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2011

The Healthcare Environment

George Mills, Sr. Engineer

Standard Interpretation Group

The Joint Commission

SIG Engineering 2011 - 2

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Risk Assessment

Use to evaluate any issue that lacks a clear decision

Educated guess that drives your assumptions

Clearly document the process Determine when to re-assess the issue Problem solving approach to determine

appropriate response Preventive strategies to address

potential issues

SIG Engineering 2011 - 3

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Risk Assessment

The hospital identifies safety and security risks associated with the environment of care. Risks are identified from internal sources such as ongoing monitoring of the environment, results of root cause analyses, results of annual proactive risk assessments of high-risk processes, and from credible external sources such as Sentinel Event Alerts.

EC.02.01.01 EP 1

The hospital takes action to minimize or eliminate identified safety and security risks in the physical environment.

EC.02.01.01 EP 3

SIG Engineering 2011 - 4

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Risk Assessment in the Healthcare Environment

Several tools exist to facilitate risk assessment in the Physical Environment Environmental ToursObserve the environment

Manage By Walking AroundDocumentation

Inspect, Test & Maintain Evaluate the effectiveness of the

processes

SIG Engineering 2011 - 5

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Environmental Tours

Make sure that all areas of your organization are included:Public waiting areas

Floor covering in safe/functional condition Seating

Grounds, Sidewalks, Garages, Parking Lots Egress to the “Public Way”

ElevatorsDesignated off-site locations

SIG Engineering 2011 - 6

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EC.02.06.01

EP 1: Interior spaces meet the needs of the individuals served for safety and suitability for the care, treatment or services provided.

SIG Engineering 2011 - 7

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Visual Observations

Evaluate typical processes Include affected staff Eliminating “work-

around” Eliminating

hazards/safety issues

Proper storage of items Supplies

Patient / Non-patient Refrigerators

Medications, food, biohazards, supplies

Housekeeping carts & closet

Hand hygiene products Alcohol gels, paper

towels, gloves, etc. Equipment

SIG Engineering 2011 - 8

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Visual Observations

Personal Space Outside areas for use by individuals Waiting & Reception areas

Restrooms are appropriate Lighting is suitable for care, treatment, or

services Ventilation, temperature and humidity levels Furnishings Dining environment

SIG Engineering 2011 - 9

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Staff Interviews

Purpose: Establish staff

knowledge Evaluate Trend

Process: Random selection Evaluate against

policy

Examples of processes evaluated: Reporting patient and

employee injury events Referencing

policies/procedures Evacuation Plans

Labeling/reporting broken/non-functioning equipment

Role in Emergency Operations Plan

SIG Engineering 2011 - 10

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Summary

Make sure that all identified issues are followed up on in a timely matter

Close the loop Utilize data collected as a performance

improvement tool

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Questions?

SIG Engineering 2011 - 12

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SIG Engineers: 630 792 5900

George Mills, MBA, FASHE, CEM, CHFM, CHSP

Senior Engineer SIG

Michael Chisholm, CPE, CHFM

Engineer SIG

Anne Guglielmo, CFPS, LEED, A.P.

Engineer SIG

SIG Engineering 2011 - 13

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The Joint Commission Disclaimer

These slides are current as of 2/17/2011. The Joint Commission reserves the right to change the content of the information, as appropriate.

These slides are only meant to be cue points, which were expounded upon verbally by the original presenter and are not meant to be comprehensive statements of standards interpretation or represent all the content of the presentation. Thus, care should be exercised in interpreting Joint Commission requirements based solely on the content of these slides.

These slides are copyrighted and may not be further used, shared or distributed without permission of the original presenter or The Joint Commission.