the preliminary planning session

The Preliminary Planning Session

Healthcare Engineering Consultants

How Should I Prepare for the Preliminary Planning Session?



Occurs on the morning of the first survey day

Will be performed by the surveyors “alone”

Will create strong first impressions (“Blink!”)

Will impact the rest of the survey!

Will be document-based (documents should

always be up-to-date and ready)

Hospital must be prepared for this!

Should trigger the “Rapid Response Team”

The Life Safety Surveyor may come at a later time



Documents to be reviewed include:

The six required management plans plus the “EOP”

Safety committee minutes from the last 12 months

The most recent annual effectiveness evaluations from each “EC”

area and Emergency Management

Statement of Condition documents (reviewed by the LSS)

Fire plans and fire drill evaluations

Interim life safety measures policy

Safety officer signed appointment letter with intervention

authority statement

Categorical waiver letter, if applicable

The Management Plans


Expectations Include:

A description of the program, not a rewrite of the program!

Consistent format, in a labeled, tabbed binder

A list of applicable facilities to avoid multiple plans

A description of each “element of performance”

Responsibilities from governing body to staff

Performance improvement and training information

Risk assessment and ICES information

An annual review by the safety committee

Note 1: Emergency Management requires an Emergency Operations Plan (EOP), not a management plan

Note 2: “High Risk” plans include safety, hazmat, biomed, utilities

The Management Plans


Best Practices Include:

Cross-reference or cite supporting policies that already exist

Note when the AHJ has a stricter interpretation or code reference

Reference other related Joint Commission standards (example: HR, LD, PI, IM standards)

Distribute plans to each applicable “off-site” facility

Don’t just list or restate the required standards or EC numbers

Consider the plans to be a “roadmap” to effective EC management

Consider appendix documents that reference applicable policies, define responsibilities and list performance indicators

Note: Refer to additional information regarding “EC management Plans” in the June, 2013 issue of Perspectives

The Emergency Operations Plan


Expectations Include:

The Emergency Operations Plan (EOP) is not a management plan, but a robust description of emergency operations procedures and information

At a minimum, the EOP should describe the following:

1. The Hazard Vulnerability Analysis (HVA)

2. Mitigation, Preparedness, Response, Recovery (MPRR)

3. The Incident Command System structure (ICS)

4. The six critical core areas of emergency management, including:

communications, resources and assets, safety and security, staff roles

and responsibilities, utilities and patient management

Also include a description in the EOP of emergency drills and reference emergency codes, procedures, and other materials that exist and supplement the program

The Safety Committee


Best Practices Include:

Leadership representative (VP-level or equivalent) present at every meeting

Multi-disciplinary membership

Attendance of standing members at least 70%

Meet often enough to limit meeting time to 1 hour or less

Document and distribute meeting minutes within two weeks of the meeting and use the C-R-A-F format

Use dashboards or spreadsheets to track regulatory and performance improvement data

Track the resolution of issues with a monitoring chart

Use the meeting time to solve problems, not to review data or information that does not require any action

Safety Committee Issue Monitoring


Safety Committee Issue Monitoring Sheet

Issue Number

Issue Description Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

10-17 10-23 10-26 11-01 11-02 11-03 11-04 11-05 11-06 11-07 11-08 11-09 11-10 11-11

Fire exit plans Safety manual In-services Disaster reports Recall sheet Rear parking OB project Sharps in trash Slick pavement Snow removal Telephone system. Haz Com Fire reports Rehab door

F F T P P P P P

F C F F T T F F P P P

C

F R R F V R C C F P P P

Key to issue numbers: year of issue initiation followed by issue number in committee minutes Key to action: P = problem initiated; F = follow-up; R = recommendation; T = tabled; NA = no action; V = vote taken; C = complete

Annual Evaluations

The written Annual Evaluations must include the following sections:

SCOPE - What is being evaluated?

OBJECTIVES - What are the numerical goals/ benchmarks?

PERFORMANCE - What does the data show?

EFFECTIVENESS - How does the performance (data) compare to the objectives?

WHAT NEXT? - What objectives do we define for next year, based on this year’s performance?


Annual Evaluations

“Best Practice” Guidelines for the Evaluations

Demonstrate that the program has improved

Provide numerical data

Demonstrate “effectiveness” rather than “busyness”

To effectively communicate the report to others, include a narrative explanation, spreadsheets and graphs and charts

Indicate whether the regulatory and performance improvement goals and objectives have been “met” or “not met”, with a clear method of determination

Include goals and objectives for the following year, based on the results of the previous year


Annual Evaluations

Additional “Best Practice” Guidelines

Document evaluations for every “EC” area, and Emergency Management

Create the evaluations as soon as possible at the end of the fiscal or calendar year (within 30 days, if possible)

Review and approve by the Safety Committee (within 60 days)

Review and approve by the Governing Body (within 90 days)

Re-read the annual evaluations before the survey to be prepared for the Physical Environment Interview session

The annual evaluations are a “Direct Impact” score


The Statement of Conditions Review


LS.01.01.01: SOC and Life Safety Code

The SOC completion will be verified through the Joint Commission Connect site (BBI’s and PFI’s)

Have the SOC notebook available for review

The PFI documents from the previous survey may be reviewed to verify completion of deficiencies (have them available, if requested)

The compartmentation drawings will be reviewed to assist in planning the facility tour

Life Safety Code compliance will be verified during the facility tour

The Statement of Conditions


What is the SOC?The Statement of Conditions (SOC) is a document that is required to be completed by every healthcare facility that applies for accreditation by the Joint Commission. It references the *2000 edition of the Life Safety Code and consists of the following sections:

Basic Building Information (BBI) Form – electronic on Connect site

Life Safety Assessment (LSA) Form – not on Connect site

Plan for Improvement (PFI) Form – electronic on Connect site

*Note 1: The Joint Commission permits other LSC editions to be selected, but the entire edition must then be followed; CMS also requires compliance with the 2000 Life Safety Code

Note 2: It is likely that the 2012 Life Safety Code will be adopted by CMS and the Joint Commission in 2015



SOC Notebook (Best Practice)

A SOC notebook is strongly recommended to contain “hard copies” of the SOC documents

The notebook should include at least the following sections:

Section 1: The SOC policy and responsibility statement

Section 2: Current copies of the downloaded BBI forms

Section 3: Accurate, color-coded compartmentation prints

Section 4: The latest, completed LSA-type document

Section 5: Current and previous, downloaded PFI forms

Section 6: Any correspondence with the Joint Commission,

including equivalencies, letters and emails



Why Should I have an SOC Policy?

The SOC policy describes how the Statement of Conditions program is organized for the facility

What Should the SOC Policy Include?

Who is responsible for completing and maintaining the SOC

How often the SOC documents are reviewed

Who reviews the SOC documents for timeliness

PFI guidelines (when does a work order become a PFI?)

Whether a BMP is implemented

Whether an above-the-ceiling program is in place

How the SOC documents are organized

The Statement of Conditions Document


The current Statement of Conditions “hard copy” document is dated 5/2004 and can still be downloaded as a pdf file from JointCommission.org for the LSA form only (do not use the BBI or PFI “hard copies” – they are obsolete)

Note: Most organizations do not use this document at all!

Statement of Conditions Document


Notes About the e-BBI Form

List on the e-BBI cover page every occupancy that will be surveyed, even for business occupancies (make sure that the BBI and survey list match!)

The e-BBI questionnaires are only required for ambulatory and healthcare facilities, not business occupancies

Fill in the e-BBI comments section regarding SOC preparer, location of building drawings, mixed occupancies, equivalencies, special building features or local AHJ requirements, including the CMS “Categorical Waivers”

If multiple occupancies are entered, the greatest percentage defaults to the BBI form, so multiple BBI entries are required

Be sure to print the electronic version of the BBI form at least annually so that a “back-up” is available, and place a copy in the SOC Notebook



Compartmentation Requirements

Mixed Occupancies: (LSC sections: 19.1.2.1, 19.1.2.2)

Sections of health care facilities shall be permitted to be classified as other occupancies (such as business), provided that they meet the following conditions:

1) They are not intended to serve health care occupants for purposes of housing, treatment, or customary access by patients incapable of self-preservation

2) They are separated from the health care occupancy by a fire rating of at least 2 hours

3) The facility is not intended to provide services simultaneously for four or more health care patients who are “litterborne”

4) Separation between ambulatory and business occupancies only requires a 1-hour rating (LSC: 21.1.2.1)



e-BBI Form – Buildings

Be sure to complete for all healthcare and ambulatory facilities

Optional for business occupancies, but strongly suggested to include the cover page to indicate “surveyable facilities”



e-BBI Form – page 3

“Previous inspections” data provides valuable information to the survey team!

Be sure to list local or regional requirements (example: limited generator testing due to high pollution days) in the “Comments” section at the bottom of the form as well as other requested information, including: 1) location of the compartmentation drawings; 2) e-SOC preparer; 3) mixed occupancies, and; 4) equivalencies or issued variances, including CMS “Categorical Waivers”



Life Safety Building Compartmentation Drawings

Typical line colors might include:

Blue – smoke barrier Green – 1 hour fire wall (typically a hazardous area) Red – 2 hour fire wall

Note 1: A color-coded drawing is “best practice”

Note 2: Be sure to indicate the following features on the drawings:

Hazardous areas

Smoke/ fire barriers

Suites w/ sizes, other information

Linen/ waste chutes, shafts, chases

Exits

Sprinkled/ non-sprinkled areas

Approved equivalencies

A legend with fire safety features



LSA Form (is not electronic):

Is a voluntary assessment tool, although some assessment is required at least annually

Is not required for “Business Occupancies”

The Joint Commission surveyor normally expects some type of form, document or evaluation to be completed

Dated 5/2004, so a cover sheet that is signed annually is recommended

Can still be downloaded from the Joint Commission home page website JointCommission.org (type “Statement of Conditions” in the search box)

Can use other assessment tools (2011 form) or checklists for the LSA

Comments in LSA must match PFI deficiencies



LSA Documentation Options:

Can manually complete the 2004 LSA form available on the Joint Commission home website (JointCommission.org) in Adobe format

Can complete the updated 2011Joint Commission questionnaire form available from the “EC Essentials” book

Can create a new form or process for internal use

Can contract with an outside vendor

2011 Form

May, 2004 Form



Notes About the PFI Forms

The forms should not be used for “operational deficiencies”, such as exit lights burned out, doors out of minor adjustment or small penetrations that can be easily filled – these should be completed using the routine work order system

The normal “trigger time” from a work order to PFI is 45 days

Document the “PFI’s” on a continuing basis – be sure that the PFI log is up-to-date and ready to be reviewed by the surveyor

Don’t forget to enter the projected start and completion dates and the actual completion date

Be sure to document an ILSM evaluation for every PFI!

Failure to meet the completion dates without a delay approval results in Contingent Accreditation 6 months after the projected completion date has passed!

If applicable, keep any previously signed PFI copies available



The second page for the electronic PFI forms is used to indicate the deficiency resolutions

Don’t forget to complete all of the requested information, including the proposed action, source of funds and the projected start and completion dates

The projected completion dates can be altered until they are “frozen” before or during the actual survey!

Be sure to check “YES” on the form to indicate that interim life safety measures (ILSM) have been evaluated for the PFI



Changes to the SOC Process – effective 7/1/2014

Open PFI’s will now be listed in the final decision report, so will be available to anyone who has access to the report

Failure to resolve a PFI beyond the 6-month “grace” period will result in a phone call from the Joint Commission and a possible on-site survey if it is not resolved in a timely basis

Once a delay for a PFI is granted, the 6-month grace period is no longer applicable!

Equivalencies that are requested from the Joint Commission will now be forwarded to the CMS regional (state) office for review and possible approval – the Joint Commission will no longer issue equivalencies unless approved by CMS!

The Safety Officer Appointment


Should be in a letter format

Should identify an individual (or multiple people) by name

Must include an “intervention authority statement”

Should be signed by the organization CEO and

CMO if they are on the same organizational level

Can be signed by the Governing Body President to indicate additional organizational support

Only requires a re-issue if any individuals change positions


Questions?


the preliminary planning session

Documents

ec management plans

required management

patient management

emergency operations

effective ec management

multiple plans

eop of emergency drills

reference emergency