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With the Joint Commission’s DireCtor of engineering: george mills

Got Standards Compliance Troubles? Proceed to the Portal

New Physical Environment Portal provides online resources to help with challenging standards


Environment of Care® News publishes the column Clarifications and Expectations, authored by George Mills, MBA, FASHE, CEM, CHFM, CHSP, director, Depart- ment of Engineering, The Joint Commis- sion, to clarify standards expectations and provide compliance strategies.


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t the conclusion of the classic film Casablanca, Captain Renault, portrayed by actor

Claude Rains, utters the famous line, “Round up the usual suspects.” If you were to ask The Joint Commission for its list of usual suspects—meaning the most challenging Life Safety (LS) and Environment of Care (EC) standards— 8 particular standards, along with related

25 elements of performance (EPs), would continually pop up. Dominating the

list of findings for all hospital surveys during the past five years, these 8 remain in the top 20 routinely cited standards, and pose a serious threat to the health and safety of patients, staff, and visitors within health care organizations. Also, they apparently create vexing challenges to facilities personnel and administrators.

To appreciate the severity of non­ compliance, consider the repercussions of the standard most frequently cited by hospital surveyors: EC.02.05.01: The hospital manages risks associated with its utility systems.

The inability of some aging venti­ lation systems to operate as expected, for example, could result in airborne contaminants that lead to health care–

associated infections (HAIs) and harm to patients. Consider that US hospital patients acquire an estimated 722,000 HAIs each year, according to the US Centers for Disease Control and Pre­ vention1; that equates to approximately 1 infection for every 25 patients.1

Seeing the same standards appear on surveys year after year can be frustrat­ ing. Contributing to the problem, we’ve learned, are gaps in education among facilities managers and leadership’s failure to ask facilities teams the right questions.


New site stresses safety

Now, The Joint Commission has created a powerful new weapon to combat these problem areas and reduce the incidence of noncompliance associated with them. It’s called the Joint Commission Physical Environment Portal (JCPEP), available at www.jointcommission.org/JCPEP. The portal serves as a valuable online repos­ itory of information and tools designed to better educate hospitals and health care facilities about requirements and compliance related to these standards.

The portal’s goal is to improve safety by stressing best practices in the patient care milieu and encourage leaders to build high reliability organizations. Using videos, charts, case studies, assessments, graphics, articles, and links, the site serves as a definitive resource that facili­ ties managers, hospital leaders, clinicians, and quality coordinators can turn to for solutions to the most common trouble spots within the physical environment.

Best of all, it’s completely free and open to any visitor who needs this information (though Joint Commission– accredited organizations have exclusive access to additional resources, including surveyor comments).

To help with this initiative, The Joint Commission has joined forces with

the American Society for Healthcare Engineering (ASHE), which brings to the project a wealth of knowledge, best practices from its 6,000 members, and unique relationships with vendors and suppliers. ASHE Executive Director Dale Woodin and his team have proven to be indispensable partners in the creation and evolution of the portal. I’m also proud to appear with Dale as hosts in a series of videos called “Fireside Chats” intended to walk the user through differ­ ent topics and standards.


Module modus operandi

The portal has been structured to include eight different educational modules.

Each module represents the eight afore­ mentioned standards, with a new module examined every two months. The portal provides links to ASHE’s “Focus on Compliance” site, and provides many resources for each corresponding mod­ ule. The first month of the module is geared to facilities managers by empha­ sizing what the requirements are and what compliance should be. The second month of the module concentrates on re­ sources for leadership to aid in evaluating the organization’s level of compliance,


and provides a discussion on clinical impact. The module schedule and corre­ sponding topics are as follows:

Utility Systems

EC.02.05.01 (Aug/Sept 2015)


General Requirements

LS.02.01.10 (April/May 2016)

Means of Egress

LS.02.01.20 (Oct/Nov 2015)


LS Protection

LS.02.01.30 (June/July 2016)

Built Environment

EC.02.06.01 (Dec/Jan 2015/16)


Automatic Suppression Systems

LS.02.01.35 (Aug/Sept 2016)

Fire Protection

EC.02.03.05 (Feb/March 2016)


Haz Mat/Waste Management

EC.02.02.01 (Oct/Nov 2016)

services provided, and maintaining ventilation, temperature, and humid­ ity (51% noncompliance rate).


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* Life Safety Code® is a registered trademark of the National Fire Protection Association, Quincy, MA.

EC.02.02.01, EPs 5 and 7: Focusing on minimizing risks associated with selecting, handling, storing, transport­ ing, using, and disposing hazardous chemicals and selecting and using hazardous energy sources (36% non­ compliance rate).

Although the 16­month series of eight modules will conclude by Decem­ ber 2016, all portal content, including the modules, will remain accessible and

available to users indefinitely. The portal’s effectiveness will be evaluated over time, with the possibility of new modules being added in the future.


High hopes for higher reliability

This portal serves as the realization of a goal shared by myself and several key players, including Joint Commission President and CEO Mark R. Chassin,

MD, who said it was created in response

(continued on page 11)



to customer needs identified through 10 focus groups comprised of surveyors and accredited organizations. So far, it’s been a big hit: The portal has benefited from a robust rollout that yielded over 7,000

unique visitors within the first two weeks after launching on July 14 at the ASHE Annual Conference.

During that period, the portal home page ranked number eight among

the top 10 pages viewed on the Joint Commission website. A strong commu­


social media posts will be issued.

As with any tool, the portal’s useful­ ness will depend on the effort, deter­ mination and diligence of its users.

Alongside ASHE, we are going to do our part in creating, posting and pro­ moting the information and resources you need; we hope you’ll do your part by visiting the portal regularly, accessing the modules, applying the best practices you learn from them, and sharing the knowledge and web addresses with peers and supervisors.

Ultimately, we all need to be concerned about patient safety and


we can increase compliance and better safeguard patients. It is my hope that, when we evaluate the portal and gauge its effectiveness next year, we will see a significant decrease in non­compliance rates, indicating higher reliability among health care organizations.

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By the way, you may recall that the cele­ brated last line of dialogue in Casablanca, uttered by Rick (Humphrey Bogart): “I think this is the beginning of a beautiful friendship.” Thanks to the support of ASHE and the healthy initial interest in our portal among engaged health care professionals, I feel the same way. EC

nications campaign has also included the

protecting the built environment. By rec­

issuing of a news release, a social media announcement via Facebook, Twitter, and LinkedIn, the creation of a help­ ful infographic and a Joint Commission Online article, and several posts that have appeared more than 11,000 times, directly reaching thousands of people. As each new module is released, new

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Visit the portal at www.jointcommission.org/JCPEP

ognizing problem areas within The Joint Commission’s Environment of Care, Life Safety, and Emergency Management standards, and understanding why and how these three areas work together,

Reference

1. US Centers for Disease Control and Preven­ tion. Hand Hygiene in Healthcare Settings: Hand Hygiene Basics. (Updated: May 1, 2014.) Accessed Oct 29, 2015. http://www

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.cdc.gov/handhygiene/Basics.html.