S02 ATTACHMENT FORTY NINE 49 VHA Directive 1608 Comprehensive Environment of Care CEOC.pdf

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Department of Veterans Affairs VHA DIRECTIVE 1608 Veterans Health Administration Transmittal Sheet Washington, DC 20420 February 1, 2016

COMPREHENSIVE ENVIRONMENT OF CARE (CEOC) PROGRAM

1. REASON FOR ISSUE: This Veterans Health Administration (VHA) Directive establishes the process that will be used to define, standardize, monitor, review, maintain, and improve the environment in which health care services are provided throughout VHA.

2. SUMMARY OF CONTENT: This Directive outlines policies and responsibilities for the VHA Comprehensive Environment of Care (CEOC) Program. Funding for the program is paid from existing funds at those VHA organizations establishing programs.

3. RESPONSIBLE OFFICE: The Deputy Under Secretary for Health for Operations and Management (10N) is responsible for the contents of this Directive. Questions may be addressed to Director, Environmental Programs Service (10NA7) at 202-632-7881.

4. RELATED ISSUES: None.

5. RESCISSIONS: None.

6. RECERTIFICATION: This VHA Directive is scheduled for recertification on or before the last working day of February 2021.

David J. Shulkin, M.D.

Under Secretary for Health

DISTRIBUTION: Emailed to the VHA Publication Distribution List on 2/3/2016.

February 1, 2016 VHA DIRECTIVE 1608

COMPREHENSIVE ENVIRONMENT OF CARE (CEOC) PROGRAM

1. PURPOSE: This Veterans Health Administration (VHA) Directive establishes policy and assigns responsibilities for the Comprehensive Environment of Care (CEOC) Program. This Directive is intended to promote consistent operation of the 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 has traditionally had a strong commitment to ensuring that all facilities have appropriate systems in place to assure that VHA meets The Joint Commission Environment of Care (EC) standards, as well as VHA requirements for providing a safe, clean, and high quality care environment. Over the years, the VHA program for monitoring the environment has moved well beyond The Joint Commission EC standards. The VHA program outlined in this Directive includes adherence to not only The Joint Commission EC standards, but also addresses additional programmatic areas. These programmatic areas include nursing care, infection control, patient safety, employee safety, utility management, medical equipment management, cleanliness, facility security, as well as patient considerations such as privacy, dignity, respect, and confidentiality of personal identifiable information or patient health information. This VHA program is referred to as the Comprehensive Environment of Care (CEOC) Program, in order to differentiate it from The Joint Commission EC standards.

3. POLICY: VHA will provide a safe, clean, functional, and high quality environment for Veterans, their families, visitors, and employees in VHA Healthcare facilities in accordance with applicable Joint Commission EC standards, federal regulatory requirements, applicable Department of Veterans Affairs (VA) and the requirements for CEOC Rounds established in this Directive.

4. RESPONSIBILITIES:

a. Under Secretary for Health. The Under Secretary for Health, or designee, is responsible for:

(1) Providing a safe, clean, functional, and high quality environment for Veterans, their families, visitors, and employees in VA medical facilities.

(2) Establishing CEOC Program performance standards for the Deputy Under Secretary for Health for Operations and Management.

b. Deputy Under Secretary for Health for Operations and Management.

The Deputy Under Secretary for Health for Operations and Management (10N), or designee, is responsible for:

(1) Overseeing the development and implementation of the VHA CEOC Program and policies.

VHA DIRECTIVE 1608 February 1, 2016

(2) Establishing CEOC Program performance standards for the Assistant Deputy Under Secretary for Health for Operations and Management for Administrative Operations and the Assistant Deputy Under Secretary for Health for Operations and Management for Clinical Operations.

(3) Ensuring the establishment of a CEOC Steering Committee and reporting to the designated National Leadership Council (NLC) members.

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

c. Assistant Deputy Under Secretary for Health for Operations and Management for Administrative Operations. The Assistant Deputy Under Secretary for Health for Operations and Management for Administrative Operations (10NA), or designee, is responsible for:

(1) Establishing and co-chairing the CEOC Steering Committee.

(2) Ensuring that staffing, funding, and training are adequate to implement the VHA CEOC Program.

(3) Maintaining those elements of the VHA CEOC Program that fall within the purview of 10NA program office operations.

(4) Establishing VHA CEOC Program performance standards for all subordinate officials.

d. Assistant Deputy Under Secretary for Health for Operations and Management for Clinical Operations. The Assistant Deputy Under Secretary for Health for Operations and Management for Clinical Operations (10NC), or designee, is responsible for:

(1) Maintaining those elements of the VHA CEOC Program that fall within the purview of 10NC program office operations.

(2) Establishing CEOC Program performance standards for all subordinate officials.

e. Deputy Under Secretary for Health for Policy and Services (10P). The Deputy Under Secretary for Health for Policy and Services, or designee, is responsible for:

(1) Maintaining those elements of the VHA CEOC Program that fall within the purview of 10P program office operations.

(2) Establishing CEOC Program performance standards for all subordinate officials.

f. CEOC Steering Committee. The CEOC Steering Committee shall be co-chaired by the Assistant Deputy Under Secretary for Health for Operations and

Management for Administrative Operations, and a VISN Director. The CEOC Steering Committee shall be comprised of, but not limited to, VHA CEOC Program stakeholders.

The CEOC Steering Committee is responsible for:

(1) Defining VHA CEOC Program reporting requirements.

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

(3) Defining contract requirements for the VHA CEOC Program.

(4) Identifying funding requirements.

(5) Identifying training requirements.

(6) Defining and monitoring compliance with the requirements for CEOC rounds (see paragraph 5 below).

(7) Reference the Environment of Care Assessment and Compliance Rounding Process Guide for greater details at http://vaww.ceosh.med.va.gov/10N/10NA7- EPS/documents/EOC%20Assessment%20%20Compliance%20Guide%20v07%208-03- 2014.pdf. NOTE: This is an internal VA Web site that is not available to the public.

g. Director, Office of Environmental Programs Service. The Director, Office of Environmental Programs Service (EPS 10NA7), or designee, is responsible for:

(1) The coordination of operational components of the VHA CEOC Program.

(2) Oversight of the development, deployment, and maintenance of the CEOC Assessment and Compliance Tool, in coordination with the CEOC Steering Committee, Office of Information Technology (OIT), CEOSH, VA/VHA Contracting Office, and contractor/vendor.

(3) Development and maintenance of the CEOC Rounding Guide.

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

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

h. Director, Center for Engineering & Occupational Safety and Health. The Director, CEOSH (10NA11), or designee, is responsible for:

(1) Serving as a member and technical liaison to the CEOC Steering Committee.

(2) Developing and maintaining CEOC Program resources on the CEOSH Web site (http://vaww.ceosh.med.va.gov/). NOTE: This is an internal VA Web site that is not available to the public.

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

i. VHA Program Office Directors. Each VHA Program Office Director under 10NA or 10NC, or designee, is responsible for:

(1) Developing, for review and approval by the CEOC Steering Committee, CEOC performance measures and targets that are objective, measurable, and consistent with VHA CEOC standards, for the area of responsibility of the respective VHA Program Office.

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

(3) Conducting periodic trend analysis of data collected with the CEOC Assessment and Compliance Tool for performance measures and targets within these respective areas of responsibility.

(4) Using the results of data analyses to improve performance within their respective areas of responsibility.

j. Veterans Integrated Service Network Directors. Each (VISN) Director or designee is responsible for:

(1) Ensuring their VISN has a written policy that establishes and maintains a CEOC Program at the VISN level that complies with the requirements of this Directive.

(2) Ensuring adequate resources are provided to the medical centers for the implementation of this Directive.

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

(4) Ensuring the CEOC Compliance and Assessment Tool is used to collect all data associated with CEOC rounds at all facilities within their VISN.

k. VA Medical Facility Director. Each VA medical facility Director, or designee, is responsible for:

(1) Ensuring their VA medical facility has a written policy that establishes and maintains a CEOC Program at the local medical facility level that complies with the requirements of this Directive.

(2) Ensuring the CEOC Assessment and Compliance Tool (ACT) is used to collect all data associated with CEOC rounds within their facility.

(3) Providing resources for maintaining the facility CEOC Program.

(4) Designating a CEOC Program Coordinator to oversee and coordinate all aspects of the CEOC Program at the medical facility.

5. REQUIREMENTS FOR CEOC ROUNDS: The requirements for CEOC rounds fall under the purview of the CEOC Steering Committee. CEOC rounds shall comply with the following:

a. CEOC Rounds shall be performed on a recurring basis by the facility CEOC Rounds Team.

b. CEOC Rounds shall be conducted a minimum of once per fiscal year in non-patient care areas, and twice per fiscal year in patient care areas (all buildings, all floors, all rooms, and all spaces, including off-campus sites of care).

c. The CEOC Rounds Team shall be led by the medical facility Director or designee that is a member of the Executive Leadership Team (i.e. Deputy Director, Associate Director, Assistant Director, Chief of Staff or Nurse Executive).

d. In addition to the medical facility Director or Deputy/Associate/Assistant Director, the CEOC Rounds Team core membership shall include subject matter expertise from:

(1) Nursing Service.

(2) Environmental Management Service.

(3) Engineering Service:

(a) Utility Management.

(b) Biomedical Engineering.

(4) Safety Office (including Industrial Hygienist when applicable).

(5) Patient Safety.

(6) Infection Control.

(7) Facility Level ISO.

(8) HIPAA Privacy/Facility Information Management.

(9) Women Veterans Program Manager.

(10) Police/Security.

(11) Logistics/Materials Management.

(12) Other members as appropriate for the areas being surveyed.

e. CEOC Rounds Team members shall use, as a minimum, standard questions/survey criteria as provided in the CEOC ACT. Supplemental questions/survey criteria can be added in accordance with procedures established by the CEOC Steering Committee.

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

6. REFERENCES:

a. The Joint Commission EC standards.

b. National Fire Protection Association (NFPA) requirements.

c. Occupational Safety and Health Administration (OSHA) regulations.

d. CEOC Assessment and Compliance Tool (https://eoc.va.gov/login/).

7. DEFINITIONS:

a. Environment of Care (EOC). EOC is defined as the building or space, including how it is arranged and the special features that protect patients, visitors, and staff;

equipment 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.

b. CEOC Rounds. CEOC Rounds are defined as recurring facility tours used to determine the presence of unsafe and/or untoward conditions and whether the facility’s current processes for managing the environmental of care are practiced correctly and are effective.

c. CEOC Assessment and Compliance Tool (ACT). The CEOC ACT is a VA intranet-based vehicle for documenting, reporting, and showing trends for facility CEOC Rounds compliance.