Management of the Environment of Care (EC)

Recent Articles & Updates

Jan 2009

EOC News Jan '09 Vol 12 #1 Pg01- Environment of Care^® News: Broadens Focus - Emergency Management, Life Safety Given New Emphasis Joint Commission accreditation manuals for hospitals and ambulatory care (all Phase One programs) now have two new chapters: “Emergency Management” (EM) and “Life Safety” (LS). Behavioral Health Care for 2009 only has the new “Life Safety” chapter. This article delineates plans for 2009 Issues of EC News, which include expansion of coverage to provide specific, practical, and accurate advice on how to meet the requirements of all the EC-related chapters. An overview of Emergency Management expectations includes attention to the six critical functions during an emergency and evaluation of emergency planning. The summary of Life Safety emphasizes that format of the new LS chapter (applicable for both hospitals and behavioral health) incorporates the structure of the Life Safety Code, NFPA 101-2000. This also includes a brief mention of each specific standard that shifted from EC to other chapters for 2009. This is a good review for EOC and JCSC.

EOC News Jan '09 Vol 12 #1 Pg06- Emergency Management's Six Critical Functions: Function 1: Emergency Communications - How to Keep the Lines Open [**REF**] The standard EM.02.02.01—Emergency Communications is discussed, including each Element of Performance. The article provides useful assistance for EOCand E&M to understand each EP. Sidebars include: ”Key Tips for Emergency Management Communications”; “Tips for Notifying Outside Staff of an Emergency”; “Tips for Notifying In-Building Staff of an Emergency” ; and “Tips for Backup communications Systems”.
EOC News Jan '09 Vol 12 #1 Pg08- Universal Design for Health Care Facilities - Addressing Safety, Access to Care for a Diverse Patient Population The concept of Universal Design (UD) ensures that facilities, products, and services are usable by all people. For healthcare facilities, this means eliminating barriers to patient care while improving patient safety, going beyond the minimum requirements set by law. A sidebar lists the “Seven Principles of Universal Design”. For our hospitals, the best way for LDR and E&M to begin thinking in these terms is to pay closer attention to individuals who you identify as potentially receiving inadequate care, such as those who are hearing impaired, have language barriers, have physical or other challenges. For more info on UD, goto The Center for Universal Design (CUD)

Feb 2009

EOC News Feb '09 Vol 12 #2 Pg01-   The New "Life Safety" Chapter: What It Applies to and How Organizations Can Comply with It : [**REF**] This is a good review for E&M, EOC and SFT of occupancy types and approaches to comply with the new separate chapter devoted to fire safety, as required by the National Fire Protection Association (NFPA) Life Safety Code.   Occupancies include not only health care and ambulatory, but also the occupancies often maintained by state hospitals as group homes (usually lodging and rooming house occupancy) and residential facilities for 17 or more occupants (hotel and dormitory occupancy).
       A concise outline of the Occupancy Types is provided in a sidebar. For freestanding business occupancies, the TJC does not require compliance with the Life Safety Code or LS standards; however, these occupancies, like all others, must comply with EC.02.03.02, EP4, which requires the organization to maintain free and unobstructed access to all exits.
       Approaches covered in the article are Resolution of LSC deficiencies and creating a Building Maintenance Program.   To resolve each LSC deficiency identified by your organization or others, your organization has three options: 1.) Correction within 45 days through a management process or corrective maintenance program. 2.) Obtain a LSC equivalency approved by TJC; or 3.) Create a Plan for Improvement (PFI).
       The Building Maintenance Program (BMP) is an optional, proactive way to manage specific features of the hospital’s life safety program. The article provides an overview of various items included in a BMP, such as specific types of doors, grease-producing devices, horizontal exit doors, prohibition of combustible decorations, etc.

Mar 2009

Perspectives Mar 09 Vol 29 #3 Pg06- Top Standards Compliance Issues for First Half of 2008 [ALERT:JCSC, PPR, E&M, P&T] Standards most frequently identified in surveys as “not compliant” are listed for each program. Forty percent (40%) or more hospitals received RFI’s for EC.5.20 regarding Life Safety code compliance; NPSG #2C regarding measurement and improving timeliness of critical tests, results and values; and IM.6.50 regarding verbal and telephone orders.Download 17 Most Challenging Standards for First Half of 2008

Apr 2009

EOC News, Vol 12 #4 Pg06- Help for When the Sky Is Falling and You're Facing Evacuations: The National Weather Service and Severe Weather Events [**REF**] E&M can find additional assistance from the National Weather Service (NWS) in making the important decision about the need to evacuate. Hospitals can consult with a 'warning coordination meteorologist' (WCM) by calling your local NWS office*. [Pearl] WCM resource persons not only provide weather warning information, but are also available for outreach, education and training exercises, especially for administrative staff and professional development (free of charge). Hospitals (e.g., Louisiana) subject to hurricanes or flooding should also take advantage of the advance warning provided in a new NWS tool, 'Tropical Cyclone Impact Graphics'. An example of the latter is provided in the article. *Note: The person listed with each local office is usually the WCM and is often at extension 223
EOC, Vol 12 #4 Pg08- Managing Outside Maintenance Contractors: Keeping an Eye on Who's Minding the Shop EOC Ldrshould review the TJC expectations in this article related to contract management. A chief recommendation is that contracts be structured to define performance expectations. For example, you can stipulate that documentation of any test explain what was done to demonstrate that the equipment or system passed the evaluation. E&M should also consider developing a “dashboard” matrix of equipment that is being maintained by contractors. This could be monitored by the Safety Committee (SFTcom)

May 2009

EOC May 09 Vol 12 #5 Pg01- Completing the Statement of Conditions™: Examining the "Life Safety" Chapter, Part 2

[••REF••] This article focuses on the first of two administrative standards in the LS chapter and its four associated EP. In EP#1 management responsibilities for the individual (or individuals) assigned to manage LS compliance is detailed in 3 areas (i.e., assessing LS compliance, resolving LS deficiencies and managing the SOC).
     There is a particularly useful discussion of EP#3 that confirms the automatic 6-month grace period for meeting PFI deadlines and when extensions need to be requested.
     It should also be noted that under EP#4 organizations are now required to have documentation (e.g., when/where inspections occurred and the report's location) about state or local fire inspections

Jun 2009

Perspectives June 09, Vol 29 #6 Pg03- Conducting the Fire Watch of Standard LS.01.02.01 [••REF••] SFT, EOC. This article addresses two key questions regarding LS.01.02.01. When is it necessary to conduct and fire watch and who can/should do to. A useful checklist defines 'Out Of Service' responsibilities.

Jul 2009

Perspectives July 2009 Vol 29 #7 Pg03- Top 10 Standards Compliance Issues for 2008 [•• REF••] The top 10 are provided on tear-out cards in the hard copy edition of Perspectives. JCSC and those expecting survey soon should be aware that the 10 include EC.5.20 (45%), IM.6.50 (43%), MM.2.20 (37%), NPSG 2C (37%), IM.6.10 (31%), EC.5.40 (26%), NPSG 3D (25%), HR.1.20 (22%), UP 1C (21%) and NPSG 8A (19%).
EOC News Jul '09 Vol 12 #7 Pg06- Mitigating Life Safety Deficiencies with ILSM: Examining the "Life Safety" (LS) Chapter, Part 3 [••REF••] This is the 3rd in a series of articles on the new LS chapter. It is an excellent review of ILSM compliance requirements for SFT, E&M, LDR, EOC and JCSC. The first thing to be noted is that the implementation of ILSM measures are not just for periods of construction, but 'any time there is a Life Safety Code deficiency that cannot be immediately addressed'. The article also places emphasis on the requirement for an ILSM policy (LS.01.02.01, EP#3). The author sees all the subsequent EP's being dependent on having a comprehensive, written, and regularly reviewed ILSM policy. There is also a brief overview of the 11 ILSM activity options to be considered in that plan. Note: Parts 1 and 2 were presented in the Feb and May issues of EC News and also reviewed in our Feb and May RT newsletters.
EOC News Jul 09 Vol 12 #7 Pg05- Conducting the Fire Watch of Standard LS.01.02.01 [••REF••] SFT, EOC. This is the same article first published in June Perspectives. See review in our June RT.

Aug 2009

Perspectives Aug 09 Vol 29 #8 Pg03- Errata for 2009 Accreditation Manuals [ALERT: EOC, E&M] Effective immediately, there is a correction to Standard EC.02.03.05, EP 18, (in the print manual and E-dition) that changes the frequency for operating fire and smoke dampers to "1 year after installation and then at least every 6 years" E&M should read the full text for complete details.
EOC News Aug 09 Vol 12 #8 Pg01- How to Use Social Media to Manage Emergencies: Twitter, Facebook, YouTube, and More [PEARL: LDR, IT, IM. Louisiana] This is a fascinating 'Spotlight on Success-type article that should expand one's thinking about the use of modern social media to enhance communication. The focus here is on its use in disasters/emergencies, but the potential application in other communication efforts such as marketing, recruitment and even staff moral are easily apparent. Just don't forget that social media tools require two-way communication and therefore a willingness and commitment to a certain amount of responsiveness. Get your 'techies' to read this article and then discuss the implications and potential with them in a leadership group. The article also refers to a white paper called Social Media … Here to Stay: Effective Technologies for Reaching Audiences that may be a useful primer and background read.

Sep 2009

EOC Sept. 09 Vol 12 #9 Pg04- Designing and Maintaining Buildings to Minimize the Effects of Fire: Examining the "Life Safety" (LS) Chapter, Part 4 [••REF••] This 4th article in a series on the Life Safety Chapter focuses on LS.02.01.10. It provides a good overview of the requirements related to A - height, construction and sprinklers, B - building separations/penetrations and C - fire door features (e.g., closing, latching, gaps, protective panels, decorations). This is well worth reading by E&M, SFT.

Oct 2009

Perspectives, Oct. '09, Vol 29 #10 Pg16- Accepted: New and Revised Hospital Elements of Performance Related to CMS Application Process [ALERT: LDR, JCSC, MDx, HR, PI] & [••REF••] In response to the need for more specificity to meet CMS deemed status application requirements, TJC has now released a third revision of EP for TJC/CMS-DS hospitals. The article says "the majority of revisions are minor editorial changes…" A box is provided with descriptions of "More substantive changes…" made to 10 EP. This includes 7 new EP for 1/1/2010 implementation (EC.02.04.03, EP 14 - HR.01.01.01, EP 28 - LD.04.01.05, EP 9 MS.03.01.01, EP 16/17 - PC.03.01.01, EP 10 - RI.01.07.01, EP 18), 2 revised EP for 1/1/2010 implementation, (LD.04.04.05, EP 13 - PI.01.01.01, EP 2) and 1 New EP for 7/15/2010 implementation (LD.01.05.01, EP 8). There are also 3 revised EP related to telemedicine (LD.04.03.09, EP 4/9 - MS.13.01.01, EP 1), but TJC is still hoping to achieve allowance for credentialing and privileging by proxy that is currently not permitted by CMS. Their implementation is delayed until 7/15/2010. [Color code: relates to Nuclear Medicine, Anesthesia] See also full details in the 2010 Pre-Publication Standards [Info] {PDF}

Nov 2009

EOC, Nov. '09, Vol 12 #11 Pg03- Surveys LDR, GB, EOC, SFT, PtAd This case study provides insights into the 10-year experience of the M.D.AndersonCancerCenter's in purposely using art as part of the healing process.

Dec 2009

EOC, Dec. '09, Vol 12 #12 Pg01- Ensuring Appropriate Means of Fire Egress: Examining the "Life Safety" (LS) Chapter, Part 5 [••REF••] Part 5 in this series of LS Chapter reviews focuses on the 32 EP of LS.02.01.20. The EP are divided into 5 groupings covering Doors/Exits, Corridors, Suites, Travel Distances and Exit Illumination/Signage. It is a useful review for EOC and SFT.

REFERENCE ARTICLES

EOC, Dec. '09, Vol 12 #12 Pg01- Ensuring Appropriate Means of Fire Egress: Examining the "Life Safety" (LS) Chapter, Part 5 [••REF••] Part 5 in this series of LS Chapter reviews focuses on the 32 EP of LS.02.01.20. The EP are divided into 5 groupings covering Doors/Exits, Corridors, Suites, Travel Distances and Exit Illumination/Signage. It is a useful review for EOC and SFT.

EOC News, 2009 April Vol 12 #4 Pg06- Help for When the Sky Is Falling and You're Facing Evacuations: The National Weather Service and Severe Weather Events [**REF**] E&M can find additional assistance from the National Weather Service (NWS) in making the important decision about the need to evacuate. Hospitals can consult with a 'warning coordination meteorologist' (WCM) by calling your local NWS office*. [Pearl] WCM resource persons not only provide weather warning information, but are also available for outreach, education and training exercises, especially for administrative staff and professional development (free of charge). Hospitals (e.g., Louisiana) subject to hurricanes or flooding should also take advantage of the advance warning provided in a new NWS tool, 'Tropical Cyclone Impact Graphics'. An example of the latter is provided in the article. *Note: The person listed with each local office is usually the WCM and is often at extension 223

EOC News (2008 May Vol 11 #5) Pg06- Assessing Risk: Proactively Identifying and Responding to Hazards Within the Environment of Care: [**REF**] For EC and SFT this is a good review of the risk assessments expected under the EC standards. Article includes a suggested approach to pro-active risk assessment. Tip: Establish a specific process for risk assessment that will assure its consistency, comprehensiveness and appropriate responses to identified risks.

EOC News (2008 Jan., Vol. 11, #1) Pg04- Preparing for Catastrophes and Escalating Emergencies: Answers to Questions About 96-Hour Sustainability Requirements, Escalating Scenario Exercises - [**REF**] - This is the best explanation we have seen to date of the issue of 96-Hour Sustainability (to include identification of several acceptable responses and what needs to be in your EOP related to it) and how to conduct the Escalating Scenario Exercises. Must read for SFTofco and EOC .
EOC News Jun '08, Vol 11 #6 Pg04- Preventing Workplace Violence: Tips for Safety in Emergency Department and Psychiatric Hospitals [**REF**] To address EC.2.10, management of security risks, this article is based on OSHA statistics and guidelines. It covers factors related to workplace violence in health care; the five main components of a program to prevent workplace violence; getting staff buy-in for the program; and safety tips for staff. A sidebar provides a summary of tips for recognizing and defusing anger and violence, which involves application of “de-escalation” skills. FYI: SFT, LDR, RNx. - by VK

EOC News Oct 08 Vol 11 #10 Pg01-    Gaining Fire Safety Equivalencies

   [**REF**] When your building(s) do not meet all requirements for applicable Life Safety Code, the Joint Commission has procedures for granting two types of equivalencies:

#1Traditional Equivalency is based on sound fire safety principles confirmed by at least one acceptable life safety professional and sent to the Joint Commission (by mail or electronically).

#2 Fire Safety Evaluation System (FSES) is an approach that assesses the entire building and uses a measurement method to determine acceptable alternatives to the LSC and must be sent to the Joint Commission by paper mail. In addition to equivalencies, Plan for Improvement (PFI) expectations are covered briefly, emphasizing that six months is the maximum timeline. Some details for requesting extensions are also provided. A sidebar on pg 11 pictures the online submission form for traditional equivalency. A sidebar on pg 5 outlines information to include when submitting an extension (for PFI) or Equivalency request to TJC. Note also that, even though TJC and CMS both use the 2000 edition of the LSC, they do not recognize each other’s equivalency. FYI: EOC, E&M, and SFT - by VK

EOC News Dec 08 Vol 11 #12  Pg08- Suicide Prevention and the Inpatient Room: Bricks and Sticks and Beyond [**REF**] David M. Sine, ARM, CSP, CPHRM and James M. Hunt, AIA are co-authors of [PEARL] Design Guide for the Built Environment of Behavioral Health Facilities, the bible for in-room furnishings that help prevent suicide. In this article they share updates on some of the latest materials and approaches used to reduce the environmental risk of suicide. Did you know that all bathrooms do not have to be ADA compliant? (refer to Code of Federal Regulations at 28 CFR 36.301(b).)   SFT, EOC and E&M should definitely read this article and download a free copy of their Design Guide to help better address EC.1.10, EC.1.20 andEC.8.10.

EOC News Feb '09 Vol 12 #2 Pg01-   The New "Life Safety" Chapter: What It Applies to and How Organizations Can Comply with It : [**REF**] This is a good review for E&M, EOC and SFT of occupancy types and approaches to comply with the new separate chapter devoted to fire safety, as required by the National Fire Protection Association (NFPA) Life Safety Code.   Occupancies include not only health care and ambulatory, but also the occupancies often maintained by state hospitals as group homes (usually lodging and rooming house occupancy) and residential facilities for 17 or more occupants (hotel and dormitory occupancy).

       A concise outline of the Occupancy Types is provided in a sidebar. For freestanding business occupancies, the TJC does not require compliance with the Life Safety Code or LS standards; however, these occupancies, like all others, must comply with EC.02.03.02, EP4, which requires the organization to maintain free and unobstructed access to all exits.

       Approaches covered in the article are Resolution of LSC deficiencies and creating a Building Maintenance Program.   To resolve each LSC deficiency identified by your organization or others, your organization has three options: 1.) Correction within 45 days through a management process or corrective maintenance program. 2.) Obtain a LSC equivalency approved by TJC; or 3.) Create a Plan for Improvement (PFI).

       The Building Maintenance Program (BMP) is an optional, proactive way to manage specific features of the hospital’s life safety program. The article provides an overview of various items included in a BMP, such as specific types of doors, grease-producing devices, horizontal exit doors, prohibition of combustible decorations, etc.

EOC News Jul '09 Vol 12 #7   Pg06- Mitigating Life Safety Deficiencies with ILSM: Examining the "Life Safety" (LS) Chapter, Part 3 [••REF••] This is the 3rd in a series of articles on the new LS chapter.   It is an excellent review of ILSM compliance requirements for SFT, E&M, LDR, EOC and JCSC. The first thing to be noted is that the implementation of ILSM measures are not just for periods of construction, but 'any time there is a Life Safety Code deficiency that cannot be immediately addressed'. The article also places emphasis on the requirement for an ILSM policy (LS.01.02.01, EP#3). The author sees all the subsequent EP's being dependent on having a comprehensive, written, and regularly reviewed ILSM policy. There is also a brief overview of the 11 ILSM activity options to be considered in that plan. Note: Parts 1 and 2 were presented in the Feb and May issues of EC News and also reviewed in our Feb and May RT newsletters.

EOC Sept. 09 Vol 12 #9 Pg04- Designing and Maintaining Buildings to Minimize the Effects of Fire: Examining the "Life Safety" (LS) Chapter, Part 4 [••REF••] This 4th article in a series on the Life Safety Chapter focuses on LS.02.01.10. It provides a good overview of the requirements related to A - height, construction and sprinklers, B - building separations/penetrations and C - fire door features (e.g., closing, latching, gaps, protective panels, decorations). This is well worth reading by E&M, SFT.

Perspectives, Oct. '09, Vol 29 #10 Pg16- Accepted: New and Revised Hospital Elements of Performance Related to CMS Application Process [ALERT: LDR, JCSC, MDx, HR, PI] & [••REF••] In response to the need for more specificity to meet CMS deemed status application requirements, TJC has now released a third revision of EP for TJC/CMS-DS hospitals. The article says "the majority of revisions are minor editorial changes…" A box is provided with descriptions of "More substantive changes…" made to 10 EP. This includes 7 new EP for 1/1/2010 implementation (EC.02.04.03, EP 14 - HR.01.01.01, EP 28 - LD.04.01.05, EP 9 MS.03.01.01, EP 16/17 - PC.03.01.01, EP 10 - RI.01.07.01, EP 18), 2 revised EP for 1/1/2010 implementation, (LD.04.04.05, EP 13 - PI.01.01.01, EP 2) and 1 New EP for 7/15/2010 implementation (LD.01.05.01, EP 8). There are also 3 revised EP related to telemedicine (LD.04.03.09, EP 4/9 - MS.13.01.01, EP 1), but TJC is still hoping to achieve allowance for credentialing and privileging by proxy that is currently not permitted by CMS. Their implementation is delayed until 7/15/2010. [Color code: relates to Nuclear Medicine, Anesthesia] See also full details in the 2010 Pre-Publication Standards [Info] {PDF}

Useful Guidelines & Resources

Perspectives June 09, Vol 29 #6 Pg03- Conducting the Fire Watch of Standard LS.01.02.01 [••REF••] SFT, EOC. This article addresses two key questions regarding LS.01.02.01. When is it necessary to conduct and fire watch and who can/should do to. A useful checklist defines 'Out Of Service' responsibilities.

  EOC May 09 Vol 12 #5  Pg01- Completing the Statement of Conditions™: Examining the "Life Safety" Chapter, Part 2   [••REF••] This article focuses on the first of two administrative standards in the LS chapter and its four associated EP. In EP#1 management responsibilities for the individual (or individuals) assigned to manage LS compliance is detailed in 3 areas (i.e., assessing LS compliance, resolving LS deficiencies and managing the SOC).
     There is a particularly useful discussion of EP#3 that confirms the automatic 6-month grace period for meeting PFI deadlines and when extensions need to be requested.
     It should also be noted that under EP#4 organizations are now required to have documentation (e.g., when/where inspections occurred and the report's location) about state or local fire inspections

Perspectives June 09, Vol 29 #6 Pg08- Update: Additional Scoring Changes for All 2009 Accreditation Manuals [ALERT: JCSC, EOC, SFT, P&T, PPR] Last month and now again this month, TJC has found the 'need for additional' scoring changes. Effective 7/1/09 most of the latest changes (14 EP in EC, 17 In LS, 6 MM, 2 PC, 3 PI, 1 RI and 1 in LD) will be applicable to hospitals.

EOC News June 09 Vol 12 # 6 Pg06- Function 3: Emergency Safety and Security: Keeping Patients and Staff Safe and Secure During a Disaster [••REF••] EOC and SFT should review this 3rd installment of articles providing compliance guidance for requirements related to the six critical functions of emergency management. This one focuses on four aspects of safety and security.
1 - Defining the roles of community security agencies and such issues as what law enforcement agents are to do with their weapons when they come on to hospital grounds/buildings.
2 - Disposing of hazardous materials and waste or where they could be stored if regular pickup services were disrupted for significant periods of time.
3 - Controlling movement of potentially increased numbers of persons (not just patients) within the hospital and with the community
4 - Controlling vehicles that access the facility and dealing with accidents, abandoned vehicles or other traffic flow concerns.
Note that as a result of their hurricane experiences in recent years, two of our Louisiana members (ELMHS and CLSH) have special insight into some of these issues. Refer also to EC News January and March (or our reviews in Reading Tips for January and March) for the first two articles in this series.