|Matthew F. Baretich, PE, PhD|
The Joint Commission has begun implementing its Standards Improvement Initiative, which has broad implications for all of its accreditation programs. Here we are going to focus on changes in the Environment of Care standards for hospitals, particularly those related to medical equipment management.
In the past, the Elements of Performance (EP) for each standard have been divided into A, B, and C scoring categories. For 2009, the B category has been eliminated.
EPs in category A are “usually related to structural requirements (for example, policies or plans) that either exist or do not exist.” Therefore, they are scored as 0 (insufficient compliance) or 2 (satisfactory compliance). Partial compliance is not an option.
EPs in category C “relate to regularly occurring processes or outcomes” and can be scored as partially compliant. A hospital receives “a score of 2 if there are one or no occurrences of noncompliance, a score of 1 if there are two occurrences, and a score of 0 if there are three or more occurrences.”
“Supplemental findings” have been eliminated. If an EP receives a score of less than 2, the surveyor will issue a formal Requirement for Improvement. If that occurs, you will need to provide follow-up information to The Joint Commission. And, if the EP is accompanied by a Measure of Success (MOS) symbol (white M in a black circle), you must include objective data demonstrating compliance.
An EP may also be accompanied by a Documentation Required symbol (black D in a white circle). For these EPs, the surveyor will expect to see something on paper (or in a computer) that demonstrates compliance.
Accreditation decisions are now based on the “impact to patient care.” Noncompliance that severely impacts patient care is dealt with more harshly than noncompliance having a smaller impact. There are four levels of criticality.
- Immediate Threat to Life represents egregious noncompliance. Examples cited by The Joint Commission include adult-strength medications on a pediatric crash cart and an inoperable fire alarm.
- Situational Decision Rules. EPs at this level are marked with a white 2 in a black triangle. There are two life safety EPs (now located in a separated LS chapter) that have this high level of criticality.
- Direct Impact Requirements are “likely to create an immediate risk to patient safety or quality of care” and are marked with a black 3 in a white triangle. Many EPs in the EC chapter are at this level, including some for medical equipment management.
- Indirect Impact Requirements “increase risk to patient safety or quality of care over time if not resolved.” EPs at this level are not marked and represent the majority of EPs.
What’s the best way to make sense of all this? Get a copy of the latest version of all the standards for which you are responsible. Review the scoring rules that apply to each of your EPs. Then, adjust your program to provide the appropriate level of documentation, performance, and priority.
The EC chapter now uses a new numbering scheme. There are four sections:
- EC.01.01.01 Plan
- EC.02.xx.xx Implement
- EC.03.01.01 Staff Competence
- EC.04.01.xx Monitor and Improve
Within the second section there are six sections:
- EC.02.01.xx Safety and Security
- EC.02.02.xx Hazardous Materials and Waste
- EC.02.03.xx Fire Safety
- EC.02.04.xx Medical Equipment
- EC.02.05.xx Utility Systems
- EC.02.06.xx Other Physical Environment Requirements
The medical equipment management standards are EC.02.04.01 and EC.02.04.03, with EC.02.04.02 reserved for future use.
Some material has been relocated. A good example is EC.03.01.01, which deals with EC-related training for hospital staff. A few years ago this standard moved from EC to HR. Now it’s back. Does this mean that you need to do the training yourself? No, The Joint Commission requires only that someone actually does the training. However, questions about the hospital’s compliance will now be asked during the EC portion of the survey. Make sure someone in that room has the answer.
You should review your areas of responsibility to see what has moved in or out. The key is to make sure that every requirement, wherever it is located in the standards manual, is covered by someone in the hospital. You should carefully review the “cross-walk” information provided by The Joint Commission (online and in the publication recommended below).
The Joint Commission asserts that there are no new requirements for 2009. The implication is that if you were in compliance in 2008 then you do not need to do anything more in 2009. However, there are some changes in the text that are worth noting.
Perhaps the most important is EC.02.04.01 EP1, which deals with medical equipment planning. In recent years the standards have required only that the hospital have a process in place. Now, the requirement is that “the hospital solicits input from individuals who operate and service equipment.” Expect surveyors to ask for documentation, such as committee minutes, showing active involvement of equipment users and maintainers.
Again, you should carefully review “cross-walk” material to compare 2008 and 2009 wording of standards and EPs. Where there are differences, assess the impact on how you run your program.
But Wait, There’s More
The Joint Commission has already begun making more changes in wording and even creating entirely new EPs without the comment periods usually provided. In most cases these are efforts to make the standards precisely match CMS regulations. To keep up with these changes you should follow the literature and monitor professional organizations. The American Society for Healthcare Engineering (ASHE) has been especially good at pushing key information out to its members.
I also recommend getting a copy of Environment of Care Essentials for Health Care from The Joint Commission. The current (ninth) edition has a wealth of information, including a “cross-walk” comparing the 2008 and 2009 standards.
Matthew F. Baretich, PE, PhD, is a member of 24×7’s editorial advisory board, and is president of Baretich Engineering Inc, Fort Collins, Colo (www.baretich.com). The company helps health care organizations achieve cost-effective compliance with The Joint Commission’s Physical Environment standards. For more information, contact .