For most, the EOC 'tracer' breeds fear; follow these tips to be prepared

Tips and tools for a successful building safety survey

If the thought of The Joint Commission surveying you on your environment of care or building safety makes you squirm, you're not the only one. And there's good reason. Of the top five challenging requirements for hospitals in the first half of 2010, four of the five standards were related either to the environment of care or life safety code chapter, according to The Joint Commission. Those four, respectively, are:

  • with a 50% noncompliance rate: LS.02.01.20 — The hospital maintains the integrity of the means of egress;
  • with a 44% noncompliance rate: LS.02.01.10 — Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat;
  • with a 38% noncompliance rate: EC.02.03.05 — The hospital maintains fire safety equipment and fire safety building features;
  • with a 37% noncompliance rate: LS.02.01.30 — The hospital provides and maintains building features to protect individuals from the hazards of fire and smoke.

According to Glenn D. Krasker, MHSA, FACHE, president and CEO of Critical Management Solutions, a consulting firm based in Wilmington, DE, the life safety code used to be a part of the environment of care chapter, but in 2009, The Joint Commission separated the two.

"Life safety is essentially the hospital's compliance with the National Fire Protection Association's Life Safety Code, which means whether the hospital is fire-safe, whether it is constructed and built in a way and maintained in a way that will prevent the fire from starting and the fire from spreading... The environment of care chapter is more global in that it addresses the entire physical environment of the hospital, more importantly, the inter-relationship between the occupants of the building — visitors, patients, staff, and the building itself." Both life safety and environment of care fall under hospital safety standards.

Within the environment of care chapter, there are six management programs, Krasker says:

  • safety;
  • security;
  • hazardous materials and waste;
  • emergency preparedness;
  • medical equipment;
  • utility systems.

For each of the six, you must have a management plan or document describing the program, says Scott Anderson, principal consultant with the Quality Systems Group LLC in Linn, OR.

In 2010, EOC and emergency management are a combined session for ambulatory care, behavioral health care, home care, long-term care, and office-based surgery accreditation surveys. For both critical access hospitals and hospitals, the two now are separate sessions.

The environment-of-care session itself is separated into two parts: a sit-down discussion reviewing documents and policies, as well as corrective plans that have been identified by the organization; and a tracer, Anderson says.

The life safety code specialist mainly handles building inspections, while another surveyor generally does the environment-of-care session, Anderson says. "There is overlap because your fire safety program is just one element or program under the umbrella of environment of care," he says.

Krasker says, "My intelligence tells me that starting in 2011, The Joint Commission is going to change their survey process a little bit," including increasing the number of days the life safety code specialist is on site. "I see that the life safety specialist will really be surveying all aspects of the environment of care and life safety."

What's included in an EOC session?

As part of the sit-down session, The Joint Commission will want to see a lot of documentation, Anderson says, including:

  • the six required management plans, plus your emergency operations plan;
  • minutes from your safety committee for the last 12 months;
  • annual effectiveness evaluations from each of the six management areas;
  • statement of condition documents.

In looking at the six management plans, Krasker says, The Joint Commission will look at the scope and content of the plans and also "the indicators or performance measures the hospital has identified" in each, as well as "the data they have collected and what they have done with those data, what conclusions they have drawn."

Surveyors want to see areas you have identified as needing improvement and what you have done. Krasker says surveyors will take one or two of the management programs and run them through the EOC risk management cycle, which includes planning, teaching, implementing, responding, monitoring, and improving.

Surveyors want to see the EOC risks the hospital has identified, the plan of action, and what has been done or will be done to mitigate the risk identified. As an example, Krasker says, if you find the medical gas system is not functioning properly or generators are not producing enough power, surveyors are going to look for "what steps have been taken, what do you need to do in the meantime while you are implementing that plan" or while you are getting the money together to repair a system, what you are doing in the interim. If you have identified a risk, produced a plan for corrective action, but you have not done enough on that, you would certainly be cited, he says.

He says that he sees, too often, hospitals getting cited "for not following up, taking corrective actions to repair [the failing system] or making necessary repairs in a timely manner. It's almost as if they get these reports from inspections from outside companies that do a lot of testing for them and they just don't pay attention to them. They just don't jump on these issues that need to be addressed very timely... That's something The Joint Commission is keyed in on.

"Whether it's the building or any aspect of the environment of care, medical equipment or your utilities systems, if they are not functioning properly, what is your plan to fix them and to repair them?; and in the meantime, what have you done to keep the environment or keep the occupants safe while those repairs are pending?" he says.

As part of that session, Anderson says surveyors also will meet with the chairman of the safety committee and other committee members to discuss risk areas and corrective actions. "You are provided a fair amount of latitude with regard to standards and regulations about committee membership. You need to have a cross section of the organization represented. There are some state regulations, which are more specific as to committee membership," he says. He suggests a cross section of staff including clinical, nonclinical, clinical inpatient, and outpatient representatives. Many larger organizations, he says, construct sub-committees based on the six management plans.

The statement of conditions, he says, is a Joint Commission management tool that allows hospitals to "do a self-evaluation of their compliance with the life safety code. It has four sections, but the major section is where you identify, based on a very rigorous tool and inspection of the hospital, life safety code deficiencies — whether it's holes in smoke and fire barriers, whether it's doors that don't positively latch." For those deficiencies that are going to take longer than 45 days to repair, you must develop a call for improvement, or PFI, he says. That should state what you are going to do to fix that deficiency, the time frame it will take to complete, and the cost. If surveyors see something you have identified and the due date has not passed, you won't be cited, he says. If surveyors do find something that is not in the statement of conditions but violates standards, you will be cited.

Preparing for the EOC session

In preparing the documents The Joint Commission will review and to accommodate the breadth of activities required by the EOC standards, Kurt Patton, MS, RPh, CEO of Patton Healthcare Consulting in Glendale, AZ, and former executive director of accreditation services at The Joint Commission, says, hospitals should:

• Organize activities such as tests or drills by when evaluations are required.

There are myriad time tables in the EOC chapter, Patton says. "We have a tool that we give people. When you look in the chapter, it talks about all these things you've got to do once a month, once a week, once a year, every six months." As part of the tool, he organized those activities that you do on an infrequent basis — such as semi-annual — or on a quarterly, monthly, or weekly basis. (See the tool.)

• "Document every aspect of the tests that they do so that it mirrors the requirements of the elements of performance precisely."

"Think of something like generator testing. Hospitals say, 'Yes, we do generator testing.' But then when you look at The Joint Commission standards, do you do the generator testing every month? No less than every 20 days? No more than every 40 days? And, surprisingly, you look at some hospitals, and they do one test 19 days apart and they do one test 41 days apart. That's not compatible with the standard," Patton says.

• Check your documentation for the level of detail and make sure you're getting details from your vendors as well.

The standard Patton refers to above also requires that during the generator test you should ensure that when the generator goes on, that you transfer the power using automatic transfer switches and document whether those work and how many seconds it took to throw the power. "Hospitals do it by observation, but they don't check and say, 'That transfer switch, No. 1, took us eight seconds. That transfer switch, No. 2, took us five seconds.' And The Joint Commission is looking for that level of detail."

He says you must require the same level of specificity from your vendors. Echoing Krasker's sentiments, Patton says, The Joint Commission is focusing a lot more on documentation and also looking that you've resolved any identified risks. He, too, sees hospitals that have a vendor test something and the vendor reports that a certain system, such as medical or gas alarms, isn't functioning properly. "And the hospital gets the report and doesn't act upon it. That's worse than not knowing," he says.

Working with vendors, engineers

One of the most common "flaws" he sees is when a vendor hands the hospital an invoice for $4,000 and says, "I tested your fire alarms." "But what the vendor needs to do is say, 'I tested the following fire alarms, I tested the following fire strobes, and they all worked successfully,'" Patton says. The vendor should leave a complete listing of all the devices that were tested.

Patton also says many hospitals should improve how they work with engineers. "We have in each hospital a quality department, and they make sure the doctors are doing what they are supposed to do, they make sure nurses are doing what they are supposed to do... And when it comes to engineering, for some reason, they seem to turn a blind eye to it. It's very technical. Perhaps people aren't welcoming of others looking over their shoulder, but you've got to do it. Just like you would in any other part of the hospital." And since the QI department houses "experts in knowing how The Joint Commission works," he says, they should "look for a certain degree of documentation that engineers might not automatically think of."

(Editor's note: EOC tracer tools, below.)

Department Walkthrough EOC Checklist

Area/Item to be checked:

Status (OK or Gap)

Action Needed & Taken

Compressed gas cylinders are secured

Hazardous materials properly stored/labeled

Sharps containers secured/not overfilled

Chemicals have not passed expiration date

Eyewash stations have water temperature regulated to prevent burning from hot water

Under sink storage clear of patient care items

Corridors/stairways free of clutter and storage

Exits signs are illuminated and visible

Fire hoses and extinguishers are accessible

Monthly fire extinguisher checks complete

18" clearance under sprinkler heads

Fire doors close properly & are unobstructed

Doors positively latch & door wedges not used

Storage areas are clean

Medical gas shutoff clearly marked/ accessible

Ceiling tiles are in place and unstained

All lights are working

Handrails are in good repair

HVAC vents are clean and unobstructed

Walls, ceilings, and doors in good repair

Area is clean and uncluttered

Soiled equipment & linen separated from clean

Refrigerators/freezers/microwaves clean

Refrig/Freezer temperature logs complete

Patient supplies kept off the floor

Disinfectants/chemicals include manufacturer warning labels

Doors to Biohazard areas are kept closed

Patient care equipment is cleaned per policy

Microwave is clean

Access to sensitive areas is enforced

Medications are properly secured

Syringes/Prescription pads secured

ID badges worn by all employees

Patient information inaccessible to public

Defib and crash cart checks done per policy

Electric panel secure and unobstructed

Electric outlets/switch plates/cords in good condition

Quality Checks are documented for Point of Care testing (e.g. Glucose Meters)

Solution bottles & test strips are dated when opened and are not expired

Other:

Source: Kurt Patton Consulting.

2010 Tracer Tool — Environment of Care Walk Around

Life Safety
• Fire exits accessible? Clearly marked?
• Exits signs are illuminated and visible
• Fire doors close and latch
• Fire door have proper gaps and undercuts
• Fire door with appropriate fire rating
• Fire alarm pull stations accessible
• Evacuation route maps posted and accurate
• Fire extinguishers inspected monthly and annually
• Fire extinguisher and hoses accessible
• Fire drills completed as required and documented
• Fire alarm system testing up to date
• Ceiling tiles are in place and clean
• 18" clearance under sprinkler heads
• Corridors/stairways free of clutter and storage
• Hallways clean and uncluttered – 8 foot
unobstructed
• Fire doors close properly & are unobstructed
• Doors positively latch & door wedges not used
• Penetrations in walls or ceilings properly sealed
• Walls, ceilings, and doors in good repair

Environment, Storage, and Equipment
• Medical equipment PMs up to date
• Medical equipment is cleaned per policy
• Under sink storage clear of patient care items
• Storage areas are clean free of combustible material
• Medical gas shutoff clearly marked/ accessible
• Medical gas alarm panels working
• Handrails are in good repair
• HVAC vents are clean and unobstructed

Source: Kurt Patton Consulting.

• Soiled equipment & linen separated from clean
• Refrigerators/freezers/microwaves clean
• Refrig/Freezer temperature logs complete
• Microwave is clean
• Defib and crash cart checks done per policy
• Electric panel secure and unobstructed
• Electric outlets/switch plates/cords in good condition

Safety
• Negative pressure rooms functioning, testing complete
• Access to sensitive areas is enforced
• ID badges worn by all employees
• Required PPE available in department/area
• Safety glasses and face shield NIOSH approved (Z87.1)
• Compressed gas cylinders are secured
• No more than 12 E cylinders in a smoke compartment
• Eyewash stations have water temperature regulated to prevent burning from hot water

Hazardous Material/Waste
• Hazardous materials properly stored/labeled
• Waste receptacles emptied before overfilled
• Sharps containers secured/not overfilled
• Sharps containers mounted below 4'10"
• Doors to Biohazard areas are kept closed, labeled
• Disinfectants/chemicals include manufacturer warning labels
• Chemical containers properly stored and labeled
• Chemicals have not passed expiration date
• Material safety data sheets up-to-date and accessible