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Tie EC and IC together to create a safe environment


September 1, 2010

Joint Commission compliance and survey success depend on effective management of the care environment, says Steven MacArthur, safety consultant at The Greeley Company, a division of HCPro, Inc., in Marblehead, MA.

Creating a safe hospital environment requires paying attention to both EC and infection control (IC) standards, especially those points where the requirements cross over each other.

When it comes to the 25 most frequently cited Joint Commission survey findings in 2009, three standards have both EC and IC implications, says MacArthur, who spoke at the 4th annual Hospital Safety Center Symposium May 6 in Las Vegas.

The three standards that demand attention by hospital safety officers and IC professionals are:

  • EC.02.06.01: Safe/clean environment
  • EC.02.01.01: Safety and security (general duty clause)
  • IC.02.02.01: Device/equipment processing and storage of supplies

Elements of performance (EP) that are cited most frequently and are historically the most problematic get the most scrutiny during surveys, MacArthur says.

Standard EC.02.06.01 focuses on the need for hospitals to create a safe, functional environment. The standard addresses the maintenance of ventilation, temperature, and humidity levels under EP 13. It also requires that areas used by patients be kept clean and free of offensive odors under EP 20. Additionally, hospitals must keep furnishings and equipment safe and in good repair under EP 26.

EC.02.01.01 sets the expectation that hospitals will take action to minimize or eliminate identified safety risks in the physical environment (EP 3). It is roughly equivalent to OSHA’s general duty clause and is a standard the whole survey team can invoke to ensure a safe environment, MacArthur says.

This performance element is a “C” element, which means it is rate-based. The Joint Commission expects a minimum compliance rate of 90% or better.

Effective in 2009, The Joint Commission made a change in sample size from three to two for “C” elements when it dropped the practice of using “supplemental recommendations,” MacArthur says. In previous years, surveyors were required to find three instances of noncompliance to cite an organization under this standard; they now need to find only two instances. For example, if surveyors find two unsecured compressed gas cylinders, it can result in a requirement for improvement (RFI).

 “You are standing much closer to a finding than in 2008,” MacArthur says. However, you can use data from your rounds to document a historical compliance rate of 90% or better over time and have a realistic expectation of clarifying an RFI in the process following your survey.

Standard IC.02.02.01 sets requirements for medical device processing and medical supplies storage. It requires the cleaning and disinfecting of medical equipment, devices, and supplies under EP 1. It addresses sterilizing (EP 2), disposing of (EP 3), and storing (EP 4) medical equipment, devices, and supplies.

Clearly, hospitals’ management of medical devices is undergoing a lot of scrutiny, MacArthur says.

Other standards that create perennial problems

Those aren’t the only standards you need to worry about, however, says MacArthur. There are some others he calls “perennial contenders” that cause problems during survey. Those include:

• EC.02.06.05, which requires the management of the environment during demolition, renovation, or new construction. It requires hospitals do a pre-construction risk assessment (EP 2) and take action to minimize risk based on that assessment (EP 3). 

When it comes to compliance, “assessment is key,” says MacArthur.

• EC.02.05.01 addresses utility system risks. It requires the minimization of pathogenic biological agents in water systems (EP 5); controlling airborne contaminants by providing appropriate pressure relationships, air exchange rates, and filtration efficiencies (EP 6); as well as dealing with utility system disruptions (EP 9).

• EC.02.05.05 requires hospitals to inspect, test, and maintain IC utility system components on the inventory and document those activities (EP 4). This loosely translates as, ‘Say what you do and do what you say,’ Macarthur says.

Tips for compliance

MacArthur says he gets many questions when it comes to these utility system requirements and offers the following tips for EC and IC compliance:

• Check your FAQs. One step hospitals can take to stay on top of Joint Commission issues is to check the accreditor’s FAQs on a regular basis, MacArthur says. You can find the FAQs on The Joint Commission’s website at www.jointcommission.org/Standards/FAQs

The Joint Commission updates many safety concepts through its FAQs. Once posted, they are considered as enforceable as the EPs, MacArthur says.

Some of the topics the FAQs have addressed are:

  • Under-sink storage
  • Refrigerator temperature management 
  • Food and drink in patient care areas 
  • Utility systems and hospital-acquired illness 
  • Use of fans
  • Alcohol-based hand rub dispensers
  • Patient-owned equipment 

When it comes to under-sink storage, The Joint Commission doesn’t say what is required, MacArthur says. The accreditor’s expectation is that organizations will manage the risk appropriately. “We have to determine what is appropriate,” he says.

• Decide how your hospital will manage infection risks. With regards to your risk assessment, there are frequently no standards-based requirements, MacArthur says. However, your state’s department of health may have regulations you need to follow.

For example, what are your hospital’s requirements for flash sterilization? Storing cardboard boxes? Storage on the floor? 

These issues are cited under general rules based on surveyor preference, MacArthur says. It is up to the organization to decide what is and is not appropriate management of infection risks, he says.

• Keep four steps in mind. When you start your risk assessment process, says MacArthur, follow these four steps:

  • Review any regulatory requirements
  • Review other available literature (Web searches included)
  • Review your own experience
  • Make your decision, then document what you have done with committee meeting minutes and your annual evaluation

For example, under-sink storage is a problem that continues to plague many hospitals. 

As part of your risk assessment, you need to identify the issues, and Web searches can help you learn what other hospitals are doing, MacArthur says.

Evaluate your own experience with the issue. “You know your staff. You know your building,” MacArthur says. Sometimes it will become your responsibility to educate surveyors as to what compliance means in your organization.

Finally, decide how your organization will deal with the issue. You might decide that nothing should be stored under sinks, or that only a spray bottle for cleaning can be stored there. You can use your committee minutes to document your process. Review the issue as part of your annual evaluation.

• Beware of surveyor “wisdom.” When surveyors come through your hospital’s door, don’t assume they are the experts in all areas. Surveyors are not experts in all standards nor are they experts in identifying what works best in your organization, MacArthur says—“That’s you.”

• Manage the FAQs and surveyor opinions. Don’t let surveyors manage your program, MacArthur says. Consider adopting their suggestions only if they make sense and you understand the pathway to successful implementation. “They may not work in your organization,” he adds.

Remember, there are no one-size-fits-all solutions. The standards reflect the desired outcomes for programs of all shapes and sizes, MacArthur says. For the most part, they are very gray and allow organizations to decide what works best. 

• Define and evaluate. How have you defined:

  • Safe?
  • Compliant?
  • Prepared? 
  • Competent?
  • Collaboration?

How do you evaluate those factors?

  • Can you measure this?
  • Can you see performance?
  • Can you see improvement?
  • How will you know when you get there?

• Make frequent use of the required processes. You are required to have a safety committee and should take advantage of this group. Use it to communicate with your organizational leadership. Leadership has the obligation to support safety programs, MacArthur says.

Use the annual evaluations of your EC program to record some of the compliance challenges that you’re managing. This process allows you to determine what was improved and why, as well as what didn’t improve and why, MacArthur says.

Perfection is not a standards-based requirement; no hospital environment is perfect. Instead, your programs must be reality-based and recognize your vulnerabilities.

“We do data-driven surveillance activities all the time,” MacArthur says. “It’s about minimizing the effects of those imperfections.”

The data should count toward compliance, not deficiencies, he says. For instance, for every item improperly stored under a sink, others are managed appropriately. In order to be in compliance with many of these standards, organizations need to demonstrate compliance more than 90% of the time, he says.

For example, for the one compressed gas cylinder left standing in the corner of a patient’s room, there are that many more that are appropriately secured, says MacArthur. That number may put you in the 99% range.

“That’s the best way to manage compliance,” he says. You can always find deficiencies, but you want them to occur so infrequently that they’re not putting people at risk.

Recognize that deficiencies happen. Surveyors will always find a wooden door wedge somewhere in a facility, MacArthur says. Perfection is an ever-receding destination, but organizations can stay within the 10% range of compliance.

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