The Compliance Puzzle: Putting the Pieces Together

1. H2E The Compliance Puzzle:Putting the Pieces Together JCAHO A Guide to comply with JCAHO, EPA, OSHA, DOT, H2E and beyond. EPA Janet Brown, H2E Partner Program Mgr. Ph: 413/253-0254 E-mail: janet.brown@h2e-online.org www.h2e-online.org DOT/ OSHA

2. Today’s Objectives • The Status of Environmental Compliance in Healthcare • JCAHO Survey vs. EPA Inspections • H2E JCAHO Environmental Compliance and Improvement Guide

3. JCAHO Update • Rewriting all EOC Standards for 2009 • Field Review • Life Safety Chapter welcoming feedback right now. • Emergency Management Standard will be pulled into its own chapter in 2008. • So there will be 1. eoc, 2. emergency mgmt and 3. life safety

4. JCAHO Definition/Background • The Joint Commission for the Accreditation of Healthcare Organizations • Sets standards for care and quality improvement • Minimum standards are set by Center Medicare and Medicaid Services (CMS) • JCAHO accredited organizations meet and exceed CMS standards • Other accreditation organizations • E.g. Institute for Healthcare Improvement • Also, state licensure • Methodology • Healthcare processes divided into areas, e.g. Environment of Care, Leadership, Treatment, Human Resources, Patient Rights • Each area has a set of standards • The standard is the “goal” • “Rationale” explains why important to reach the goal. • “Elements of Performance” are the steps necessary to reach the goal. JCAHO

5. Joint Commission • http://www.jointcommission.org/ Top Stories Tell Us What You Think About The Proposed Standard Revisions to The Joint Commission’s Standards - Patient Rights

6. Joint Commission • NEW!  Safe by DesignDesigning Safety in Health Care Facilities, Process, and Culture by John Reiling.   Learn the latest design trends and how they can enhance patient safety in health care environments.  Read about health care organizations that have succeeded in designing and constructing safe environments.  Discover the value of involving nurses, physicians, patients, and others in health care facility design. http://www.jcrinc.com/26632/

7. Standards Improvement Initiative http://www.jointcommission.org/Standards/SII/ The Joint Commission has launched a Standards Improvement Initiative (SII) to: • Clarify standards language • Ensure that standards are program-specific • Delete redundant or non-essential standards • Consolidate similar standards • As additional benefits to users, the manuals will be reorganized and the scoring and decision process will be refined. • Improvements—both format and language edits—are targeted to go into effect January 2009 for the ambulatory, critical access hospital, home care, hospital, and office-based surgery programs. Beginning in 2008, The Joint Commission will seek feedback on standards for the behavioral health care, laboratory and long term care accreditation programs.  • Questions can be sent to standardsimprovement@jointcommission.org.

8. JCAHO’s Environment of Care • Goal: • To provide a safe, functional, supportive and effective environment for patients, staff and others in the facility. This is crucial to providing quality patient care, achieving good outcomes and improving patient safety. • Effective management of EC includes activities and processes for: • Reduce & control environmental hazards and risks • Prevent accidents and injuries • Maintain safe conditions for patients, staff & visitors • Maintain an environment that minimizes unnecessary environmental stresses for patients, staff and visitors*. *Crosswalk of 2003 Management of the Environment of Care Standards to 2004 Management of Environment of Care Standards for Hospitals, JCAHO, 2005.

9. JCR - www.jcrinc.com/26632/ • The environment in which care is provided can make a differenceNumerous studies demonstrate that factors in the physical and social environment can impact patients for better or worse.  Let JCR help you take a fresh look at your existing facility, or provide best practices in maintenance and design for a building prototype.  Our Environment of Care products and services provide organizations with the tools to build a safer environment for patients, staff, and visitors.

10. JCAHO “Performance Improvement*” • Is a continuous process • Involves measuring importance processes and services and identifying changes that enhance performance • These changes are incorporated into new or existing processes • Performance is monitored to ensure the improvements are sustained. *Crosswalk of 2003 Improving Organization Performance Standards for Hospitals to 2004 Improving Organization Performance Standards for Hospitals, JCAHO, 2005.

11. Hospitals for a Healthy Environment • Born out of a partnership between the US EPA, American Hospital Ass’n, American Nurses Ass’n and Healthcare without Harm, 1998. • Provides assistance to healthcare industry • Memorandum of Understanding setting goals for environmental improvement in healthcare • Elimination of mercury • Total waste reduction • Minimize persistent, bioaccumulative pollutants such as dioxins, heavy metals and others. • Awards program for facilities meeting and exceeding goals. H2E

12. JCAHO “Leadership” • Leaders provide framework for planning, directing , coordinating, providing and improving care, treatment and services to respond to community and patient needs and improve healthcare outcomes. • Effective leadership depends on: • Governance • Management-enables the hospital to fulfill its mission and meet/exceed its goals • Planning • Improving safety and quality of care • Use of clinical practice guidelines • Teaching and coaching staff. *Crosswalk of 2003 Leadership Standards for Hospitals to 2004 Leadership Standards for Hospitals, JCAHO, 2005.

13. Hazardous Materials

14. Regulated Medical Waste

15. JCAHO “Hazardous Materials and Waste” • Materials whose handling, use and storage are guided or regulated by local, state or federal regulation* • Examples • EPA • Chemicals & waste • DOT • Hazardous materials, including infectious agents • transportation requirements • OSHA • Hazardous substances • Blood borne pathogens • Ionizing radiation, hazardous energy sources • Nuclear Regulatory Commission • Radioactives • NIOSH • Hazardous drugs • State defined infectious waste *Crosswalk of 2003 Management of the Environment of Care Standards to 2004 Management of Environment of Care Standards for Hospitals, JCAHO, 2005.

16. 10 Steps to Reducing RMW http://www.h2e-online.org/pubs/tensteps/Rmw10steps.pdf Sample Tools – 10 Step Guides

17. Regulatory Compliance in Healthcare • Healthcare has flown under the regulatory radar for years… • Mid 1990’s EPA had focus on Colleges and Universities -- overlapped with university hospitals… What they found: • 1 out of 2 hospitals has a penalty violation • Compared to 1 out of 30 in general industry

18. “OUR TOXIC HOSPITALS” • January 18, 2004 -- New York City hospitals are flouting environmental laws - spewing toxic fumes into the air and mishandling medical waste, The Post has learned. • … recent violations by 10 private and public city hospitals, which led to fines as high as $500,000 for polluting. • "With all we know about air pollution and its health effects, it's troubling that health-care institutions would be contributing to the problem," said a spokesman for the American Lung Association of New York State. • The problem is so bad that the federal EPA began stepping up hospital inspections in 2002 because of "systemic problems" in meeting environmental codes. • "We are focusing on them as an industry that needs extra attention," said EPA spokeswoman

19. EPA Enforcement - Top Ten Violations • Hazardous materials and waste not identified (EC 3.10.2, 3, 5) • Illegal disposal of waste (LD 1.30, EC 3.10.3) • Waste not properly labeled (EC 3.10.3, 9) • Staff not trained (EC 3.10.3, HR 2.20, HR 3.10) • Appropriate authorities not notified (EC 3.10.2, 3, 7).

20. EPA Top Ten Violations (cont.) • Manifest records lacking (EC 3.10.8) • Hazardous waste containers not kept closed (EC 1.20.4, EC 3.10.3, HR 2.20, HR 3.10) • Containers not inspected (EC.2.10.6, EC 3.10.3) • Waste not stored to prevent leaks, spills or breakage (EC 3.10.3, 4, 6). • Wastewater authorities not notified regarding sewer disposal of waste/permits not obtained (EC 3.10.3, 7)

21. Environmental Compliance Violations found in Region 2: Primarily NY and NJ

22. What does that have to do with Joint Commission? Inspected hospitals expressed confusion that despite just “passing” JCAHO, they still had significant compliance violations under EPA • Shouldn’t JCAHO have told us or cited us? • It must not be that important since JCAHO didn’t survey on environmental compliance. • Confusing maze of who regulates what. ? ?

23. Compliance… • Is not optional… • ‘Compliance’ is a term used for both JCAHO and other regulatory requirements -- JCAHO is typically reliant on other regulatory statutes for its elements of performance. • BUT JCAHO Surveyors are not expected to be defacto inspectors for other regulatory agencies, like EPA • OSHA: Bloodborne Pathogens, HazCom • RCRA • EPCRA • CAA • CWA • SPCC • DOT • HIPAA

24. Comprehensive Approach to ALL Compliance Issues • While preparing for Joint Commission… incorporate environmental requirements. • Use JCAHO’s emphasis on Environment of Care (EOC) and environmental requirements to leverage resource support for environmental compliance and pollution prevention programs. • Use environmental programs as performance improvement initiatives for the Joint Commission.

25. How does the JCAHO Guide Work? JCAHO standards address an organization’s performance in key functional areas. Each standard is presented as a series of "Elements of Performance" (EP) -- expectations that establish the broad framework that JCAHO surveyors use to evaluate a facility's performance. Many of the environmentally relevant Elements of Performance fall under the Environment of Care (EC) standard, but others are included in the Human Resources (HR) and Leadership (LD) standards. The Guide relates each JCAHO Element of Performance to specific federal regulations, to help facilities be in compliance with both.

26. Symbols in JCAHO Guide = Compliance = Environmental Improvement = Tools and Resources

27. ENVIRONMENTAL COMPLIANCE AND IMPROVEMENT GUIDE

29. Choose a Standard.

30. "Clip Board" Versions

31. Standards and Elements of Performance“Full” Versions – 3.10.3

32. Compliance Language Pollution Prevention Language

33. Understand the Links Click on blue link: EPA Reference

34. Takes you straight to CFR citation for that requirement!

35. Understand the Links Click on teal link: HERC Reference

36. Refers directly to other areas of the H2E website

37. Understand the Links Click the green link: JCAHO Reference (Topic Locator)

38. TOPIC LOCATOR

39. Leadership Standard: Compliance Counts

40. JCAHO Performance Improvement • Write up Environmental Programs as Performance Improvement Initiatives • H2E has sample write-ups for Performance Improvement Initiatives on: • Regulated Medical Waste Reduction • Mercury Elimination • Glutaraldehyde Elimination Please let us know your experiences…

41. Evidence of Comprehensive Programs… Three lists … 1. Facility infrastructure that fundamentally addresses environmental compliance and improvement programs; 2. Current top compliance violation issues in healthcare; 3. Overall comprehensive environmental program management - priority issues.

42. Infrastructure • Institutional • Environment of Care Standard 3.10: The organization manages hazardous materials and waste risks • e.g., comprehensive environmental management policy • Leadership • LD 1.20 - Staff resources - Is there enough staff and resources to appropriately manage and respond • e.g., written commitment and policy from all levels within organization; includes roles of Safety Committee and staff • HR Competencies 2.10, 2.20 - Staff appropriately respond

43. Violations - Hazardous materials and waste not identified • EC 3.10: The organization manages hazardous materials and waste risks (EP 3.Implementation) • EC 3.10 EP 8 - Hazardous Waste Manifests - Manifest records lacking • A RCRA hazardous waste determination has been made, and documented, for all solid waste that is generated. • Manifest and other records are comprehensive and up-to-date. • Staff shows core competency in proper management and minimization based on proper determination • How to do it! --- JCAHO Guide and the HERC Hazardous Waste Determination Page

44. Hazardous materials and waste not identified (EC 3.10 EP 3)

45. Comprehensive Programs • Mercury Management, for example • Surveyors might look for evidence of • a Plan, • an Inventory, • Implementationprogram and results including staff competency,   • Emergency and Safety plan - spill policy and competency, • Leadership - mercury elimination commitment statement • MMMF Award • How to do it! --- www.h2e-online.org

46. The Fit! DOT/ OSHA EPA H2E • EPA • Environmental regulations • Waste, water, air, land • DOT • Hazardous materials in transportation • OSHA • Environment affects workers • Hazardous materials/substances • JCAHO • Environment affects patients, visitors and healthcare staff • H2E • Goals for improving environmental performance in healthcare JCAHO

47. Feedback on the Guide! • Continuous Quality Improvement - it’s a work in progress… • Is it useful? • Is it confusing? • Suggestions for additional tools and resources?

48. Summary • JCAHO standards cover all environmental regulations • H2E JCAHO guidance tool to assist with compliance and improvement • Tool is free and online. Use is easy especially with practice. • For comments or suggestions on the tool or training, contact Laura Brannen of H2E.

49. H2E JCAHO Guidance • Introduction • Table of Contents • JCAHO standards • http://www.h2e- online.org/regsandstandards/jcahointro.html

50. Where to Get More Information • Laura Brannen, H2E Executive Director • Laura.Brannen@H2E-online.org • 603/795-9966 • Catherine Zimmer, MnTAP • zimme053@umn.edu • 612/624-4635 • www.mntap.umn.edu • Hospitals for a Healthy Environment • www.h2eonline.org