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Utilities Management

Utilities Management. CSHE Los Angeles Chapter 2013 Annual Devin J Hugie, SASHE, CHFM, CHSP-FSM, CHEP. Criticality. Criticality defined as “the immediacy of risk to patient safety or quality of care as a result of noncompliance with a joint commission requirement.” 4 levels of Criticality:

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Utilities Management

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  1. Utilities Management CSHE Los Angeles Chapter 2013 Annual Devin J Hugie, SASHE, CHFM, CHSP-FSM, CHEP

  2. Criticality • Criticality defined as “the immediacy of risk to patient safety or quality of care as a result of noncompliance with a joint commission requirement.” • 4 levels of Criticality: • Immediate Threat to Life (ITL) *PDA Until Resolved • Situational Decision Rules * Based on Specific situations at time of Survey. • Direct Impact Requirements * Noncompliance may create an immediate risk to patient safety or quality of care. • Indirect Impact Requirements * Based on planning and evaluation or care processes

  3. What Triggers ITL(Immediate Threat To Life) • Significantly compromised fire alarm system • Significantly compromised fire sprinkler system • Significantly compromised emergency power supply system • Significantly compromised medical gas master alarm panel • Significantly compromised exits • Other situations that place patients, staff or visitors at extreme danger

  4. Criticality of Findings & Immediacy of Risk • The amount of time for submitting the ESC (Evidence of Standards Compliance) is based on the criticality of the finding and the immediacy of risk as follows • Direct Impact Within 45 Days • Indirect Impact Within 60 Days • D- Documentation is required • C- “C” Standards, All others are “A” standards

  5. EC.02.05.01 Manages Utility Systems Risks • Design/Installs systems that meet pt care / op needs • Written inventory of components D • Identifies inspection / maintenance activities D C • Identifies intervals for inspecting, testing, maintain componentsD • Minimizes pathogenic biological agents in cooling towers, etc • Pressure relationships; air-exchanges, filtration efficiencies (the ventilation systems provides appropriate pressure relationships, air-exchange rates, and filtration efficiencies) • The hospital maps distribution of utility systems D • The hospital Labels emergency shut downs • The hospital has written procedures for responding to utility system disruptions D • The hospitals’ procedures address shutting off the malfunctioning systems and notifying staff in affected areas. • The hospitals procedures address performing emergency clinical interventions during utility systems disruptions. • The hospitals procedures addresses the following: How to obtain emergency repair services. • The hospital responds to utility system disruptions as described in its procedures

  6. EC.02.05.03 Emergency Electrical Power Provides Emergency power for • Alarm systems per LSC (NFPA 99) • Exit route and exit sign illumination • Emergency communication system • Elevators (at least 1 for non-ambulatory pts) • Equipment that could cause harm if fails • Areas where loss of power cause result in PT harm (Or’s)

  7. EC.02.05.05 Maintain Utility Systems • Tests components before initial use D C • Inspects/tests/maintains Life Support Utility Systems D • Inspects/tests/maintains inf Cont utility system components D • Inspects/tests/maintains Non-Life Support Utility components D C

  8. EC.02.05.07 Maintains Emergency Power Systems • 30 day intervals, test battery-powered lights for 30 seconds (if required for egress) D C • 12 months, tests battery-powered lights for 1.5 HRS or replace all batteries @ 12 months/random tests 10% (if required for egress) D C • SEPSS tested for 5 min monthly/annual full load D • 12/year tests emergency generator for 30 minutes D • Emergency generator tested @ 30% or exhaust temp or annual load bank: 25% for 30 min, 50% for 30 min, 75% 60 min • 12/yr tests all automatic transfer switches D • 36 months, generator tested for 4 continuous hours D • 36 month test uses 30% nameplate rating or temp • Per Occurrence: If test fails, implements measures to protect pts until repaired • Perform retest after repairs

  9. EC.02.05.09 Maintains Medical Gas and Vacuum Systems • Inspects, tests, maintains critical components per defined timeframes D • Tests for purity, correct gas, pressure when installed, modified, repaired D • Shutoff valves accessible and clearly identifies control areas EC.02.05.09 Monitors conditions in environment • Utility systems management problems, failure, use errors C

  10. EM.02.02.09 Utility Disruption Emergency Operations Plan identifies alternative means of providing: • Electricity • Water needed for consumption and essential care activities • Water needed for equipment and sanitary purposes • Fuel required for building operations or essential transport activities • Medical gas/vacuum systems • Utility systems defined as essential, such as • Vertical & horizontal transport • Heating & cooling systems • Steam for sterilization • Utility needs identified in the HVA

  11. New Areas of Focus On the increase are observations related to: • Electrical Panel Schedules • Room Pressure relationships • Fire Sprinkler lines used for support • Battery back up lighting in Generator rooms • Eyewash Stations

  12. Questions Thank You

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