Your Key to Understanding EC, EM, and LS

Third Edition

 i
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Development Team
Executive Editor: Carolyn Schierhorn, MA
Editorial Coordinator: Kristine Stejskal
Associate Director, Production: Johanna Harris
Executive Director, Global Publishing: Catherine Chopp Hinckley, MA, PhD

Reviewers for the Third Edition

Joint Commission Division of Healthcare Improvement
Diane Cullen, MSN, MBA, RN, CIC, Associate Director, Standards Interpretation Group
Sylvia Garcia-Houchins, MBA, RN, CIC, Director of Infection Prevention and Control
Herman A. McKenzie, MBA, CHSP, Director of Engineering, Standards Interpretation Group

Joint Commission Division of Accreditation and Certification Operations

James Kendig, MS, CHSP, CHCM, CHEM, LHRM, Field Director, Surveyor Management and Development
Timothy Markijohn, MBA/MHA, CHFM, CHE, Field Director, Surveyor Management and Support

Joint Commission Division of Healthcare Quality Evaluation

Caroline Christensen, Project Director–Technical, Department of Standards and Survey Methods

Joint Commission Resources

Lisa Hardesty, MA, CFI-1, CHSP, HEM, Principal Consultant, Environment of Care
 Table of Contents
Table of Terms................................................................................................................ vii

Introduction......................................................................................................................1

Chapter 1: Who’s Who in EC...........................................................................................9

Key Concepts.......................................................................................................... 9
• Responsibility for the Environment of Care..................................................................10
• Key Staff and Organizations.......................................................................................11
• The EC Committee....................................................................................................15
• Leadership Levels and Performance Improvement.......................................................18
Tools of the Trade.............................................................................................................19
• Environment of Care Contact Sheet
• Sample EC Committee Reporting Items Schedule

Chapter 2: What’s What in EC......................................................................................21

Key Concepts...................................................................................................................21
• EC Management Plans...............................................................................................22
• EC Risk Assessments................................................................................................28
• Environmental Tours..................................................................................................34
• EC Documentation....................................................................................................38
• Information Collection ...............................................................................................39
• Competent, Well-Trained Facilities Staff......................................................................41
Tools of the Trade.............................................................................................................42
• Sample Safety Management Plan
• EC Management Plan Evaluation Checklist
• EC Management Plan Annual Evaluation Process Policy
• EC Tour Checklist
• EC Assessment Checklist

Chapter 3: Safety...........................................................................................................43
Key Concepts...................................................................................................................43
• General Safety..........................................................................................................44
• Worker Safety...........................................................................................................46
• Infection Prevention and Control in the Environment of Care.........................................49
• Slips, Trips, and Falls................................................................................................51
• Medical Gas Cylinder Storage.....................................................................................52
• Smoke- and Vaping-Free Policy....................................................................................53
• Product Notices and Recalls......................................................................................55

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Tools of the Trade.............................................................................................................56
• Work Flow Assessment Checklist
• Environmental Services Checklist: Cleaning of Patient Rooms
• Sharps Injury Administrative Controls Checklist
• Smoke- and Vaping-Free Policy Development Checklist
• Smoke- and Vaping-Free Policy Scripts

Chapter 4: Security........................................................................................................57
Key Concepts...................................................................................................................57
• Access Control..........................................................................................................58
• Abductions and Elopements.......................................................................................60
• Environmental Suicide Risks and Ligature Resistance..................................................63
• Workplace Violence...................................................................................................67
• Security Incident Reporting........................................................................................71
• Security Risk Assessment and Analysis......................................................................73
Tools of the Trade.............................................................................................................74
• Environmental Risks for Workplace Violence Assessment Checklist
• Pocket Card: Workplace Violence De-Escalation Strategies
• Security Risk Analysis Form

Chapter 5: Hazardous Materials and Waste.................................................................75

Key Concepts...................................................................................................................75
• Creating a Hazmat Management Plan ........................................................................76
• Hazmat Inventory......................................................................................................78
• Hazmat Procedures...................................................................................................82
• Managing Specific Types of Materials.........................................................................85
• Labeling and Safety Data Sheets................................................................................90
• Hazardous Waste Disposal........................................................................................93
• Responding to Hazmat Incidents................................................................................95
Tools of the Trade.............................................................................................................97
• Hazardous Materials Inventory Form
• Hazardous Waste Storage Inspection Checklist
• Hazardous Chemicals—Engineering and Other Controls Checklist
• Eyewash Station/Drench Shower Risk Assessment Checklist

Chapter 6: Medical Equipment and Utility Systems....................................................99

Key Concepts...................................................................................................................99
• Medical Equipment: Managing the Program...............................................................100
• Medical Equipment: Inventory..................................................................................103
• Medical Equipment: Maintenance.............................................................................106
• Medical Equipment: Responding to Failures..............................................................111
• Equipment Management..........................................................................................112

iv EC Made Easy: Your Key to Understanding EC, EM, and LS, 3rd Edition
 • Utility Systems: Managing the Program.....................................................................117
• Utility Systems: Inventory of Operating Components..................................................119
• Utility Systems: Maintenance...................................................................................120
• Utility Systems: Infection Prevention and Control.......................................................120
• Utility Systems: Piped Medical Gas...........................................................................124
• Utility Systems: Emergency Power Supply System......................................................125
• Utility Systems: Responding to Failures.....................................................................129
Tools of the Trade...........................................................................................................130
• Medical Equipment and Utility Systems: Documentation Checklist
• AEM Program Checklist
• Ventilation in Critical Care Areas Policy
• Waterborne Pathogen Prevention Checklist
• Mock Tracer Worksheet: Utility Outages

Chapter 7: Fire Safety and Life Safety........................................................................131

Key Concepts.................................................................................................................131
• Fire Safety vs. Life Safety........................................................................................132
• Fire Safety..............................................................................................................133
• Life Safety..............................................................................................................140
• Occupancy..............................................................................................................145
• “Defend in Place” and the Unit Concept....................................................................147
• Statement of Conditions™.......................................................................................150
Tools of the Trade...........................................................................................................152
• Fire Drill Matrix
• Testing by Time Frame
• Checklist for Compliance with Standard EC.02.03.05
• Quick-Look Door Check
• Fire Protection—Engineering Controls Checklist
• Fire Safety Equipment and Building Features Maintenance Policy
• Sample Life Safety Drawing Detail

Chapter 8: Emergency Management..........................................................................153

Key Concepts.................................................................................................................153
• Leadership Accountability in Emergency Management................................................154
• Hazard Vulnerability Analysis....................................................................................156
• The Four Phases of Emergency Management.............................................................158
• The Emergency Operations Plan...............................................................................161
• The Six Critical Areas of Response...........................................................................162
• Incident Command System......................................................................................168
• Community Networking............................................................................................170
• Emergency Response Exercises...............................................................................172
• Evacuation .............................................................................................................174
• Cyber Emergencies..................................................................................................176

Table of Contents v
Tools of the Trade...........................................................................................................177
• Sample Emergency Operations Plan Contents
• Emergency Response Staff Training Checklist
• Decontamination Event Procedure Checklist
• High-Consequence Infectious Disease Preparedness Checklist
• Integrated Emergency Preparedness Plan

Chapter 9: Construction..............................................................................................179
Key Concepts.................................................................................................................179
• Planning and Design................................................................................................180
• Managing Construction Risks...................................................................................189
• Commissioning.......................................................................................................195
Tools of the Trade...........................................................................................................196
• Room Data Sheet
• Pre-Construction Risk Assessment Checklist
• Post-Construction Checklist

Chapter 10: The EC Survey.........................................................................................197

Key Concepts.................................................................................................................197
• The On-Site Survey Process.....................................................................................198
• The Survey Analysis for Evaluating Risk® (SAFER™) Matrix.........................................203
• After the Survey......................................................................................................206
• Continuous Compliance...........................................................................................212
Tools of the Trade...........................................................................................................213
• Required EC Documentation Checklist
• What to Do on the First Day of a Survey—A Checklist
• The SAFER™ Matrix

Appendix: Resources...................................................................................................215

Index............................................................................................................................223

vi EC Made Easy: Your Key to Understanding EC, EM, and LS, 3rd Edition