Transcript Crosswalking” Hospitals for a Healthy Environment (H2E

“Crosswalking”
Hospitals for a Healthy
Environment (H2E)
& the Joint Commission for the
Accreditation of Healthcare
Organizations
(JCAHO)
Catherine Zimmer, BSMT, MS
MnTAP Healthcare Specialist
Fall 2002
Overview
• JCAHO & Standards
–General
–Environment of Care (EC)
–Performance Improvement
• H2E Goals
• Using H2E to meet JCAHO
What is JCAHO?
• Accrediting entity for the
Healthcare industry
–ensures appropriate
planning, procedures &
policies are enacted and
improved upon.
JCAHO Standards
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Leadership (LD)
Patient Rights & Organizational Ethics (RI)
Assessment of Patients (PE)
Care of Patients (TX)
Education (PF)
Continuum of Care (CC)
Improving Organization Performance(PI)
Management of the Environment (EC)
Management of Human Resources (HR)
Management of Information (IM)
Surveillance, Prevention & Control of Infection (IC)
Governance (GO)
Medical Staff (MS)
• Performance Measurement (PM)
JCAHO Process
• “Surveys”
–reviews records and
documents
–interviews staff & patients
–observation
–interviews leadership
–information from public
• Surveyors
– doctors, administrators,
nurses
EC Standard Areas
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Safety (General & Staff)
Security
Hazardous Materials and Waste
Emergency Management
Life Safety
Medical Equipment
Utility Systems
Environment of Care Standards EC.1
[Plan]
• EC.1 The organization plans for a safe,
accessible, effective and efficient
environment consistent with its
mission, services, law and regulation.
– EC 1.1 The organization plans for a safe
environment.
EC 1.1.1 The organization plans for worker safety.
EC 1.2 The organization plans for a secure
environment.
EC 1.3 The organization plans for managing
hazardous materials and waste.
Environment of Care Standards
EC.2 [Do]
• EC.2 The organization provides for a
safe, accessible, effective and efficient
environment consistent with its
mission, services, law and regulation.
– EC.2.1 The organization implements its safety
plan.
– EC.2.2 The organization implements its
security plan.
– EC.2.3 The organization implements its plan
for managing hazardous materials and waste.
Environment of Care Standards
EC.4 [Check, Act]
• EC.4 The organization evaluates and
improves conditions in the
environment.
– EC.4.1 the organization collects information
about deficiencies and opportunities for
improvement in the environment.
– EC.4.2 the organization analyzes identified
environment issues and develops
recommendations for resolving them.
– EC.4.3 the organization works to implement
recommendations to improve the environment
and monitor effectiveness of
recommendations’ implementation.
Steps in the Environment of Care
Performance Improvement Cycle*
*Performance Improvement in the Environment of Care, Joint
Commission Resources , JCAHO, 2001.
PLAN &
DESIGN
TEACH
IMPROVE
IMPLEMENT
AGGREGATE
& ANALYZE
EC.1.3 The organization plans for
managing hazardous materials and waste
• Intent: the organization identifies how it
manages hazardous materials and waste.
– Includes identifying processes for:
• selecting, handling, storing, transporting,
using and disposing of hazardous
materials and waste from receipt or
generation through use or final disposal;
• establishing written criteria consistent
with applicable law and regulation
(example, Environmental Protection
Agency) to identify, evaluate and
inventory hazardous
material and waste……
– Sec 3002(b) RCRA requires waste
minimization.
Performance Improvement (PI)
• “..Goal is to ensure that the
organization designs processes well
and systematically monitors,
analyzes and improves its
performance to improve patient
outcomes.”*
*Joint Commission Resources, Department of Education, “A
Beginner’s Guide to Mock Survey Preparation”,
2002.
Performance Improvement
• Environment of Care has a PI
component (EC.4).
• Leaders are required to do PI
– PI.1 The leaders establish a planned,
systematic, organizationwide approach to
process design, and performance
measurement, analysis and improvement.
Why Should Leaders Choose P2 for PI?
• PI.1.1 Collaborative and interdisciplinary
activity
– cross functional bet EC, HR, L and possibly
others
• PI.1.2 (Intent) Pollution Prevention
consistent with the organization’s mission
as it relates to community health
• PI.1.2 (Intent) Meets the needs of
individuals served, staff and
others.(increases patient safety)
• PI.1.2 Reducing costs associated with
waste, pollution and risk are sound
business practice
• PI.1.2 Its easily measurable and
implementable.
“Crosswalking”
between H2E and
JCAHO