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Peel apart the distinctions of the 2009 EC standards


December 1, 2008

Peel apart the distinctions of the 2009 EC standards

Inattention to details can lead to potential survey pitfalls

You’ve probably spent a good chunk of this year getting ready for The Joint Commission’s reorganization of its EC standards for 2009, which formally takes effect on January 1, 2009.

Now it’s time to double-check policies and documentation to make sure outdated standard numbers no longer appear anywhere, said Steve MacArthur, safety consultant at The Greeley Company, a division of HCPro, Inc., in Marblehead, MA. MacArthur spoke at HCPro’s September 5 Environment of Care for 2009 seminar in Boston.

MacArthur recommended hospitals delete EC standard numbers altogether to save work and avoid getting cited on a survey for outdated documentation and plans. This approach is especially useful for those plans requiring annual reviews; you don’t want to have outdated standard numbers attracting surveyor scrutiny.

The good news is that “they’ve shaken things up quite a bit in terms of renumbering,” MacArthur said. There are no new standards, just a reshuffling of previously existing compliance conditions.

The bad news? New interpretations and clarifications written into the standards’ various elements of performance (EP) may force hospitals to create new compliance policies.

“The overarching concept is that there will be no new requirements,” MacArthur said. “After looking at these standards for quite a long time, I’m still not convinced that a hard-line, no-new-requirements [method] was actually enacted, but I think in some instances, they’ve clarified what their expectations were all along.”

For example, EC.02.05.03 (emergency power systems) will only have six EPs, revised from 17 in its former state as EC.7.20. The Joint Commission (formerly JCAHO) combined certain provisions, which made them clearer.

An attempt to help safety officers

A review of the EC standards for 2009 suggests that Joint Commission officials are trying to help facilities, said Stephen Schwenke, safety officer at Door County Memorial Hospital in Sturgeon Bay, WI.

“They have included cross-references to other sections of the EC standards, other chapters, and even outside entities such as [the National Fire Protection Association] and OSHA,” Schwenke said. “The expectations seem to be headed toward a clarity that hasn’t been seen before. I don’t think they are there yet, but maybe they will be soon.”

For example, EP 4 under EC.02.03.03 (formerly EC.5.30) will require staff members who work in buildings in which patients receive treatment to participate in drills, which is a broad directive, Schwenke said.

Specific actions related to this participation (e.g., reactions in response to discovering a fire) would be better.

“I know this may seem to oversimplify, but I would definitely help John Q. Facilities Director in providing what is expected,” Schwenke said.

Potential hotspots to tackle now

The August and September Briefings on Hospital Safety covered some of the EC changes coming in 2009 (e.g., the combination of safety and security under one standard and the return of safety competencies to the EC chapter).

Based on conversations with recently surveyed hospitals and the way The Joint Commission reworded or moved some standards into other chapters, additional potential survey hotspots for 2009 include:

  • Eye wash station testing and maintenance. This is covered under the risk assessment provisions of EC.02.01.01 (formerly EC.1.10).
  • Unsecured E-size medical gas cylinders. This problem has popped up routinely in surveys and is also covered under EC.02.01.01.
  • Hazardous materials and waste management. Additional references to hazardous gases and vapors will appear in EC.02.02.01 (formerly EC.3.10), suggesting surveyors might zoom in on this standard. However, infectious waste standards have been moved to the infection control chapter.
  • Fire risks. Although many fire safety protection directives will move to the new life safety chapter, EC.02.03.01 (formerly EC.5.10) still requires hospitals to manage fire risks. Among the EPs is one calling for “free and unobstructed access to all exits in business occupancies.”
  • Fire drills. There is talk that in 2010, EC.02.03.03 (formerly EC.5.30) will require all fire drills, not just half of them, to be unannounced, MacArthur said.
  • Fire safety equipment and building feature testing. EC.02.03.05 (formerly EC.5.40) will encompass this testing and includes 20 EPs. Testing of fire alarm supervisory signals, valve tamper switches, and duct detectors—which were previously all part of one EP—will be broken into three separately scored EPs.
  • Biological testing on dialysis water. Under EC.02.04.03 (formerly EC.6.20), EP 5 will more clearly state that hospitals must perform biological testing on dialysis water, which is a change from documenting testing in previous editions of the standard. MacArthur says he isn’t sure whether that would change surveyors’ expectations, but it’s a good idea to bring the wording change to the attention of leaders who steer compliance strategies.
  • Utility systems management. EC.02.05.01 (formerly EC.7.10) will require hospitals to identify in writing the inventory of utility components, inspection and maintenance activities, and the intervals for those activities.
  • Safe environment maintenance. EC.02.06.01 (formerly EC.8.10) calls for hospitals to maintain safe environments. EP 13 requires ventilation, humidity, and temperature levels “suitable” for patient care. That is a vague term that caught MacArthur’s attention, and hospitals may want to check standards from the American Society of Heating, Refrigerating, and Air-Conditioning Engineers (www.ashrae.com) as a starting point. “You get to decide what works in your house,” but be ready to defend your decision to surveyors, MacArthur said.

Meanwhile, Schwenke says facilities should carefully read any notes that appear after EPs. Under EP 9 of EC.02.02.01, The Joint Commission requires hospitals to minimize risks associated with hazardous gases and vapors.

A note after the EP, which Schwenke characterizes as a “hand grenade,” presents examples of hazardous gases, but leaves the list open to further interpretation by surveyors. “They really do throw some humdingers in there with those notes,” Schwenke said.

A word about documentation

MacArthur also notes that The Joint Commission provided some general guidance regarding documentation in its June Environment of Care News, which is useful when reviewing the reworded standards.

If confusion arises as you attempt to determine what paper trails your facility must generate to demonstrate compliance, the accreditor offers clues about its expectations in each EP: When a written document is required, the words “in writing,” “written,” or “documented” will appear in the text of the EP. If this is not specifically stated, a written document is not required to show evidence of compliance. A circled D icon next to an EP also indicates documentation is necessary.

However, be careful about standards that don’t indicate documentation is necessary, MacArthur said. EC.02.06.05 (formerly EC.8.30) doesn’t mandate documentation for preconstruction risk assessments, but in that case, you’d be hard-pressed not to document your efforts.

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