2014

Report
2014
Anne M. Guglielmo, Engineer
Engineering Department
The Joint Commission
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THE HEALTHCARE ENVIRONMENT
2013 Non
Compliance
RC.01.01.01
LS.02.01.20
IC.02.02.01
61%
51%
42%
55%
54%
47%
EC.02.05.01
LS.02.01.10
34%
46%
46%
46%
EC.02.03.05
40%
44%
LS.02.01.30
LS.02.01.35
39%
34%
43%
38%
EC.02.06.01
MM.03.01.01
35%
35%
36%
33%
Department of Engineering 2014 - 2
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2012 Non
Compliance
Standard/NPSG
2013 Non
Compliance
EC.02.02.01
PC.01.03.01
MM.04.01.01
30%
25%
26%
33%
26%
24%
EC.02.05.07
EC.02.05.09
22%
23%
23%
22%
HR.01.02.05
PC.01.02.03
EC.02.03.01
16%
25%
19%
22%
21%
19%
MS.01.01.01
PC.03.01.03
21%
19%
18%
18%
Department of Engineering 2014 - 3
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2012 Non
Compliance
Standard/NPSG
ASHRAE voted in July 2013 to move endoscopy procedure
rooms from positive to N/A. FGI is planning on releasing
this in the November publication of the 2014 FGI
Guidelines.
Therefore, if an organization had made a documented
decision based on risk assessment to no longer monitor
endoscopy procedure rooms as per the 2013 ASHRAE
action, we would accept this.
If the organization has not made a documented decision,
the room should be evaluated as per the below table
and construction date.
No change to bronchoscopy procedure rooms.
Department of Engineering 2014 - 4
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NOTE: THIS JUST IN
GUIDELINES VENTILATION TABLE:
ENDOSCOPY & BRONCHOSCOPY
ENDOSCOPY
PRESSURE
PROCEDURE
DIRECT EXHAUST
2014 (pending)
N/A
N/A
PROCESSING (CLEANING)
DIRECT EXHAUST
PRESSURE
YES
Negative (-)
PROCEDURE
DIRECT EXHAUST
PRESSURE
YES
Negative (-)
2010
Positive (+)
N/A
Negative (-)
YES
Negative (-)
YES
2006
Neutral
N/A
Negative (-)
YES
Negative (-)
YES
2001
Negative (-)
N/A
N/A
N/A
Negative (-)
YES
1996/1997
N/A
N/A
N/A
N/A
Negative (-)
YES
1992/1993
N/A
N/A
N/A
N/A
N/A
N/A
1987
N/A
N/A
N/A
N/A
N/A
N/A
1979
N/A
N/A
N/A
N/A
N/A
N/A
Department of Engineering 2014 - 5
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Edition
BRONCHOSCOPY
THE FOLLOWING ARE AVAILABLE
WITH CERTAIN PROVISIONS.
THESE ARE BASED ON
CMS S&C 13-58-LSC
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2012 LIFE SAFETY CODE
UPDATE
BACKGROUND
 The Joint Commission provided CMS with a
list of items, based on later editions of the
Life Safety Code, that would immediately
have a positive impact on all healthcare
recommendation in the form of a State &
Certification letter (S&C 13-58-LSC)
 The action is a series of Categorical Waivers
Department of Engineering 2014 - 7
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 CMS acted on the Joint Commission
If the organization decides to adopt these categorical
waivers they must
1. Ensure full compliance with the appropriate code
reference
2. Document the decision to adopt the categorical waiver
 For Life Safety Code items annotate the “Additional
Comments” Section in the Statement of Conditions™
Basic Building Information (BBI)
 For Environment of Care items document by Minutes
in discussion at the Environment of Care Committee (or
equivalent)
3. Declare the decision at the beginning of any survey
Department of Engineering 2014 - 8
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PROCESS
RH 20 – 60% RANGE
ASC to align with the 2010 FGI Guidelines for Design &
Construction of Health Care Facilities use of ASHRAE 1702008
 Reduced the relative humidity (RH) in certain areas to a
range of 20 – 60%
 This 2013 CMS action matched the Joint Commission’s
1/2011 adoption of the 2010 Guidelines and the 20 – 60%
RH range provided
 The S&C had two criteria
1. Document the decision
2. Declare at the beginning of a survey the decision
Department of Engineering 2014 - 9
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 CMS first issued a Categorical Waiver in S&C 13-25-LSC &
MEANS OF EGRESS 18/19.2.1
18/19.2.1 which allow, under certain
Department of Engineering 2014 - 10
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circumstances, existing openings to exit
enclosures to mechanical room spaces
as provided at section 7.1.3.2 Exits and
more specifically the requirements at
7.1.3.2(9)(c)
EXISTING OPENINGS TO MECHANICAL SPACES
Section 7.1.3.2.1(9)(c):
 (c) Existing openings to mechanical equipment spaces
protected by approved existing fire protection–rated
door assemblies shall be permitted, provided that the
following criteria are met:
 The space is used solely for non-fuel-fired mechanical
equipment.
 The space contains no storage of combustible
materials.
 The building is protected throughout by an approved,
supervised automatic sprinkler system in accordance
with Section 9.7.
Department of Engineering 2014 - 11
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 18/19.2.1 requires compliance with Chapter 7, including
18/19.2.5.7 SUITES
circumstances, one of the exit access doors in a
sleeping suite be permitted to be directly to an exit
stair, exit passageway or exit to the exterior;
 18/19.2.5.7.3.1(B) which allow, under certain
circumstances, one of the exit access doors in a
non-sleeping suite be permitted to be directly to an
exit stair, exit passageway or exit to the exterior;
 18/19.2.5.7.1.2 which allow, under certain
circumstances, suites to be separated by corridor
wall requirements;
Department of Engineering 2014 - 12
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 18/19.2.5.7.2.1(B) which allow, under certain
MEANS OF EGRESS 18/19.2.2.2
certain circumstances, more than one
delayed egress in the egress path
18/19.2.2.2.6 which allow, under
certain circumstances, remote control
of locks for the rapid removal of
occupants
Department of Engineering 2014 - 13
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18/19.2.2.2.4 which allow, under
MEANS OF EGRESS 18/19.2.2.2
circumstances, door locking arrangements
where clinical needs of patients require
specialized security measures or where
patients pose a security threat
 18/19.2.2.2.5.2 which allow, under certain
circumstances, door locking arrangements
based on the patient special needs requiring
specialized security measures for their
safety
Department of Engineering 2014 - 14
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 18/19.2.2.2.5.1 which allow, under certain
SUITES
allow, under certain circumstances, patient
sleeping suites up to 10,000square feet
 18/19.2.5.7.2.2(C) which allow, under certain
circumstances, one of the two required exits in a
sleeping suite to exit into another suite
 18/19.2.5.7.3.2(C) which allow, under certain
circumstances, one of the two required exits in a
non-sleeping suite to exit into another suite;
Department of Engineering 2014 - 15
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 18/19.2.5.7.2.3(B) and 18/19.2.5.7.2.3(C) which
96 GALLON CONTAINERS
circumstances container used
 solely for recycling clean waste or
 patient records awaiting destruction
 up to 96 gallons not be stored in a room
identified as hazardous storage.
 Soiled linen or trash receptacles shall not exceed
32 gallons and comply with 18/19.7.5.7.1
Department of Engineering 2014 - 16
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 18/19.7.5.1 which allow, under certain
MODIFIED S&C 12-21-LSC
CATEGORICAL WAIVER NOW APPLIES:
WHEELED EQUIPMENT EXPANDED
specifically the requirements at 18/19.2.3.4 which
allow, under certain circumstances, projections into
the means of egress corridor width for wheeled
equipment including lifts and transport equipment
 Provided
 5ft clear corridor width is maintained
 Fire plan addresses management of storage
 Accommodates current “equipment in use” criteria
Department of Engineering 2014 - 17
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 18/19.2.3 Capacity of Means of Egress and more
MODIFIED S&C 12-21-LSC
CATEGORICAL WAIVER NOW APPLIES:
FIXED SEATING ALLOWED
specifically the requirements at 18/19.2.3.4 which
allow, under certain circumstances, projections into
the means of egress corridor width for fixed
furniture
 Provided
 provided 6ft clear width
 < 50sqft with 10’ between groupings
 Groupings must be on same side of the egress
corridor
Department of Engineering 2014 - 18
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 18/19.2.3 Capacity of Means of Egress and more
MODIFIED S&C 12-21-LSC
CATEGORICAL WAIVER NOW APPLIES:
CORRIDOR COOKING ALLOWED
requirements at 18/19.3.2.5.2 - 18/19.3.2.5.5 which allow
certain types of alternative kitchen cooking arrangements
 One cooking area may be open to the egress corridor per
smoke compartment
 Any additional cooking areas must be in protected room
similar to hazardous areas
 Provisions:
 No deep fat fryers
 Safety equipment to de-activate fuel supply
 Grease baffles installed
 No solid fuel (i.e. charcoal)
Department of Engineering 2014 - 19
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18/19.3.2.5 Cooking Facilities, more specifically the
MODIFIED S&C 12-21-LSC
CATEGORICAL WAIVER NOW APPLIES:
FIREPLACES PLACEMENT MODIFIED
Conditioning more specifically the requirements
at 18/19.5.2.3(2), (3) and (4) which allow
 the installation of direct vent gas fireplaces in
smoke compartments containing patient
sleeping rooms and
 the installation of solid fuel burning fireplaces
in areas other than patient sleeping areas
Department of Engineering 2014 - 20
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 18/19.5.2 Heating, Ventilating, and Air
MODIFIED S&C 12-21-LSC
CATEGORICAL WAIVER NOW APPLIES:
COMBUSTIBLE DECORATIONS ADJUSTED
including sections 18/19.7.5.6 which allow the
installation of combustible decorations on walls,
doors and ceilings.
1. On non-fire rated doors and do not interfere with
latching or area limits at 18/19.7.5.6(b), (c), (d)
2. < 20% of wall, ceiling and door, inside a room or
space of a smoke compartment that is not
protected throughout with approved automatic
sprinkler system
Department of Engineering 2014 - 21
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 18/19.7.5 Furnishings, Mattresses, and Decorations
MODIFIED S&C 12-21-LSC
CATEGORICAL WAIVER NOW APPLIES:
COMBUSTIBLE DECORATIONS ADJUSTED
3. < 30% of wall, ceiling and door inside a room or
space of a smoke compartment that is protected
throughout by an approved supervised automatic
sprinkler system
4. < 50% of wall, ceiling and door, inside a patient
sleeping room with capacity of < 4 persons in a
smoke compartment that is protected throughout
with approved, supervised automatic sprinkler
system
Department of Engineering 2014 - 22
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 Continued:
CENTRALIZED COMPUTER SYSTEM FOR
MEDICAL GAS MASTER ALARM
edition of the Health Care Facilities Code,
and more specifically 5.1.9.2.2 which allows
a centralized computer system to be
permitted to be substituted for one of the
medical gas master alarms required at
5.1.9.2.1 if the computer system complies
with 5.1.9.4.
Department of Engineering 2014 - 23
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 101-2012 Section 2.2 refers to the 2012
ANNUAL LOAD BANK TEST REDUCED
25% SAVINGS
the requirements at 8/19.2.9.1 which refers to
7.9, which refers to NFPA 110-2010 which
includes requirements for annual load bank tests
as follows:
 30 minutes at 50% of nameplate, and
 60 minutes at 75% of nameplate
 see NFPA 110-2010 8.4.2.3
 Cost savings of 25% based on reduction of two
hour test by 25%
Department of Engineering 2014 - 24
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 18/19.2.9 Emergency Lighting, more specifically
WEEKLY CHURN NOW MONTHLY:
ELECTRIC MOTOR DRIVEN FIRE PUMP
Requirements, and more specifically the
requirements at 9.7.5 Maintenance and Testing
which refers to NFPA 25-2011. This edition of NFPA
25, the Standard for the Inspection, Testing &
Maintaining of Water-Based Fire Protection
Systems section 8.3.1.2.which requires the electric
motor driven fire pump exercise to be monthly;
 Cost savings of reducing a weekly test to monthly is
a 77% cost savings
Department of Engineering 2014 - 25
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 LSC sections 18/19.3.5 Extinguishment
WATER FLOW ALARM TEST
SEMI-ANNUALLY
specifically the requirements at 9.7.5 Maintenance
and Testing which refers to NFPA 25-2011. This
edition of NFPA 25, the Standard for the Inspection,
Testing & Maintaining of Water-Based Fire
Protection Systems section 5.3.3.2 which requires
the vane type pressure switch water flow alarm to
be tested every six months;
 Cost savings of 50% when reducing a
quarterly test to semiannual
Department of Engineering 2014 - 26
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 18/19.3.5 Extinguishment Requirements, and more
EC.02.06.05 EPS 2 & 3
Preconstruction Risk Assessment (PRA)
Construction or renovation in occupied
healthcare facilities can result in environmental
problems such as:
 Noise
 Vibration
 Creation or spread of contaminants
 Disruption of essential services
 Emergency Procedures
 Air quality
Department of Engineering 2014 - 27
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PRA
INTERIM LIFE SAFETY MEASURES
 Order of Standards (LS.01.02.01)
 EP 1 & 2 regardless of ILSM policy
including
 AFS 10 Process
 When to implement
 What to do to protect occupants
 Both construction related and noncompliance with the LSC
 EPs 4 – 14 align with policy and
implementation strategies
Department of Engineering 2014 - 28
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 EP 3 must clearly define the ILSM policy
2014
THE HEALTHCARE ENVIRONMENT
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STATEMENT OF CONDITIONS™
UPDATE
STATEMENT OF CONDITIONS™
update.
 Most of the update was to the operating system
and updating the appearance of the site
 There are no significant functional changes to the
program that affect how the organization uses
the SOC
 Management of the Statement of Conditions™ is
required for Hospitals, Critical Access Hospitals,
Behavioral Health Care , and Ambulatory Health
Care (not business) (LS.01.01.01)
Department of Engineering 2014 - 30
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 The Statement of Conditions has received an
ILSM ASSESSMENT: Y/N
 For NEW PFIS:
Y/N
 This must be answered as either Yes or No
• Yes indicates that the organization
assessed based on the ILSM policy
• No indicates that the organization has not
assessed based on the organization ILSM
policy
 The View All screen has a column that
identifies this decision.
Department of Engineering 2014 - 31
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 ILSM Assessment
ADDITIONAL FEATURES OF THE SOC
displays PFI status in a pie chart
 Filter by
 One Building
 All Buildings
 Open
 Closed
 All PFIs
Department of Engineering 2014 - 32
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 Another feature is a management tool which
ADDITIONAL FEATURES OF THE SOC
 Enhanced access to BBI or PFI
 Selecting PFI bypasses the BBI
the building
 The BBI includes the Construction Type table
from NFPA 101-2000 18/19/1.6.2 as a pop
up table

Select Cancel to return to the BBI
Department of Engineering 2014 - 33
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 The BBI may be modified if changes occur in
Department of Engineering 2014 - 34
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ENTERING THE STATEMENT OF CONDITIONS™
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BASIC BUILDING INFORMATION (BBI)
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Construction
Types
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Entering the PFI Section
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Create New
PFI :
Deficiency
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ILSM Assessment?
Department of Engineering 2014 - 40
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Create New
PFI :
Resolution
Department of Engineering 2014 - 41
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PFI View All Screen
Department of Engineering 2014 - 42
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HISTORY AUDIT TRAIL
THE HEALTHCARE ENVIRONMENT
CHANGES TO STANDARDS LANGUAGE
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2014
CHANGES TO ELEMENTS OF PERFORMANCE
 Standard EC.02.02.01

EP11: For managing hazardous materials and waste, the hospital
has the permits, licenses, manifests, and material safety data
sheets required by law and regulation
 EC.02.05.07, EP 4
Twelve times a year, at intervals of not less than 20 days and not
more than 40 days, At least monthly, the hospital tests each
emergency generator under load for at least 30 continuous
minutes. The completion dates of the tests are documented.
 EC.02.05.07, EP 6


Twelve times a year, at intervals of not less than 20 days and not
more than 40 days, At least monthly, the hospital tests all
automatic transfer switches. The completion date of the tests is
documented.
Department of Engineering 2014 - 44
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
CHANGES TO ELEMENTS OF PERFORMANCE


The emergency generator monthly tests for diesel-powered
emergency generators are conducted with a dynamic load that is at
least 30% of the nameplate rating of the generator or meets the
manufacturer’s recommended prime movers’ exhaust gas
temperature. If the hospital does not meet either the 30% of
nameplate rating or the recommended exhaust gas temperature
during any test in EC.02.05.07, EP 4, then it must test each the
emergency generator once every 12 months using supplemental
(dynamic or static) loads of 25% of nameplate rating for 30 minutes,
followed by 50% of nameplate rating for 30 minutes, followed by
75% of nameplate rating for 60 minutes, for a total of 2 continuous
hours.
Note: For non diesel-powered generators tests need only to be
conducted with available load.
Department of Engineering 2014 - 45
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 EC.02.05.07, EP 5
CHANGES TO ELEMENTS OF PERFORMANCE
 EC.02.05.07, EP 7


At least once every 36 months, hospitals with a diesel-powered
generator providing emergency power for the services listed in
EC.02.05.03, EPs 5 and 6, test each the emergency generator for a
minimum of 4 continuous hours. The completion date of the tests is
documented.
Note: For additional guidance, see NFPA 110, 2005 edition, Standard
for Emergency & Standby Power Systems.


The 36-month diesel-powered emergency generator test uses a
dynamic or static load that is at least 30% of the nameplate rating of
the generator or meets the manufacturer’s recommended prime
movers' exhaust gas temperature.
Note: For non diesel-powered generators tests need only to be
conducted with available load.
Department of Engineering 2014 - 46
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 EC.02.05.07, EP 8
The Joint Commission EC chapter defines time as:
 Daily, weekly, monthly are calendar references
 Quarterly will be once every three months +/- 10 days
January 1, 2014
 Semi-annual is 6 months from the last scheduled event
month +/- 20 days
 Annual is 12 months from the last scheduled event
month +/- 30 days
 3 years is 36 months from the last scheduled event
month +/- 45 days
NOTE 1: The above does not apply to required frequencies
NOTE 2: An alternative of developing either a unique, written policy or adopting
NFPA definitions when available is acceptable
Department of Engineering 2014 - 47
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TIME RE-DEFINED
QUARTERLY: +/- 10 DAYS
SEMIANNUAL: +/- 20 DAYS
ANNUAL: +/- 30 DAYS
10
20
Scheduled
Month
Due
Date
+
10
10
20
20
30
30
Quarterly
Jan
Semiannual
June
Annual
Jan
Aug
Sept
March
Apr
Oct
Dec
Nov
F M A M J J A S O N
10
20
30
30
February
July
Scheduled
Month
+
D
Jan
Frequencies required by Code may not be modified
(e.g. EC.02.05.07 EP 4 & 7)
Department of Engineering 2014 - 48
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Due
Date
CHANGES TO ELEMENTS OF PERFORMANCE
EFFECTIVE 7/1/2014
 Replaced “At 30 day intervals…”
Department of Engineering 2014 - 49
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EC.02.05.07, EP 1
At least monthly, the hospital performs a
functional test of battery-powered lights
required for egress for a minimum duration
of 30 seconds. The completion date of the
tests is documented.
 Replaced: “…the buildings fire alarm system.”
Department of Engineering 2014 - 50
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CHANGES TO ELEMENTS OF PERFORMANCE
EFFECTIVE 7/1/2014
EC.02.03.03, EP 4
Staff who work in buildings where patients are
housed or treated participate in drills according
to the hospital’s fire response plan.
Note: When drills are conducted between 9:00
p.m. and 6:00 a.m., the hospital may use
alternative methods to notify staff instead of
activating audible alarms.
CHANGES TO ELEMENTS OF PERFORMANCE
EFFECTIVE 7/1/2014
 EC.02.03.03, EP 3
 When quarterly fire drills are required, at
 Added: “Fire drills are held at unexpected
times and under varying conditions.”
Department of Engineering 2014 - 51
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least 50% are unannounced. Fire drills are
held at unexpected times and under
varying conditions.
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MAINTENANCE STRATEGIES TO
MAXIMIZE RESOURCES &
ENHANCE QUALITY
The hospital maintains a written inventory of all operating
components of utility systems or maintains a written
inventory of selected operating components of utility
systems based on risks for infection, occupant needs,
and systems critical to patient care (including all lifesupport systems).
The hospital evaluates new types of utility components
before initial use to determine whether they should be
included in the inventory.
(See also EC.02.05.05, EPs 1, 3-5)
Department of Engineering 2014 - 53
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EC.02.05.01 EP 2
EC.02.05.01 EP 3
The hospital identifies, in writing, inspection and maintenance
activities for all operating components of utility systems on
the inventory.
Note: Hospitals may use different approaches to maintenance.
For example, activities such as predictive maintenance,
reliability- centered maintenance, interval-based
maintenance, corrective maintenance, or metered
maintenance may be selected to ensure dependable
performance.
Department of Engineering 2014 - 54
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(See also EC.02.05.05, EPs 3 - 5; EC.02.05.09, EP 1)
EC.02.05.01 EP 4
 The hospital identifies, in writing, the intervals for
(See also EC.02.05.05, EPs 3-5)
Department of Engineering 2014 - 55
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inspecting, testing, and maintaining all operating
components of the utility systems on the inventory,
based on criteria such as
 Manufacturer‘s recommendations
 Risk levels
 hospital experience
Documentation is completed for both life support and non-life
support devices on the inventory
 Accuracy of Inventory
 All Life Support equipment must be on the inventory
 Preventive maintenance frequencies must be clearly
defined in writing
 Confirm work done as per scheduled activities
 Ensure appropriate work is scheduled based on
maintenance strategies
 Evaluate equipment failure and scheduled actions
Department of Engineering 2014 - 56
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EQUIPMENT SURVEY PROCESS
SURVEY PROCESS: STAFF INTERVIEWS
 Department Leader
Establish how the inventory was created
 Establish the Maintenance Strategies used
 Evaluate the Monitoring processes
 Evaluate the effectiveness of the program

 Equipment Maintainers
Evaluate their understanding of the maintenance
process/strategies
 Evaluate competencies based on repeat work orders
 Evaluate work scheduled against completed
Department of Engineering 2014 - 57
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
SURVEY PROCESS: STAFF INTERVIEW
 Users of the Equipment
Evaluate equipment reliability
 Evaluate response time when equipment fails
 Evaluate emergency response process
 Evaluate “Culture of Safety”
 Appropriate training of staff related to equipment use
 Customer satisfaction with department
 Contract Services
Evaluate reliability of equipment serviced
 Evaluate integration of the process

Department of Engineering 2014 - 58
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
CMS ISSUE
manufacturers’ recommendations, Life Safety Code
adoption and other issues
 CMS has indicated that The Joint Commission may
continue to use their current process for
equipment and utilities management
 State agents will not be so instructed
 ASHE & AAMI met with CMS to continue to discuss
the concerns related to equipment management
 Responded by clarifying several issues
Department of Engineering 2014 - 59
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 Joint Commission met with CMS and discussed
S&C 14-07-HOSPITAL

A hospital may adjust its maintenance, inspection, and testing
frequency and activities for facility and medical equipment
from what is recommended by the manufacturer, based on a
risk-based assessment by qualified personnel, unless:
 Other Federal or state law; or hospital Conditions of
Participation (CoPs) require adherence to manufacturer’s
recommendations and/or set specific requirements.
• For example, all imaging/radiologic equipment must be
maintained per manufacturer’s recommendations; or
 The equipment is a medical laser device; or
 New equipment without a sufficient amount of maintenance
history has been acquired.
Department of Engineering 2014 - 60
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 S&C 12-07-Hospital Superceded
S&C 14-07-HOSPITAL
medical equipment or operating components of utility
systems in accordance with manufacturers’
recommendations with insufficient maintenance history
to support the use of alternative maintenance
strategies.
 Maintenance history may be gathered from
documented evidence such as
 Provided by the organizations contractors
 Available publically from nationally recognized
sources
 Through the organizations experience over time
Department of Engineering 2014 - 61
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 The organization inspects, tests & maintains New
24. For [organizations] that use Joint Commission accreditation for
deemed status purposes: The [organization] inspects, tests, and
maintains the following in accordance with manufacturers’
recommendations (See also EC.02.04.01, EPs 3 and 4):
 Medical lasers
 Imaging and radiologic equipment (whether used for diagnostic or
therapeutic purposes)
 New medical equipment with insufficient maintenance history to
support the use of alternative maintenance strategies.
Note: Maintenance history may be gathered from documented
evidence
 provided by the [organization’s] contractors
 available publically from nationally recognized sources, or
 through the [organization’s] experience over time
Department of Engineering 2014 - 62
© Copyright, The Joint Commission
EC.02.04.03 EP 24 (EFFECTIVE 7/1/2014)
6. For [organizations] that use Joint Commission accreditation
for deemed status purposes: The [organization] inspects,
tests, and maintains new operating components of utility
systems in accordance with manufacturers’ recommendations
with insufficient maintenance history to support the use of
alternative maintenance strategies.
Note: Maintenance history may be gathered from documented
evidence:
 provided by the [organization’s] contractors
 available publically from nationally recognized sources
or
 through the [organization’s] experience over time
Department of Engineering 2014 - 63
© Copyright, The Joint Commission
EC.02.05.05 EP 6 (EFFECTIVE 7/1/2014)
S&C 14-07-HOSPITAL:
EVALUATING PROGRAM EFFECTIVENESS
written policies & procedures
 Evaluating the program:
 How is equipment evaluated to ensure no
degradation of performance?
 How are equipment-related incidents investigated?
 How to sequester equipment deemed unsafe?
 Is there a performance process to evaluate if
modifications to the maintenance strategy is
needed?
Department of Engineering 2014 - 64
© Copyright, The Joint Commission
 The equipment management programs must have
S&C 14-07-HOSPITAL:
SURVEY STRATEGIES
 Evaluate the accuracy of the inventory
Are imaging/radiologic equipment and medical laser devices
exempt from the alternative maintenance program?
Verify the inspection, testing & maintaining activities and
frequencies are documented
Evaluate the process for equipment being maintained, including
qualified personnel
Ask staff questions related to the alternative maintenance
program
 Equipment inclusion process
 Assignment of maintenance strategies and frequencies
Verify evaluation of the program is occurring and being reported




Department of Engineering 2014 - 65
© Copyright, The Joint Commission

© Copyright, The Joint Commission
CLINICAL ALARMS AND
SURGICAL SITE FIRES
© Copyright, The Joint Commission
Department of Engineering 2014 - 67
THE ALARMING PROBLEM
 More and more devices and alarms
alarm-based devices
 150-400+ alarms per patient per day in a
typical critical care unit
 Alarm-based devices are not standardized
in many organizations
 Inconsistent use of alarms due to flexible
alarm setting features
Department of Engineering 2014 - 68
© Copyright, The Joint Commission
 More patients connected to alarms or
© Copyright, The Joint Commission
Department of Engineering 2014 - 69
© Copyright, The Joint Commission
Department of Engineering 2014 - 70
© Copyright, The Joint Commission
Department of Engineering 2014 - 71
Department of Engineering 2014 - 72
© Copyright, The Joint Commission
NATIONAL PATIENT SAFETY GOAL
NPSG ON ALARM MGMT
 In Phase I (beginning January 2014)
Hospitals will be required to:
on their own internal situations.
 Input from medical staff and clinical depts
 Risk to patients due to lack of response,
malfunction
 Are specific alarms needed or contributing to
noise/fatigue
 Potential for patient harm based on internal
incident history
 Published best practices/guidelines
Department of Engineering 2014 - 73
© Copyright, The Joint Commission
 establish alarms as an organization priority and
 identify the most important alarms to manage based
NPSG ON ALARM MGMT
 In Phase II (beginning January 2016)
Hospitals will be expected to:
policies and procedures that address at minimum:
 Clinically appropriate settings
 When they can be disabled
 When parameters can be changed
 Who can set and who can change parameters and
who can set to “off”
 Monitoring and response expectations
 Checking individual alarm signals for accurate
settings, proper operation and detectability
 educate those in the organization about alarm system
management for which they are responsible
Department of Engineering 2014 - 74
© Copyright, The Joint Commission
 develop and implement specific components of
Department of Engineering 2014 - 75
© Copyright, The Joint Commission
RESOURCES
© Copyright, The Joint Commission
Department of Engineering 2014 - 76
OTHER RESOURCES
http://www.aami.org/htsi/alarms/index.html
 ECRI website page on Alarm Management resources:
https://www.ecri.org/Forms/Pages/Alarm_Safety_Resou
rce.aspx
 Pennsylvania Patient Safety Authority:
http://patientsafetyauthority.org/ADVISORIES/AdvisoryLi
brary/2011/sep8(3)/Pages/105.aspx (physiologic alarm
management)
 Healthcare Technology Foundation:
http://thehtf.org/clinical.asp (national clinical alarm
survey)
Department of Engineering 2014 - 77
© Copyright, The Joint Commission
 AAMI website page on Clinical Alarms:
SURGICAL SITE FIRES
 >50 million hospital & ASC surgeries
 Estimated 550 – 650 surgery fires per year
30 Serious
 Multiple fire related deaths annually
 Fire sites:
 34% airway
 28% head/face
 38% other
Department of Engineering 2014 - 78
© Copyright, The Joint Commission

SURGICAL SITE FIRES
 74% occurred in
oxygen enriched
environment


68% electrosurgical
equipment
13% lasers
Department of Engineering 2014 - 79
© Copyright, The Joint Commission
 Ignition Source:
RECOMMENDATIONS
 Recommendations:
prevent surgical site fires)
 Review alarm procedures
 Review rescue techniques
 Review shut off locations
 Joint Commission response:
 Life Safety Code Surveyors gown and survey
Department of Engineering 2014 - 80
© Copyright, The Joint Commission
 Fire drills & Staff Education (including how to
DEPARTMENT OF ENGINEERING
630 792 5900
George Mills, MBA, FASHE, CEM, CHFM, CHSP, Green Belt
Director
Anne Guglielmo, CFPS, LEED, A.P., CHSP
Engineer
John Maurer, CHFM, CHSP, SASHE
Kathy Tolomeo,
CHEM
Engineer
James Woodson, P.E., CHFM
Engineer
Department of Engineering 2014 - 81
© Copyright, The Joint Commission
Engineer
THE JOINT COMMISSION DISCLAIMER
reserves the right to change the content of the information, as
appropriate.
 These slides are only meant to be cue points, which were
expounded upon verbally by the original presenter and are not
meant to be comprehensive statements of standards
interpretation or represent all the content of the presentation.
Thus, care should be exercised in interpreting Joint
Commission requirements based solely on the content of these
slides.
 These slides are copyrighted and may not be further used,
shared or distributed without permission of the original
presenter or The Joint Commission.
Department of Engineering 2014 - 82
© Copyright, The Joint Commission
 These slides are current as of 5/1/2014. The Joint Commission

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