The Joint Commission recently published new EC and LS chapters with two documents posted to the TJC website, one being just the new standards and the second being a side-by-side comparison of the new standards and the old standards. This latter document is the most useful of the two to analyze because it allows you to scan each requirement to see what is identical and what is new. You want someone with great attention to detail and reading skills to read this document and highlight each requirement that is new, or now includes new NFPA references.
For exampleis already a very challenging standard and one of the requirements is to include the NFPA references in your documentation of testing fire safety systems. Some vendors began to do this, but many more did not. As a result many hospitals built cover sheets for their test documentation that included the appropriate NFPA references. These have all changed and will need to be updated. TJC and CMS had been using the 2001 version of the NFPA life safety code 101 and this cross-referenced many other NFPA manuals, usually from 1998 or 1999. These cross-references now have also been updated to 2010, 2011 and 2012 versions. This may also involve a sizeable expense in your hospitals as you may need to purchase these updated references to ensure you have all the appropriate content corresponding to the new 2012 version of life safety code and cross references.
There also is new content or new requirements detailed that need to be incorporated into management plans and work order systems. For example, EP’s 9 and 10 discuss managing hazardous medical gases and vapors. Previously this EP mentioned glutaraldehyde, ethylene oxide, cauterizing equipment such as lasers, and nitrous oxide. Now the EP has been expanded to specifically add mention of waste anesthesia gas, laboratory rooftop exhaust and, in EP 10, monitoring for residual gas at a frequency determined by law and regulation.
There are other examples where additional detail has been added to an element of performance. For exampleEP 9 has required the hospital to develop a Fire Response Plan. Now the EP has been expanded in its level of detail to describe that this fire response plan should include information on the specific roles of staff and LIP’s, at and away from the fires point of origin, including when and how to sound and report the alarm, how to contain smoke and fire, how to use a fire extinguisher, how to assist and relocate patients and how to evacuate. Previously you may have had these details in policies and training materials, but now these details will be needed in the plan itself. This is potentially a classic “gotcha” if you don’t update a new plan requirement to match the EP requirement.
Sometimes the additional details now included are helpful in explicitly stating something that previously required knowing exemptions and details from other NFPA manuals. For exampledescribes conducting fire drills and many people knew that NFPA allowed us to not sound the alarm at night. Now the expanded content in the EP makes this clear that it is between the hours of 9:00 PM and 6:00 AM. We also have seen TJC scoring the mixing of full, partial and empty oxygen cylinders for several years, but never saw any explicit reference in the standards that said you had to separate them. The reference was elsewhere in another NFPA manual you had to be knowledgeable of. Now you have that explicit reference right in the EP 9 of that makes it clear full and empty need to be separated.
, EP 13 has two new notes added to it which help explain some new flexibility relative to corridor clutter. Note 1 discusses the long standing exception for emergency crash carts and now adds patient lifts and transport equipment. These would have been scored as clutter in the earlier version of the code. Note 1 does mention that there must still be 5 feet of clearance in the hallway and the fire response and training program addresses relocation of this equipment in the event of an emergency. Note 2 discusses a second new permissible item and that is fixed furniture on one side of the hallway providing the corridor still has 6 feet of clearance and the area has supervised smoke detection, or is in direct line of sight by staff. There are some additional limitations on this such as making sure the fixed furniture does not block fire fighting equipment.
Our suggestion here is to make this a high priority team project. Try to find someone, staff, intern, administrative resident to highlight the changes. Then create a management project to update the EC plans, related policies, training materials and scheduled work order systems to include new requirements, frequencies and details. You also have an opportunity to decide what new flexibility you might want to take advantage of. If you are due for survey in the first half of 2017 you will need to fast track completion. Remember TJC is committed to making survey dates more random and that requires moving people forward in their schedule to create that randomness for the unannounced survey.
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