Transcript Planning for a Hospital Evacuation Georgia Society for

Environmental Tours
Standard & Programs
Nebraska Society of
Healthcare Engineers
Fall Meeting
The Cornhusker Marriot Hotel
Lincoln, Nebraska
Presented October 23, 2014
By Ken Gregory
Vice President, Accreditation
TSIG Consulting, Inc
Program Goals
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Standards requiring the environmental tours
Involvement. Who needs to participate
Documentation
Structure of the survey
Follow-up on deficiencies
Reporting
Requirements
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EC.02.01.01
The hospital manages Safety and Security Risks
 EP1 The hospital identifies safety and security risks
associated with the environment of care
 EP2 The hospital takes action to minimize or
eliminate identified safety and security risks in the
physical environment
Requirements
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EC.04.01.01
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The hospital collects information to monitor
conditions in the environment
Requirements
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EC.04.01.01
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EP 12 The hospital conducts environmental tours every six months in
patient care areas to evaluate the effectiveness of previously
implemented activities intended to minimize or eliminate environment of
care risks
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EP 13 The hospital conducts annual environmental tours in
nonpatient care areas to evaluate the effectiveness of previously
implemented activities intended to minimize or eliminate environment of
care risks
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EP 14 The hospital uses its tours to identify environmental deficiencies,
hazards, and unsafe practices
Requirements
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EC.04.01.03
The hospital analyzes identified environment of
care issues
EP 1 Representatives from clinical,
administrative, and support services participate in
the analysis of environment of care data
 EP 2 The hospital uses the results of data analysis to
identify opportunities to resolve environmental
safety issues
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Requirements
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EC.04.01.05
The hospital improves its environment of care
EP 1 The hospital takes action on the identified
opportunities to resolve environmental safety issues
 EP 2 The hospital evaluates changes to determine if
they resolved environmental safety issues
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Requirements
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Scoring opportunities
Standard
EC.02.01.01
EC.04.01.01
EC.04.01.03
EC.04.01.05
EP
1
2
12
13
14
1
2
1
2
Category
A
C Direct Impact
A
C
A
A
C
C
C
Involvement
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Safety Officer
Sub-committee chairs and/or member (if
applicable)
Facilities/Engineering
Representative(s) of administrative team
Representative(s) of clinical staff
Infection Control
Involvement
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Security
Laboratory staff
Biomedical equipment staff
Department representative of the area being
toured
Repeat offenders 
Structure
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Team Leader
Coordinates schedule to ensure all required areas
have been toured
 Controls the tour to ensure effective and efficient
touring
 Ensures all Environment of Care (EC) areas are
evaluated
 Coordinates all survey sheets and creates final survey
document
 Coordinates follow-up of deficiencies
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Structure
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Other Representatives (Have at least one person
assigned to these areas as their primary duty)
General Safety Representative
 Security Representative
 Fire Safety Representative
 Hazmat Representative
 Medical Equipment Representative
 Utility System Representative
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Creating Schedule
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This is obviously effected by facility size, but
ensure EVERY area of the facility is toured
according to the requirements (patient care
semi-annually, non-patient care annually)
Make a list of all departments, separate by semi
or annual, then create a matrix showing ALL
departments with their dates
Creating Schedule
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Don’t forget the grounds/exterior
EC.02.01.01 EP 5 states that “The hospital
maintains all grounds and equipment”
 This is an excellent way to show the effectiveness of
the required maintenance
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!!!!! STICK TO THE SCHEDULE !!!!!
Documentation
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Ensure your forms have a section for EACH of
the six environment of care management areas
at a minimum
Safety
 Security
 Fire Safety
 Hazardous Materials and Waste
 Medical Equipment
 Utility Systems
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Documentation
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Include:
Staff knowledge questions in each EC area
 Questions from “Hot Buttons” with TJC or other
Authority Having Jurisdiction (AHJ)
 Items previous tours have identified as “Areas
Needing Improvement”
 PI indicators you may have chosen from the six
areas
 Infection Control items
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Documentation
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Safety Example Questions
Are ceiling tiles clean and free from stains
 Are heavy items stored low and easy to handle
 Do wire rack shelves have splash plates on bottom
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Documentation
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Safety Example Questions
Are needles accessible that could be used against
staff as weapons
 Do trip hazards exist
 Is there evidence of smoking
 Are medical gases stored appropriately
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Documentation
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Security Example Questions
Are employees wearing ID badges as per policy
 Are staff member belongings secured
 Are electrical and mechanical rooms secured
 Are security sensitive areas secured
 Do staff freely give out security door codes
or write them on the door frame!!
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Documentation
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Fire Safety Example Questions
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Are corridors free of clutter
Are exit doors unobstructed
Are fire extinguishers in place and inspections up to date
Are flammables >10 gallons in flammable cabinet or 2 hr
FRR room
Do fire doors self close and latch
Do smoke barrier doors self close
Do staff know where smoke compartments boundaries are
located
Documentation
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Hazmat Example Questions
Are all containers labeled
 Is medical waste kept in proper containers
 Are chemicals stored out of patient areas and other
clean areas
 Are clean items not stored in soiled rooms
 Are MSDS/SDS available for employees working
with chemicals
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Documentation
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Medical Equipment Example Questions
Is all equipment tagged/inventoried
 Are equipment inspection tags up to date
 Do staff know proper procedure to report medical
equipment failures
 Do staff know proper procedure to report medical
equipment failures that possible injure a patient or
staff member
 Does any equipment have frayed cords
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Documentation
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Utility System Example Questions
Are patient care areas free from 2 pronged cords
 Are extension cords being used
 Are medical gas zone valve labels accurate
 Do soiled rooms have negative air relationship to the
corridor
 Do clean supply rooms have positive air relationship
to the corridor
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Documentation
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Infection Control Example Questions
Are gloves, gowns, eyewear, and masks readily
available?
 Are refrigerator logs maintained and up to date in
medicine and patient refrigerators?
 Were employees eating or drinking in designated
areas only?
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Documentation
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Infection Control Example Questions
Are needle boxes under 2/3 full?
 Is clean linen kept separate from the dirty linen
disposal?
 Are medicines and food kept in separate
refrigerator?
 Are medication refrigerators recorded, monitored, or
alarmed
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Documentation
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All surveyors can answer all questions, but
ensure someone is responsible for each section
at a minimum.
Aggregate all the data, then distribute to the
appropriate department DIRECTOR
Set timelines for responses
Documentation
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When no responses can be obtained within a
reasonable timeframe, escalate to the line
administrator, then CEO, etc.
Occasional spot checks for accuracy of
corrections being implemented are encouraged
If a major deficiency is noted, ensure
documented follow-up is performed
Perform a quarterly review of deficiencies in
order to identify trending patterns developing
Documentation
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Create a set agenda item in the governing
committee to report:
Areas recently toured
 Deficiencies identified
 Follow-up (or lack of) from previous tours
 Developing Trends
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Documentation
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Keep one master document that has all noted
deficiencies listed by EC management area
Use this data when performing the annual
reviews of the environment of care management
plans.
Adjust forms each year to pick up on new
trends, and/or to use for educational purposes
Summary
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You can be scored in at least 10 EPs (You could
also be scored in leadership if no follow-up can
be demonstrated
Ensure all the right players are included. This
isn’t a one person show
Clear documentation is key
Follow-up on deficiencies
Reporting on a regular basis to keep everything
on track
Questions
Ken Gregory
Vice President of Accreditation
TSIG Consulting
740 Broadway
New York, NY 10003
(615) 598-2652
[email protected]