The Compliance Puzzle: Putting the Pieces Together : The Compliance Puzzle: Putting the Pieces Together A Guide to comply with JCAHO, EPA, OSHA, DOT, H2E and beyond. EPA H2E DOT/
OSHA JCAHO Janet Brown, H2E Partner Coordinator
Ph: 413/253-0254
E-mail: janet.brown@h2e-online.org
www.h2e-online.org
Today’s Objectives : Today’s Objectives The Status of Environmental Compliance in Healthcare
JCAHO Survey vs. EPA Inspections
H2E JCAHO Environmental Compliance and Improvement Guide
JCAHO Definition/Background : 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
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.
JCAHO’s Environment of Care
JCAHO “Performance Improvement*” : 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.
Hospitals for a Healthy Environment : 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 by 2005
Total waste reduction of 50% by 2010
Minimize persistent, bioaccumulative pollutants such as dioxins, heavy metals and others.
Awards program for facilities meeting and exceeding goals. H2E
JCAHO “Leadership” : 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.
H2E - Institutionalizing Change : H2E - Institutionalizing Change
www.h2e-online.org
Hazardous Materials : Hazardous Materials
Regulated Medical Waste : Regulated Medical Waste
JCAHO “Hazardous Materials and Waste” : 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.
10 Steps to Reducing RMW : 10 Steps to Reducing RMW http://www.h2e-online.org/pubs/tensteps/Rmw10steps.pdf Sample Tools – 10 Step Guides
Regulatory Compliance in Healthcare : 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
“OUR TOXIC HOSPITALS” : “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
EPA Enforcement - Top Ten Violations : 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).
EPA Top Ten Violations (cont.) : 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)
Environmental Compliance Violations found in Region 2: Primarily NY and NJ : Environmental Compliance Violations found in Region 2: Primarily NY and NJ
What does that have to do with Joint Commission? : What does that have to do with Joint Commission?
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. ? ? Inspected hospitals expressed confusion that despite just “passing” JCAHO, they still had significant compliance violations under EPA
Compliance… : 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
Comprehensive Approach to ALL Compliance Issues : 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.
How does the JCAHO Guide Work? : 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.
Symbols in JCAHO Guide : Symbols in JCAHO Guide = Compliance = Environmental Improvement = Tools and Resources
ENVIRONMENTAL COMPLIANCE AND IMPROVEMENT GUIDE : ENVIRONMENTAL COMPLIANCE AND IMPROVEMENT GUIDE
Slide25 : Choose a Standard.
"Clip Board" Versions : "Clip Board" Versions
Standards and Elements of Performance “Full” Versions – 3.10.3 : Standards and Elements of Performance “Full” Versions – 3.10.3
Slide28 : Compliance Language Pollution Prevention Language
Understand the Links : Understand the Links Click on blue link: EPA Reference
Slide30 : Takes you straight
to CFR citation for
that requirement!
Understand the Links : Understand the Links Click on teal link: HERC Reference
Slide32 : Refers directly to other areas of the H2E website
Understand the Links : Understand the Links Click the green link: JCAHO Reference (Topic Locator)
Slide34 : TOPIC LOCATOR
Leadership Standard: Compliance Counts : Leadership Standard: Compliance Counts
JCAHO Performance Improvement : 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…
Evidence of Comprehensive Programs… : 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.
Infrastructure : 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
Compliance Violations (pg 1 of 2) : Compliance Violations (pg 1 of 2) 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).
Violations - Hazardous materials and waste not identified : 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
Hazardous materials and waste not identified (EC 3.10 EP 3) : Hazardous materials and waste not identified (EC 3.10 EP 3)
Pages for more detailed Information : Pages for more detailed Information
Comprehensive Programs : Comprehensive Programs Mercury Management, for example
Surveyors might look for evidence of
a Plan,
an Inventory,
Implementation program 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
The Fit! : The Fit! 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 H2E EPA DOT/
OSHA
Feedback on the Guide! : 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?
Summary : 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.
H2E JCAHO Guidance : H2E JCAHO Guidance Introduction
Table of Contents
JCAHO standards
http://www.h2e-
online.org/regsandstandards/jcahointro.html
Where to Get More Information : 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
Toll Free Hotline: 800-727-4179 E-mail: h2e@h2e-online.org www.h2e-online.org : Toll Free Hotline: 800-727-4179 E-mail: h2e@h2e-online.org www.h2e-online.org
Cecilia DeLoach, State Partnership Programs Coordinator Cecilia.DeLoach@H2E-online.org
800-727-4179
Chen Wen, EPA Coordinator Chen.Wen@H2E-online.org
202-564-8849
Laura Brannen, Director Laura.Brannen@H2E-online.org
603-795-9966
Janet Brown, Partner Coordinator Janet.Brown@H2E-online.org
413/253-0254
Sarah O’Brien, Champion Coor. Sarah.obrien@h2e-online.org
(802) 479-0317 H2E Program Contacts