The Joint Commission Triannual Accreditation Consultant Services for Tripler Army Medical Center

1.2 Background: Tripler Army Medical Center (TAMC) participates in The Joint Commission’s (TJC) Triannual Accreditation Survey which Facilities Management Division (FMD) is a key member of the Environment of Care and Life Safety chapters that provide the hospital with the Standards and Elements of Performances (EPs) to maintain a safe physical environment. Standard EC.01.01.01 requires that each area in the Environment of Care (EC) has a written Management Plan to assist in managing risks.  Further, LS.01.01.01 (The hospital designs and manages the physical environment to comply with the Life Safety Code), EP 2, states that the hospital performs a building assessment to determine compliance with the Life Safety chapter. 

1.3 Objectives: Provide support to conduct TAMC’s LS Building Assessment and update Fire Plans.  Onsite building assessment of TAMC’s Main Hospital is required to meet the LS requirements for TJC accreditation. 

1.4 Scope: Provide Tripler Army Medical Center (TAMC) model Management Plans and Sample Annual Evaluations electronically for all Environment of Care (EC) and Emergency Management areas. Servicesincludea total of seven Plan Holder (Safety/Fire Safety, Life Safety, Security, Hazardous Material & Waste, Medical Equipment, Utility Management, and Emergency Management) each with individual Management Plans and Annual Evaluations. Provide 5-days of onsite support to Tripler Army Medical Center (TAMC) regarding updates to the required Joint Commission Environment of Care (EC) and Life Safety (LS) Management Plans and Annual Evaluations.  Conduct on-site meetings with each of the owners of the following plans:

• Safety Management
• Security Management
• Hazardous Materials and Waste Management
• Life/Fire Safety Management
• Medical Equipment Management
• Utility Systems Management
• Emergency Management

These individual meetings shall be required to understand and reflect TAMC’s local regulations, policies, and standard operating procedures, as well as ensure each plan holder’s understanding of the process and elements of their plan(s). Updates to the plans shall meet the requirements of current TJC Standards and Elements of Performance. In support of this process, an Environment of Care Overview presentation will also be provided addressing the EOC Standards, as well as specific changes as applicable.  A Staff Knowledge education session will further be provided to address what TAMC staff members need to know with respect to the EOC Plans and Standards.