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Tie EC and IC together to create a safe environment

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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.

 

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.



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