Discussion Summary from the JCAHO Panel Update Session

Held at the 37th Annual ASHE.  Conference on Monday, July 10,2000 Panelists:

Carol Patterson , MN, RN -Director -The Standards Interpretations Group, JCAHO
Dean Samet, Associate Director, Department of Standards, JCAHO
Ken Peterson, Surveyor, JCAHO
Douglas Erickson , F ASHE, Consultant, Codes and Standards; ASHE
Susan McLaughlin, MBA, CHSP, MT (ASCP) SC, President, SBM Consulting Moderator:
Curt Hibbard, SASHE, ASHE President-elect

Onenin2 Comments from Panelist:

Carol Patterson

In September, JCAHO embarked on a restructuring of its whole operation and the way it does business with its health care clients. The standards department has moved from the research division to the accreditation operations division (where surveys are scheduled, staffed and conducted). User questions are now being answered by the Standards Interpretation Group, which includes Dean Samet, Britt Berek, and George Stevens. Other changes are that JCAHO is moving to a web based approach of answering questions. Later this year you will be able to find the SIG (Standards Interpretation Group) site as you enter the JCAHO home page. This site will be populated by answers to frequently asked questions.

In June a white paper and letter was mailed to all accredited organizations to ask them to enter into a dialog with JCAHO to discuss how changes to the survey process should occur. One of the changes posed in the paper is an 18-month inter-cycle partial survey (similar to a scheduled focus survey). Experience from JCAHO pilot programs ( e.g.. Orion project) is that hospitals prefer being continuously ready for survey. ( as compared to the cost and human resource time to ramp up for the 36-month survey). These pilot programs included some form of contact with health care organizations on a quarterly basis. The white paper discussed quarterly contact through multiple methods including a self-assessment tool; web based educational program, or on-site contact. At this point these concepts are under intensive discussion within JCAHO with all health care organizations and multiple state agencies invited to participate. The 18-month survey is one of the possible changes under consideration -it is not final.

Dean Samet

EC.2.10 Fire Drill Requirements Revised: (Effective July 1,2000)
The requirement for 20% staff observation of quarterly fire drills has changed. The extent of the observations is now up to the individual health care organization as defined in their fire plan. At the time of survey, the JCAHO surveyor will focus on two issues relative to fire drills:

1. Are you performing fire drills per your fire plan?
2. Are you performing an annual evaluation of the effectiveness of staff training on the fire plan?

EC.l.9 Utilities Systems Management Revised (effective 1/1/2001)
The intent statement has new language to address the issues of organization-acquired illness and infection. Managing pathogenic biological agents in cooling towers, domestic hot water, and other aerosolizing water systems must now be included in the Utilities System  Management Plan. Changes are detailed in the Environment of care News and the periodical Perspectives (both published by JCAHO) as well as on the JCAHO web-site www .-..icaho.org under HOT SPOTS.

Ken Peterson

The JCAHO Mission Statement was changed on 1/1/2000 adding the words "continuously" and "safety". It now reads: "To continuously improve the safety and quality of health care". The survey process has been changed to be more flexible and therefore less predictable in the survey agenda. This includes longer patient unit visits (now 90 minutes) which allows the nurse surveyor and physician surveyor more time to get more in-depth and to review more areas. The building tour and the Environment of Care document review session have each been expanded by 30 minutes to allow the surveyors more time to decide what they would like to look at. Off shift surveys (other then the day shift) were pilot tested between October 1999 and March 2000. These are night shift or evening shift appearances by the surveyors, but can also occur on the weekend if the survey extends from Friday to Monday. These are selected surveys lasting from two to four hours Random unannounced surveys, which occur for 5% of organizations, formerly were at mid cycle (18 months after previous survey). The window has now expanded to occur anytime from 9 to 30 months after the tri-annual survey. In addition, the survey is truly unannounced (no 24 hour notice). The survey consists of 5 selective elements (described in October/November 1999 JCAHO Perspectives publication). JCAHO will have a satellite educational broadcast on July 20,2000 covering managing of Environment of Care standards.

Susan McLaughlin

EC.l.6 Emergency Management Revised (effective 1/1/2001)

 It is interesting to note that the name of the standard will change for Emergency Preparedness to Emergency Management. It brings health care organizations in line with the way that emergencies are managed in the community -Placing emphasis on integration with community emergency management. The incident command system is not specific; rather the intent is to integrate with the incident command system used in your community to manage community based emergencies. Other changes deal with planning for emergencies with a Hazard Vulnerability Analysis addressing issues of mitigation, preparedness, response, and recovery. The term recovery is common in industry but has not been written into previous hospital requirements. Other changes include changes in wording and emphasis to existing sections. For example more specific wording of patient care issues during an emergency situation and more specific wording of security functions. Experience has shown that an organization's staffs' ability to handle an emergency situation is tied to their own personal situation. There is new wording for 2001 which addresses support of the staff families. These things will require us to look at Emergency Management more in depth for next year .

Douglas Erickson

EC.l.9 Utilities Systems Management Revised (effective 1/1/2001)

In addition to Dean Samet's comments on water borne pathogens (e.g. legionnella) -In order to meet this standard it is not necessary to culture all of your spigots and end of line devices. Rather, work with your infection control committee to make sure you have a plan in place to effectively handle an outbreak if one occurs. You QQ..nQ! have to pro actively go out and culture spigots and shower heads! In thesame-standard-there-is.another-element.that.addresses-the-control-of air borne contaminants. You need to describe in the management plan that you are effectively taking care of your HV AC systems. Describe how you ensure that positive pressure rooms are indeed positive, that in isolation rooms you are managing the negative pressure environment. How are you collecting the data to ensure that the rooms are effective when you have a suspected or active tuberculosis patient? ALA guidelines define positive pressure rooms (operating rooms special procedure rooms, etc) up against equal pressure rooms. You also need to properly air balance your systems within Patient sensitive areas (the footnote at the bottom of the standard specifies patient sensitive areas only) -areas here your Infection Control committee has identified as treating immunocompromised patients ( e.g. bone marrow transplant patients, neonatal ICU patients, chemotherapy areas, etc. ). It does not mean that you have to have a semi-annual or annual air balance of your facility. Be aware of venders contacting you and telling you that annual air balancing is part of the standard -that is not the intent of the standard. You need to look at filter efficiencies, static pressure, and change filters as appropriate for your conditions and types of filters. Refer to AlA guidelines with regard to filter efficiencies, air pressure relationships, etc. and improve your program based on those guidelines.

Questions to Panelists and Their Responses:

1. Q -Why in an unannounced survey does the JCAHO spend so much time on Life Safety and the Environment of Care? It seems as if there are greater issues within health care today such as infection control, medication errors, nursing, leadership, medical staff, etc.
   
   A -One of the five fixed elements in the random survey is EC.l.l dealing with Life Safety Code (LSC) compliance. LSC, along with medical credentialing, are two of the more prescriptive standards ( either it is or it isn't) consequently these standards tend to result in more frequent recommendations made to organizations. Medical staff re-credentialing and medication errors are also parts of the five fixed elements .
    
2. Q -If JCAHO goes to 18 month intervals for inspection, doesn't it seem likely that hospitals will now request state agencies to do HCFA inspections, since they are typically done every 12 months at a fraction of the cost?
   
   A- One of the issues of the white paper (discussed in Carol Patterson 's comments) is decreasing the cost to both health care organizations and JCAHO, as well as increasing the public perception 's about a safe environment existing in health care organizations. The concept of continuous readiness has been part of the management plans for years. This interval change extends this readiness to the whole hospital. JCAHO needs to work with hospitals to understand what the standards require and to have them implement the standards on a continuous basis.
    
3. Q -How would survey fees be structured if JCAHO did go to an 18 month survey? What payment options are under consideration?
   
   A -A/though there will be some service free on the web-site, right now the survey is fee for service with additional fees for educational boob and publications. There have been many options discussed within the task force. One option is subscription models with different levels of support ( e.g. one lump sum buys a certain level of services from JCAHO or spread the costs over the entire 36 months). Additional options in between these examples are being considered.
    
4. Q -Is it necessary. for business occupancy clinics to have staff wear identification badges for security or otherwise?
   
   A -EC.l.4 calls for tagging staff and visitors as appropriate. It 's up to the organization to determine if badges are needed given the setting. JCAHO does not require badges.
    
5. Q -What is the rule on smoke wall penetrations for business occupancies?
    
   A -JCAHO does not survey business occupancy for Life Safety Code. Surveyors are only looking for general fire safety; they are relying on the local AHJ for a more thorough fire code inspection.
    
6. Q -How does the Process for Improvement (PFI) get documented without a requirement for a Statement of Conditions (SOC) in buisness occupancies?
   
   A- The organization can show JCAHO its last fire inspection sheets, present meeting minutes addressing fire code issues, hazard surveillance findings with resolution to identified issues, etc. There are many different ways that can be shared with the surveyor at the time of the survey. They can also use the SOC if they so desire.
    
7. Q -Most of the hospitals here today need to comply with both JCAHO and HCFA requirements. Could someone from JCAHO comment on the strategy being used to communicate better and synchronize JCAHO focus and HCF A focus so we as hospitals are not caught up in dual requirements or confusion around compliance.
   
   A -HCF A is a federal agency separate from JCAHO. Intensive efforts have been made in the past to persuade HCF A to adopt a more current version of the Life Safety Code. Even though assurances have been made by HCF A to move to the current version, no evidence of movement has been apparent (notice of proposed rule making language in the F federal Register is required). Senior senators have been involved in attempting to persuade HCF A to adopt the current Life Safety Code (effectively bringing these two organizations together). JCAHO has given their assurances that they will adopt the 2000 version of the LSC when HCF A moves to adopt the code. Reasons for non-movement from HCF A have included the presidential election in the fall. Doug Ericbon challenged the leadership of A SHE to undertake a letter writing campaign to senators and representatives to exert pressure on HCF A to adopt the 2000 LSC.
    
8. Q -Does JCAHO consider Renal Dialysis patients incapable of self-preservation? At issue is the occupancy classification of 4 -6 chair regional satellite renal dialysis centers. Are they business occupancies or ambulatory care occupancies?
   
   A- The issue is the degree of illness of the patients coming to the center. Are they ambulatory, able to walk around, or are they truly sick? You have to look at that yourself, make the risk assessment, and then make that determination of the standard. Determine what the centers typical patient population is, are they capable of self-preservation in emergency situations, and then present that assessment to the surveyor. The surveyor may ask about patient education, as well as interview the patients to determine if they have been taught the procedures to safely disconnect from the equipment under emergency conditions (commonly termed "clamp & cut"). If the organization determines that the typical patient population is not capable of self- preservation, and there are 4 or more patients, then it is considered an ambulatory care facility based on definitions in chapter 13 of the Life Safety Code.
    
9. Q -Is there a 95% completion requirement for preventive maintenance inspections on equipment in your plan? What are your views on risk based maintenance and how do you implement the program?
   
   A -I believe this pertains -to- utility systems Most organizations in corporate tlll of their utility systems in their plan with maintenance schedules for lubrication, filter change, etc. The surveyor will like to see this occur 95% of the time. (this percentage also pertains to preventive maintenance in the Biomedical Equipment standard). This is an infrequently cited standard. {Doug Erickson added that a more general question should be asked -Can you write out a risk based criteria system and exclude a certain amount of utility equipment with regard to monitoring preventive maintenance? Answer- yes, JCAHO will permit you to eliminate types of equipment from the monitored PM program provided that the plan goes through a multi disciplinary committee ( e.g. Safety Committee) for approval to write out certain elements. Once approved these elements are no longer included in the 95% scoring system. In addition, JCAHO reviews the percentage of scoring on a quarterly basis you can have peaks and valleys and still get a 1 score. Weather related issues, or emergencies, or strike, etc. can cause you to fall below 95% for a given month but as long as the quarterly score is above 95% you are ok. } {Tom Schipper, CCE, F ASHE commented from the floor: Kaiser has been doing risk based , maintenance since 1980. The new terminology of Reliability Centered Maintenance (RCM) is the direction that maintenance is going. The principles of RCM are very solid. The challenge to JCAHO is that, up to now, the standards have talked about interval based maintenance (monthly, quarterly, semiannual, etc.). In the RCM realm, we need to make serious consideration to ~ we do maintenance (based on a hour schedule, e.g. 500 hours, 1,000 hours, etc., like what is used for respiratory ventilators). The challenge will be for JCAHO and state agencies to believe you when you say we have our emergency generators on an RCM program and our next scheduled maintenance is in 250 hours -and get them to believe that we have it right. This is a big challenge -but this is where our industry is going. } The 95% standard for Biomedical Equipment is being looked at by JCAHO. If this is changed, then most likely the Utility Systems will also change. Discussions are underway with ASHE to review this requirement for a more realistic standard. Performance based standards will be taken under consideration in these discussions.
    
10. Q -If afternoon and evening surveys are going to be held -Is the hospital told this ahead of time? Many managers have family commitments with children, working spouse, etc. that might need to be cleared, as I am sure you want the manager present during the survey.
    
    A- These surveys are not prearranged or pre-announced. The essence is that management need not required to be present for this part of the survey.
     
11. Q -Does the JCAHO have regulations on the use of hospital emergency generators for local utility companies power share program? We are committed to run our generators at the electric company's command.
    
    A -Power sharing is acceptable. Several hospitals are currently taking part in power sharing. If an organization would like to submit a statement of their arrangement with the Power Company to Dean Samet he will review it. This usage may also meet some of the testing requirements (if load and time duration meet criteria) in the Utility Management standards.
     
12. Q -Why do JCAHO definitions of construction types vary from building code definitions?
    
    A -JCAHO follows the NFP A Life Safety Code. They do not follow Standard Building Code, National Building Code, or Uniform Building Code. The reality is that there are two types of standards and therefore two ways to define occupancy. It is not that hard to reference one code to another. Maybe ASHE can do a crosswalk between Life Safety Code and Building Codes with the new International Building code coming out.
     
13. Q- Could.youfurther.explain-'~hazar.d vulnerability-analysis':?-.Whaltyp.es,of.analysi$ are you looking for? How often are they performed?
    
    A -A hazard vulnerability analysis, with respect to emergency management, has been done by most organizations informally, possibly under another title. What it really is, is looking at the whole list of disasters that could happen to your hospital, to look at them from the standpoint - what is your risk of being impacted- how would it effect your facility, and what is its probability? (Le. the risk of being impacted by a severe snowstorm is probably pretty low in Miami, conversely a hurricane in Minnesota is remote) don't to a lot of planning for something of low probability. It is really just a more formalized term and process for looking at how any given type of emergency situation might impact you.
     
14. Q- Changes to codes & standards are generally from input of public and business. For example changes to NFP A. Will, or does, JCAHO accept input from health care organizations?
    
    A -JCAHO has a committee on health care safety, which has a broad spectrum of members on it from different classifications in health care. Proposed changes in the standards are reviewed by this committee and recommendations go to the JCAHO Board committee on standards and survey process. If approved at that level, these recommendations become revisions to standards. Currently, ASHE members Douglas Erickson and Curt Hibbard are on this committee. OSHA, NFP A, and Fire Marshals are also represented on this committee.
     
15. Q -Please address the requirement for designated smoking/smoking shelters in reference to distancing from the facility and areas of egress & ingress.
    
    A -JCAHO standards do not have a specified distance that smokers or smoking shelters must be from entrance doors. The designated areas for smokers must be far enough away from an entrance to a health care facility that smoke does not blow into the building under normal conditions. A simple way to verify that smoke doesn't track back to the building (or into the path of patients, visitors, and staff entering or leaving the building) is to perform a smoke test with a volunteer smoker, on an average day, to see which way the smoke migrates.
     
16. Q -Is the Environment of Care standards being renumbered in 2001 ? Any details on this revision?
    
    A -The Environment of Care standard has been rewritten so that the numbering of like standards is consistent across each manual for all types of organizations (hospitals, long term care, ambulatory, behavioral health, etc.). The intent is to set core standards across all of the ten or eleven manuals to ensure constancy and simplify surveys for integrated health care systems that provide a variety of services. This rewrite is part of an incremental process to rewrite all standards (in 1999 the Performance Improvement standard was the first standard reorganized).

Acronyms:
JCAHO = Joint Commission on Accreditation of Health care Organizations
FEMA = Federal Emergency Management Authority,
AHJ = Authority Having Jurisdiction
HCFA = Health Care Financing Authority