Transcript H2E and JCAHO Compliance

H2E AND
JCAHO COMPLIANCE
Susan B. McLaughlin
Barrington, Illinois
JCAHO AND THE
GOVERNMENT
Health Care Finance Administration
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Deemed status
Medicare reimbursement
Go-behind surveys
OIG report, 1999
Occupational Safety & Health
Administration (OSHA)
• Worker safety
• Applicable law and regulation
JCAHO/OSHA
PARTNERSHIP
• Established 1996
• Educational
– Surveyors and Inspectors
– Health care organizations
• Reduce duplicative compliance activities
RELATIONSHIP
ENVIRONMENT
OF
CARE
ENVIRONMENT
OF
WORK
OSHA
JCAHO
STATUS
• Renewed for 3 years in 2000
• “Hammer Award”
• Remains educational
• Additional examples of compliance
MOVING FORWARD
• Cooperative arrangement with Veterans
Administration
– Some exemplary hospitals will invite OSHA in
with JCAHO to survey organization
• 10 facilities
• Central office
– Evaluation of programs
– NOT enforcement
SURVEYOR FOCUS
• Increased knowledge of OSHA issues
• Emphasize areas of overlap in requirements
– Example of “applicable law and regulation” in
EC.1.3
• Verification vs. inspection
• New emphasis in standards
– EC.1.1.1: Worker Safety
EPA ISSUES
• Storage > 180 days
– Toxic waste storage facility
JCAHO / EPA
RELATIONSHIP
• No formal relationship
• Letter to Committee on Healthcare Safety
• Cited as an example of “applicable law and
regulation” in EC.1.3
DOT ISSUES
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Department of Transportation
Hazardous materials
Regulated medical waste
Shipping papers
Training
Home care
JCAHO / DOT
• No formal relationship
• “Applicable law and regulation”
REMEMBER
• Always comply with the strictest authority
having jurisdiction (AHJ)
• JCAHO frequently asked question (FAQ)
related to hazmat, www.jcaho.org
ENVIRONMENT OF CARE®
REQUIREMENTS
ENVIRONMENT OF CARE®
• Seven management plans
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Safety
Security
Hazardous Materials & Waste
Emergency Management
Fire Prevention
Medical Equipment
Utilities
EC REQUIREMENTS
Written plans
Implementation of plans
Risk assessment
Staff knowledge and skill
Maintenance, testing, inspection activities
Monitoring and evaluation
Annual evaluation
RISK ASSESSMENT
• All management plans
• Specific to organization
• Non-prescriptive standards
PERFORMANCE
MONITORING
• Actual or potential risk
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Staff knowledge & skills
Level of staff participation
Monitoring & inspection activities
Emergency & incident reporting
Inspection, PM, & testing of equipment
• At least one monitor per management plan
PERFORMANCE
MONITORING
• Data collection
• Report to Safety Committee
• At least one annual recommendation for a
performance improvement activity in EC
made to leadership
• Leadership prioritization and decision
SURVEY PROCESS
• Size of organization determines:
– Length of survey
– Number of surveyors
• Administrator - Nurse - Physician
• Nurse - Physician
• Surveyor cross-training
CLOSED DOCUMENT
REVIEW
• All seven EC management plans
• Statement of Conditions™ (SOC)
• Safety Officer Documentation
– Job Description
– Appointment Letter
– Intervention Authority
• Interim Life Safety Measures (ILSM) policy
& documentation
BUILDING TOUR
• Participants
– Administrator or Nurse
Surveyor
– Safety Officer
– Engineering Director
– Etc.
• Function
– Validation of SOC
– Assessment of
Implementation
– Staff Interviews
EC DOCUMENT REVIEW
• All seven EC management plans
• Documentation of performance monitoring
& performance improvement activities
• Hazmat permits, licenses, manifests
• Hazard surveillance surveys (12 months)
• Safety Committee records
EC.1.1 SAFETY
MANAGEMENT
• Policies distributed,
practiced, enforced
• Policies reviewed at least every 3 years
EC.1.1.1 WORKER SAFETY
• Occupational illness
• Personnel injury
• Safety orientation and training
EC.1.3 HAZMAT & WASTE
A)
B)
C)
D)
E)
Selection, handling, storage,
transportation, use, disposal
Applicable law and regulation
Space and equipment
Performance monitoring
Monitoring & disposing of hazardous
gases & vapors
EC.1.3 “CRADLE TO GRAVE”
A) 1. Selection
-What is to be purchased
-Supplier
-Screening Process
2. Handling
» Receipt
» Documentation
EC.1.3 “CRADLE TO GRAVE”
3. Storage
-Chemical type
-Medical gas
4. Transportation
-Chemicals
-Cylinders
-Intra- and inter-facility
EC.1.3 “CRADLE TO GRAVE”
5. Use
-Training
6. Disposal
-Chemicals
-Potentially infectious medical waste
-Empty gas cylinders
-Waste anesthetic gas
B) APPLICABLE LAW &
REGULATION
1. OSHA
2. EPA
3. DOT
“Includes but not limited to. . .”
B) 1. OSHA ISSUES
• Bloodborne Pathogens
• Hazard
Communication
– Hazardous Drugs
• Formaldehyde
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Ethylene Oxide
Tuberculosis
Respiratory Protection
Personal Protective
Equipment (PPE)
• Etc.
B) 2. & 3. EPA, DOT, other
• EPA
– Clean Air Act
– Clean Water Act
– Federal Insecticide,
Fungicide, &
Rodenticide Act
– Incinerators
– Generators (proposed)
– Boilers (proposed)
– Etc.
• DOT
– Medical Waste
– Hazardous Materials
B) 2. MANAGING WASTE
• Chemical
• Chemotherapeutic
• Radioactive
• Regulated medical
– Sharps
B) 2. MANAGING WASTE
• Intra-facility tracking
• Disposal methods
• Training
• Documentation
C) SPACE & EQUIPMENT
• Adequate
• Appropriate
• Segregation
REPORTING and
INVESTIGATING
– Problems, failures, user errors
– Information collection and evaluation
system (ICES)
– Input into Safety Committee
E) GASES & VAPORS
1. Formaldehyde
2. Ethylene Oxide
3. Waste Anesthetic Gas
4. Glutaraldehyde
5. Xylene
ORIENTATION &
EDUCATION
• Personnel who use or have contact with
hazmat
– Procedures & Precautions
– Emergency Procedures
• Spills and exposures
– Health Hazards
– Reporting Procedures
• Spills or exposures
• Spills
EMERGENCY
PROCEDURES
– Chemical
• Mercury
– Potentially infectious
– Chemotherapy
• Major clean-up operations
– OSHA Hazardous Waste Operations
(HAZWOPR)
– Fire department
EMERGENCY
PROCEDURES
• Radiation Exposure
• Personal Protective Equipment
D) PERFORMANCE MONITORING
• Examples:
– Waste volume
• Solid waste
• Hazardous waste
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Waste disposal costs
Staff knowledge and skill
Monitoring of gases & vapors
Etc.
DOCUMENTATION
• EC.2.3: Implementation
– Permits
– Licenses
– Manifests
EC.1.4 EMERGENCY
MANAGEMENT
• Facilities for chemical and radioactive
decontamination
FREQUENTLY ASKED
SURVEYOR QUESTIONS
• What chemical are you using?
• How did you learn about it?
• Where would you go to get more
information?
• What would you do if you spilled it?
• May I see the MSDS?
• May I see the mercury spill clean-up
procedure?
H2E IMPACT ON
JCAHO COMPLIANCE
WASTE REDUCTION
• Demonstrated performance improvement
• Less expensive to use “environmentally
friendly” disposal methods
– Decreased waste volume
– Decreased hazardous waste
• Increased worker safety (i.e., sharps
reduction)
CHEMICAL WASTE
MINIMIZATION
• Demonstrated performance improvement
• Reduced need for:
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Storage
Training
PPE
MSDS
CHEMICAL WASTE
MINIMIZATION
• Eliminating some chemicals completely
– Reduce number of policies & procedures
– Eliminate particular disposal processes
– Potentially eliminate some regulatory
compliance
• Decreased documentation
• Improved worker safety
MERCURY VIRTUAL
ELIMINATION
• Demonstrated performance improvement
• Eliminate need for spill clean-up procedure
• Eliminate specialized disposal
• Reduce regulatory compliance
• Worker / patient safety improved
THE BOTTOM LINE
• If you have less to manage. . .
– Less waste
– Fewer chemicals
– No mercury
• . . .you will streamline your process
AND JCAHO WILL HAVE
LESS TO QUESTION AND
LOOK AT ON SURVEY!