part 7: meeting the standards challenges healthcare engineering consultants strategies for the...

Part 7: Meeting the Standards Challenges

Healthcare Engineering Consultants

Strategies for the Standards Challenges

Safety Management


Issue:

Proactive Risk Assessments for Safety

Tip for Compliance:

Think of risk assessments as simply prioritizing potential problems

Documenting Risk Assessments


Risk Assessment:

“Prioritization and management of resources though an assessment of

probability and impact”

Why Perform Risk Assessments?

Not enough time!

Not enough staff!

Not enough money!


Calculating Risk Assessments

Risk =

Probability X Impact


Global Risk Assessments

What’s a Global Risk Assessment and What is

it’s Purpose?


Performing a Global Risk Assessment

Step 1: Identify a “Global” Area to Assess

Step 2: Select a Team of Stakeholders

Step 3: Brainstorm and List the Risk Elements

Step 4: Assign Probability and Impact to the Risk Elements

Step 5: Prioritize the Risk Elements

Step 6: Perform the Specific Risk Assessments


Documenting Risk Assessments


Global Risk Assessment Form

Department/ Area:_____________________________ Date: _____________ Completed by: _____________________

Risk Element Description Occurrence Probability(1-5)

Occurrence Impact(1-5)

Total Impact Score(Probability X Impact)

Notes: To use this form, list all of the possible risk elements associated with the department or area that may impactpatient or staff safety or result in damage to buildings or equipment. Using all available data sources, including experienceand previous history, insert numerical values for the probability and impact for each element. Calculate the total impactscore for each element, prioritize in descending numerical order and select a “cut-off” limit. For all scores above the “cut-off”, perform the six step risk assessment process.

Example Global Safety Risk Assessment


Global Risk Assessment for Safety Management

Risk Element Description Occurrence Probability (1-5) Occurrence Impact (1-5) Total Impact Score(Probability X Impact)

Employee injuries 5 2 10Ergonomic issues 4 2 8Unauthorized staff appliances 4 2 8Unauthorized smoking 5 1 5Egress corridor clutter 4 1 4Unlocked clean supply roomsin inpatient areas

4 1 4

Improper storage 3 1 3General housekeeping 3 1 3Unlocked supply rooms inoutpatient clinics

2 1 2

Improperly stored cylinders 1 1 1

Note 1: This form is used to determine the possible impact to safety that may occur in the hospital resulting from a variety ofdifferent risk elements. Each of the risk elements is prioritized based on the total impact score, starting with the highest scoreobtained. Specific assessments are then performed for each risk element (starting with the highest impact score) to determineactions that may be taken or processes that may be altered to reduce the overall risk to the hospital.

Note 2: The scoring is defined as follows:

Probability Score Description Impact Score Description

1 Very unlikely to ever occur 1 No injury is likely to occur 2 Unlikely to occur in one year 2 Minor injury is likely to occur 3 May occur in one year 3 Moderate injury is likely to occur 4 Likely to occur in one year 4 Serious injury is likely to occur 5 Almost certain to occur within one year 5 Death is likely to occur

Example Global Security Risk Assessment


Global Risk Assessment for Security Management

Risk Element Description Occurrence Probability (1-5) Occurrence Impact (1-5) Total Impact Score(Probability X Impact)

Infant abduction 1 3 3Pediatric abduction 1 3 3Assaultive behavior - ED 5 3 15Assaultive behavior – mentalhealth unit

5 3 15

Theft – gift shop 4 1 4Theft – pharmacy 2 2 4Theft of hospital property 5 2 10Theft from patients 5 2 10Auto accidents on hospitalproperty

4 3 12

Trespassing 4 1 4Auto vehicle break-in 4 2 8Weapons brought ontohospital property

4 1 4

Utility systems intentionallyturned off or damaged

2 4 8

Terrorist activity near or onhospital property

1 5 5

Toxic gas introduced intohospital air intakes

2 4 8

Note 1: This form is used to determine the possible impact to security that may occur in the hospital resulting from a variety ofdifferent risk elements. Each of the risk elements is prioritized based on the total impact score, starting with the highest scoreobtained. Specific assessments are then performed for each risk element (starting with the highest impact score) to determineactions that may be taken or processes that may be altered to reduce the overall risk to the hospital.

1

Specific Risk Assessments

What’s a Specific Risk Assessment and What is

it’s Purpose?


Performing a Specific Risk Assessment

Step 1: Identify Issues and Select a Team

Step 2: Analyze Factors

Step 3: Make a Decision

Step 4: Document the Evaluation and Decision

Step 5: Make the Necessary Changes

Step 6: Monitor and Reassess


Specific Risk Assessment Examples

Lock clean supply room doors?

Infant/ pediatric abduction measures

Safe environment for mental health

Medical equipment test tags

Utility system PM intervals

Security “sensitive areas”

Other?


Understanding RCA’s and FMEA’s

What’s the Difference Between an FMEA and an RCA?

Are They Both Risk Assessments?


Safety Management


Issue:

What about recurring operational deficiencies?

Tip for Compliance:

You can’t improve what you can’t measure!

How Do We Solve This Problem?

Steps required to reduce operational deficiencies:

1. Determine how to measure the problem severity

2. Establish a numerical baseline score

3. Explain measurement system to area staff

4. Let staff determine an improvement goal

5. Re-measure scores at unscheduled times

6. Provide numerical feedback to staff

7. Celebrate achievement of goal

8. Continue measurement until the culture changes


Solving the Hallway Clutter Problem


Step 1: Determine how to measure the problem severity

Solution and Procedure: Assign points to various types of egress corridor deficiencies, based on severity of violation



Point Score Examples

Description of Deficiency Point Score(per occurrence)

Small medical device on wheels (NIBP unit), against wall, charging, not blocking shut-offs

1

Equipment or furniture, not in use, one side of corridor only, not blocking shut-off or fire alarm

3

Large furniture or equipment, on both sides of corridor, not in use, not blocking shut-off/ alarm

5

Large furniture or equipment, in corridor, not in use, blocking emergency shut-off or fire alarm

8

Large furniture or equipment, in corridor, preventing fire or smoke door from closing

10



Step 2a: Establish a numerical baseline score for a specific hospital area (4 West)

Procedure: Use the point values for deficiencies that have been assigned and determine total scores by randomly inspecting the area once per day for at least one week



Operational Deficiency Scorecard Area: 4 West Reviewed By: GDS Date: September 18, 2006 Description of Deficiency

Points per Deficiency Number of Deficiencies Total Category Points

Chair blocking fire door

10 1 10

Gurney in corridor; blocking alarm pull box, zone valve

8 1 8

Furniture, without wheels, both sides of corridor

5 2 10

Items in corridor, with wheels (IV, NIBP units)

1 5 6

Total Points: 34



Point Score Results of Daily Inspections

Day Mon. Tues. Wed. Thurs. Fri.

Points 34 27 39 42 28

Cum. Average

34 32 33 36 34

This is the baseline number for 4 West



Graphical Results

0

10

20

30

40

50

60

70

Mon Tues Wed Thurs Fri

4 West Daily Data Baseline



Graphical Results

0

10

20

30

40

50

60

70

Mon Tues Wed Thurs Fri

4 West Daily Data New Goal

New goal: 25 pointsDaily Scores

Safety Management


Issue:

How to solve the smoking dilemma?

Tips for Compliance: Create a practical policy

Recognize the “citation priority”

Monitor smoking compliance

Smoking Monitoring


Summary of Smoking Violations

Location of Smoking Violation Time of Observed Violation Description of Violator

Area directly outside of EmergencyCenter; “B-C” corridor area

All shifts Staff, patients, visitors

Loading dock attached to “B” building First and second shift Staff, vendors

Loading dock attached to “D” building First and second shift Staff, vendors

Second level stairway exterior from “B”building

Second and third shift Staff

Main entrance to “A” building (within 50feet)

First shift Visitors and patients

Summary of Compliance Strategies

New anti-tobacco policy, effective 18 October, 2004 Smoking shelters are on order and will be installed in January, 2005 near the “A” building entrance Current signage will be replaced with universal “No Smoking” signs in January, 2005 New protocols for staff discipline have been implemented with the new policy Additional training for all staff regarding smoking policies has been provided Smoking cessation classes for hospital staff have been implemented; all smokers are encouraged to participate

Security Management


Issue: Security Responsibility Appointment

Tips for Compliance:

Letter provided by leadership

Identify security responsibility

Include:

Coordination

Development and implementation

Monitoring

Security Management


Issue: Security Risk Assessment


Include security sensitive areas:

ED, OB/ Gyn, Pharmacy, Infectious waste

Other areas?

Evaluate facility access control

Provide training for staff in sensitive areas

Security Management


Issue: Security “Special Cases”

Tips for Compliance: Consider the following –

Use of firearms or other means of force

Mental health areas

Medication and infectious waste security

Infant/ child abduction prevention and drills

Cell phones with cameras/ privacy issues

Access to unauthorized areas

Security in construction areas

Hazardous Materials and Wastes


Issue: MSDS Sheets


Ensure an accurate inventory

Provide staff training

Consider MSDS options:

Binder with data sheets

1-800 “Fax-on-Demand”

Internet or intranet access



Issue: Chemical Waste Stream


Ensure disposal procedures for:

Chemicals

Chemotherapeutics

Radioactive materials

Medical waste and sharps

Waste phamaceuticals

Per applicable laws (OSHA, EPA, NRC, DOT)



Issue: Compressed Cylinder Storage


For stored gases <300 cubic feet in smoke compartment:

- Enclosures not required (NFPA 99, section 9.4.3)

For stored gases >300 but <3,000 cubic feet:

- Outdoors: enclosed space with doors or gates (9.4.2.1)

- Indoors: an enclosure with minimum ½ hour protection (9.4.2.3)

For stored gases >3,000 cubic feet:

- Walls, floors, ceilings, doors at least 1-hour rated (5.1.3.3.2)

- Racks, chains or fastenings to secure all cylinders (5.1.3.3.2)

- Continuous powered ventilation within 1 foot of floor (5.1.3.3.3)



Issue: Compressed Cylinder Storage


Requirements for stored gas only, not in-use tanks!

In-use gas includes:

- Tanks on code carts

- Tanks on wheelchairs

- Tanks on gurneys

Empty tanks do not count toward the total

Use of fire-rated cabinets can be used on floors



Issue: Alcohol-Based Hand Rub Units Requirements


Patient safety goal 7 requires CDC compliance with Category I recommendations, suggests Category II compliance!

When no soiling is present, ABHR units are recommended (Cat I)

ABHR is permitted in a corridor at least 6 feet in width, at least 4 feet apart, and not directly over electrical outlets (6 inches from dispenser)

ABHR dispensers can be used over carpeted surfaces only in sprinklered smoke compartments!

ABHR permissible volumes:

- 10 gallons in dispensers/ 5 gallons in storage per smoke compartment

- Maximum individual dispenser capacity: .3 gallons

- Maximum dispenser size per suite of rooms: .5 gallons



Issue: Eyewashes and Showers


Use risk assessment to determine placement

ANSI standards have not been officially adopted by the

Joint Commission

Testing policy is required – specify test intervals

Documentation of test results is required

Differentiate between eyewash station and “first aid”

station, such as mounted bottles



Issue: Hazardous Vapor Monitoring


Clinical lab: formaldehyde and xylene

Central supply: ethylene oxide

OR’s: nitrous oxide, methyl-methacrylate

Respiratory: glutaraldehyde

Sleep lab: collodion

Monitor and document per OSHA requirements!

Approved Changes for 2009

EMERGENCY


The organization of the standards :

EM.01.01.01: Plans for managing emergencies

EM.02.01.01: Develops an emergency operations plan

EM.02.02.01: Establishes emergency communication strategies

EM.02.02.03: Establishes strategies for managing resources

EM.02.02.05: Establishes strategies for managing safety and security

EM.02.02.07: Defines and manages staff roles and responsibilities

EM.02.02.09: Identifies an alternative means for providing utilities

EM.02.02.11: Identifies strategies for patient management

EM.02.02.13: Privileges to LIP’s

EM.02.02.15: Privileges to volunteer staff

EM.03.01.01: Annual effectiveness review

EM.03.01.03: Regularly tests the emergency operations plan

Emergency Management

EMERGENCY


EM.01.01.01: The organization plans for managing the consequences of emergencies

Medical and clinical staff participate in planning

A Hazard Vulnerability Analysis (HVA) is performed and documented

The hazards are prioritized

Communication of emergency plan with community responders

Mitigation, Preparedness, Response, Recovery

Assets and resources are inventoried and documented (CAP)

Asset and resource inventories are monitored during emergencies (CAP)

The emergency management program is evaluated annually (S,O,P,E)


EMERGENCY


Tips for Compliance with EM.01.01.01:

Appoint a physician and administrative representative to actively participate on the emergency management planning committee

Perform and document the Hazard Vulnerability Analysis (HVA) for all geographically separate facilities – review annually!

Be ready to describe the Mitigation, Preparedness, Response and Recovery procedures in the EOP

Ensure that emergency resources are inventoried (PPE, utility and medical supplies and pharmaceuticals) and monitored

Evaluate the emergency management program annually (S,O,P,E) and report the results to the safety committee


EMERGENCY


EM.02.01.01: The organization develops and maintains an Emergency Operations Plan (EOP)

Written EOP includes an “all hazards” command structure

An incident command structure (ICS) is established and is consistent with the community plan

The ICS identifies a reporting structure

Activation of ICS is identified

Activation of ICS phases is identified

The EOP identifies the organization response when community non-support may occur for up to 96 hours (CAP)

Alternative care sites are identified


EMERGENCY


Tips for Compliance with EM.02.01.01

Create a written emergency operations plan (EOP) that describes the incident command structure and process that is in use (HICS 4?) as well as how ICS integrates into the six critical core areas:

1. Emergency communications

2. Resources and assets

3. Safety and security

4. Staff roles and responsibilities

5. Management of utilities

6. Clinical and support activities

The EOP can either describe the ICS and core area integration in detail or reference existing documents


EMERGENCY


Incident Commander

Public Info Officer

Liaison Officer

Safety Officer

Med/ Tech Specialist(s)

Operations Section Chief

Planning Section Chief

Logistics Section Chief

Finance/ Admin Section Chief

HICS Organizational Chart


EMERGENCY



Create two color-coded timeline charts the indicate how long utilities will be operational and how long consumable supplies will be available in the event of an emergency in which no re-supply is possible

Ensure that decisions are made to determine whether any utility or supply changes will be implemented to extend “green zones”

Create two 96-hour plans that assume the following scenarios:

PLAN A: Supplies are available and are ordered and received

PLAN B: Internal supply shortages or utility failures require partial or

total patient evacuation

PLAN C: Shortages and/ or utilities are not sufficient to continue

normal patient care, although evacuation is not possible


EMERGENCY


Critical Utilities and Supplies Timeline

Assume external help is not available

Create timeline for utilities and critical supplies, such as food and medications

Determine time-dependent status:

- Green: Continue all services as usual

- Yellow: Transition to conservation mode

- Red: Discontinue patient treatment, evacuate


EMERGENCY


Utility Failure Operational Impact Chart

Hours after utility failure 0 8 16 24 32 40 48 56 64 72 80 88 96 Normal power failure Emergency power failure Water pressure low Entire loss of water pressure Loss of steam generation (winter) Loss of steam generation (summer) Loss of natural gas Loss of propane Chiller failure (winter) Chiller failure (summer) Major air handler failure Failure of sewage system Sump pump failure Loss of bulk oxygen Loss of medical air Loss of bulk nitrous oxide Loss of medical vacuum Computer server failure Telephone switch failure Failure of elevators Pneumatic tube system failure


EMERGENCY


Consumable Supply Operational Impact Chart

Hours after emergency occurs 0 8 16 24 32 40 48 56 64 72 80 88 96 Fuel oil (winter) Fuel oil (summer) Gasoline Propane fuel Natural gas Potable water Non-potable water Oxygen Medical air Nitrous Oxide Nitrogen Nutrition supplies Pharmaceutical supplies IV solutions Pharmaceutical medications General patient supplies Surgical supplies Environmental cleaning supplies Central sterile supplies General office supplies


EMERGENCY


EM.02.02.01: The organization establishes emergency

communications strategies Staff notification procedures are created

Provisions for ongoing staff communication during the emergency

Process to notify external authorities

Communication with patients and their families

Communication with the community and media

Communication with vendors and suppliers (CAP)

Sharing information with other health care providers

Providing information about patients to third-parties (FEMA, CDC, etc.)

Communication with alternative care sites

Establishment of back-up communication systems and technologies


EMERGENCY



Create notification charts with phone numbers, email addresses, etc.

Include for staff, external authorities, community, media, vendors

Determine what information will be shared with other health care providers in the area

Ensure that liaisons are established with government agencies

Verify that MOU’s for alternative care sites are updated

Establish and check operation of back-up communication systems, such as the internet, cell phones, two-way radios, emergency land lines, and amateur radio operators


EMERGENCY


EM.02.02.03: The organization establishes strategies for managing

resources and assets during emergencies

Plans for obtaining medications and non-clinical supplies

Replenishing medical supplies and equipment during the emergency

Replenishing pharmaceutical supplies

Replenishing non-medical supplies (food, water, fuel, linens, etc.)

Managing staff and family support activities

Sharing of resources with other health care organizations in and outside of the local community (CAP)

Horizontal, vertical and total evacuation (CAP), including transportation of patients, medications, equipment, staff and medical record information


EMERGENCY


Tips for Complying with EM.02.02.03

Plans should be in place to stockpile and reorder critical clinical and non-clinical supplies

Written procedures should describe how the needs of staff and families of staff will be met during an emergency

A plan to share community resources and assets should be in place

A practical patient evacuation plan that includes horizontal and vertical movement within the facility as well as partial or total evacuation outside of the facility is required

Logistics for evacuation should include: 1) transportation; 2) staffing; 3) medications; 4) equipment, and; 5) the medical record


EMERGENCY



safety and security during emergencies

Internal safety and security measures are established

Role of community security agencies is established with the healthcare organization and means of coordination is identified (CAP)

Processes for handling hazardous materials and waste are developed (CAP)

Plans are developed for radioactive, biological, chemical decontamination

Patients susceptible to wandering are identified (CAP)

Access into and out of the facility are controlled

Movement of staff and patients is controlled within the facility

Traffic accessing the facility is controlled


EMERGENCY



Security staffing plans during emergencies must be established

Expectations with outside police agencies should be identified

Plans to dispose of infectious and hazardous waste must be created

Procedures to treat contaminated patients must be written (radioactive, biological and chemical)

Methods to lock down the facility to prevent entry must be provided

Methods to minimize staff and patients from leaving the facility must be planned

Plans must be in place to control traffic accessing the facility


EMERGENCY


EM.02.02.07: The organization defines and manages staff roles and responsibilities

Staff roles and responsibilities are defined for the critical areas (communications, resources and assets, safety and security, utilities, clinical activities)

Staff are trained relative to their responsibilities (CAP)

Roles of LIP’s are specifically defined (CAP)

Care providers and command center staff are identified (ID badges, vests, caps, etc.)


EMERGENCY



Review and update as necessary, the ICS organizational chart and job action sheets (check after each drill)

Ensure that hospital staff have participated in NIMS training

Discuss emergency expectations with the independent physicians who have privileges at the hospital

Select the primary and back-up command center locations

Have a method to identify incident command staff (ID badges, vests, caps, etc.)


EMERGENCY


EM.02.02.09: The organization establishes strategies for managing utilities during emergencies, such as:

Electricity

Potable and non-potable water

Fuel for building operations or transport vehicles (CAP)

Other essential utility needs, such as:

- HVAC equipment

- Medical gas and vacuum systems

- Fire systems

- Sewer


EMERGENCY



Complete the utility 96-hour timeline chart

Determine which utilities require additional supplies, especially water and fuel

Determine the feasibility of redundant systems or supplies

Examples: Water – on-site well, water tower or nearby lake

Electricity – additional generators installed

Boilers – portable boiler “on a truck”

Medical gas – low pressure external connection, manifold


EMERGENCY



clinical and support activities during emergencies, including:

Patient scheduling, triage, assessment, treatment admission, transfer, discharge and evacuation

Clinical services for vulnerable patients, such as: pediatric, geriatric, disabled or serious chronic conditions or addictions

Personal hygiene and sanitation

Mental health needs (CAP)

Mortuary services (CAP)

Tracking and documenting patient information (CAP)


EMERGENCY



Identify which patients in the hospital are considered “vulnerable”

(neonatal intensive, pediatric, geriatric, dementia, behavioral health)

Plan for patient and staff hygiene and sanitation without water or sewer

Determine mortuary needs in the event of a pandemic

Evaluate back-up methods to track patient information in the event that

the electronic information system fails


EMERGENCY


EM.02.02.13: During disasters, the organization may grant privileges

to licensed independent practitioners

Privileges granted only when EOP has been activated

Medical staff bylaws indicate to who and how to grant privileges, and policies will indicate how performance will be evaluated

Minimum privileging requirements include:

1. Current picture ID and license to practice

2. Must be a member of a recognized disaster response group

3. Proof of government authority to provide services during a disaster

Hospital determines within 72 hours if privileges should continue


EMERGENCY


EM.02.02.15: During disasters, the organization may assign disaster

responsibilities to volunteer practitioners

Hospital assigns responsibilities only when EOP has been activated

Hospital identifies in writing who is eligible and how to assign disaster responsibilities to non-LIP’s

Minimum requirements to assist during disasters include:

1. Current picture ID and license to practice professional specialty

2. Must be a member of a recognized disaster response group

3. Confirmation by hospital staff the individual is qualified

Hospital determines a method to evaluate performance and decide within 72 hours if responsibilities should continue


EMERGENCY


EM.03.01.01: The organization evaluates the effectiveness of its

emergency management planning activities

The Hazard Vulnerability Analysis (HVA) is evaluated annually to determine if revisions are necessary

The Emergency Operations Plan (EOP) is evaluated annually with regard to the Scope, Objectives, Performance and Effectiveness of the program

The hospital conducts an annual review of the inventory process with regard to emergency supplies, and documents the results


EMERGENCY


EM.03.01.03: The organization regularly tests its emergency

operation plan

Twice over 12 months, either as a drill or actual emergency

Once per year in a business occupancy

One “influx of patient” drill per year

One escalation per year to test community “non-support”

One “community-wide” drill per year

Drills are realistic and based on the HVA

A dedicated, trained individual must evaluate the drill


EMERGENCY


EM.03.01.03: The organization regularly tests its emergency

operation plan (continued)

The six critical areas are monitored: 1) Communication; 2) Resource mobilization; 3) Safety and security; 4) Staff roles and responsibilities; 5) Utility systems, and; 6) Patient clinical and support activities

Exercises are critiqued with a multi-disciplinary group, including leadership, physician and support staff and evaluate deficiencies

The operations plan is revised based on the drill findings

Subsequent exercises evaluate the improvements to the EOP

Drill evaluations are reported to the hospital safety committee


EMERGENCY



Two drills per rolling 12-month period should be performed, based on the HVA

At least one drill per 12 months in a business occupancy

At least one “influx” drill for a disaster receiving station

Community-wide and influx drills can be performed concurrently

The community 96-hour “non-support” drill can be a tabletop

Trained staff, including a physician and leadership, must evaluate the drill and must document the six core areas in the evaluation

Infant abduction (EC.2.10) and patient surge (IC.6.10) drills are highly

recommended

Fire Prevention


Issue: Fire Drills


Healthcare and ambulatory:

1 drill per shift per quarter

Business occupancy:

1 drill per shift per year

Drill monitoring as defined in the plan

Evaluate effectiveness annually in written report

Fire Prevention


Issue: Interim Life Safety Measures


A policy must describe the program

Document whether ILSM is or is not required

Determine ILSM applicability for PFI’s!

Document which measures are applicable

Document required inspections

Failure to meet ILSM provisions: CON04!

Medical Equipment Management


Issue: Equipment Test Scoring


100% PM completion for “life support” devices, based on scoring (A)

90% PM completion for “non-life support” devices (C)

Determine test interval by “PM effectiveness” and MTBF data

Test tags with due dates recommended, but not required! What about Ongoing PM vs. initial test only?

Medical Equipment Management


Issue: Other Medical Equipment Issues


Patient-owned equipment

Diagnostic and therapeutic (example: CPAP)

Personal use (iPods, cell phones, blackberries)

Rental devices

Demo, loaner and trial equipment

Radio-frequency interference

Utility Systems Management


Issue: Waterborne Pathogens


Waterborne pathogens policy must include:

1. Patient risk assessment for pathogen

vulnerability

2. Operational description of measures to reduce

waterborne pathogens

3. Remediation procedures if hospital-acquired

waterborne infection is determined



Issue: Airborne Pathogens


An airborne pathogens policy must exist that describes:

Air filter maintenance, room air exchange rate and pressure relationships for operating rooms, delivery rooms, special procedure rooms, patient isolation rooms, clinical laboratories, sterile supply rooms and pharmacies

Note: Refer to AIA document for requirements

Note: “Grandfathering” permitted for air handlers



Issue: Utility System Test Scoring


All devices included in the utility systems management program must be at least initially tested

Expected PM completion rate for “critical life support” and “critical infection control” components based on “A” scoring: 100%

Expected PM completion rate for “critical non-life support” components based on “C” scoring: 90%

“Non-critical” components are not scored

Appropriate Environment


Issue: The “General Duty Clause”


Patient areas are safe, clean, comfortable

Lighting is suitable

Ventilation provides for acceptable temperature

Locks and restraints per regulation

Emergency access for locked spaces



Issue: New Construction


AIA document, 2001 edition (2006 soon?)

Applicable federal, state or local

guidelines

Equivalent design criteria



Issue: Pre-Construction Risk Assessment (PCRA)

Tips for Compliance: Include all of the items listed below in the PCRA evaluation

Noise

Vibration

Air quality

Infection control

Emergency procedures

Utility failures

Interim life safety measures

Infection Control Risk Assessment (ICRA)


Risk Criteria for Infection Control

Type A Type B Type C Type D

Group 1 (lowest) I II II III

Group 2 (medium) I II III IV

Group 3 (medium high) II III III IV

Group 4 (highest)

III

III IV IV

Construction TypePatient

Risk



Issue: Ongoing Monitoring


• Controls include measures to reduce risk and minimize the impact of the construction activities

• Daily monitoring checklist is recommended

• Consider posting required PCRA permits, such as hot work, ICRA, above-the-ceiling work, etc. on door entrance to construction area

part 7: meeting the standards challenges healthcare engineering consultants strategies for the...

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