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Hospital Safety Center May 2010


May 1, 2010
Think beyond D icons for your EC documentation

It’s risky just to stick with required records

You might be surprised to hear how many EC elements of performance (EP) appear to require documentation even though they aren’t designated with a D icon.

Briefings on Hospital Safety has identified more than 30 EPs in the EC chapter for which paperwork would seem to be the only way to demonstrate compliance, even without a direct requirement for documentation.

EC.02.05.07, which sets provisions for inspecting, testing, and maintaining emergency power systems, offers a good example of this dilemma.

EP 4 requires hospitals to test their generators 12 times per year, and the EP has a D icon next to it.

Under EP 9, hospitals must institute interim measures if any emergency power test fails. There is no D icon next to this EP, yet it’s almost impossible to believe a surveyor wouldn’t want to see paperwork showing what interim steps you’ve assessed. 

 “A lot of times [Joint Commission officials] leave it up to surveyors to interpret,” says consultant Marcia Trenn, president of the Trenn Group in North Kingstown, RI.

The list on pp. 4–5 details formally required documentation noted in EPs for the EC standards and also identifies EPs that seem to imply necessary paperwork, although to be clear, this is our assessment and not The Joint Commission’s.

An important point to note is that EC documentation may be available from sources on which you already rely.

“My consultative advice is to make use of the means of documentation that already exist—minutes, evaluations, etc.,” says Steven MacArthur, safety consultant at The Greeley Company, a division of HCPro, Inc., in Marblehead, MA, and the contributing editor for Briefings on Hospital Safety. 

MacArthur will also be appearing at the 4th Annual Hospital Safety Center Symposium May 6–7 in Las Vegas (go to www.hospitalsafetycenter.com for more details).


It’s how you manage risks that counts

One of the most prominent EC requirements, the risk assessment process, resides in EC.02.01.01. EPs 1 and 3 require hospitals to assess safety and security risks and take action to minimize the hazards. Neither EP has a D icon.

Trenn compares risk assessment results to those of a hazard vulnerability analysis (HVA) under the emergency management standards. “To me, a risk assessment is just like an HVA for a facility, so unless you put it on paper, you just don’t have [proof of your work],” she says.

Don’t be fooled into thinking that documenting a risk assessment is merely just to prove you did one, MacArthur says. 

Instead, the bigger point from The Joint Commission’s perspective is whether you’re managing risks properly, which you may be able to gauge through hazard surveillance results, safety committee meeting minutes, and performance improvement efforts.

“If you have effective surveillance [and] occurrence reporting processes, then those processes become all the documentation you need, if you use it correctly,” says MacArthur. 

When talking to clients, “the question I ask is what got better in the management of the care environment over the last 12 months, to which I then follow with: How do you know?” he says. “The bottom line is you have to have a way of knowing where you are in terms of compliance, because if you don’t know or indeed cannot articulate that knowledge, you can’t be sure that your program is doing what it’s supposed to.” 


Proving staff competencies for safety

Staff competencies under EC.03.01.01 revolve around employees being able to demonstrate or describe various aspects of eliminating or responding to EC risks. There are no D icons for any of the EPs under EC.03.01.01.

If surveyors attempt to verify staff member competency, it would be a difficult chore without backup paperwork.

“How do you prove competencies?” Trenn says. “There’s normally a post-test that says, ‘Yes, I had that training.’ ”

An alternative approach would be to use other activities to measure staff competency, such as fire drills and hazard surveillance rounds, MacArthur says. 

“There are no rules about what you can and can’t ask during those activities,” he says. “My personal philosophy has been you need to take advantage of every moment of face time you get with frontline staff.”

For example, you could add a line to your fire drill assessment form that prompts you to ask participants about other safety issues, such as how to find a material safety data sheet for a particular chemical.

Construction and investigations crop up

The following are other areas where documentation is not required but implied:

  • EC.02.06.05. During construction or renovation, EP 2 wants hospitals to conduct pre-construction risk assessments for air quality, infection control, utilities, noise, vibration, and other hazards. The pre-construction assessment is prime ground for documentation to show your deliberations to surveyors or other regulators, Trenn says. 
  • EC.04.01.01. For example, EPs 3 and 5 require hospitals to report and investigate injuries to patients while in the hospital and incidents of property damage. To Trenn, both of these mandates are no-brainers for documentation even if it’s not required by The Joint Commission. She recommends that safety committees complete quarterly reports about patient injuries and property damage, and then track that information against prior quarter and the same quarter year-to-year.
  • EC.04.01.05. Performance improvement results must be reported by the hospital to people who analyze EC issues, such as the safety committee, according to EP 3. Could such a report detailing these results be given verbally? Sure, it’s possible, but we’ve all heard Joint Commission officials say, “If it’s not documented, it didn’t happen.” But perhaps the safety committee noting receipt of this verbal report in meeting minutes would pass muster with surveyors.

Dilemma goes beyond the EC standards

The life safety and emergency management chapters also have examples of implied documentation.

LS.01.02.01 sets up interim life safety measures (ILSM), but only a few of the individual ILSMs require documentation. 

EP 4, for example, discusses inspecting exits daily if a life safety violation exists in the area, yet there is no D icon that requires organizations to document this inspection.

In fact, George Mills, FASHE, CHFM, CEM, senior engineer at The Joint Commission, told Joint Commission Resources’ Environment of Care News that documentation, even if not mandated, can prove ILSM compliance.

“When implementing any of these ILSMs, organizations should document when and how they implemented the measures,” Mills said in the July 2009 issue. “Although only EP 12—inspect and test temporary systems monthly—requires documentation, documenting implementation efforts associated with any of the [ILSMs] would illustrate compliance during an internal review or Joint Commission survey.”

Now to be clear, Environment of Care News does not carry the weight of official Joint Commission standards, so Mills’ views in this case are only suggestions. However, his thinking is clear to interpret, and it is likely he repeats the same advice to surveyors.


Sampling of official vs. implied EC documentation rules

Editor’s note: The following list outlines formal and possibly implied recordkeeping requirements for many of The Joint Commission’s EC standards. Official documentation mandates are noted by a D icon. Those elements of performance (EP) marked as “implied” requirements below have been selected by Briefings on Hospital Safety for your consideration, but don’t necessarily represent the view The Joint Commission would take.

EC.01.01.01—Minimizing EC risks

  • EP 1 (implied): Identifying a person to manage safety risks
  • EP 2 (implied): Identifying a person to intervene when safety risks threaten life or health
  • EP 3 (D icon): Having a written plan for managing environmental safety
  • EP 4 (D icon): Having a written plan for managing security
  • EP 5 (D icon): Having a written plan for managing hazardous materials and waste
  • EP 6 (D icon): Having a written plan for managing fire safety
  • EP 7 (D icon): Having a written plan for managing medical equipment
  • EP 8 (D icon): Having a written plan for managing utilities

EC.02.01.01—Managing safety and security risks

  • EP 1 (implied)—Identifying safety and security risks
  • EP 3 (implied)—Minimizing safety and security risks
  • EP 9 (D icon)—Having written procedures to follow during a security incident

EC.02.01.03—Prohibiting smoking

  • EP 1 (D icon)—Developing a written policy that prohibits smoking

EC.02.02.01—Managing hazardous materials and waste risks

  • EP 1 (D icon)—Having a written inventory of hazardous materials and waste on site
  • EP 3 (D icon)—Having written procedures to follow during a hazardous materials or waste spill
  • EP 10 (implied)—Monitoring levels of hazardous gases
  • EP 11 (D icon)—Maintaining required permits and licenses for hazardous materials and waste

EC.02.03.01—Managing fire safety risks

  • EP 9 (D icon)—Having a written fire response plan

EC.02.03.03—Conducting fire drills

  • EP 5 (D icon)—Critiquing fire drills

EC.02.03.05—Inspecting, testing, and main-taining fire protection equipment

  • All 20 EPs have D icons for various equipment

EC.02.04.01—Managing medical equipment risks

  • EP 2 (D icon)—Maintaining a written inventory of all medical equipment or selected medical equipment by risk
  • EP 3 (D icon)—Identifying inspection, testing, and maintenance activities for medical equipment
  • EP 4 (D icon)— Identifying inspection, testing, and maintenance frequencies for medical equipment
  • EP 6 (D icon)—Having written procedures to follow during medical equipment failures

EC.02.04.03—Inspecting, testing, and maintaining medical equipment

  • EP 1 (implied)—Performing functional checks on equipment before initial use
  • EP 2 (D icon)—Inspecting, testing, and maintaining life support equipment
  • EP 3 (D icon)—Inspecting, testing, and maintaining non–life support equipment
  • EP 4 (D icon)—Testing and maintaining sterilizers
  • EP 5 (D icon)—Testing and maintaining hemodialysis water
  • EP 14 (D icon)—Inspecting, testing, and calibrating nuclear medicine equipment

EC.02.05.01—Managing utility risks

  • EP 2 (D icon)—Maintaining a written inventory of all utility components or selected utility components by risk
  • EP 3 (D icon)—Identifying inspection and maintenance activities for utility components
  • EP 4 (D icon)—Identifying inspection, testing, and maintenance intervals for utility components
  • EP 6 (implied)—Providing appropriate air pressures and exchange rates in ventilation systems designed to control airborne contaminants
  • EP 7 (D icon)—Mapping utility distribution
  • EP 9 (D icon)—Having written procedures to follow during utility disruptions

EC.02.05.05—Inspecting, testing, and maintaining utility systems

  • EP 1 (D icon)—Testing utility components
  • EP 3 (D icon)—Inspecting, testing, and maintaining life support utility components
  • EP 4 (D icon)—Inspecting, testing, and maintaining infection control utility components
  • EP 5 (D icon)—Inspecting, testing, and maintaining non–life support utility components

EC.02.05.07—Inspecting, testing, and maintaining  emergency power systems

  • EP 1 (D icon)—Performing 30-second tests on battery-powered lights 
  • EP 2 (D icon)—Performing 90-minute tests on battery-powered lights 
  • EP 3 (D icon)—Performing tests on stored emergency power supply systems
  • EP 4 (D icon)—Performing 30-minute tests on generators 
  • EP 6 (D icon)—Performing tests on automatic transfer switches
  • EP 7 (D icon)—Performing four-hour tests on generators
  • EP 9 (implied)—Carrying out interim measures when an emergency power system fails
  • EP 10 (implied)—Performing retests after repairs 

EC.02.05.09—Inspecting, testing, and maintaining  medical gas and vacuum systems

  • EP 1 (D icon)—Performing tests on medical gas systems
  • EP 2 (D icon)—Performing tests on piped medical gas and vacuum systems when modified

EC.02.06.01—Maintaining a safe and functional environment

  • EP 13 (implied)—Maintaining suitable ventilation, temperature, and humidity levels

EC.02.06.05—Reducing risks during demolition, construction, and renovation

  • EP 2 (implied)—Conducting a pre-construction risk assessment
  • EP 3 (implied)—Minimizing risks during demolition, construction, and renovation

EC.03.01.01—Ensuring staff members and licensed independent practitioners are familiar with safety responsibilities

  • EP 1 (implied)—Describing or demonstrating ways to minimize EC risks
  • EP 2 (implied)—Describing or demonstrating actions to take during an EC incident
  • EP 3 (implied)—Describing or demonstrating how to report EC risks

Editor’s note: To see our full list of documentation concerns for the EC standards, as well as those for the life safety and emergency management standards, please log on to www.hospitalsafetycenter.com and click the Special Reports link in the left column.


State OSHA agency fines hospital for alleged H1N1 slips

When federal OSHA issued its compliance directive in November 2009 regarding healthcare worker protection against H1N1, many worried that the requirement for N95 respirators was nearly impossible to comply with, given supply shortages. 

OSHA indicated that when respirators were not commercially available, an employer would be considered compliant if a “good faith effort” had been made to acquire N95s. Part of that effort included documenting attempts to order respirators and including the Centers for Disease Control and Prevention’s (CDC) H1N1 prevention guidelines in the facility’s respiratory protection plan. 

State cites hospital $8K

For those who were unsure how officials would enforce this directive, the state OSHA agency in Washington gave an early lesson. 

On January 29, Sacred Heart Medical Center in Spokane, WA, received a citation and an $8,000 fine from the state Department of Labor and Industries’ (L&I) Division of Occupational Safety and Health for failing to adhere to state and national H1N1 safety standards. 

According to the Washington State Nurses Association (WSNA), L&I found the facility to be in violation in eight instances, and cited the following alleged problems:

  • Inadequate written respiratory protection plan
  • Inadequate respirator fit testing and training 
  • No provision for men with facial hair, which affects a respirator’s seal around the face

Union prompts investigation

At presstime in mid-March, Sacred Heart had not returned requests for comment. 

The WSNA may have played a role in the citations, as the organization and affiliated labor union filed a complaint with the state against Sacred Heart for allegedly failing to provide proper equipment after hearing from multiple nurses that the appropriate safety and infection control measures were not in place. 

“As the exclusive bargaining representative, that’s what we do,” says Christine Himmelsbach, RN, assistant executive director of labor relations at the WSNA. “We protect workplace safety and took appropriate action by actually filing the complaint.”

It was difficult to quickly obtain H1N1 supplies, but many facilities successfully reacted to the OSHA directive, Himmelsbach says.

“I think when the flu season first began, it certainly was a challenge, and yes indeed, we did see across the state that it was a common problem that people were trying to react to the need for the proper equipment and have proper programs in place and it all happened very quickly,” Himmelsbach says. “Many of the hospitals responded appropriately, and in the case of Sacred Heart, they did not.”

However, the citation led to reevaluation of the facility’s program, she says. Equipment was made available and employees felt they were protected from the H1N1 virus. 

Other hospitals should take notice

After OSHA released its H1N1 compliance directive, there was debate over whether N95s were actually necessary, as the CDC suggested. Many wondered whether surgical masks, typically used for patients with seasonal influenza, would suffice. 

The Washington citation will put healthcare facilities on notice that failure to follow CDC guidelines to protect employees against H1N1 could result in OSHA fines. 

“It certainly sent a huge message in my opinion that this is a serious matter,” says Himmelsbach.  

According to Himmelsbach, the WSNA purchased a large supply of N95 respirators prior to the inspection, and provided them to the nurses at Sacred Heart. 

“I’m sure the hospital’s claim [is] that it’s a very lengthy process and very complicated to go through the fit testing,” Himmelsbach says. “I also think too there might have been issues stockpiling the supplies that they did have.”


Hospital Safety Center Symposium preview

HVA events will let surveyors test your flexibility

We all know that The Joint Commission expects your disaster drills to feature escalating scenarios that tax the ability of staff members to respond.

This mandate falls under EM.03.01.03, element of performance 3. But how do surveyors check this provision?

For starters, surveyors should review past drill and actual emergency event critiques to see whether any of those situations pushed the envelope in terms of response and what lessons hospitals learned, says Joseph Cappiello, BSN, MA, chair of Cappiello & Associates in Elmhurst, IL.

But a more likely way for surveyors to gauge your facility’s ability to respond during escalating scenarios is to initiate tabletop exercises, says Cappiello, who will be a featured speaker at the 4th Annual Hospital Safety Center Symposium, which takes place May 6–7 in Las Vegas (go to www.hospitalsafetycenter.com for more details). At the symposium, Cappiello will discuss business recovery strategies as part of hospital emergency preparedness. 

There’s no guarantee of a tabletop

A surveyor could request a tabletop exercise during your emergency management session, although based on reports we’ve received from the field, there are many hospitals that aren’t asked to carry out a tabletop.

In some cases, that decision may rest on a surveyor’s comfort with emergency management. For example, a nurse with an infection control background is going to spend time digging deep into infection prevention practices because that is what he or she knows best.  

Meanwhile, a physician surveyor who is an obstetrician may be more apt to focus his or her review on operating rooms and labor and delivery units—not necessarily emergency management planning, Cappiello says.

Nonetheless, if a surveyor requests a tabletop, a likely source for scenario ideas will be the hospital’s hazard vulnerability analysis (HVA), which is mandated under EC.01.01.01.

Don’t focus all energy on the top HVA risk

Savvy surveyors may not conduct a tabletop of your top-rated disaster scenario from the HVA, but instead perhaps test your No. 2 or 3 rated risk, Cappiello says.

Good surveyors won’t necessarily use the No. 1 HVA scenario because there’s an assumption that hospitals have spent time preparing for their No. 1 event, he says.

A good tip is to practice your lower-ranked HVA risks during emergency exercises once you have your No. 1 risk down cold. Besides, continually exercising the same scenario will not keep staff interest high.

“You’ve got to prepare for other kinds of things” if you expect to increase flexibility through your staff training, Cappiello says.

Emergency planner can’t be the only voice

Another way surveyors can check for your facility’s ability to adapt to escalating situations is to limit the amount of time an emergency management coordinator participates in either the emergency management review session or a tabletop. 

Some surveyors “won’t let the emergency manager take the floor and be the only one who talks,” Cappiello says. “Some will even tell the emergency manager, ‘Just be still.’ ”

With that approach, other members of the emergency preparedness team will be forced to participate, which will give surveyors a better sense of how well-thought-out an emergency operations plan truly is and how knowledgeable staff at all levels understand their roles.


Ideas on how to discipline workers for OSHA violations 

Unless safety officers work in a medical facility with perfectly compliant employees, they’ll be forced into the unenviable but inevitable job of confronting an employee who is not adhering to OSHA worker safety regulations.

On most occasions, safety managers encounter an innocent mistake or a one-time offense that is easily correctable. On other occasions, however, persistent or especially hard-headed employees will demonstr


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