’ operations.

(6) Ensuring that each VA medical facility’s record of compliance with this directive is made publicly available.

(7) Communicating relevant CEOC Program elements to the various AUSHs responsible for aspects of the CEOC Program.

e. Assistant Under Secretary for Health for Clinical Services. The Assistant Under Secretary for Health for Clinical Services, or designee, is responsible for maintaining those elements of the CEOC Program that fall within the Assistant Under Secretary for Clinical Services purview of program offices’ operations.

f. Comprehensive Environment of Care Steering Committee, The CEOC Steering Committee must be co-chaired by the Deputy Assistant Under Secretary for Health for Support and a VISN Director or Deputy VISN Director. The CEOC Steering Committee must be comprised of, but not limited to CEOC Program stakeholders. The CEOC Steering Committee is responsible for:

(1) Defining CEOC Program reporting requirements.

(2) Defining CEOC Program goals, objectives, performance metrics, and targets.

(3) Defining contract requirements for the CEOC Program.

(4) Identifying funding requirements.

(5) Identifying training requirements.

(6) Defining and monitoring compliance with the requirements for CEOC Rounds

(7) Ensuring other appropriate program offices review and update annually the inspection checklist.

(8) Ensuring that each VA medical facility’s compliance with the CEOC standards is reported to the Under Secretary for Health on an annual basis.

(9) Providing CEOC Program advisory support to the Assistant Under Secretary for Health for Support.

g. VHA Office of Environmental Programs Service, Director. The Director, VHA Office of Environmental Programs Service, or designee, is responsible for:

(1) Coordinating the operational components of the CEOC Program.

(2) Ensuring oversight of the development, deployment, and maintenance of the CEOC Assessment and Compliance Rounding Tool, in coordination with the CEOC Steering Committee.

(3) Coordinating the development and maintenance of the CEOC Assessment and Compliance Standard Operating Procedure (SOP).

NOTE: The VHA CEOC Assessment and Compliance SOP can be accessed at https://dvagov.sharepoint.com/sites/VHA10NA5C/EOCMonitor/SitePages/EOC-Policies- %26-Directives.aspx. (This is an internal VA Web site that is not available to the public.)

(4) Serving as a member of the CEOC Steering Committee.

(5) Serving as technical liaison for vendor training associated with the CEOC Rounding Assessment and Compliance Tool.

(6) Providing CEOC Rounding Assessment and Compliance Tool data analysis and reports to appropriate VHA staff, as defined by the CEOC Steering Committee.

h. VHA Program Office Directors. The VHA Program Office Director, or designee, aligned under the Assistant Under Secretary for Health for Support or the Assistant Under Secretary for Health for Clinical Services, within their areas of responsibility is responsible for:

(1) Reviewing, at least annually, the CEOC checklist to ensure that the most current standards are referenced and relevant.

(2) Developing training for those CEOC standards that are contained within their respective areas of responsibility.

(3) Conducting trend analysis of data collected with the CEOC Assessment and Compliance Rounding Tool within these respective areas of responsibility and making recommendations for performance improvement activities VHACO leadership, VISN leadership and VA medical facility leadership.

i. Veterans Integrated Service Network Directors. The VISN Director, or designee, is responsible for:

(1) Ensuring there is a VISN CEOC oversight program with a charter that complies with the requirements of this directive and the CEOC Assessment and Compliance

SOP.

NOTE: A sample CEOC VISN charter can accessed at https://dvagov.sharepoint.com/sites/VHA10NA5C/EOCMonitor/SitePages/EOC-Policies- %26-Directives.aspx (This is an internal VA Web site that is not available to the public).

https://dvagov.sharepoint.com/sites/VHA10NA5C/EOCMonitor/SitePages/EOC-Policies-%26-Directives.aspx https://dvagov.sharepoint.com/sites/VHA10NA5C/EOCMonitor/SitePages/EOC-Policies-%26-Directives.aspx https://dvagov.sharepoint.com/sites/VHA10NA5C/EOCMonitor/SitePages/EOC-Policies-%26-Directives.aspx

(2) Ensuring adequate resources are provided to VA medical facilities for the implementation of this directive.

(3) Ensuring CEOC Program requirements for VA medical facilities are met at all facilities within their VISN.

(4) Establishing requirements for annual compliance reporting for each VA medical facility with their VISN.

(5) Submitting a compliance report, incorporating CEOC data from each VA medical facility within their VISN, to the CEOC Steering Committee on an annual basis.

NOTE: A sample compliance report can be accessed at https://dvagov.sharepoint.com/sites/VHA10NA5C/EOCMonitor/SitePages/EOC-Policies- %26-Directives.aspx (This is an internal VA Web site that is not available to the public).

(6) Ensuring the CEOC Compliance and Assessment Tool is utilized and data is reviewed by the VISN CEOC oversight program at least quarterly.

j. VA Medical Facility Director. The VA Medical Facility Director is responsible for:

(1) Developing and implementing a written policy that maintains a facility CEOC Program that complies with the requirements of this directive and the CEOC Assessment and Compliance SOP. NOTE: A sample CEOC facility policy can be accessed at https://dvagov.sharepoint.com/sites/VHA10NA5C/EOCMonitor/SitePages/EOC-Policies- %26-Directives.aspx. This is an internal VA Web site that is not available to the public.

(2) Establishing and monitoring an effective facility CEOC Program through a multi-disciplinary CEOC Committee that is chaired by a member of the VA medical facility’s Executive Leadership Team (ELT) (defined as a Quadrad or Pentad Official).

(a) Ensuring the CEOC facility level Committee monitor CEOC Round performance metrics in accordance with this directive and the CEOC Assessment and Compliance SOP on a quarterly basis.

(b) Ensuring the CEOC facility level committee, develop a CEOC remediation plan (action plan) if noncompliance with an EOC performance metric is found. Remediation plans will be tracked to resolution.

NOTE: A sample facility remediation plan) can be accessed at https://dvagov.sharepoint.com/sites/VHA10NA5C/EOCMonitor/SitePages/EOC-Policies- %26-Directives.aspx. This is an internal VA Web site that is not available to the public.

(3) Ensuring proper utilization of the CEOC Assessment and Compliance Rounding Tool for the collection and analysis of all CEOC Rounds data.

(4) Allocating the appropriate resources to achieve CEOC Program compliance in https://dvagov.sharepoint.com/sites/VHA10NA5C/EOCMonitor/SitePages/EOC-Policies-%26-Directives.aspx https://dvagov.sharepoint.com/sites/VHA10NA5C/EOCMonitor/SitePages/EOC-Policies-%26-Directives.aspx https://dvagov.sharepoint.com/sites/VHA10NA5C/EOCMonitor/SitePages/EOC-Policies-%26-Directives.aspx https://dvagov.sharepoint.com/sites/VHA10NA5C/EOCMonitor/SitePages/EOC-Policies-%26-Directives.aspx accordance with this directive.

(5) Designating a CEOC Rounds Coordinator to administer all aspects of the CEOC Program at the VA medical facility.

(6) Assessing facility CEOC Program compliance and providing reports to the VISN Director. Compliance reporting will be accomplished in accordance with requirements established by the VISN CEOC Committee.

k. CEOC Rounds Coordinator. The CEOC Rounds Coordinator is responsible for:

(1) Scheduling and coordinating all CEOC rounds for their designated facility while ensuring care is not disrupted in clinical space.

(2) Maintaining inspection records.

(3) Creating and monitoring PFAs.

(4) Monitoring completion of corrective actions.

(5) Resolving process/system issues that may involve several disciplines.

(6) Providing recurring reports on trends and problem areas to the facility CEOC Committee or leadership concerning CEOC rounds.

(7) Maintaining the CEOC Assessment and Compliance Rounding Tool.

(8) Maintaining CEOC-related competencies through continued education and utilization of resources to facilitate a successful facility level CEOC Program.

(9) Providing education and training on the CEOC Assessment and Compliance Rounding Process and CEOC Assessment and Compliance Tool to the CEOC Rounding Team members.

(10) Granting permissions and access to the CEOC rounding software for their respective facilities.

6. REQUIREMENTS FOR CEOC PROGRAM

a. The requirements for CEOC Rounds fall under the purview of the facility CEOC Committee.

b. CEOC Rounds must be conducted in all VHA owned or leased spaces including off-campus sites. This includes all buildings, floors, rooms, and spaces. The frequency must be a minimum of once per fiscal year in non- patient care areas, and twice per fiscal year in all areas where patient care is delivered.

c. The designated VA medical facility ELT member, designated as the Chair of the facility CEOC Committee, has full authority and responsibility for the VA medical facility

CEOC Program, to include assessments, evaluations, and metrics associated with the following:

(1) Infection Prevention and Control;

(2) Patient Safety;

(3) HIPAA/Privacy Rules;

(4) Safety;

(5) Engineering Programs;

(6) Healthcare Technology Management;

(7) Healthcare Environmental Sanitation;

(8) VHA Law Enforcement and Security;

(9) Privacy and Dignity;

(10) Supply Chain Management; and

(11) Interior Design.

d. The VA medical facility CEOC Rounds Team must be led by the VA Medical Facility Director or a member of the ELT (i.e. Deputy Director, Associate Director, Assistant Director, Chief of Staff or Nurse Executive). In addition, the core CEOC Rounds Team must include representation from the following disciplines in accordance with the CEOC Assessment and Compliance SOP:

(1) Infection Prevention and Control;

(2) Patient Safety;

(3) HIPAA/Privacy Rules;

(4) Safety;

(5) Engineering Programs;

(6) Healthcare Technology Management;

(7) Healthcare Environmental Sanitation;

(8) VHA Law Enforcement and Security;

(9) Privacy and Dignity (Women’s Health Program);

(10) Supply Chain Management;

(11) Interior Design; and

(12) Other members as appropriate for the areas being surveyed and/or to represent other checklists approved by the CEOC Steering Committee.

e. CEOC Rounds Team members must use, at minimum, the standardized questions and survey criteria as identified in the CEOC Rounding Assessment and Compliance Tool. Supplemental questions and survey criteria may be added in accordance with procedures established by the CEOC Steering Committee.

f. Deficiencies and opportunities for improvement identified during CEOC Rounds must be tracked until resolved, in accordance with procedures established by the CEOC Steering Committee.

7. RECORDS MANAGEMENT

All records regardless of format (e.g., paper, electronic, electronic systems) created by this directive shall be managed as required by the National Archives and Records Administration (NARA) approved records schedules and VHA Records Control Schedule 10-1. Questions regarding any aspect of records management should be addressed to the appropriate Records Officer.

8. TRAINING

There are no formal training requirements associated with this directive.

9. REFERENCES

a. The Joint Commission. Hospital Accreditation Standards, Latest Edition.

b. 38 U.S.C. § 7301(b).

c. VHA CEOC SharePoint:

https://dvagov.sharepoint.com/sites/VHA10NA5C/EOCMonitor/SitePages/EOC-Policies- %26-Directives.aspx. NOTE: This is an internal VA Web site that is not available to the public.

d. CEOC Assessment and Compliance Tool (https://eoc.va.gov/login/). NOTE: This is an internal VA Web site that is not available to the public.

https://dvagov.sharepoint.com/sites/VHA10NA5C/EOCMonitor/SitePages/EOC-Policies-%26-Directives.aspx https://eoc.va.gov/login/