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2008 Advisories & Alerts

Regulatory Advisory: The 2009 Joint Commission Standards and Scoring Process (December 2, 2008)

The Joint Commission has issued a new scoring and decision-making process for all accreditation and certification programs, to take effect January 1, 2009. This process has been developed to take into account the criticality of meeting Joint Commission standards and associated elements of performance (EPs).

In addition, significant revisions have been made to TJC standards that affect the hospital physical environment:

  • A new chapter on life safety has been created and included in most TJC accreditation manuals, including the hospital accreditation manual.
  • The Environment of Care chapter has been revised
  • The Emergency Management chapter has been revised.

Based on the total number of EPs that relate to the health care physical environment, it appears that compliance expectations have substantially increased. Although it is true the number of EPs related to the health care physical environment, especially in the Life Safety chapter, have increased dramatically in the 2009 standards, most of these are requirements that facilities have been responsible for under the 2008 standards.

ASHE encourages you to understand the concept of criticality in scoring and to begin looking at the new standards and assessing your organization's compliance.

  • 2009 Scoring and Decision-Making Process
  • New Life Safety Chapter
  • Revised Environment of Care Chapter
  • Revised Emergency Management Chapter
  • Appendix A: 2009 Scoring and Decision-Making Process FAQsRevised Emergency Management Chapter
  • Appendix B: Life Safety Chapter FAQs
  • Appendix C: Environment of Care Chapter FAQs
  • Appendix D: Emergency Management Chapter FAQ

NFPA 99 Piped Gas Technical Committee Proposes New Requirements for Maintaining Medical Gas Systems (September 9, 2008)

Once again we need your assistance in providing information on the need for including new requirements for testing frequencies, especially the annual testing of ALL medical gas station outlets/inlets for; flow (pressure and suction), attachment/detachment, labeling, and leakage.

Operating Rooms to be Considered Wet Locations: Your Support is Needed Today (August 12, 2008)

A proposal has been submitted to NFPA 99 that would change the current definition of "wet locations" to include all operating rooms. If this proposal is allowed to go through as written, it will ultimately require isolated power systems to be installed in all newly constructed or renovated ORs. This debate on whether ORs are in fact wet locations and whether isolated power systems need to be installed has been going on for over 30 years. The way the current NFPA 99 standard is written, it leaves the decision to classify a location as wet up to the governing body of the healthcare organization.

At the ASHE 45th Annual Conference & Technical Exhibition a panel discussion was devoted to debating whether all operating rooms should be considered wet locations. Members where able to express their views and the expert panel gave their opinions on the subject. At the end of the session, the participants in attendance (approximately 120) voted unanimously to have ASHE oppose this change and to seek additional guidance from the ASHE membership. [More ... ]

Guidance Statement: Considering Evidence-Based Design? (July 31, 2008)

In the ever-changing world of healthcare design, the application of science and data collection to the design process has become more prevalent than ever before. One resulting new trend is the practice of “evidence-based design” (EBD). The Board of Directors and staff of the American Society for Healthcare Engineering of the American Hospital Association are concerned with potential misrepresentations of the EBD concept and the apparently widespread application of this new design methodology. This ASHE Advisory provides an overview you and your staff can use to objectively evaluate claims related to the use of EBD in the project development process.

Regulatory Advisory: Joint Commission 2009 Standards Available for Download (July 2, 2008)

A Message to ASHE Members:

On July 1, 2008 the Joint Commission (TJC) announced that the 2009 standards, rationales, and elements of performance are available online. The standards will take effect January 1, 2009. To access specific Hospital Standards click on the links below:

ASHE's Commitment

As the proposed LS Chapter and new scoring process are finalized, ASHE will be providing guidance, tools and education opportunities to assist all ASHE members in the transition. It is ASHE's goal to be your trusted source for information and assistance.

For questions or comments contact Tim Adams at tadams@aha.org or 312-422-3804

Advocacy Advisory: The Journal of the American Medical Association Releases RFID Test Interference Results (June 25, 2008)

The Journal of the American Medical Association has published a study from the University of Amsterdam on "Electromagnetic Interference from Radio Frequency Identification Inducing Potentially Hazardous Incidents in Critical Care Medical Equipment" (JAMA June 25, 2008-Vol 299, No. 24) in which they documented a number of cases of interference with a variety of commonly used critical medical devices.

This well documented study shows that RFID devices in both the active and passive design may cause interference to critical medical devices. Interference classified as hazardous was noted in a range from six feet to a few inches for nine different types of medical devices. The authors state that the tests are based on the specific signal characteristics of their RFID system and do not necessarily apply "to other RFID systems if based on different signal characteristics or deployments." In addition, in order to mimic a worst case scenario, they used maximum power settings. Their conclusion is that RFID systems should have on-site Electromagnetic Interference (EMI) tests done before installing a system.

With the number of wireless devices being introduced into hospitals increasing, this study should remind hospitals to properly manage the use of the electromagnetic spectrum in house by pre-installation testing under all reasonable operating conditions of wireless medical devices and continuous monitoring and investigation of all reports of "interference".

Advocacy Update: Scoring of the 2008 Emergency Management Standards (April 25, 2008)
The Joint Commission Accreditation Committee at its April 17, 2008 meeting approved a plan to not count non-compliance with the new emergency management standards in accreditation decisions during 2008. ASHE commends The Joint Commission for their responsiveness to use this grace period as time to assess capacities, usage of supplies and resources, and to build local relationships within the community. According to Gail Weinberger, Director, Accreditation & Certification Policy & Administration at The Joint Commission, "non-compliance with these requirements will continue to be cited in an organization's report and will be required to be addressed in an Evidence of Standards Compliance (ESC). However, they will not be included in the count of the Requirements for Improvement contributing towards a Conditional Accreditation or a Preliminary Denial of Accreditation decision." More ...

The Joint Commission Proposes a New Chapter on Emergency Management-- Your Comments are Needed! (March 25, 2008)

A Message to ASHE Members:
The Joint Commission (TJC) is seeking public comment on a proposed new Chapter in their standards, Emergency Management You are encouraged to seize this opportunity to review and comment on the proposed standards.

As part of TJC's Standards Improvement Initiative, a new chapter has been created that will be used to assess compliance with the Emergency Management. While this may appear to be a huge increase in requirements, please don't panic. Most of the new Standards and Elements of Performance (EPs) in the new EM chapter are items that healthcare organizations are currently responsible for.

The Joint Commission Proposes a New Chapter on Life Safety - Your Comments are Needed! (January 14, 2008).Click here for the complete advisory Adobe PDF

The Joint Commission (TJC) is seeking public comment on a proposed new Chapter in their standards, Life Safety (LS). You are encouraged to seize this opportunity to review and comment on the proposed standards.

As part of TJC's Standards Improvement Initiative, a new chapter has been created that will be used to assess compliance with the Life Safety Code. While this may appear to be a huge increase in requirements, please don't panic. Most of the new Standards and Elements of Performance (EPs) in the new LS chapter are items that healthcare organizations are currently responsible for.

As the transition to the new TJC Life Safety Chapter takes place, ASHE will provide its members with guidance, tools and educational opportunities, and be your trusted source for information and assistance.