The JCAHO requirements that apply to environmental management programs are described in the management of the environment of care (EC) standards. They are divided into four major parts:
EC.1 - Planning. This group of standards includes a description of design requirements for each of seven required safety and environmental management programs. Other areas covered include personnel orientation and education requirements and provisions for performance monitoring to evaluate the effectiveness of each management program. Establishment of a no-smoking policy that is communicated and enforced throughout all buildings.
EC.2 - Implement/Teach. These standards generally describe ways in which facilities should be able to demonstrate that they have met the intent of the management programs described in EC.l. Areas in which staff may be asked to explain or demonstrate hospital procedures during a survey are detailed. Other topics addressed include: fire drills, emergency drills, maintenance requirements, and safety surveillance.
EC.3 — Other environmental considerations. Establishment of a care environment in consideration of issues such as the need for appropriate space to support services, preservation of dignity and privacy, and support for patient personal growth is required under the EC.4 standards.
EC.4 – Monitor & Improve. Development and operation of an organization-wide information collection and evaluation system or ICES is required under these standards. The standards also describe the role and responsibilities of the safety officer and a multidisciplinary group such as the safety committee in collecting, assessing, and acting on such information.
Seven EC Management Programs
The EC standards require appointment of a qualified individual and designation of a committee responsible for managing environment of care. The standards also require the development, implementation, evaluation, and continuous improvement of written management programs for seven major areas:
- Hazardous materials and waste;
- Emergency preparedness;
- Life safety;
- Medical equipment; and
- Utility systems.
Written management plans include: policies and procedures, performance standards, written criteria, and stated goals & objectives. An annual evaluation of the objectives, scope, performance, and effectiveness of each management program also is required. In most cases, the commission will rely on management plans and staff interviews for evidence of compliance, according to the CAMH.
JCAHO requires hospitals to use the National Fire Protection Association’s Life Safety Code® (LSC), 2000 edition (NFPA 101-2000), in designing the environment of care in both newly constructed and existing facilities. For every building in which patients are treated or housed overnight, a comprehensive Statement of Conditions® that describes the current condition of structural features of fire protection must be submitted to the Joint Commission.
In cases where a facility is not in compliance with NFPA 101-2000 and does not have a documented equivalency granted by JCAHO, a written Plan for Improvement is required. The plan should address all LSC® deficiencies identified in the Statement of Conditions®.
The JCAHO EC standards also require that organizations use design criteria referenced by the health care community for new construction, alteration, or renovation of facilities.
Generally, each accredited hospital is required to establish a safety management program. Policies and procedures should be based on experience, compliance with applicable laws and regulations, and accepted practices.
A qualified individual, sometimes called a safety officer or director, is to be appointed by the chief executive officer and charged with responsibility to develop, implement, and monitor the safety management program. A safety or other committee, which includes representatives of administration, clinical services, and support services, also is to be established to analyze identified EC management issues and develop recommendations for resolving them. The safety officer then is required to work with appropriate staff to implement these recommendations and monitor their effectiveness.
Under the EC standards, the safety management plan must describe how the hospital will provide a physical environment that is free of hazards and manage staff activities to reduce the risk of human injury. In addition, the safety management plan must establish a staff orientation and education program that addresses safety issues, program performance, monitoring provisions, and provisions for periodic review.
Under the security standards, accredited hospitals are required to establish and maintain a security management program. The security management plan must establish a staff orientation and education program, program performance monitoring provisions, and provisions for periodic plan review. Emergency security proceduresalso must be established to address: actions taken in the event of a security incident or failure, handling of civil disturbances, handling of situations involving VIPs or the media, and provision of additional staff to control human and vehicle traffic in and around the environment of care during disasters.
Hazardous Materials and Waste
A hazardous materials and waste management program is required under the EC standards. The hazardous materials and waste management plan must establish a written staff orientation and education program, program performance monitoring provisions, emergency procedures, and procedures for plan review.
Operation of an emergency preparedness management program is required under the EC standards. The written emergency preparedness plan must identify an alternative source of essential utilities, a backup communication system, facilities for radioactive or chemical isolation and decontamination, and alternate roles and responsibilities of personnel. The plan also must establish a written staff orientation and education program, program performance monitoring provisions, and procedures for plan review.
A life safety management program is required to protect persons and property from fire hazards. The life safety management plan must include provisions for staff orientation and education on life safety issues, program performance monitoring provisions, and periodic plan review.
In addition, the plan must establish emergency procedures that address: facility-wide and area-specific fire-response needs, fire evacuation routes, and specific roles and responsibilities of personnel at and away from a fire’s point of origin and in preparing for building evacuation. A written policy must be developed, implemented, and enforced for the use of interim life safety measures to address hazards created by National Fire Protection Association Life Safety Code® deficiencies or construction projects.
The medical equipment management program should describe how the organization will establish and maintain a program to promote safe and effective use of medical equipment. The medical equipment plan should cover processes for selection and acquisition of medical equipment. It also should establish criteria for identifying, evaluating, and taking inventory of equipment to be included in the program before the equipment is used, as well as for reporting medical equipment incidents to the federal government under the Safe Medical Devices Act.
The medical equipment management plan also should provide for an orientation and education program, program performance monitoring provisions, emergency procedures, and procedures for plan review.
A utility systems management program is required to promote a safe, controlled, comfortable environment of care; assess and minimize risks of utility failures; and ensure operational reliability of utility systems.
The utility management plan also should establish an orientation and education program, program performance monitoring provisions, emergency procedures for systems disruptions or failures, and provisions for periodic plan review.
Other Environmental Considerations
The standards under EC.4 require establishment of a care environment that supports the hospital’s basic mission and services. The care environment should support the care process and the needs of the population served by the organization. The standards cover the following four categories:
- Space - organizations provide appropriate space to support patient services.
- Human dignity - organizations provide an environment that fosters a positive self-image for the patient and preserves his or her human dignity.
- Privacy - organizations’ built environment provide appropriate privacy to patients.
- Interests, shills, and personal growth – organizations provide a built environment that supports the development and maintenance of the patient’s interests, skills, and opportunities for personal growth when required.
A no-smoking policy must be communicated and enforced throughout all buildings. Any exceptions to the smoking prohibition must be authorized for a patient by a licensed independent practitioner’s written authorization, based on criteria defined by the medical staff.