“Crosswalking” Hospitals for a Healthy Environment (H2E) & the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO)

Catherine Zimmer, BSMT, MSMnTAP Healthcare SpecialistFall 2002

Overview

• JCAHO & Standards–General–Environment of Care (EC)–Performance Improvement

• H2E Goals• Using H2E to meet JCAHO

What is JCAHO?

•Accrediting entity for the Healthcare industry

–ensures appropriate

planning, procedures &

policies are enacted and

improved upon.

JCAHO Standards

• Leadership (LD)• Patient Rights & Organizational Ethics (RI)• Assessment of Patients (PE)• Care of Patients (TX)• Education (PF)• Continuum of Care (CC)* Improving Organization Performance(PI)* Management of the Environment (EC)• Management of Human Resources (HR)• Management of Information (IM)• Surveillance, Prevention & Control of Infection (IC)• Governance (GO)• Medical Staff (MS)

• Performance Measurement (PM)

JCAHO Process

• “Surveys”– reviews records and

documents– interviews staff & patients– observation– interviews leadership– information from public

• Surveyors – doctors, administrators,

nurses

EC Standard Areas

• Safety (General & Staff) • Security• Hazardous Materials and Waste• Emergency Management• Life Safety • Medical Equipment• Utility Systems

Environment of Care Standards EC.1 [Plan]

• EC.1 The organization plans for a safe, accessible, effective and efficient environment consistent with its mission, services, law and regulation. – EC 1.1 The organization plans for a safe

environment.EC 1.1.1 The organization plans for worker safety.EC 1.2 The organization plans for a secure environment.EC 1.3 The organization plans for managing hazardous materials and waste.

Environment of Care Standards EC.2 [Do]

• EC.2 The organization provides for a safe, accessible, effective and efficient environment consistent with its mission, services, law and regulation. – EC.2.1 The organization implements its

safety plan.– EC.2.2 The organization implements its

security plan.– EC.2.3 The organization implements its plan

for managing hazardous materials and waste.

Environment of Care Standards EC.4 [Check, Act]• EC.4 The organization evaluates and

improves conditions in the environment.– EC.4.1 the organization collects information

about deficiencies and opportunities for improvement in the environment.

– EC.4.2 the organization analyzes identified environment issues and develops recommendations for resolving them.

– EC.4.3 the organization works to implement recommendations to improve the environment and monitor effectiveness of

recommendations’ implementation.

Steps in the Environment of CarePerformance Improvement Cycle*

*Performance Improvement in the Environment of Care, JointCommission Resources , JCAHO, 2001.

IMPROVE

PLAN &DESIGN

TEACH

IMPLEMENT

AGGREGATE& ANALYZE

EC.1.3 The organization plans for managing hazardous materials and waste

• Intent: the organization identifies how it manages hazardous materials and waste.– Includes identifying processes for:

• selecting, handling, storing, transporting, using and disposing of hazardous materials and waste from receipt or generation through use or final disposal;

• establishing written criteria consistent with applicable law and regulation (example, Environmental Protection Agency) to identify, evaluate and inventory hazardous

material and waste……– Sec 3002(b) RCRA requires waste

minimization.

Performance Improvement (PI)

• “..Goal is to ensure that the organization designs processes well and systematically monitors, analyzes and improves its performance to improve patient outcomes.”**Joint Commission Resources, Department of Education, “A

Beginner’s Guide to Mock Survey Preparation”, 2002.

Performance Improvement

• Environment of Care has a PI component (EC.4).

• Leaders are required to do PI– PI.1 The leaders establish a planned,

systematic, organizationwide approach to

process design, and performance

measurement, analysis and improvement.

Why Should Leaders Choose P2 for PI?

• PI.1.1 Collaborative and interdisciplinary activity– cross functional bet EC, HR, L and possibly

others

• PI.1.2 (Intent) Pollution Prevention consistent with the organization’s mission as it relates to community health

• PI.1.2 (Intent) Meets the needs of individuals served, staff and others.(increases patient safety)

• PI.1.2 Reducing costs associated with waste, pollution and risk are sound business practice

• PI.1.2 Its easily measurable and implementable.

“Crosswalking” between H2E and JCAHO