what’s new for 2008? healthcare engineering consultants does the joint commission manual have...

What’s New for 2008?

Healthcare Engineering Consultants

Does the Joint Commission Manual Have Major Changes

for 2008?

Organization of the 2008 Accreditation Manual


Section 1 - Patient Focused Functions

Ethics, Rights and Responsibilities (RI)

Provision of Care, Treatment and Services (PC)

Medication Management (MM)

Surveillance, Prevention and Control of Infection (IC)

Section 2 - Organization-Focused Functions

Improving Organization Performance (PI)

Leadership (LD) - (includes previous governing body)

Management of the Environment of Care (EC)

Management of Human Resources (HR)

Management of Information (IM)

Section 3 - Clinical Functions

Medical Staff (MS)

Nursing (NR)

No Major Change!Note: Standards rewrite in 2009



What Will the Survey Process be Like in

2008?

Unannounced Surveys in 2008


Typical Surveys Include:

Two to five days “on-site”

Two, three or more surveyors (usually nurses

and physicians - includes a “Life Safety Specialist”

for all hospitals in 2008; multiple days for >750K

square feet

Review of documents (survey planning meeting)

Life safety-focused facility tour

Three-part “EC” interview

Questions to staff based on tracer methodology

Summary conference to present tentative findings

Unannounced Surveys in 2008


Can Occur Due To:

Regular unannounced survey

Random off-cycle selection (5%)

Sentinel event follow-up

Adverse media coverage of specific issue

Complaint from the public

Note: All new applicants for the accreditation process as well as changes to a new classification (example: critical access designation) will now have unscheduled surveys



What Scoring Rules Apply for 2008?

Joint Commission Scoring Guidelines


No major scoring changes for 2008, except SOC:

“EP’s” scored 0, 1 or 2

0 = insufficient compliance

1 = partial compliance

2 = satisfactory compliance

Scoring categories have been continued for each

EP: A, B or C (B may be eliminated later!)

Standards are scored “compliant” or “non-

compliant”

No grid score calculation

Rationale is not scored

Joint Commission Scoring for EP’s


Category A: usually used for policies and procedures

or the presence or absence of a requirement

Scored either “0” or “2”

A “2” may become a “1” or “0” if the track record is

insufficient

Category B: used for process requirements

If requirement exists, then process design and

track record is scored (may be eliminated during 2008!)

Category C: instances of non-compliance

Score “2”: 1 or no instances of non-compliance

Score “1”: 2 instances of non-compliance

Score “0”: 3 or more instances of non-compliance

Joint Commission Scoring for EP’s


If any “EP” is scored “0”, the standard is

not compliant

If 65% of the EP’s are scored “2”, then

the standard is considered “compliant”,

unless any other EP is scored “0” (up to

35% of the EP’s may be scored a “1”!)

Special Scoring for SOC Deficiencies


“X” is considered a minor deficiency Example: a fire door does not latch properly (item 1C2) – Score 1

“Y” is considered a midrange deficiency Example: the same fire door above is missing hardware (item 1C2) – Score 2

“Z” is considered a major deficiency Example: the building is not of an allowable type of construction (item 1A1) or each floor does not have at least two approved exits (item 5A) – Score 4

Note 1: Use the scoring grid and key to determine the X, Y and Z scores; 1-5 total score is partial compliance; 6 or greater is non-compliance, or a “Z” score!

Note 2: Use of the BMP “caps” scores for each category at “1”

Joint Commission Scoring Decisions


Accreditation Decision Rules for 2008

Accredited (same)

Provisional Accreditation (same)

Conditional Accreditation (change)

10 or more non-compliant standards (< 100 ADC)

14 or more non-compliant standards (>100 ADC)

Preliminary Denial of Accreditation (change)

14 or more non-compliant standards (<100 ADC)

18 or more non-compliant standards (>100 ADC)

Denial of Accreditation (same)

Preliminary Accreditation (same)

“EC”-Related Scoring Rules


Preliminary Denial of Accreditation (PDA)

PDA01 - Immediate threat to health or safety

PDA03 - Falsification of documentation

PDA06 - Non-compliant standards 3 standard

deviations above the mean (14 or 18 RFI’s)

Conditional Accreditation (CON)

CON01 - Non-compliant standards count 2 standard

deviations above the mean (10 or 14 RFI’s)

Note: In 2008, will be 1.5 deviations above the mean

CON03 - Failure to clear repeat non-compliant

standards

CON04 - Delayed PFI or no ILSM’s when required



Which Areas Have Historically Been the

Lowest Scoring?

Lowest Scoring JC Areas


Percent Scored Not Compliant for Hospitals

IM.3.10 (44%) – Information management

MM.2.20 (36%) – Medications storage

PC.13.20 (29%) – Operative procedure planning

EC.5.20 (19%) – Compliance with the Life Safety Code

MM.3.20 (19%) – Clear medication orders

IM.6.50 (15%) – Transcription of verbal orders

IM.6.10 (15%) – Complete and accurate medical record

PC.8.10 (14%) – Pain assessment and treatment

PC.2.120 (13%) – Definition of initial assessment time frame

EC1.10 (12%) – Safety management risk assessment

Lowest Scoring “EC” Areas


Percent Scored Not Compliant for Other Facilities

Assisted Living – EC.1.5 (33%) Fire prevention planning

Assisted Living – EC.2.2 (33%) Security planning

Assisted Living – EC.2.5 (33%) Fire prevention implementation

Assisted Living – EC.1.4 (33%) Emergency planning

Ambulatory Care – EC.4.10 (19%) Emergency management

Behavioral Health Care – EC.4.10 (10%) Emergency management

Behavioral Health Care – EC.4.20 (5%) Emergency drills

Critical Access Hospital – EC.1.10 (10%) Safety risk management

Critical Access Hospital – EC.7.10 (4%) Utility management

Lowest Scoring “EC” Areas


Percent Scored Not Compliant for Other Facilities

Laboratory – EC.6.20 (11%) Equipment testing and inspection

Long Term Care – EC.4.10 (18%) Emergency management

Long Term Care – EC.9.10 (14%) Monitoring the environment

Office Based Surgery – EC.4.20 (13%) Emergency drills

Office Based Surgery – EC.1.20 (8%) Safe environment

Office Based Surgery – EC.5.40 (8%) Fire equipment maintenance

Home Care – EC.4.10 (20%) Emergency management

Home Care – EC.4.20 (10%) Emergency management drills

Home Care – EC.6.60 (7%) Medical equipment testing



What will be the Other Major EC

Changes for 2008?

Possible Change for 2008


2006 AIA Document:

Approval voted June, 2005

May be adopted by JCAHO in the future

Available for purchase now! (AIA.org or ASHE.org)

Multiple changes for single rooms, expanded

ICRA, space revisions, HVAC changes, patient

safety language, surge capacity information in

Appendix

Other Changes for 2008


Electronic SOC Document

All BBI’s and PFI’s must be electronically entered into

the Joint Commission Connect site

Deadlines: BBI’s: 1/1/07 PFI’s: 9/1/07

Annual submission of SOC with PPR delayed!

Entered data will be “frozen” after approval by surveyor

PFI entries should be continuous

Password for organization will be required for data entry

Actual completion dates must be entered as they occur

Be sure to fill out forms, even if “No Deficiencies” on PFI

Download the data and put “hard copy” in notebook

Other Changes Continued for 2008


Electronic SOC Document PPR process will now include questions about the e-SOC

No longer “busted plan” – now termed “Non-Compliant”

e-SOC will track when completion dates are changed prior

to approval by surveyor

PFI’s completed beyond 6 months of intended date may be

cited under: EC.5.20, LD.2.20, LD.3.80 or LD.4.50

Can delete buildings on BBI, but not sites!

PFI summary uses the following colors:

- Yellow for 4 months beyond intended completion date

- Orange when beyond the 6-month grace period

- Salmon when PFI completed after 6 months of intended date

Other Changes Continued for 2008


Generator Run Tests (EC.7.40) 4-hour run at greater than 30% of nameplate load every three years; first due 7/1/07

Load test should be dynamic (actual hospital load), although the Joint Commission will accept load bank tests

Any 4-hour @ 30% load test since July 1, 2004 will count and the next test will not be required until the 3-year anniversary date

Test failure requires interim measures until repairs are completed; successful retest is required after initial failure

All other existing generator tests still required; reference NFPA 110, 2005 edition

Simultaneous monthly, annual load bank and trienniel tests will count, as long as first 30 minutes are at 30%, rather than 25% of load (NFPA 70 panel does not yet agree!)

Expectations for 2008


Sentinel Event Alert #37 Recommendations

Perform emergency power system gap analysis

Maintain complete, labeled, accurate inventory of loads served by the emergency power system (EPS)

Ensure competency training of staff who are responsible for the testing and maintenance of the EPS

Test generator fuel oil on an annual basis and filter or replace, as necessary

Communicate EPS capabilities and limitations to clinical staff and hospital management

Establish clinical contingency plans in the event of brief or prolonged failure of the EPS

Other Changes for 2008


Operational Damper Tests

Re-inspection now every six rather than four years in hospitals; other occupancies still four years per NFPA

Change effective January 1, 2008

Result of move from NFPA 90A to NFPA 80 (fire dampers) and NFPA 105 (smoke dampers), the 2007 editions

For smoke dampers, the inspection shall occur one year after installation and then on a six-year basis

Inaccessible dampers should be placed on the PFI form and given a 6-year time period for completion; completion date can be extended after the 6-year period has expired

Emergency ManagementEMERGENCY


What are the Newly-Adopted Changes for 2008? EC.4.11: Plans for managing emergencies

EC.4.12: Development of emergency operations plan

EC.4.13: Emergency communications strategies

EC.4.14: Management of resources and assets

EC.4.15: Strategies for managing safety and security

EC.4.16: Management of staff roles and responsibilities

EC.4.17: Strategies for managing utilities

EC.4.18: Management of clinical and support activities

EC.4.20: Implementation of emergency drills 2X per year

Note: One drill requires external “non-support” simulation

Top “EC” Focus Areas for 2008


Patient Safety

Infection Control

Emergency Management

(Katrina impact – 2008 changes)

Life Safety (life safety specialist

surveyor change)

Risk Assessment

“EC”-Related Patient Safety Goals for 2008


For Ambulatory, Behavioral Health, Home Care and Hospital Facilities

Add Goal #13: Encourage patient’s active involvement in their own care as a patient safety strategy (define and communicate the means for patients and families to report safety concerns)

Add Goal #15: The organization identifies safety risks inherent in its patient population (identify suicide risk – relates to patients being treated for emotional and behavioral disorders)



What Other Chapters in the Manual Will Impact

EC in 2008?

Organizational Function Overview


Human Resources (HR)

Staff training, competency and performance

Leadership (LD)

Compliance, resources, patient safety (LD.3.50,

oversight of contracts/ services; 7/1/07)

Performance Improvement (PI)

Data collection, aggregation, analysis , action

Information Management (IM)

Data collection, aggregation, security

Infection Control (IC)

Measurement and reduction of infections



What will the EC Chapter look like

in 2009?

The 2009 EC Chapter


What will be the major EC changes?

Mostly editorial changes

Emergency management and life safety (not fire safety) will have their own chapters

Staff competency (including for clinical staff) will be returned to the EC chapter

Safety and security will be combined into one standard

An entirely new numbering system will be used

Numbering the EC Standards


EC.1.01 – Management Plan Requirements

EC.2.01, 2.03 – Safety and Security

EC.3.01 – Hazardous Materials and Wastes

EC.4.01 through 4.04 – Fire Safety

EC.5.01, 5.02 – Medical Equipment

EC.6.01 through 6.05 – Utilities Management

EC.7.01, 7.03 – Other Physical Environment

EC.8.01 – Staff Competency

EC.9.01 through 9.03 – Monitoring, Improvement

Understanding the Four “EC” Vulnerabilities


What are the Four Survey Points of EC

Vulnerability for 2008?

The Four Survey Points of Vulnerability


The Survey Planning Session

LSC Facility Tour

The “EC” Interview Session

Involves all seven EC areas

Documents and staff must be available

Consists of three phases

“EC” Tracers

The Four “EC” Vulnerabilities


What is the Expectation Triad?

The Expectation Triad


Regulatory Compliance

Performance

ImprovementRisk Assessment



Regulatory Compliance:

“Ensuring that all of the required

standards are being met”



Performance Improvement:

“Attempting to measure and

improve performance on an

ongoing basis in the

Environment of Care”



Risk Assessment:

“Prioritization and management

of resources through an

assessment of probability

and impact”