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Compliance News: Changes to The Joint Commission’s Standards

| David Stymiest

The Joint Commission recently issued numerous changes to its Hospital Accreditation Standards (HAS) Environment of Care (EC) and Life Safety (LS) chapters. TJC accredited hospitals should closely review all changes within the HAS book itself.

TJC’s Prepublication Requirements issued June 20, 2014 identified the below-listed EC chapter changes that took effect July 2, 2014. There were also many other changes to other HAS chapters that are not discussed here.

Under Standard EC.02.02.01 (managing hazardous material and waste risks)

o   New EP18 requiring periodic checks of radiation worker exposure

o   New EP19 requiring new procedures regarding trash storage and disposal

Under Standard EC.02.0301 (managing fire risks)

o   Revision to EP10 requiring that the fire response plan now include reporting fire alarms. This should require updates to most fire response plans.

Under Standard EC.02.05.03 (emergency power sources)

o   Revision to EP6 adding intensive care areas and emergency rooms to the list of areas requiring emergency power. This change should not require modifications to installed infrastructure but will likely require changes to many existing policies.

 TJC’s Prepublication Requirements issued July 1, 2014 identified numerous other changes to the EC chapter. The effective date for these changes was also July 2, 2014. There were additionally several other changes to other Hospital Accreditation Standards (HAS) chapters that are not discussed here.

Under Standard EC.02.04.01 (managing medical equipment risks)

o   New EPs and changes to existing EPs that reflect detailed requirements and limitations for the new CMS-allowed alternative equipment maintenance (AEM) program for medical equipment. These changes may require risk assessments reflecting the use of the new term “high-risk medical equipment” and will affect medical equipment policies, medical equipment inventories and medical equipment PMs.

Under Standard EC.02.04.03 (medical equipment Inspection testing & maintenance)

o   Changes that strengthen requirements for equipment checks after major equipment repairs and upgrades

o   Other changes reflecting the new high-risk equipment phraseology

Under Standard EC.02.05.01 (managing utility system risks)

o   A major change to EP2 requiring “a written inventory of all operating components of utility systems” for all accredited hospitals using their TJC accreditation for deemed status. This change can have a major effect on hospitals that have previously limited the content of their utility inventories based upon their utility risk assessments.

o   A new requirement that the hospital identify the “high-risk operating components” on the utility inventory. The new term appears to reflect an expansion of concept beyond just life support to include any component whose failure could result in serious harm or death. One wonders if perhaps the new phrase will now facilitate the inclusion of life safety utility components, a category previously unidentified within the TJC utility inventory framework. Regardless, it appears that new risk assessments will be required to address the new phraseology and its description.

o   New EPs and changes to existing EPs that reflect detailed requirements and limitations for the new CMS-allowed alternative equipment maintenance (AEM) program for utility systems and equipment. These changes will affect utility system policies, utility inventories and utility equipment PMs.

Under Standard EC.02.05.05 (utility equipment inspection testing & maintenance)

o   Changes that strengthen requirements for equipment checks after major equipment repairs and upgrades

o   Other changes reflecting the new high-risk utility system components phraseology

 A review of the detailed July 2014 HAS Update also indicates additional EC and LS chapter changes (along with numerous changes in other chapters) that are not discussed within the two TJC publications referenced above. Hospitals should review all of the shaded changes within the July 2014 HAS update pages. The below list of selected changes is not all-inclusive.

Under Standard EC.02.03.03 (fire drills)

o   A new requirement for quarterly fire drills to be held at unexpected times and under varying conditions. This is likely to affect hospitals that have been holding their 3rd shift fire drills early in the day just before shift change.

o   A clarification that differentiates between not activating the audible alarms (added) and not activating the fire alarm system (deleted) between 9:00 PM and 6:00 AM.

Under Standard EC.02.05.07 (emergency power ITM)

o   Changing the “at 30-day intervals” language to “at least monthly” for the EP1 battery lighting tests. (Note: For a discussion of other TJC 2014 changes related to testing intervals, please refer to the previous SSR compliance news articles entitled “TJC defines ‘quarterly’ and ‘every 3 years’ for 2014” and “TJC modifies emergency power test intervals for 2014” – both articles were in our January 2014 SSR Compliance News.)

Under Standard LS.02.01.20 (maintaining means of egress integrity)

o   Toughening the EP1 language regarding doors in the means of egress. The previous language required that these doors not be locked in the direction of egress. The new language is more restrictive and affects the door hardware.

o   A new note to EP26 (dead-end corridors) permitting existing (not new buildings) dead-end corridors to be retained in certain situations.

Also within the LS chapter, new language replacing the corridor door and smoke door equivalent wording with new wording “constructed to resist fire for not less than 20 minutes.”

Other LS chapter changes reflecting clarifications related to NFPA 101 language, and modifications to several of the NFPA 101 paragraph references for both health care occupancies and ambulatory health care occupancies.

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