By Dean Samet, CHSP
The Joint Commission eliminated 16 elements of performance (EPs) from their hospital accreditation program with a July 1, 2010 effective date, as announced in the June 9, 2010 Joint Commission Online publication.
These and other EPs went through an extensive evaluation process as part of TJC’s internal Robust Process Improvement (RPI) initiative started in mid-2008. The RPI establishes a measurement ranking scale against which all standards for all of TJC programs will purportedly be evaluated going forward. As part of this evaluation, more than 300 hospitals were invited to provide their perceptions of what constitutes a “valuable” standard and which standards they believed contributed the least value towardquality and safety. TJC defines a valuable standard as one that:
Wednesday, September 29, 2010
Thursday, July 29, 2010
Compliance News: Fire Sprinkler System Main Drain Test
By Robert Trotter, CBO, CFM
The Joint Commission’s 2010 Hospital Accreditation Standards for the Environment of Care describes requirements for the main drain tests on sprinkler and standpipe systems. EC.02.03.05 Element of Performance 9 states, “For automatic sprinkler systems: Every 12 months, the hospital tests main drains at system low point or at all system risers. The completion date of the tests is documented.” For additional information refer to the 1998 edition of NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. Although The Joint Commission requires an annual test, NFPA 25 requires this test to be conducted quarterly. Section 9-2.6 states, “A main drain test shall be conducted quarterly at each water-based fire protection system riser to determine whether there has been a change in the condition of the water supply piping and control valves.”
Note: The test for standpipe systems should be done at the low point drain for each standpipe or the main drain test connection where the supply main enters the building.
The Joint Commission’s 2010 Hospital Accreditation Standards for the Environment of Care describes requirements for the main drain tests on sprinkler and standpipe systems. EC.02.03.05 Element of Performance 9 states, “For automatic sprinkler systems: Every 12 months, the hospital tests main drains at system low point or at all system risers. The completion date of the tests is documented.” For additional information refer to the 1998 edition of NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. Although The Joint Commission requires an annual test, NFPA 25 requires this test to be conducted quarterly. Section 9-2.6 states, “A main drain test shall be conducted quarterly at each water-based fire protection system riser to determine whether there has been a change in the condition of the water supply piping and control valves.”
Note: The test for standpipe systems should be done at the low point drain for each standpipe or the main drain test connection where the supply main enters the building.
Compliance News: New and Existing Elevators
By Robert Trotter, CBO, CFM
According to the 2000 edition of NFPA 101®, Life Safety Code® elevators in all occupancies must comply with Section 9.4 which addresses general requirements, code compliance, fire fighters’ service, number of cars, elevator machine rooms, elevator testing, and openings. The Joint Commission’s 2010 Hospital Accreditation Standards for Life Safety have specific Elements of Performance for new and existing healthcare occupancies and ambulatory healthcare occupancies. LS.02.01.50 EP 4 and LS.03.01.50 EP 1 require new elevators to be equipped with the following:
• Fire fighters’ service key recall
• Smoke detector automatic recall
• Fire fighters’ service emergency in-car key operation
• Machine room smoke detectors
• Elevator lobby smoke detectors
Existing elevators that have a travel distance of 25 feet or more above or below the level that best serves the needs of fire fighters shall also meet these requirements.
According to the 2000 edition of NFPA 101®, Life Safety Code® elevators in all occupancies must comply with Section 9.4 which addresses general requirements, code compliance, fire fighters’ service, number of cars, elevator machine rooms, elevator testing, and openings. The Joint Commission’s 2010 Hospital Accreditation Standards for Life Safety have specific Elements of Performance for new and existing healthcare occupancies and ambulatory healthcare occupancies. LS.02.01.50 EP 4 and LS.03.01.50 EP 1 require new elevators to be equipped with the following:
• Fire fighters’ service key recall
• Smoke detector automatic recall
• Fire fighters’ service emergency in-car key operation
• Machine room smoke detectors
• Elevator lobby smoke detectors
Existing elevators that have a travel distance of 25 feet or more above or below the level that best serves the needs of fire fighters shall also meet these requirements.
Compliance News: Relative Humidity Levels in Operating Rooms Reduced
By Dean Samet, CHSP
The American Society for Healthcare Engineering (ASHE) announced in May 2010 that effective the end of June 2010 the requirement for relative humidity levels in operating rooms has been reduced to a minimum of 20%. The new design range for ORs and short-term patient treatment stay areas is now 20-60% relative humidity (RH).
The above changes are a result of actions taken by the ANSI/ASHRAE/ASHE Standard 170: Ventilation of Health Care Facilities Standing Committee and were approved as issued in ASHRAE Standard 170, Addendum “d.” ASHRAE (American Society of Heating, Refrigerating and Air-Conditioning Engineers) 170 has been incorporated into The Facility Guidelines Institute’s 2010 edition of Guidelines for Design and Construction of Healthcare Facilities. According to ASHE, the publication of Addendum (d) “stresses the aspects of relative humidity in operating rooms in terms of clinical outcomes, comfort, and engineering concepts.”
The American Society for Healthcare Engineering (ASHE) announced in May 2010 that effective the end of June 2010 the requirement for relative humidity levels in operating rooms has been reduced to a minimum of 20%. The new design range for ORs and short-term patient treatment stay areas is now 20-60% relative humidity (RH).
The above changes are a result of actions taken by the ANSI/ASHRAE/ASHE Standard 170: Ventilation of Health Care Facilities Standing Committee and were approved as issued in ASHRAE Standard 170, Addendum “d.” ASHRAE (American Society of Heating, Refrigerating and Air-Conditioning Engineers) 170 has been incorporated into The Facility Guidelines Institute’s 2010 edition of Guidelines for Design and Construction of Healthcare Facilities. According to ASHE, the publication of Addendum (d) “stresses the aspects of relative humidity in operating rooms in terms of clinical outcomes, comfort, and engineering concepts.”
Compliance News: Polyurethane Expanding Foam
By Robert Trotter, CBO, CFM
The use of polyurethane expanding foam is expressly not permitted by The Joint Commission for sealing penetrations in fire-rated walls and floors. According to the 2010 Hospital Accreditation Standards LS.02.01.10 Element of Performance 9, "The space around pipes, conduits, bus ducts, cables, wires, air ducts, or pneumatic tubes that penetrate fire-rated walls and floors are protected with an approved fire-rated material." The Joint Commission included this specific note, "Polyurethane expanding foam is not an acceptable fire-rated material for this purpose." According to the 2000 edition of NFPA 101®, Life Safety Code® section 8.2.3.2.4.2 requires the space between the penetrating item and the fire barrier to be filled with a material that is capable of maintaining the fire resistance rating of the fire barrier or it must be protected by an approved device that is designed for the specific purpose.
The use of polyurethane expanding foam is expressly not permitted by The Joint Commission for sealing penetrations in fire-rated walls and floors. According to the 2010 Hospital Accreditation Standards LS.02.01.10 Element of Performance 9, "The space around pipes, conduits, bus ducts, cables, wires, air ducts, or pneumatic tubes that penetrate fire-rated walls and floors are protected with an approved fire-rated material." The Joint Commission included this specific note, "Polyurethane expanding foam is not an acceptable fire-rated material for this purpose." According to the 2000 edition of NFPA 101®, Life Safety Code® section 8.2.3.2.4.2 requires the space between the penetrating item and the fire barrier to be filled with a material that is capable of maintaining the fire resistance rating of the fire barrier or it must be protected by an approved device that is designed for the specific purpose.
Compliance News: Electrical Arc Flash Safety: How close is too close?
By David Stymiest, PE, FASHE, CHFM, GBE
NFPA 70E® defines a series of boundaries related to electrical safety near energized equipment. These boundaries can be based on the voltage; the available short-circuit current and the predicted fault duration. The definitions are not repeated here, but the following considerations are useful to gain an overview of the issues involved.
• Flash Protection Boundary – an imaginary boundary within which there is the potential for a second-degree burn injury. Fire resistive protection (also called PPE) is required. This is the first item that must be determined by an arc flash hazard analysis.
NFPA 70E® defines a series of boundaries related to electrical safety near energized equipment. These boundaries can be based on the voltage; the available short-circuit current and the predicted fault duration. The definitions are not repeated here, but the following considerations are useful to gain an overview of the issues involved.
• Flash Protection Boundary – an imaginary boundary within which there is the potential for a second-degree burn injury. Fire resistive protection (also called PPE) is required. This is the first item that must be determined by an arc flash hazard analysis.
Compliance News: CMS Corridor Obstructions Stance Revised
By Dean Samet, CHSP
In a May 14, 2010 Centers for Medicare & Medicaid Services memorandum, Ref: S&C-10-18-LSC, CMS announced changes to previous policies regarding the use of corridor wall-mounted computer touch screens in healthcare facilities.
In a May 14, 2010 Centers for Medicare & Medicaid Services memorandum, Ref: S&C-10-18-LSC, CMS announced changes to previous policies regarding the use of corridor wall-mounted computer touch screens in healthcare facilities.
CMS is now allowing certain wall-mounted technologies and other items to be wall-mounted in corridors as long as they don’t project out more than six inches from the corridor wall or conflict with other sections of the National Fire Protection Association’s Life Safety Code®.
Saturday, May 29, 2010
Compliance News: Locks on Doors in Means of Egress
By Robert Trotter, CBO, CFM
According to the 2000 edition of NFPA 101®, Life Safety Code®, “Experience indicates that panic seldom develops, even in the presence of danger, as long as occupants of buildings are moving towards exits that they can see…” However, the stoppage of egress travel such as an exit door locked with a padlock (as shown on a marked exit door in an industrial occupancy of a hospital) is potentially conducive to panic. Healthcare occupancies as well as business, industrial and storage occupancies are required to comply with the means of egress provisions for locks, latches and alarm devices for doors. Section 7.2.1.5.1 of the Life Safety Code® states, “Doors shall be arranged to be opened readily from the egress side whenever the building is occupied.” It is also important that locks, if provided, “shall not require the use of a key, tool, or special knowledge or effort from the egress side.”
According to the 2000 edition of NFPA 101®, Life Safety Code®, “Experience indicates that panic seldom develops, even in the presence of danger, as long as occupants of buildings are moving towards exits that they can see…” However, the stoppage of egress travel such as an exit door locked with a padlock (as shown on a marked exit door in an industrial occupancy of a hospital) is potentially conducive to panic. Healthcare occupancies as well as business, industrial and storage occupancies are required to comply with the means of egress provisions for locks, latches and alarm devices for doors. Section 7.2.1.5.1 of the Life Safety Code® states, “Doors shall be arranged to be opened readily from the egress side whenever the building is occupied.” It is also important that locks, if provided, “shall not require the use of a key, tool, or special knowledge or effort from the egress side.”
Compliance News: Labeling Utility System Controls
By Robert Trotter, CBO, CFM
Accurate labeling of utility system controls is essential during routine and emergency shutdown situations. Hospitals are required by The Joint Commission 2010 Hospital Accreditation Standards for the Environment of Care to manage risks associated with its utility systems. EC.02.05.01 Elements of Performance 1 through 13 describe the specific requirements. In regard to the electrical utility, hospitals should pay particular attention to labeling of electrical panelboards as required by EC.02.05.01 EP 8, “The hospital labels utility system controls to facilitate partial or complete emergency shutdowns.”
While The Joint Commission has recently been finding these deficiencies under the Environment of Care Standard it is possible the same finding could be noted under the Life Safety Standard relative to building services. For additional information refer to the 1999 edition of NFPA 70®, National Electrical Code Article 384-13, “All panelboard circuits and circuit modifications shall be legibly identified as to purpose or use on a circuit directory located on the face or inside of the panel doors.”
Accurate labeling of utility system controls is essential during routine and emergency shutdown situations. Hospitals are required by The Joint Commission 2010 Hospital Accreditation Standards for the Environment of Care to manage risks associated with its utility systems. EC.02.05.01 Elements of Performance 1 through 13 describe the specific requirements. In regard to the electrical utility, hospitals should pay particular attention to labeling of electrical panelboards as required by EC.02.05.01 EP 8, “The hospital labels utility system controls to facilitate partial or complete emergency shutdowns.”
While The Joint Commission has recently been finding these deficiencies under the Environment of Care Standard it is possible the same finding could be noted under the Life Safety Standard relative to building services. For additional information refer to the 1999 edition of NFPA 70®, National Electrical Code Article 384-13, “All panelboard circuits and circuit modifications shall be legibly identified as to purpose or use on a circuit directory located on the face or inside of the panel doors.”
Compliance News: NFPA® Codes Available On-Line (Free)
By Pete Kendrick, CHFM, CPMM
Have you ever desired to review a National Fire Protection Association (NFPA®) code that is not part of your facility library? If so, it might be useful to know that you can do so for free on the NFPA® website, and the service is available to both members and non-members. There are some limitations which will be addressed below, but here is how to find a code. Let’s look up NFPA 99 Standard for Healthcare Facilities just for fun.
First, go to the website at http://www.nfpa.org/. Click on Codes & Standards which is just below the “sign-in” box. On the left you will see a second link for a “List of NFPA codes & standards” and you should select that. For an example, scroll down and click on NFPA 99 under the Code No. in the center of the page. Select “View the document online (read only).”
Have you ever desired to review a National Fire Protection Association (NFPA®) code that is not part of your facility library? If so, it might be useful to know that you can do so for free on the NFPA® website, and the service is available to both members and non-members. There are some limitations which will be addressed below, but here is how to find a code. Let’s look up NFPA 99 Standard for Healthcare Facilities just for fun.
First, go to the website at http://www.nfpa.org/. Click on Codes & Standards which is just below the “sign-in” box. On the left you will see a second link for a “List of NFPA codes & standards” and you should select that. For an example, scroll down and click on NFPA 99 under the Code No. in the center of the page. Select “View the document online (read only).”
Compliance News: Damaged Sprinkler Heads
By Robert Trotter, CBO, CFM
Damaged sprinkler heads can have a detrimental effect on the performance of sprinklers by affecting water distribution patterns, insulating thermal elements, delaying operation, or otherwise rendering the sprinkler inoperable or ineffectual. According to The Joint Commission’s 2010 Hospital Accreditation Standards for Life Safety, hospitals must provide and maintain systems for extinguishing fires. LS.02.01.35 Element of Performance 5 states, “Sprinkler heads are not damaged and are free from corrosion, foreign material, and paint.” The standard offers the following: (For full text and any exceptions refer to NFPA® 25-1998: 2-2.1.1.) Section 2-2.1.1 of NFPA® 25, Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems states, “Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.” Note that sprinklers installed in concealed spaces such as abovesuspended ceilings do not require inspection.
Damaged sprinkler heads can have a detrimental effect on the performance of sprinklers by affecting water distribution patterns, insulating thermal elements, delaying operation, or otherwise rendering the sprinkler inoperable or ineffectual. According to The Joint Commission’s 2010 Hospital Accreditation Standards for Life Safety, hospitals must provide and maintain systems for extinguishing fires. LS.02.01.35 Element of Performance 5 states, “Sprinkler heads are not damaged and are free from corrosion, foreign material, and paint.” The standard offers the following: (For full text and any exceptions refer to NFPA® 25-1998: 2-2.1.1.) Section 2-2.1.1 of NFPA® 25, Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems states, “Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.” Note that sprinklers installed in concealed spaces such as abovesuspended ceilings do not require inspection.
Compliance News: Electrical Arc Flash Safety: Why is it important?
By David Stymiest, PE, FASHE, CHFM, GBE
With the release of the 2009 edition of NFPA 70E®, Standard for Electrical Safety in the Workplace®, increased attention is being focused on electrical power system safety and the dangers associated with electrical arc flashes.
According to CDC’s National Institute of Occupational Safety & Health (NIOSH), electricalhazards cause more than 300 deaths and 4,000 injuries in the workplace each year. Someelectrical injuries are instantly fatal, while up to 40% of electrical injuries are ultimately fatalaccording to a paper written by three critical care physicians and referenced in a recent electrical industry magazine article. A research and consulting firm specializing in workplace injuries hascompiled often-quoted statistics indicating that five to ten reported electrical equipment arc flash explosions occur per day in the USA.
With the release of the 2009 edition of NFPA 70E®, Standard for Electrical Safety in the Workplace®, increased attention is being focused on electrical power system safety and the dangers associated with electrical arc flashes.
According to CDC’s National Institute of Occupational Safety & Health (NIOSH), electricalhazards cause more than 300 deaths and 4,000 injuries in the workplace each year. Someelectrical injuries are instantly fatal, while up to 40% of electrical injuries are ultimately fatalaccording to a paper written by three critical care physicians and referenced in a recent electrical industry magazine article. A research and consulting firm specializing in workplace injuries hascompiled often-quoted statistics indicating that five to ten reported electrical equipment arc flash explosions occur per day in the USA.
Compliance News: Measures of Success and Scoring Category Changes
By Dean Samet, CHSP
According to the April 28, 2010 Joint Commission Online, a number of Measures of Success (MOS) requirements have been deleted effective April 26, 2010 and several Elements of Performance (EPs) will change from a “C” to an “A” scoring category effective July 1, 2010. Compliance with affected Elements of Performance is still expected. If your organization is currently completing the MOS data submission for the affected EPs based on your last survey, go to The Joint Commission Connect extranet and enter “MOS requirement removed” in the text box and submit.
Before showing the recent changes, let’s review the particulars of what an MOS is and what the scoring categories are.
According to the April 28, 2010 Joint Commission Online, a number of Measures of Success (MOS) requirements have been deleted effective April 26, 2010 and several Elements of Performance (EPs) will change from a “C” to an “A” scoring category effective July 1, 2010. Compliance with affected Elements of Performance is still expected. If your organization is currently completing the MOS data submission for the affected EPs based on your last survey, go to The Joint Commission Connect extranet and enter “MOS requirement removed” in the text box and submit.
Before showing the recent changes, let’s review the particulars of what an MOS is and what the scoring categories are.
Saturday, May 1, 2010
Opening Day: Transitioning from Construction to Survey-Ready Operation
By David l. Stymiest, P.E., FASHE, CHFM (in Health Facilities Management)
Construction project turnover time is hectic. Facility activation and move-in are usually foremost and it is often difficult to get all of the compliance work done on time. Lacking a solid process for transitioning from construction to operations and survey-ready compliance at occupancy can put a hospital at risk during an early survey.
Challenges and Limitations
There are many challenges in health care facility activation. Among them are managing economic, operational, patient safety and compliance risks. The challenge in this complex undertaking is to minimize the duration while meeting all regulatory compliance requirements by initial occupancy.
Challenges and Limitations
There are many challenges in health care facility activation. Among them are managing economic, operational, patient safety and compliance risks. The challenge in this complex undertaking is to minimize the duration while meeting all regulatory compliance requirements by initial occupancy.
Read entire article here: Opening Day
Monday, March 29, 2010
Compliance News: Minimum Clear Width for Doors
By Robert Trotter, CBO, CFM
Egress doors in existing healthcare occupancies should comply with the 2000 edition of NFPA 101®, Life Safety Code® section 19.2.3.5 which states, “The minimum clear width for doors in the means of egress from hospitals; nursing homes; limited care facilities; psychiatric hospital sleeping rooms; and diagnostic and treatment areas, such as x-ray, surgery, or physical therapy, shall be not less than 32 in. wide.” There is an exception for existing 34-inch doors, and existing 28-inch corridor doors in facilities where the fire plans do not require evacuation by bed, gurney, or wheelchair. Excluding any of the four exceptions, egress doors in new healthcare occupancies must meet the requirements prescribed in 18.2.3.5. The minimum clear width for doors in the means of egress from sleeping rooms, diagnostic and treatment areas, such as x-ray, surgery, or physical therapy, and nursery rooms in hospitals and nursing homes is 41.5 inches and 32 inches in psychiatric hospitals and limited care facilities.
Egress doors in existing healthcare occupancies should comply with the 2000 edition of NFPA 101®, Life Safety Code® section 19.2.3.5 which states, “The minimum clear width for doors in the means of egress from hospitals; nursing homes; limited care facilities; psychiatric hospital sleeping rooms; and diagnostic and treatment areas, such as x-ray, surgery, or physical therapy, shall be not less than 32 in. wide.” There is an exception for existing 34-inch doors, and existing 28-inch corridor doors in facilities where the fire plans do not require evacuation by bed, gurney, or wheelchair. Excluding any of the four exceptions, egress doors in new healthcare occupancies must meet the requirements prescribed in 18.2.3.5. The minimum clear width for doors in the means of egress from sleeping rooms, diagnostic and treatment areas, such as x-ray, surgery, or physical therapy, and nursery rooms in hospitals and nursing homes is 41.5 inches and 32 inches in psychiatric hospitals and limited care facilities.
Subscribe to:
Posts (Atom)