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• PR: Clarifications and Expectations: Comprehensive Documentation Demonstrates a Safe Environment[REF: EOC, E&M, JCSC, JCCAP, SFT] Perspectives October 2012, Vol 32, # 1, Pg 8 [®]
EC.02.03.05 requires six elements of documentation (i.e., name, date, frequency and result of activity along with some contact information and NFPA standard references) for 20 specific tests. Page 10 contains a useful sidebar listing these. TJC reports that “40% of all Joint Commission hospital surveys completed in 2011 and in the first half of 2012 had findings at Standard EC.02.03.05 specifically related to lack of documentation”. In that context, this article focuses on select standards to include:
- Re: EC.01.01.01 – The six written management plans may be individual or consolidated and hospitals may have a master plan with modifications for off-site programs. The plan may be written as a ‘high-level’ description with references to more/needed detail in other documents.
- Re: EC.02.03.01-.05 The critique (“active assessment of staff, equipment, and building features during a real or simulated fire situation” ) and evaluation (review of critiques to determine effectiveness ) of fire drills must be documented.
- RE: EC.04.01.01 -.05 – Issues identified through environment of care monitoring (e.g., environmental rounds) should be documented.
- Re: Emergency Management – There must be a written Emergency Operations Plan (EOP) that addresses the six functional areas of emergency management (communications, resources and assets, safety and security, staff, utilities, and patients). A hazard vulnerability analysis (HVA) and an annual review must also be documented along with critique and evaluation of two emergency exercises per year.
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