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Joint Commission's Reorganization of the Environment of Care Standards

Uploaded by: Terry Wilkinson on 01/25/2012

Author: ASSE

Publication Date: 1/25/2012

Publication Source: ASSE Business of Safety Committee

Summary: HEALTHCARE MANAGEMENT INTERVIEW SERIES: George Mills is senior engineer for The Joint Commission’s Standards Interpretation Group. In this interview, Mark Shirley, Healthcare Practice Specialty administrator, speaks with Mills about the recent reorganization of the environment of care standards.


George Mills is senior engineer for The Joint Commission’s Standards Interpretation Group. In this interview, Mark Shirley, Healthcare Practice Specialty administrator, speaks with Mills about the recent reorganization of the environment of care standards.



Please provide an overview of the Standards Improvement Initiative (SII) that led to the recent reorganization of the environment of care standards.

SII’s goals were to evaluate the standards’ language and to eliminate bulleted lists and hard-to-survey words like "appropriate." We were able to do this with a few exceptions.

We then examined the structure of the accreditation manual, which included environment of care and two subtopics within it. One of those subtopics was emergency management. In 2008, significant changes were made to the emergency management expectations in preparation for a new emergency management chapter to be introduced in 2009.

We also examined the scoring process for the Life Safety Code. In 2008, we scored that under EC.5.20 EP1. We had a series of expectations that we scored based on an x, y and z scale, and our goal was to eliminate the x’s, y’s and z’s and to coordinate with the scoring of other standards and elements of performance. With this in mind, we approached leadership and suggested that we make it its own chapter to make it more user-friendly and functional. Leadership agreed, and we now have a new life safety chapter, which accurately reflects the Life Safety Code’s expectations and our expectations of compliance.


Was the migration of the life safety and emergency management standards to their own chapters the only significant change to the environment of care standards?

Yes, this was the only major change. However, two other changes worth mentioning include the blending of the safety and security standards and removing the safety-related staff education HR requirements from the HR chapter and putting them into the environment of care.


What was the rationale for moving the emergency management and life safety standards to independent chapters?

The Joint Commission has long been passionate about emergency management and readiness and expressed this to the [healthcare] field. Leadership felt it was important to create an emergency management chapter, not only to assist those responsible for the environment of care standards chapter, but also to make information on emergency management more accessible to clinicians and to others involved in emergency management preparations. It merited its own chapter.


This should be helpful for those who are responsible for emergency management, especially in smaller hospitals, since most do not personally have the expertise to adequately address each of the six critical areas in the emergency management standards. This should encourage more of a multidisciplinary approach to emergency management.

Yes, we think so.



Were any substantive changes made to the new standards?

There are no new requirements in 2009. This is something we must drive home. If you were compliant in 2008, content-wise, you should be compliant in 2009. SII’s purpose was to examine the language, structure and function of the standards and to refresh the standards based on those approaches.


With respect to life safety, the requirements have not changed, but you have added specificity from NFPA’s Life Safety Code to the new standards?

We have done a few things. One was to ensure that if Centers for Medicare and Medicaid Services required it, we required it as well. We made sure no gaps existed between us. This was a major issue.

We also reconciled everything with the 2000 Life Safety Code, so now our language and number sequencing reflects the Code. Additionally, we now stress interim life safety measures, which are also found in the life safety chapter.


Will combining the safety and security standards impact or change healthcare organizations’ approach toward security management?

We do not believe so. We looked at the chapters’ functionality and the fact that the safety and security standards had many parallel expectations. In other words, safety had 11 elements of performance and security had ten. The first five of safety and the first four of security were essentially the same. So in looking at the structure of the chapters, we felt it would be prudent to combine the expectations and to add in those specific to each area like recall issues and securing sensitive areas. We did this to be more functional with our chapter, not to send a message to the field.

We feel you are free to have separate safety and security departments if they function well for your organization. We also feel that if your organization wants to combine these two departments into one, you are free to do so. Historically, The Joint Commission has not been involved in an organization’s operations or management. The outcomes are more important to us.

Every accredited organization has received a fully searchable electronic edition of the new standards. We have also changed our hardcopy manual from an 8.5" x 11" format to a 6" x 9" format.


Many organizations have struggled with the recent changes to the emergency management standards. The Joint Commission recognized this by providing some scoring relief during 2008 surveys. How will The Joint Commission survey to these standards going forward?

In 2009, organizations will be surveyed as they were in 2008, with about 40% of the time spent on discussion and 60% of the time spent on observation for a total of 1½ to 2 hours with the emergency management team.

Relief is related to creating your capability assessment to self-exist for up to 96 hours. We understand that for certain things you need time to create track records for and to determine what consumption rates were for different seasons. We gave organizations up to one year to learn how to do that. Effective January 2009, all of those requirements must be compliant.


Should organizations expect the surveyor to initiate an emergency management exercise?

No, we will not initiate an actual exercise or a drill. We will conduct a simulated exercise with the emergency management team, during which we will examine the organization’s hazard vulnerability analysis (HVA), pick one of the top five items and generate a "what if" scenario based on HVA. We look for the team’s dynamics and how they can problem-solve under the pressure of an escalating scenario.


Is this a roundtable discussion?

At no time during a survey will we initiate a fire alarm or actual event where we might create any disruption within the organization.


So a surveyor will interview the organization’s team responsible for emergency management?

Right. We will ask to have your environment of care interview in your incident command center, and after your interview, we will ask to meet with the emergency management team. During the discussion, we will drill down into the emergency operations plan and HVA. If we notice that your chair is answering all of the questions, we will probably ask that person to take a break so we can see what the rest of the team knows. As we evaluate the answers, we also evaluate the team’s dynamics and whether the organization is ready to respond to an emergency situation.



Some organizations are still unsure how to address the emergency management standard requiring them to prepare for situations when they cannot be supported by the local community for at least 96 hours. Can you elaborate on this standard and explain The Joint Commission’s expectations?

Organizations must identify, based on their HVA, what it will take to self-support for 96 hours. First, there is nothing magical about the 96 hours. The Federal Emergency Management Agency said it will take them 72 hours to arrive and another 24 hours to begin to help us.

"Capabilities" means that the organization must assess if it will be able to stay open and for how long before being forced to evacuate. For example, during a water outage, an organization’s capabilities may be only 30 hours. The organization must determine that if it stays open for 30 hours, will things improve or will the organization need to consider an earlier evacuation?

The organization must also consider conservation strategies. For example, if it closes the east wing and moves those patients to the north wing, doubling all of the singles, will that reduce enough water consumption in the building to go from 30 hours to 45 hours? Maybe by closing down the ambulatory surgery center the organization would gain another five hours for a total of 50 hours.

Or with nursing intervention, baths may be given every other day instead of every day or sponge baths may be given instead of full baths to gain up to 50 hours. Dietary may use full disposable plates, cups and plastic silverware instead of china and shut down steam tables for food preparation to gain another ten hours for a total of 65 or 70 hours. At that point, the organization should determine if there would be enough time to get outside help or to evacuate patients to areas outside of the locations impacted by the water outage.

An organization must know what its resources and capabilities are based on the type of event and their HVA. The organization may have no problems with water or generator fuel, but it may find other areas of deficiency.


Managing your refill point on fuel for generators is important to ensure that you never go below the 96-hour mark.

That is a good point. Let’s say you have a 10,000-gallon tank that gives you 100 hours. A 10,000-gallon tank is never full to 10,000 gallons; 5% must be left for expansion. So 100 hours drops to 95 hours at maximum capacity.

Then you talk to staff and learn that the tank is normally allowed to drop by 60% before they refill it because your supplier does not want to bring out a partial load—they want to bring out a full 5,000 gallons. Now 95 hours have dropped to potentially 45 hours. So your assumption that you will be good for 100 hours is not always accurate. You must monitor fuel capacity on an ongoing basis so that you always know your true fuel hours.


As part of the planning process, should organizations assume the infrastructure is disrupted or assume they cannot receive relief from vendors during this 96-hour window?

That is correct. You are essentially an island unto yourself for those 96 hours.


All hospitals and critical-access hospitals are now surveyed with a Life Safety Code surveyor (LSCS). How will this individual spend his/her time while onsite?

he LSCS will survey against the new life safety chapter (LS.01.01.01 through LS.04.02.07) and also against Environment of Care: Protection Systems (EC.02.03.05), Interim Life Safety Measures (LS.02.01.01), Emergency Power (EC.02.05.07) and Medical Gas and Vacuum (EC.02.05.09).

In critical-access hospitals, they will also survey against all emergency management and environment of care standards. Additionally, hospitals and critical-access hospitals can survey three leadership standards—Leadership Holds Staff Responsible (LD.04.01.05 EP4), Resources Made Available to Correct Safety-Related Issues (LD.03.03.01 EP4) and Leadership Does Not Put a High Priority on Safety-Related Issues, (LD.04.04.01 EP2).


Historically, the Life Safety Code has been the most cited standard. Organizations emphasize preparing for this part of the survey, but several survey findings within the environment of care and life safety chapters pose an immediate threat to life and would jeopardize an organization’s accreditation status. What are some of these findings?

In the new scoring model, immediate threat to life is at the top of the pyramid. Generally, you can reach an immediate threat-to-life in four ways, which have historically been found in the environment of care, assuming no interim life safety measures are in place. These include a nonfunctional fire pump, a nonfunctional fire alarm panel, a nonfunctional medical gas panel and a nonfunctional emergency generator. Any one of these four found on a survey would most likely put you in an immediate threat-to-life situation.

The second point on the pyramid is adverse decision rules. There is no adverse decision rule in the environment of care or emergency management chapters. One adverse decision rule in the life safety chapter is CON-04, which addresses failure to make sufficient progress on a previously accepted plan for improvement as part of an organization’s statement of condition or failure to implement interim life safety measures for a previously accepted plan for improvement.



Would a CON-04 put an immediate stop to the survey?

No, neither one of these actually stops the survey. For example, if the LSCS reviews your plan for improvement and discovers that you have previously accepted items that are still open and have exceeded the six-month grace period we granted you, the surveyor would contact the team leader to discuss it. Then the surveyor contacts the field director (all of our surveyors report to a field director).

The field director will concur that they must contact the main office. At that point, the surveyor will contact the Standards Interpretation Group at the main office, ask for one of the engineers and review with us their finding in the field. We will verify that CON-04 should be invoked. This is no different from receiving an RFI, but the organization will need to resolve this in a short amount of time. In four to six months, a follow-up survey will be conducted to ensure that the issue has been resolved.

If an immediate threat to life occurs, the surveyor will bring it to the attention of the team leader, who will verify the threat and contact the field director. This tracks much like the CON-04 rule. Then they contact the central office. At that point, we use a different set of questions to confirm it is an immediate threat to life. Once our questions are answered, we bring it to the attention of Dr. Ann Blouin, executive vice president of accreditation and certification operations. If she concurs, she will bring it to the attention of Dr. Mark R. Chassin, president of The Joint Commission, for a final decision.

The remainder of the survey will continue without change, but we ask our LSCS if s/he can stay an extra day to help manage the immediate threat to life on the first day and to continue with the balance of the life safety survey on the next day. The surveys are never suspended, but during an immediate threat to life, we run a second track parallel to the normal survey.


In the past, surveyors have asked to interview those responsible for the Environment of Care. Will this still be a common practice? If so, what will surveyors look for?

An environment of care interview is conducted, and depending on the organization’s structure, whoever is involved in the environment of care will be invited to discuss. The surveyor will examine documentation, annual evaluations, meeting minutes, effectiveness assessments of the organization as it relates to the environment of care and other things you find under EC.04 with the information collection and evaluation system. This gives us a chance to look at any data we discovered on the building tour.

For example, if during the building tour we see medical equipment devices, we first ask is if the device is for life support. If the device is for life support, it is automatically included in the organization’s inventory, so we will ask for history on that device. If the device is not for life support, we ask if it is in the inventory. If it is in the medical equipment inventory, we ask for a history on that particular device.

In the physical environment, we use a sample size of ten. On a sample size of ten, one missed item will still leave you at 90%, which we consider compliant. Two missed items would put you at 80% or partially compliant, and three missed items would put you at 70% and noncompliant. We look at the history for ten items to evaluate whether the maintenance strategy as defined in the medical equipment management plan is aligned with what is actually happening in the organization. Items identified on the tour will be reviewed during the environment of care interview, so you will have time to collect those documents.


Do you foresee any changes to the environment of care, life safety or emergency management chapters in the near future? If so, what areas will The Joint Commission review?

I do. In 2009, we have nothing new. We could not add anything new because of the SII project’s requirements, but I wish we could have added a few things such as a specific requirement for medical gas cylinder management. We currently have piped gas management, but we do not address E or H cylinders in terms of handling, management or items open to the corridor. I would like to see an additional requirement for that.

The building maintenance program (BMP) from the life safety chapter was always an option. As an option, we could not make it mandatory because that would have been an increased expectation. I would like to see us revisit BMP as part of the life safety chapter in 2010 or 2011.

As we developed the standards for 2009, we created items that we would like to revisit for development in 2010. As this happens, the field will be invited to give comments on anything that we propose. Like with BMP, if we decide to make it a mandatory requirement, the field will have a chance to give us their thoughts on it. Refer to The Joint Commission Perspectives and new standards alerts. To receive notices, visit The Joint Commission’s website at www.jointcommission.org. In the E-mail Updates section, click on "Sign Up," then under the heading "Additional Joint Commission Lists," check the box labeled "Standards Field Reviews."



I suspect that facility management personnel would like to see BMP return. I understand that The Joint Commission has gone back and forth with CMS on this issue, but in my experience, most facilities managers have kept it in place.

I would strongly encourage them to keep it in place because it is a good way to manage a building.


A specific list of items is required to be supported by emergency power. However, HVAC systems in California, particularly in the central valley, are not required to be covered. So if it is 100ºF and you lose power for a significant length of time, it creates patient problems because the hospital cannot provide air conditioning. Are you looking at that list?

The list came from NFPA 99, which does not require HVAC systems to be connected to emergency power. It is not considered to be an essential, life safety or critical branch; it is just considered to be on the equipment branch. When we generate our list, we want to be consistent with NFPA.

First, NFPA 99 is being completely rewritten with a rollout for 2010, and I believe they will include HVAC in the new edition. We would need to adopt a later edition of the Life Safety Code than 2010, such as the 2012 edition.

Second, the emergency management chapter under EM 02.02.09 states, "…utilities systems as defined by the hospital, for example, vertical and horizontal transport, heating and cooling systems and steam for sterilization." While the "for example" is not an all-inclusive or mandatory list, it says the organization should consider this. Even though NFPA 99 does not say you must include it and our utilities management program does not require it, under emergency management, we say at least consider if you need to do it. If you are in a state with high temperatures, like Arizona, then it makes sense to throw a chiller on the generator. Does this make sense in northern Minnesota? Probably not.


That is where HVA comes into play?

That is exactly right.



George Mills, CHFM, CEM is senior engineer for The Joint Commission’s Standards Interpretation Group. He is a fellow with the American Society for Healthcare Engineering (ASHE) and president emeritus of HESNI, an ASHE local state chapter. Prior to joining The Joint Commission, he was the national director of regulatory compliance for a third-party contract management firm. While with the contract management firm, he was the director of facilities at a 300-bed hospital in Downers Grove, IL. Prior to this role, Mills consulted and worked for ASHE as Director of Codes and Compliance and worked for The Joint Commission from 1995-1997. He has worked in healthcare since 1985 and also has experience in the construction industry and in structural steel fabrication. He holds a master degree in business administration from California Coast University in Santa Ana, CA.

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