In The Joint Commission January 2016 Perspectives series entitled “Clarifications and Expectations” continues its discussion on. They discuss EP’s 9, 10, 11, 12, 18 and 19. When reading these requirements, staff in either hospital quality or facilities might be tempted to say, “yea, we do that” and move on to something else. This one would be worth having a detailed discussion and analysis at a hospital wide meeting to verify actual compliance. Our recommendation is to use your “show me” technique, or your “how do we do that, where is it documented” methodology.
For example the discussion on EP’s 9 and 10 points out the need to protect employees from hazardous gases and vapors. It specifically references surgical smoke and medical gases, however it references NIOSH and OSHA requirements which should be analyzed to determine if you have other hazardous gases or vapors besides those directly mentioned in the article. For example formaldehyde is not mentioned, but it too must be monitored. In addition to residual chemicals in the air and monitoring for content, the surveyors may ask for air exchange and pressure data and this should be available where ever these chemicals or vapors are likely to be produced.
The guidance on EP 11 should also be carefully examined where it discusses hazardous waste and transportation which then brings in both EPA regulations and DOT regulations. In particular EPA’s hazardous waste regulations for a waste manifest, and DOT’s regulations if transporting on public roads. The specific DOT regulation is CFR 49, part 172, subpart H and we encourage our readers to Google this resources and read the requirements in depth. Again, you are going to want to see evidence that all parts of the requirement are met. As we have seen with NFPA fire codes, high level disinfection and sterilization, air handling, knowing the Joint Commission standards is not enough. This is becoming increasingly complex in that the Joint Commission now includes so many inspection details from additional references.
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