TJC Clarifies Emergency Power Expectations

By David Stymiest, PE, CHFM, CHSP, FASHE

In the January 2014 editions of both TJC Perspectives and TJC EC News, TJC Director of Engineering George Mills listed numerous clarifications and expectations for emergency power systems.  Below are the design-related issues that he covered.

TJC Modifies Emergency Power Test Intervals for 2014

 By David Stymiest, PE, CHFM, CHSP, FASHE

The 2014 TJC Hospital Accreditation Standards include wording changes in Standard EC.02.05.07, EP-4 (generator test intervals) and EP-6 (transfer switch test intervals) that tweak the required test intervals a little.

The new 2014 test interval language in both EPs states “At least monthly, the hospital tests ….”  This is a change from the 2013 TJC wording in both EPs that stated “Twelve times a year, at intervals of not less than 20 days and not more than 40 days ….”

TJC Redefines “Quarterly” and “Every 3 Years” for 2014

 By David Stymiest, PE, CHFM, CHSP, FASHE

Take a close look at your 2014 schedules for quarterly requirements such as fire safety system testing found in several elements of performance (EPs) under Standard EC.02.03.05.  The brand new 2014 TJC definition of QUARTERLY can be found on page EC-3 at the beginning of the EC Chapter in the 2014 Hospital Accreditation Standards.  The previous definition allowed quarterly activities to be accomplished anytime during a calendar quarter.  The 2014 definition, however, is “every three months, plus or minus 10 days.”  We recommend that you interpret this new requirement conservatively as three months from the date of the previous activity, plus or minus 10 days.

Smart Money: Making the case for hospital infrastructure funding

By David Stymiest, PE, CHFM, CHSP, FASHE

This article recently appeared in Health Facilities Management.
 
Many health facilities managers would like to be more successful in obtaining depreciation dollars to fund maintenance and infrastructure capital renewal adequately. Gaining access to depreciation funding often involves being more successful at selling the maintenance mission and requires a multifaceted approach.

The rules of engagement include such disparate approaches as communicating with budget committees and chief financial officers (CFOs) while employing the terminology they use for other hospital initiatives, wise use of empirical information to communicate salient facts regarding the hospital infrastructure, making sure to shift the risk of non-funding to those who make funding decisions, and fitting budget requests into the strategic big picture.

Read More.

TJC Expands Required Documents List

In the September 2013 update to the 2013 Survey Activity Guide, The Joint Commission (TJC) added the following environment of care documents to its list of documents required at the beginning of a hospital survey. 

28. Written fire response plan
29. Interim Life Safety Measure policy
30. Fire drill evaluations

TJC Notification Requirements for CMS Categorical Waivers

The Joint Commission (TJC) recently clarified its notification requirements if an organization decides to take advantage of any CMS categorical waivers.  If a categorical waiver relates to a Life Safety Code requirement, TJC has requested that the organization identify that decision in the Additional Comments field of the eBBI section of the eSOC at TJC’s eConnect website for that organization.  On the other hand, if a categorical waiver relates to another chapter requirement, such as the motor-driven fire pump testing requirement within EC chapter Standard EC.02.03.05, TJC asks that the organization document its decision in the Safety Committee or EOC Committee meeting minutes.  This is a change from information previously disseminated by ASHE shortly after the waivers were released by CMS.

The organization should also notify the TJC surveyors at the beginning of the survey of any waivers that the organization has elected to use.

TJC Emphasizes Pressure Relationships for Infection Prevention

By David Stymiest, PE, CHFM, CHSP, FASHE

In his October 25th ASHE-sponsored webinar, TJC Director of Engineering George Mills emphasized the importance of maintaining proper pressure relationships for infection prevention where rooms are required to be positive or negative with respect to adjacent rooms or spaces.  Mr. Mills reiterated previous statements regarding how TJC surveyors will test for required pressure relationships – surveyors will use the tissue test very early to assess the adequacy of pressure relationships at the doorways of rooms subject to those requirements.  The tissue test is often performed by holding a thin tissue at the bottom door gap of a closed door.  The tissue will typically bend or flutter in the direction of air flow, which will be from a more positive to a less positive (or from a less negative to a more negative) space.  As a rule of thumb, the “more clean” areas need to be positive pressure with respect to the “less clean” areas.  If the tissue flutters from the “more clean” areas to the “less clean” areas – no problem. If the tissue flutters in the opposite direction however – big problem.  This is likely to result in a Requirement for Improvement (RFI) against Standard EC.02.05.01, Element of Performance (EP) #6, which states the requirements for areas designed to control airborne contaminants along with the concomitant need for appropriate pressure relationships, air-exchange rates, and filtration efficiencies. 

Joint Commission discusses Fire Safety Equipment Inventories at ASHE Conference

 By David Stymiest, PE CHFM CHSP FASHE

The Joint Commission (TJC) Engineering Director George Mills addressed the issue of fire safety equipment inventories at his 2013 ASHE Annual Conference plenary in July.

Mr. Mills stated that with respect to Standard EC.02.03.05, Elements of Performance (EPs) # 1 through # 20 inclusive, every device required to be tested must be documented in an inventory. He further stated that TJC surveyors will expect the facility to be able to identify specific variances in devices tested from year to year, and that simply having the total quantity of devices without more specific definition will not be adequate. Finally, Mr. Mills stated that lack of a written, electronic, or other form of inventory addressing the devices covered by any of the 20 EPs could result in a finding against that EP. Needless to say, Organizations who have yet not finalized their EC.02.03.05 inventories can be subject to numerous RFIs during survey.

TJC Addresses CMS Categorical Waivers

 
By David Stymiest, PE CHFM CHSP FASHE

 ASHE recently discussed in its Listserv TJC’s response to the CMS categorical waivers.

According to ASHE, TJC requested that organizations indicate in the eBBI’s Additional Comments field the acceptance of any categorical waivers as well as so noting those decisions in the EOC Committee minutes. TJC Life Safety Code surveyors will field-verify that the CMS conditions are being met for any accepted waiver, similarly to the CMS onsite field-verification approach.

CMS ISSUES MORE CATEGORICAL WAIVERS

By David Stymiest, PE, CHFM, CHSP, FASHE

 

Waivers address selected life safety, medical gas master alarm, emergency power testing, and firesafety equipment testing requirements.

The Centers for Medicare & Medicaid Services (CMS) issued a new Survey & Certification memorandum # S&C: 13-58-LSC to its State Survey Agency Directors on August 30, 2013.  This new S&C memo identifies several areas where several separate requirements more than a decade old are being relaxed for (and only for) those facilities that take the necessary steps to elect to use the waivers.

TJC Provides Tips for Meeting Problematic Life Safety Compliance Requirements 

By David Stymiest, PE, CHFM, CHSP, FASHE

TJC Director of Engineering George Mills provides tips for meeting problematic life safety compliance issues in the July 2013 of The Joint Commission’s EC News.  This valuable multi-page article addresses the following elements of performance (EPs) and related types of survey requirements for improvement:

ASHRAE Publishes Improved HVAC Design Manual for Hospitals & Clinics 

By Ron Holdaway, PE, CEM, LEED AP

ASHRAE recently published the 2nd edition of the HVAC Design Manual for Hospitals and Clinics.  ASHRAE states that this book, a complete rewrite of the 1st edition, focuses specifically on HVAC system design for health care facilities, omitting general system descriptions that are readily available in other ASHRAE publications.

TJC Strengthens Leadership Accountability for Emergency Management

By David Stymiest, PE, CHFM, CHSP, FASHE

In the July 2014 issue of Joint Commission Perspectives, TJC officially issued new and revised leadership requirements intended to provide “a clearer description of leadership-level oversight of emergency management.”  The new and revised elements of performance are all effective January 1, 2014. 

TJC Issues 2014 National Patient Safety Goal on Clinical Alarm System Safety

By David Stymiest, PE, CHFM, CHSP, FASHE

In its Joint Commission Online article dated June 26, 2013 (available at http://www.jointcommission.org/assets/1/23/jconline_June_26_13.pdf) The Joint Commission announced a new 2014 National Patient Safety Goal NPSG.06.01.01 on clinical alarm safety for both hospitals and critical access hospitals.  The July 2013 issue of Joint Commission Perspectives discusses the new NPSG in detail.

Compliance News: TJC Revisits EC Plans

 
By David Stymiest, PE, CHFM, CHSP, FASHE

A recent article placed in both the EC News and TJC Perspectives clarified TJC requirements for management plans.  Written for the June 2013 issues by TJC Department of Engineering Director George Mills for the Clarifications and Expectations segment of both publications, the article clarified some issues that have been resulting in TJC requirements for improvement (RFIs) during survey.