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With the Joint Commission’s DireCtor of engineering: george mills
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Most-Cited EC/LS Hospital Standards | ||
Standard | First half 2014 % Noncompliance | 2013 % Noncompliance |
EC.02.05.01 | 53% | 47% |
LS.02.01.20 | 52% | 52% |
EC.02.06.01 | 51% | 39% |
EC.02.03.05 | 50% | 45% |
LS.02.01.10 | 49% | 48% |
LS.02.01.30 | 46% | 45% |
LS.02.01.35 | 44% | 36% |
EC.02.02.01 | 36% | 34% |
which organizations struggle is nearly identical from year to year, although the order differs slightly. Once again, several En- vironment of Care (EC) and Life Safety (LS) LS standards made the list (see, “Most-Cited EC/LS Hospital Standards,” right).
Similar issues face health care organizations in all accreditation programs. For instance, according to scoring trends, organiza- tions are still wrestling with how to reliably sustain proper venti- lation in high-risk areas, eliminate corridor clutter, and maintain
fire safety equipment to name a few.
The reality is that most people in health care know what they need to do; they don’t need a repeat of the tips and strategies shared so many times before. But consistently doing the work and documenting it is what many find challenging. Compliance starts with accountability and transparency, from the process owner to the facility manager to senior leadership. A robust dashboard reporting process can be used to introduce account- ability for ensuring compliance with the EC and LS standards.
The Joint Commission EC standards require this kind of accountability and documentation, via, among other things,
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These standards are often repeat offenders for noncompliance.
EC Dashboard Keeps Compliance Front and Center
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an annual evaluation of the effectiveness of EC components (EC.04.01.01, EP 15). Using a dashboard is one option for collecting data (EC.04.01.01), analyz- ing data (EC.04.01.03), and providing regular reports to an EC committee
that are understandable and actionable (EC.04.01.05, EP 3). To tackle this problem head on, organizations should consider taking a more strategic approach to ensuring compliance, which keeps the work active and on top of the “to-do” pile. Please note: Using a dashboard will not influence survey results. This article simply presents one as a way to intro- duce transparency, accountability, and long-lasting compliance in these EC and LS areas.
What is a dashboard? Inspired by a car’s instrument panel, a dashboard is a management tool that provides a real-time snapshot of per-
formance, helping users quickly see the status of current work and areas that require attention. At its most basic level, a dashboard is a report that shows an organization’s progress toward a goal and points toward the necessary next steps.
Continuing the analogy, although a mechanic (or process owner) needs to know what’s happening under the hood with each individual system, the driver (or senior leadership) only monitors the gauges and indicator lights on the
dashboard. A car dashboard displays key performance indicators (KPIs) such as the speedometer, fuel gauge, oil pressure, and engine temperature. Careful mon- itoring of these KPIs ensures successful motoring. Similar KPIs in business, clinical, and environmental areas can
be monitored to ensure success in these areas. For example, in the care environ- ment, KPIs include barrier integrity, egress reliability, and air exchange and pressure differentials.
Although dashboard reports can
be quite complex (such as featuring four-color graphics to illustrate the current state), they do not have to be. Dashboards can be easy to understand and easy to update and still provide all the information a reader would need.
Organizations can even create these tools internally, using word processing or spreadsheet software. EC professionals shouldn’t overlook the resources they already have. Many organizations use clinical dashboarding to meet CMS requirements, and clinical colleagues can be a great resource in adapting a dash- board to help monitor and maintain a successful environment.
Using a dashboard to address EC and LS risks
This article features a dashboard, sup- ported by two worksheets, that EC pro- fessionals can adapt to help their organi- zation monitor current, real-time activity in their environment.
Standards Analysis Worksheet
The Standards Analysis Worksheet is a tool that can be used to capture the compliance status of the elements of performance (EPs) that are included in
the desired dashboard. The worksheet is flexible and could be used to overview the entire EC and LS chapters, monitor the top 10 Joint Commission compliance issues, or focus on the organization’s spe- cific Requirements for Improvement. (See page 5 for a snapshot of this worksheet; the entire completed tool can be found
at https://www.jcrinc.com/assets /1/7/ ECN0215_dash_completed.xls, and a blank tool is available at https://www. jcrinc.com/assets/1/7/ECN0215_dash_ blank.xls.)
For EPs that require a simple yes/no response, this worksheet is sufficient; for more complex EPs that require data analysis, the In-depth Data Analysis Worksheet also needs to be completed.
In-depth Data Analysis Worksheet
This tool can be used to capture data
Writable Dashboard Forms Available
The sample worksheets and dashboard presented in this article are available at https://www.jcrinc. com/assets/1/7/ECN0215_dash_ completed.xls. They are also available as blank forms, which the user can populate with organization-specific data. These are provided with the hope that using them will result in improved patient safety and reduced findings during your organization’s survey. You can access these writable forms at https://www.jcrinc.com/ assets/1/7/ECN0215_dash_blank.xls.
for multiple-issue, data-driven EPs, which require detailed analysis before determining compliance status. The re- sults from this worksheet are fed into the Standards Analysis Worksheet to prepare data for the dashboard. (See page 6 for
a snapshot of this worksheet; the entire completed tool can be found at https:// www.jcrinc.com/assets /1/7/ECN0215_ dash_completed.xls, and a blank tool
at https://www.jcrinc.com/assets/1/7/ ECN0215_dash_blank.xls.)
KPI Summary Dashboard
The KPI Summary Dashboard pro- vides an overview of the KPIs for the EPs the organization has chosen to include
in the analysis. (See page 6 for a snapshot of this dashboard; the entire completed dashboard can be found at https://www. jcrinc.com/assets /1/7/ECN0215_dash_ completed.xls, and a blank dashboard
at https://www.jcrinc.com/assets/1/7/ ECN0215_dash_blank.xls .)
The next sections of this article explain each of these tools in more detail.
Simple standards analysis
EC professionals can use the Standards Analysis Worksheet to perform an active compliance assessment of all EPs within a single standard. This evaluation is usu- ally done by the process owner who is
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EC Dashboard Keeps Compliance Front and Center
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familiar with the EP requirements. As staff members examine the various
EPs within the standard, they will find those that comprise single issues, mul- tiple issues, or data-driven issues. Most EPs address a single issue; for example, EC.02.03.01, EP 9, states “the hospital has a written fire response plan.” Either an organization has a written fire re- sponse plan or it does not. This is a sim- ple yes/no or pass/fail analysis. For these single-issue EPs, the Standards Analysis Worksheet can quickly record the com- pliance status, keeping noncompliant EPs at the forefront until the organiza- tion achieves compliance.
Other EPs may have a simple yes/no response but represent multiple issues. For example, EC.02.05.01, EP 9, states “the hospital has written procedures for responding to utility system disruptions.” Although this is a yes/no question (either an organization has the written proce- dures or it does not), it encompasses many factors, such as electricity, gas, air, and so forth. So, the worksheet should display each utility system separately to confirm that each is represented with a pass/fail status. Though this is not data driven, it does require more than a single yes/no response.
The need for in-depth data analysis
Some EPs have multiple requirements that would have more than one measur- able factor or that are data driven. For
Building Your Own Environmental Dashboard
► Step 1. Identify the scope of your monitoring project. It could be a single standard, your most recent Requirements for Improvement, the top 10 Joint Commission compliance issues, or the entire Environment of Care (EC) or Life Safety (LS) chapter.
► Step 2. Build your Standards Assessment Worksheet(s). For each standard within the scope of your monitoring project, create an individual worksheet. All of the standards can be included in a single file, with individual tabs for each standard, or each standard could be in a standalone file. Starter files (and directions) are available online at https://www.jcrinc.com/assets/1/7/ECN0215_ dash_blank.xls.
Be sure to include on each worksheet the standard number and language, each element of performance (EP), and compliance results. For multiple-issue EPs, you can list the individual factors that require a compliance assessment, such as each utility system that requires a written procedure for responding to a disruption.
You should note on your Standards Assessment Worksheet which EPs require an additional In-depth Data Analysis Worksheet(s) to capture the data used to determine compliance status.
► Step 3. Build your In-depth Data Analysis Worksheet(s). Each In-depth Data Analysis Worksheet will be different because each EP requires unique
assessment. Be sure to include what you are analyzing, the frequency of analysis, and other appropriate factors. In some cases, a single EP might require more than one In-depth Analysis Worksheet (for example, air pressure relationships,
air-exchange rates, and filtration efficiencies from EC.02.05.01, EP 15).
► Step 4. Update the Standards Analysis Worksheet. The Standards Analysis Worksheet should include the summary data for all EPs in the standard, including those that needed an In-depth Data Analysis Worksheet. Once each EP in
a particular standard is scored, determine your overall compliance with that standard.
► Step 5. Populate the KPI Summary Dashboard. Build your dashboard with the overall compliance information identified in your Standards Analysis Worksheets. The dashboard should list each standard included in the monitoring project for leadership’s review. Consider using line graphs or pie charts to provide an at-a- glance summary of the compliance status of each standard, and clearly label each entry.
► Step 6. Monitor compliance and stay accountable. With the worksheets, process owners will have the tools they need to improve how they monitor the environment and the information they need to approach improvements. With the dashboard, leaders can efficiently monitor key indicators of environmental compliance and be prepared to implement needed improvements.
example, Standard LS.02.01.10, EP 5, states:
Doors required to be fire rated have
functioning hardware, including positive latching devices and self-closing or au- tomatic-closing devices. Gaps between meeting edges of door pairs are no more than 1/8 inch wide, and undercuts are no larger than ¾ inch.
For these multiple-issue EPs that are data driven and require measurement, a separate, detailed analysis would be
conducted for each factor. The In-depth Data Analysis Worksheet provides a practical way to organize and calculate the organization’s performance on the in- dividual factors in the EP that ultimately drive overall compliance with the EP.
Summarizing data in a dashboard
Whereas a standard defines the perfor- mance expectations and/or structures or
processes that must be in place, the stan- dard’s EPs detail those expectations and/ or structures or processes. EPs are scored and determine an organization’s overall compliance with a standard. Once each EP is scored in the worksheet, EC profes- sionals can determine their organization’s overall compliance with the standard— which is the information that feeds the KPI Summary Dashboard.
The standards-level information from
Figure 1. Standards Analysis Worksheet
Standards Analysis Worksheet Example—EC.02.05.01
process for Standard EC.02.05.01 would be to populate the Standards Analysis Worksheet with the standard’s 16 EPs and begin rating compliance (see Figure 1, left).
For many of the EPs, compliance can be quickly rated as pass/fail. For example, EP 9 has multiple issues, but they can quickly be answered as pass/fail. How- ever, EP 15 presents a more complex compliance question and requires that the ventilation system in areas designed to control airborne contaminants provide appropriate pressure relationships, air-ex- change rates, and filtration efficiencies.
This EP requires staff to rate multiple factors and requires that data on those factors accurately score compliance.
The three main factors of EP 15 include appropriate pressure relationships, air exchanges, and filtration. An In-depth
the Standards Analysis Worksheet popu- lates the KPI Summary Dashboard. This high-level summary is similar to a score card in that it only indicates whether the organization is compliant with each standard. The intent is to display for the organization’s leadership a global view of
EC and LS compliance. For example, the dashboard may list the top 10 standards identified as noncompliant nationally and display the organization’s own level of compliance for any of them that are related to EC and LS.
Specific noncompliant EPs identified in the Standard Analysis and In-depth Data Analysis Worksheets should be assigned for correction to the process owner (for example, a contractor for life safety, the mechanic who services the HVAC system, or the nursing supervisor who ensures that corridors are kept un- obstructed). This process owner should keep the worksheet and the resultant dashboard on his or her desk and should refer to it frequently to make sure com- pliance is being achieved or maintained.
Periodically, the process owner should report to organization leaders on the trended status shown by the individual standards worksheets. As performance
on each EP is brought into compliance, the KPI Summary Dashboard can be up- dated. Doing this keeps the organization leaders aware of successes and improve- ments. Ongoing monitoring may be required to ensure sustained compliance.
Everyday attention to compliance data can drive ultimate and lasting change.
Knowledge of exactly what is causing noncompliance allows a team to identify targeted actions and long-lasting solu- tions. For example, if the nurse supervi- sor identifies a chronic issue with medical equipment storage on one unit, it may highlight the need to create more storage on that unit.
A dashboarding example
To help readers better understand the dashboarding process, this article looks at a specific example using Standard EC.02.05.01 (“the organization manages risks associated with its utility systems”). Historically, this has been a challeng-
ing standard for all organizations. See https://www.jcrinc.com/assets/1/7/ ECN0215_dash_blank.xls for simple instructions about using the worksheets and dashboard.
The first step in the dashboarding
Data Analysis Worksheet would be created for each factor. This example follows only the appropriate pressure relationships issue; in practice, similar in-depth analysis should also occur for air exchanges and filtration.
The organization designs an In-depth Data Analysis Worksheet to capture data on areas served by each specific
air handling unit (AHU) and whether appropriate pressure relationships are being maintained. The data used in the worksheet (as shown in the example in Figure 2, page 6) include the following information:
Each AHU (shown in column A) and the specific operating rooms, critical care units, corridors, storage areas, isolation rooms, patient rooms, and other areas supplied under the unit (column B)
Compliance measurements at scheduled intervals that roll up to a quarterly percentage (columns C and D for Quarter 1, for example) and then feed an overall compliance rate (column Q)
The process owner—in this case facility engineering staff—would measure
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EC Dashboard Keeps Compliance Front and Center
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air-pressure relationships at every access point to that room and note whether the measurement is in or out of target.
Identifying the appropriate mea- surement frequency depends on several factors that EC professionals will need to identify. Once they have identified mea- surement frequencies and the target rate, they need to capture data and identify whether the data fall within acceptable limits. If measurements fall outside acceptable limits, EC professionals
need to document it, make repairs and adjustments, and continue monitoring. In the example shown in Figure 1, recent monitoring of the ventilation system revealed an unacceptable 73.14% com- pliance rate (row 27, column Q), which moves EP 15 to a high-risk category of noncompliance.
The overall compliance of EP 15 is then transferred as noncompliant to the In-depth Data Analysis Work-
sheet, which informs the KPI Summary Dashboard. Leadership is apprised of the noncompliance by the dashboard, which identifies EC.02.05.01 as one of the top 10 national standards being monitored and shows that the organization is out of compliance with this standard (see Figure 3, right).
The process owners responsible for the noncompliant EP begin taking corrective actions. They report the compliance sta- tus, if appropriate, via an In-depth Data Analysis Worksheet. Once corrective actions have produced an acceptable rate of compliance, the EP’s status is changed to compliant on each worksheet, and the dashboard is updated.
The next step is to determine how the compliance will be monitored to ensure ongoing consistency. The monitoring system should be designed with need, ex-
Figure 2. In-depth Data Analysis Worksheet
In-depth Data Analysis Worksheet Example—EC.02.05.01, EP 15
Figure 3. KPI Summary Dashboard
KPI Summary Dashboard Example
perience, and frequency in mind. In this example, this AHU and its affected areas will be closely monitored until a trend of compliance is established.
Accountability
Accountability is critical to successful dashboarding. If monitoring efforts are embedded into the workflow, staff
members know what they are responsible for checking and how often it should
be done. An organization may find that
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EC Dashboard Keeps Compliance Front and Center
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empowering staff to manage correc- tive actions identified as KPIs in their dashboards (as informed by a Standards Analysis or In-Depth Data Analysis
Worksheet) strengthens both the culture of safety and the support of the correc- tive actions.
Leadership plays a role in account- ability, too. Compliance with EC and LS standards has a direct impact on patient safety, which is the underlying responsibility of leadership at a health care organization (per Leadership [LD] standard LD.03.01.01). At a minimum,
leadership should be monitoring the KPI Summary Dashboard and holding staff accountable for identifying and correct-
ing noncompliance.
Those standards recognized as noncompliant should have a transpar- ent reporting mechanism that displays exactly what expectation, process, or structure is noncompliant. The status of these standards and EPs must be reported to the EC committee (or equivalent), as described in standards EC.04.01.01 to EC.04.01.05. Incorporating the dash- board into the EC Committee reporting structure will help ensure that the issues are front and center, which helps increase overall compliance.
The Joint Commission does not re- quire organizations to create and main- tain dashboards to help with compliance. However, a dashboard report can be a beneficial tool, especially if your orga- nization is grappling with how to keep
track of various compliance risks. To get started, an organization may not be
able to build quarterly reports, but it can start with weekly or monthly reports. EC
Environment of Care® News publishes the column Clarifications and Expecta- tions, authored by George Mills, MBA, FASHE, CEM, CHFM, CHSP, director,
Department of Engineering, The Joint Commission, to clarify environment of care, emergency management, and life safety standards expectations and provide strategies for challenging compliance issues.
The sample worksheets and dashboard in this month’s column were created in
collaboration with Kathy Tolomeo, CHEP, engineer, Department of Engineering, The Joint Commission.