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© HTS3 2020| 1 Brentwood, TN 37027 615.309.6053 www.healthtechs3.com Keeping Your Physical Environment of Care Safe August 7, 2020 Presented By: Dr. Frank Mineo, Ph.D., FACHE, CHSP, CHEP, CEM 5110 Maryland Way 2745 North Dallas Pkwy Suite 200 Suite 100 Dallas, TX 75093 800.228.0647 www.ga ffeythealthcare.com

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Page 1: Keeping Your Physical Environment of Care Safe August 7, 2020 · consulting services and technology to: •Serving community, district, non-profit and Critical Access hospitals Example

© HTS3 2020| 1

Brentwood, TN 37027

615.309.6053

www.healthtechs3.com

Keeping Your Physical Environment of Care Safe

August 7, 2020

Presented By: Dr. Frank Mineo, Ph.D., FACHE, CHSP, CHEP, CEM

5110 Maryland Way 2745 North Dallas Pkwy

Suite 200 Suite 100

Dallas, TX 75093

800.228.0647

www.gaffeythealthcare.com

Page 2: Keeping Your Physical Environment of Care Safe August 7, 2020 · consulting services and technology to: •Serving community, district, non-profit and Critical Access hospitals Example

© HTS3 2020| 2

Host

Carolyn began her career in healthcare as a staff nurse in Intensive Care. She has worked in a variety of staff, administrative and consulting roles, and has been in her current position as Chief Clinical Officer with HealthTechS3 for the last 15 years.

In her role as Chief Clinical Officer, Carolyn conducts mock surveys for Critical Access Hospitals, Acute Care Hospitals, Long Term Care, Rural Health Clinics, Home Health and Hospice. Carolyn also assists in developing strategies for continuous survey readiness and developing plans of correction.

Carolyn has extensive experience in working with rural hospitals to both develop, and strengthen, Swing Bed programs.

[email protected]

Carolyn St.Charles,Chief Clinical Officer

HealthTechS3

Page 3: Keeping Your Physical Environment of Care Safe August 7, 2020 · consulting services and technology to: •Serving community, district, non-profit and Critical Access hospitals Example

© HTS3 2020| 3

Nationwide Client Base

Currently provides hospital management, consulting services and technology to:

• Serving community, district, non-profitand Critical Access hospitals

Example Managed Hospital Client: Barrett Hospital and Healthcare in Dillon, MT, Ranked as a Top 100 Critical Access Hospital for 8 years in a row

Example Technology and AR Services Clients: Two-hospital NFP systems in southeast GA with numerous associated physician practices

Preferred vendor to:

• California Critical Access Hospital Network

• Western Healthcare Alliance Partner with Illinois Critical Access HospitalNetwork

• Vizient Group Purchasing Organization

Page 4: Keeping Your Physical Environment of Care Safe August 7, 2020 · consulting services and technology to: •Serving community, district, non-profit and Critical Access hospitals Example

© HTS3 2020| 4

• Executive management & leadership development

• Community health needs assessment

• Lean culture

• Executive and interim recruitment

• CEOs, CFOs, CNOs

• VP and Department Directors

• Performance optimization & margin improvement

• Revenue cycle & business office improvement

• AR outsourcing

• Continuous survey readiness

• Care coordination

• Swing bed consulting

Governance & Strategy

Recruitment Clinical Care & Operations

Finance

Areas of ExpertiseStrategy – Solutions - Support

Page 5: Keeping Your Physical Environment of Care Safe August 7, 2020 · consulting services and technology to: •Serving community, district, non-profit and Critical Access hospitals Example

© HTS3 2020

Interim Executive & Department Leadership 5

▪ The Right Person – Our experience and understanding

of your hospital is the key to placing the right Executive

or Department Leader

▪ Immediate Response – Interim needs are typically

immediate. Our bench strength allows us to find the

right executive quickly to provide a seamless transition

▪ Experience – Over 49 years of supporting executives &

teams in hospitals and healthcare companies of all

sizes

▪ Support Services – Our business is managing hospitals

more efficiently. We provide comprehensive support

services to all our Interim Executives and Department Leaders

▪ Our Depth:

We support all positions including CEO, CFO, CNO,

CIO, Clinic Administration and Department

Leaders

▪ Interim Executive Placement Services:

“Blue Mountain Hospital District has benefited from

the interim executive placement services

HealthTechS3 provides. Our current CFO started as

an interim placement for BMHD, prior to joining our

organization in a permanent capacity. The

success with this placement has motivated us to

consult Health Tech with two subsequent interim executive needs.” Derek Daly, CEO BMHD

Staffing Community Hospitals since 1971

HealthTechS3 Design.Build.Optimize High Performance Teams

Retained Contingency Interim Contract

Page 6: Keeping Your Physical Environment of Care Safe August 7, 2020 · consulting services and technology to: •Serving community, district, non-profit and Critical Access hospitals Example

© HTS3 2020

Mentoring/Support Team 6

Every Interim Executive and Department Leader is backed by a support team and mentor who help ensure that the team gets the right results

HealthTechS3 Design.Build.Optimize High Performance Teams

Retained Contingency Interim Contract

Page 7: Keeping Your Physical Environment of Care Safe August 7, 2020 · consulting services and technology to: •Serving community, district, non-profit and Critical Access hospitals Example

© HTS3 2020

Community Health Needs Assessments: More Than a Regulation – A Tool to Assist in Delivering CareDate : July 14, 2020 Time : 12pm CSTPresenter : Julie Haynes, Strategic Planning ConsultantPresenter : Faith M Jones, MSN, RN, NEA-BC Director of Care Coordination and Lean Consultinghttps://bit.ly/2ZqPgzr

Ask Carolyn – Your Swing Bed Questions AnsweredDate : July 24, 2020 Time : 12pm CSTSpeaker : Carolyn St.Charles, RN, BSN, MBA – Chief Clinical Officerhttps://bit.ly/2Zw55os

More Than a Plan: Keeping Your Physical Environment of Care Safe for Patients, Staff and VisitorsDate : August 7, 2020 Time : 12pm CSTHost : Carolyn St.Charles, RN, BSN, MBA – Chief Clinical OfficerSpeaker : Dr. Frank Mineo, FACHE, CEM, CHSP, CHEPhttps://bit.ly/3eRC5ho

Effective Communication in HealthcareDate : August 14, 2020 Time : 12pm CSTHost : Carolyn St.Charles, RN, BSN, MBA – Chief Clinical OfficerSpeaker : John A. Coldsmith, DNP, MSN, RN, NEA-BChttps://bit.ly/2AiNkAq

Bringing Care Coordination to Specialty Practices: Principle Care ManagementDate : August 27, 2020 Time : 12pm CSTSpeaker : Kevin Franke, BSN, Principal Consultant, Care Partner, LLCFacilitator : Faith M Jones, MSN, RN, NEA-BC - Director of Care Coordination and Lean Consulting, HealthTechS3https://bit.ly/3dQiaya

The Role of a Rural Hospital’s Board in a Time of Crisis: How the Hospital Board and CEO Ensure an Organization’s Success During COVID-19Date : September 4, 2020 Time : 12pm CSTSpeaker : Peter Goodspeed, Vice President of Executive Searchhttps://bit.ly/38fXyOI

Rural Healthcare Challenges in Times of ChangeDate : September 11, 2020 Time : 12pm CSTHost : Carolyn St.Charles, RN, BSN, MBA – Chief Clinical OfficerPresenters : Rhonda Mason, Cobre Valley Regional Medical Center; Margie Molitor, Hot Springs County Memorial Hospital; Deborah Morris, Blue Mountain Hospital; Terry Odom, Powell Valley Healthcarehttps://bit.ly/38gZWEI

Innovating Care Models for Opioid Use Disorder PatientsDate : September 24, 2020 Time : 12pm CSTPresenter : Rebecca Morgan, CEO, Spark Creative Presenter : Faith M Jones, MSN, RN, NEA-BC - Director of Care Coordination and Lean Consultinghttps://bit.ly/2ZyjQaC

The Hospital’s Role in Getting the Right Interim Leader – What Does it Need to Know?Date : September 25, 2020 Time : 12pm CSTSpeaker : Mike Lieb, FACHE – Vice Presidenthttps://bit.ly/2BvqXZ7

An Introduction to Our Cloud-Based Optimum Financial Statement Toolkit (OFST)Date : September 30, 2020 Time : 12pm CSTPresenter : John Freeman, Associate Vice PresidentPresenter : Kevin Stringer, Associate Vice Presidenthttps://bit.ly/2YPQG7G

ALL WEBINARS ARE RECORDED

Page 8: Keeping Your Physical Environment of Care Safe August 7, 2020 · consulting services and technology to: •Serving community, district, non-profit and Critical Access hospitals Example

8© HTS3 2020|

You may type a question in the text box if you have a

question during the presentation

We will try to cover all your questions – but if we don’t get to

them during the webinar, we will follow-up with you by

e-mail

You may also send questions after the webinar to our team

(contact information is included at the end of the

presentation)

The webinar will be recorded and the recording will be

available on the HealthTechS3 web site:

www.healthtechs3.com

www.healthtechs3.com

HealthTechS3 hopes that the information contained herein will be informative and helpful on industry topics. However, please note that this information is not intended to be definitive. HealthTechS3 and its affiliates expressly disclaim any and all liability, whatsoever, for any such information and for any use made thereof. HealthTechS3 does not and shall not have any authority

to develop substantive billing or coding policies for any hospital, clinic or their respective personnel, and any such final responsibility remains exclusively with the hospital, clinic or their respective personnel. HealthTechS3 recommends that hospitals, clinics, their respective personnel, and all other third party recipients of this information consult original source materials and

qualified healthcare regulatory counsel for specific guidance in healthcare reimbursement and regulatory matters.

Instructions for Today’s Webinar

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Presenter

Dr. Frank Mineo has been involved in emergency services for more than 40 years as a provider, educator, and leader in emergency response and management, environment of care, and life safety. Frank retired as a Deputy Chief, FDNY EMS in 1999; since that time he has worked at multiple hospitals in the New York area as a Director of Emergency Management and Environment of Care/Life Safety Compliance Officer providing consultation and leading programs related to emergency management planning/operations and Environment of Care and Life Safety. Frank earned his Ph.D. in Business, Emergency Services Organization and Leadership from Capella University in 2009 and an MPA from Baruch College in 1992. He is a Fellow of the American College of Healthcare Executives (FACHE), Certified Emergency Manager (CEM), Certified Healthcare Safety Professional (CHSP), and Certified Healthcare Emergency Professional (CHEP).

[email protected]

Dr. Frank Mineo,FACHE, CEM, CHSP, CHEP

Page 10: Keeping Your Physical Environment of Care Safe August 7, 2020 · consulting services and technology to: •Serving community, district, non-profit and Critical Access hospitals Example

© HTS3 2020

Program Description 10

Maintaining a safe physical environment of care for patients, staff

and visitors is more than being ready for a survey, and/or a plan or

policy.

Rather, it is the day-to-day focus by staff, at all levels, doing their

part to ensure that safety is a way of life, one which demonstrates

the reasons (and not the rule) for maintaining a safe environment

of care.

Page 11: Keeping Your Physical Environment of Care Safe August 7, 2020 · consulting services and technology to: •Serving community, district, non-profit and Critical Access hospitals Example

© HTS3 2020

So, What is Our Goal? 11

To maintain an Always Ready safety culture that promotes and

encourages active participation from all stakeholders in maintaining

the physical environment.

Page 12: Keeping Your Physical Environment of Care Safe August 7, 2020 · consulting services and technology to: •Serving community, district, non-profit and Critical Access hospitals Example

© HTS3 2020

Objectives 12

✓ Understand the reasons for maintaining a safe physical

environment of care.

✓ Understand the importance of department-focused daily

activities as part of an organizational culture of safety.

✓ See how written policies and management plans support

department ownership of safety.

Page 13: Keeping Your Physical Environment of Care Safe August 7, 2020 · consulting services and technology to: •Serving community, district, non-profit and Critical Access hospitals Example

© HTS3 2020

Establishing an Organizational Culture of Safety 13

A culture of safety is one that embraces a practice of

responsibility and accountability by staff at all levels

throughout the organization.

Page 14: Keeping Your Physical Environment of Care Safe August 7, 2020 · consulting services and technology to: •Serving community, district, non-profit and Critical Access hospitals Example

© HTS3 2020

Focus of the Environment of Care Chapter (TJC) 14

Safety and security: addresses risks in the physical environment, access to security-sensitive

areas, product recalls, and smoking.

Hazardous materials and waste: addresses risks associated with hazardous chemicals,

radioactive materials, hazardous energy sources, hazardous medications, and hazardous

gases and vapors.

Fire safety: addresses risks from fire, smoke, and other products of combustion; fire response

plans; fire drills; management of fire detection, alarm, and suppression equipment and

systems; and measures to implement during construction or when the Life Safety Code® *

cannot be met.

Medical equipment: addresses selection, testing, and maintenance of medical equipment

and contingencies when equipment fails.

Utilities: addresses inspection and testing of operating components, control of airborne

contaminants, and management of disruptions.Source: Joint Commission

Page 15: Keeping Your Physical Environment of Care Safe August 7, 2020 · consulting services and technology to: •Serving community, district, non-profit and Critical Access hospitals Example

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EOC Chapter Standards 15

I. Plans (EC.01.01.01)

II. Implement

A. Safety and Security (EC.02.01.01, EC.02.01.03)

B. Hazardous Materials and Waste (EC.02.02.01)

C. Fire Safety (EC.02.03.01, EC.02.03.03, EC.02.03.05)

D. Medical Equipment (EC.02.04.01, EC.02.04.03)

E. Utilities (EC.02.05.01, EC.02.05.03, EC.02.05.05, EC.02.05.07,

EC.02.05.09)

F. Other Physical Environment Requirements (EC.02.06.01, EC.02.06.05)

III. Staff Demonstrate Competence (EC.03.01.01)

IV. Monitor and Improve (EC.04.01.01, EC.04.01.03, EC.04.01.05)

Source: Joint Commission

Page 16: Keeping Your Physical Environment of Care Safe August 7, 2020 · consulting services and technology to: •Serving community, district, non-profit and Critical Access hospitals Example

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Special Note 16

Where this presentation will focus primarily on the Environment of Care,

participants should also ensure that associated chapters such as Life

Safety, Infection Control. Emergency Management, and Leadership are

assessed as part of an organizational compliance program.

Specific examples include the various NFPA standards (i.e., LSC 101 and

99 related to life and fire safety); including the requirement to ensure all

testing and inspection documentation is in order and available at the

time of a survey.

Organizations must also ensure through direct observation that all

required fire/life safety equipment, barrier designations as per the Life

Safety Plans, doors, etc. are functioning as designed.

Page 17: Keeping Your Physical Environment of Care Safe August 7, 2020 · consulting services and technology to: •Serving community, district, non-profit and Critical Access hospitals Example

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Top 10 Findings (2019 TJC) 17

1) EC.02.06.01 (maintenance of a safe environment), 56%

2) EC.02.05.01 (management of utility system risks), 53%

3) IC.02.02.01 (reduction of infection risk from equipment, devices and

supplies), 52%

4) LS.02.01.20 (maintenance of egress integrity), 50%

5) RC.01.01.01 (maintenance of accurate, complete medical records for all

patients), 49%

6) EC.02.03.05 (maintenance of fire safety equipment and building

features), 48%

Source: Joint Commission

Page 18: Keeping Your Physical Environment of Care Safe August 7, 2020 · consulting services and technology to: •Serving community, district, non-profit and Critical Access hospitals Example

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Top 10 Findings (2019 TJC) cont’d 18

7) LS.02.01.10 (minimization of fire, smoke and heat damage via building

and fire protection features), 46%

8) LS.02.01.30 (building features provided and maintained to protect from

fire and smoke hazards), 43%

9) LS.02.01.35 (fire extinguishment features provided and maintained) 43%

10) EC.02.02.01 (management of hazardous materials and waste risks), 36%

Source: Joint Commission

Page 19: Keeping Your Physical Environment of Care Safe August 7, 2020 · consulting services and technology to: •Serving community, district, non-profit and Critical Access hospitals Example

© HTS3 2020

What is a Management Plan?(EC.01.01.01)

19

Source: Joint Commission Perspectives 2013

Written management plans help the hospital manage risks.

These plans are not the same as operational policies or

procedures but provide a framework for managing the

environment of care.

Page 20: Keeping Your Physical Environment of Care Safe August 7, 2020 · consulting services and technology to: •Serving community, district, non-profit and Critical Access hospitals Example

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Example of a Management Plan 20

PURPOSE: This Safety Management Plan (Plan) provides a framework to

promote a safe environment for patients, staff, and others coming to our

facilities. This plan identifies the policies, programs, and processes used

to establish, support and maintain an effective safety management

program.

SCOPE: This plan shall cover all areas of the main campus and applies to

all staff including LIPs and Volunteers.

RESPONSIBILITIES: Department managers are responsible for area-

specific safety. Department leaders as the local “owner” have a

working knowledge of their areas and are best able to maintain a safe

workplace and to motivate employee safety.

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Paper to Practice Sequence 21

Page 22: Keeping Your Physical Environment of Care Safe August 7, 2020 · consulting services and technology to: •Serving community, district, non-profit and Critical Access hospitals Example

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Plan Effectiveness(EC.04.01.01; 03; 05)

22

Plan-Do-Check-Act

The hospital uses the results of data analysis to identify

opportunities to resolve environmental safety issues.

The hospital acts on the identified opportunities to resolve

environmental safety issues.

Page 23: Keeping Your Physical Environment of Care Safe August 7, 2020 · consulting services and technology to: •Serving community, district, non-profit and Critical Access hospitals Example

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PDCA Cycle 23

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Examples of Plan Metrics(EC.03.01.01)

24

The hospital establishes a process for continually monitoring, internally reporting,

and investigating the following:

✓ Injuries to patients or others within the hospital’s facilities

✓ Occupational illnesses and staff injuries

✓ Incidents of damage to its property or the property of others

✓ Security incidents involving patients, staff, or others within its facilities

✓ Hazardous materials and waste spills and exposures

✓ Fire safety management problems, deficiencies, and failures

✓ Medical or laboratory equipment management problems, failures and use

errors

✓ Utility systems management problems, failures, or use errors

Source: Joint Commission

Page 25: Keeping Your Physical Environment of Care Safe August 7, 2020 · consulting services and technology to: •Serving community, district, non-profit and Critical Access hospitals Example

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Let’s Discuss! 25

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Safety Plan(EC.02.01.01)

26

SAFETY IS EVERYONE’S RESPONSIBILITY!

Each staff member must…

• Report any/all safety hazards to a supervisor

• Report all accidents and/or injuries to a supervisor

• Know department alarms, emergency numbers, evacuation

plans, and emergency eyewash station locations.

Page 27: Keeping Your Physical Environment of Care Safe August 7, 2020 · consulting services and technology to: •Serving community, district, non-profit and Critical Access hospitals Example

© HTS3 2020

Security Plan(EC.02.01.01)

27

• Child Abduction (may be part of the emergency plan)

• Active Shooter (may be part of the emergency plan)

• Agitated or Violent Person

• Safeguard personal property

• Report all missing, lost and found property immediately

• Display ID cards on outermost garment.

• New for Covid-19-Visitor Policies

• No Smoking Policy

• Secure Area Access Policy

Page 28: Keeping Your Physical Environment of Care Safe August 7, 2020 · consulting services and technology to: •Serving community, district, non-profit and Critical Access hospitals Example

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Hazardous Materials Plan(EC.02.02.01)

28

• Spill Response and Management

• Chemical Inventory/Safety Data Sheets

• Special Areas (i.e. labs, infusion centers)

• Storage, Labels, and Handling

• Staff Education

• Personal Protective Equipment

Page 29: Keeping Your Physical Environment of Care Safe August 7, 2020 · consulting services and technology to: •Serving community, district, non-profit and Critical Access hospitals Example

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Fire Safety Plan(EC.02.05.01)

29

Fire Dos Fire Don'ts

Every employee must know

location of emergency exits, fire

alarm pull stations & fire

extinguishers in their work area.

Never block fire pulls stations!

Never block fire extinguishers!

Never block fire or smoke doors!

Never block fire exits!

Page 30: Keeping Your Physical Environment of Care Safe August 7, 2020 · consulting services and technology to: •Serving community, district, non-profit and Critical Access hospitals Example

© HTS3 2020

RACE and PASS 30

Page 31: Keeping Your Physical Environment of Care Safe August 7, 2020 · consulting services and technology to: •Serving community, district, non-profit and Critical Access hospitals Example

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Egress Essentials 31

All egress corridors, hallways, aisles must be kept clear so that nothing

blocks the movement of stretchers or people in the event of an

evacuation.

YES NO NO

Page 32: Keeping Your Physical Environment of Care Safe August 7, 2020 · consulting services and technology to: •Serving community, district, non-profit and Critical Access hospitals Example

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Keep Fire Safety Equipment Clear! 32

Blocked fire extinguisher

and medical gas valve

Blocked fire alarm pull

station

Page 33: Keeping Your Physical Environment of Care Safe August 7, 2020 · consulting services and technology to: •Serving community, district, non-profit and Critical Access hospitals Example

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Containment No…No! 33

This….

Page 34: Keeping Your Physical Environment of Care Safe August 7, 2020 · consulting services and technology to: •Serving community, district, non-profit and Critical Access hospitals Example

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Patient Room and Corridor Outside the Room(door open)

34

Can Lead to this:

Page 35: Keeping Your Physical Environment of Care Safe August 7, 2020 · consulting services and technology to: •Serving community, district, non-profit and Critical Access hospitals Example

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Special Considerations: MRI 35

MAGNETIC FIELD WARNING

If you work around extremely high field magnets such as magnetic

resonance imaging (MRI) machines, you should only have non-

magnetic fire extinguishers on hand.

The magnetic field of an MRI machine is strong enough to make a

steel cylinder fly across the room with lethal force.

This type of extinguisher is located around the MRI Unit.

Page 36: Keeping Your Physical Environment of Care Safe August 7, 2020 · consulting services and technology to: •Serving community, district, non-profit and Critical Access hospitals Example

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Special Considerations: Peri-Operative Areas 36

Estimated Frequency: 200-240 per year in the U.S

➢ 44% on head, neck, or upper chest

➢ 26% elsewhere on the patient

➢ 21% in the airway

➢ 8% elsewhere on the patient

Of the 200-240 OR fires per year in the U.S:

➢ 20 to 30 are serious and result in disfiguring or disabling injuries

➢ 1 to 2 are fatal

Source: AORN 2015

Page 37: Keeping Your Physical Environment of Care Safe August 7, 2020 · consulting services and technology to: •Serving community, district, non-profit and Critical Access hospitals Example

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Staff Focus: Evacuation 37

• Emergent - life-threatening-move now! (the Rescue in RACE)

• Urgent/Planned - have some time (hours to days)

• Horizontal - move to same floor to an area of safety (know

where to go for safe refuge)

• Vertical - move to different floor depending on location of

emergency (know how to move patient)

Page 38: Keeping Your Physical Environment of Care Safe August 7, 2020 · consulting services and technology to: •Serving community, district, non-profit and Critical Access hospitals Example

© HTS3 2020

Medical Gas Valves 38

Know who can shut them off, and which areas the valve controls

Never Block a Valve!

Page 39: Keeping Your Physical Environment of Care Safe August 7, 2020 · consulting services and technology to: •Serving community, district, non-profit and Critical Access hospitals Example

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Staff Focus: Gas Cylinders 39

• All tanks regardless of size must be in an approved holder or

chained to the wall to prevent falling

• Stored cylinders shall be secured against unauthorized access

• Ensure tanks are stored in proper rack (full/empty)

• Separation signage

Page 40: Keeping Your Physical Environment of Care Safe August 7, 2020 · consulting services and technology to: •Serving community, district, non-profit and Critical Access hospitals Example

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Medical Equipment Plan(EC.02.04.01)

40

• Equipment Inventory

• Inspection

• Missing and/or Damaged Equipment

• Temperature/Humidity Considerations:

follow manufacturers recommendations

Page 41: Keeping Your Physical Environment of Care Safe August 7, 2020 · consulting services and technology to: •Serving community, district, non-profit and Critical Access hospitals Example

© HTS3 2020

Utility Management Plan(EC.02.05.01)

41

• Loss of power

• Water

• Telecommunications

• Computer/IT Cybersecurity

Staff should know how a failure would affect them

and/or their patient!

Page 42: Keeping Your Physical Environment of Care Safe August 7, 2020 · consulting services and technology to: •Serving community, district, non-profit and Critical Access hospitals Example

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Ligature Risk: Organizational Focus 42

Source: GNYHA 2019

• Room Design

• Evaluation (risk assessment)

• Mitigation

Page 43: Keeping Your Physical Environment of Care Safe August 7, 2020 · consulting services and technology to: •Serving community, district, non-profit and Critical Access hospitals Example

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Emergency Preparedness 43

COVID-19 Pandemic has made this a focus area of surveyors!

Page 44: Keeping Your Physical Environment of Care Safe August 7, 2020 · consulting services and technology to: •Serving community, district, non-profit and Critical Access hospitals Example

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CMS Requirements(November 2019)

44

• Must have an emergency plan (policies and procedures)

• Conduct Risk Assessment (referred to as an HVA)

• Staff education and training (drills)

• Communication Plan

Page 45: Keeping Your Physical Environment of Care Safe August 7, 2020 · consulting services and technology to: •Serving community, district, non-profit and Critical Access hospitals Example

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Emergency Plan and Procedures 45

• CMS requires an All-Hazards Emergency Plan, one which

describes how the hospital functions in any type of emergency,

regardless of cause, impact, or areas affected

• Accrediting Organizations (AO) will examine the effectiveness of

your response to the Covid-19 pandemic

• Staff and patient safety, and Infection Control are areas of

surveyor focus!

Page 46: Keeping Your Physical Environment of Care Safe August 7, 2020 · consulting services and technology to: •Serving community, district, non-profit and Critical Access hospitals Example

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Emergency Plan and Procedures 46

• Portable radios

• Emergency backup telephone system

• EMERGENCY NOTIFICATION SYSTEM

• Overhead announcements (Plain Language)

• Runners and written messages

• Up-to-Date Contact List (staff, external agencies)

• Method to contact patient care providers and family

Page 47: Keeping Your Physical Environment of Care Safe August 7, 2020 · consulting services and technology to: •Serving community, district, non-profit and Critical Access hospitals Example

© HTS3 2020

When is a Plan NOT a Plan? 47

When it’s part of a daily routine!

Page 48: Keeping Your Physical Environment of Care Safe August 7, 2020 · consulting services and technology to: •Serving community, district, non-profit and Critical Access hospitals Example

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Brainstorm Ideas 48

Consider…How can your team work together to accomplish this goal?

Understand…There is no wrong way (other than doing nothing)!

All ideas are welcome!

Page 49: Keeping Your Physical Environment of Care Safe August 7, 2020 · consulting services and technology to: •Serving community, district, non-profit and Critical Access hospitals Example

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Examples of Easy Fixes (and citations) 49

• Storage under sprinkler heads (18-inch rule)

• Penetrations

• Combination Codes on doors

• Smoking

• Medical Gas Storage

• Chemical Storage

• Alcohol-Based Hand Sanitizers (ABHS)

• Eyewash Stations

• Hazardous Waste Storage

Page 50: Keeping Your Physical Environment of Care Safe August 7, 2020 · consulting services and technology to: •Serving community, district, non-profit and Critical Access hospitals Example

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More Examples (Infection Control) 50

• Adequate cleaning

• Linen on top of cart

• Solid bottoms to storage racks

• Storage of Supplies

• Emergency pull cords are appropriate and properly

maintained hang freely. Not tied or wrapped.

• Construction/renovation projects (infection control and

life safety permits)

Page 51: Keeping Your Physical Environment of Care Safe August 7, 2020 · consulting services and technology to: •Serving community, district, non-profit and Critical Access hospitals Example

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First Steps 51

• Daily rounds using a checklist

• Dedicated “safety champions” on each shift

• Easy incident reporting process (concerns, repairs)

• Multi-disciplinary rounding team (all staff levels)

• Accountability through department (local) ownership

Page 52: Keeping Your Physical Environment of Care Safe August 7, 2020 · consulting services and technology to: •Serving community, district, non-profit and Critical Access hospitals Example

© HTS3 2020

Summary 52

Management Plans drive the policies and processes needed to

maintain a safe environment of care…but its our staff that make a

safe environment a reality!!

To be successful, organizations must adopt a safety culture that

requires staff at all levels to adopt “When I see something, I can

and will do something!”

Page 53: Keeping Your Physical Environment of Care Safe August 7, 2020 · consulting services and technology to: •Serving community, district, non-profit and Critical Access hospitals Example

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From This to This(not just on survey day)

53

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Success Cycle 54

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Reason, Not the Rule! 55

Remember:

While it’s important and necessary to ensure compliance with rules

and regulations (i.e., Accrediting Organizations, CMS, OSHA)…

Its more about keeping our patients, staff, and visitors as safe as

possible every day!

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Questions 56

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Community Health Needs Assessments: More Than a Regulation – A Tool to Assist in Delivering CareDate : July 14, 2020 Time : 12pm CSTPresenter : Julie Haynes, Strategic Planning ConsultantPresenter : Faith M Jones, MSN, RN, NEA-BC Director of Care Coordination and Lean Consultinghttps://bit.ly/2ZqPgzr

Ask Carolyn – Your Swing Bed Questions AnsweredDate : July 24, 2020 Time : 12pm CSTSpeaker : Carolyn St.Charles, RN, BSN, MBA – Chief Clinical Officerhttps://bit.ly/2Zw55os

More Than a Plan: Keeping Your Physical Environment of Care Safe for Patients, Staff and VisitorsDate : August 7, 2020 Time : 12pm CSTHost : Carolyn St.Charles, RN, BSN, MBA – Chief Clinical OfficerSpeaker : Dr. Frank Mineo, FACHE, CEM, CHSP, CHEPhttps://bit.ly/3eRC5ho

Effective Communication in HealthcareDate : August 14, 2020 Time : 12pm CSTHost : Carolyn St.Charles, RN, BSN, MBA – Chief Clinical OfficerSpeaker : John A. Coldsmith, DNP, MSN, RN, NEA-BChttps://bit.ly/2AiNkAq

Bringing Care Coordination to Specialty Practices: Principle Care ManagementDate : August 27, 2020 Time : 12pm CSTSpeaker : Kevin Franke, BSN, Principal Consultant, Care Partner, LLCFacilitator : Faith M Jones, MSN, RN, NEA-BC - Director of Care Coordination and Lean Consulting, HealthTechS3https://bit.ly/3dQiaya

The Role of a Rural Hospital’s Board in a Time of Crisis: How the Hospital Board and CEO Ensure an Organization’s Success During COVID-19Date : September 4, 2020 Time : 12pm CSTSpeaker : Peter Goodspeed, Vice President of Executive Searchhttps://bit.ly/38fXyOI

Rural Healthcare Challenges in Times of ChangeDate : September 11, 2020 Time : 12pm CSTHost : Carolyn St.Charles, RN, BSN, MBA – Chief Clinical OfficerPresenters : Rhonda Mason, Cobre Valley Regional Medical Center; Margie Molitor, Hot Springs County Memorial Hospital; Deborah Morris, Blue Mountain Hospital; Terry Odom, Powell Valley Healthcarehttps://bit.ly/38gZWEI

Innovating Care Models for Opioid Use Disorder PatientsDate : September 24, 2020 Time : 12pm CSTPresenter : Rebecca Morgan, CEO, Spark Creative Presenter : Faith M Jones, MSN, RN, NEA-BC - Director of Care Coordination and Lean Consultinghttps://bit.ly/2ZyjQaC

The Hospital’s Role in Getting the Right Interim Leader – What Does it Need to Know?Date : September 25, 2020 Time : 12pm CSTSpeaker : Mike Lieb, FACHE – Vice Presidenthttps://bit.ly/2BvqXZ7

An Introduction to Our Cloud-Based Optimum Financial Statement Toolkit (OFST)Date : September 30, 2020 Time : 12pm CSTPresenter : John Freeman, Associate Vice PresidentPresenter : Kevin Stringer, Associate Vice Presidenthttps://bit.ly/2YPQG7G

ALL WEBINARS ARE RECORDED

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We hope the information in this webinar has been helpful!

Please contact us if you would like to schedule a review of your facility,

or have questions about the presentation

Frank [email protected]

THANK YOU

Carolyn St.CharlesChief Clinical Officer,

HealthTechS3

Dr. Frank Mineo,FACHE, CEM, CHSP, CHEP

Carolyn St.Charles5110 Maryland Way

Suite 200Brentwood, TN 37027Phone: 206-605-3748

[email protected]