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Advisories and Alerts

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).

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.

Department of Homeland Security Chemical Facility Anti-Terrorism Standards: Final Rule (December 19, 2007)
The Department of Homeland Security (DHS) has issued Chemical Facility Anti-Terrorism Standards for any facility that manufactures, uses, stores, or distributes certain chemicals above a specified quantity. The standard may apply to hospitals and research institutions and you may have to file a report to DHS by 1/19/08.

Background:
On November 20, 2007 DHS published an updated Appendix A to this standard identifying nearly 300 chemicals that present a security risk. If a facility possesses amounts of a chemical at or above the threshold quantities specified in this inventory, they are required to fill out the “Top-Screen” questionnaire within 60 days of the publication date of 11-20-2007. There are three security issues involved:

  1. Release- either intentionally or detonated
  2. Theft and Diversion-chemicals that if stolen have the potential to be used or converted into weapons.
  3. Sabotage and contamination-chemicals if mixed with other materials have the potential for human harm

Recommended Action:
ASHE members are encouraged to discuss this new DHS standard with each of the appropriate professionals within their organization to assess your organizational use and storage of chemicals. The appropriate professionals may include the risk manager, safety officer, facility manager, laboratory manager, materials manager, pharmacist, chief engineer, head groundskeeper, and others.

  • To assist you in the assessment of your chemical inventory, ASHE has converted the inventory list into an excel spreadsheet available at http://www.ashe.org/ashe/codes/legislativeissues.html. This spreadsheet can be used as a tool to determine your facility’s status with regard to this Standard. If there are no chemicals present in a facility at or above the screening threshold, then nothing further is required. The threshold quantities apply to the 60 days prior to the publication date of 11-20-2007 and anytime thereafter.

For questions or comments contact John Collins at jcollins@aha.org or 312-422-3805

ASHE Proposed Revisions to NFPA 99 – Your Comments Are Needed (Sept 5, 2007)
Over the past two years, numerous ASHE workgroups have reviewed the existing language of the Standard on Health Care Facilities (NFPA 99) and have proposed revisions to modify or delete existing language and to propose new language. We need your help to review these proposed revisions and provide your comments to the workgroups so we can ensure the proposed changes actually reduce unnecessary burden and lead to improved safety and patient care. Our goal is to assist NFPA with making the standard easier to navigate, more clearly written, and assure that the requirements address actual risks and provide appropriate relief or mitigation from that risk. You can help us meet that goal by reviewing the proposed standards and providing your comments. The ASHE workgroups have reviewed the existing chapters including Electrical Equipment, Electrical Systems, Emergency Management, Gas Equipment, and Medical Gas Systems as well as addressing new potential chapters on HVAC, Information Technology, and Environmental Safety.

You can review the outputs of the various task forces and file your comments on line to ASHE by going to http://ashe.org/ashe/codes/nfpa99/index.html and clicking on the primary topic(s) you are interested in. ASHE has the opportunity to be a leader in rebuilding NFPA 99 to recognize and encourage cost effective, appropriate patient care. We need your expert knowledge, experience, and opinions to help recreate this standard to effectively address and manage risks while bringing efficiencies to the regulatory compliance burden faced by healthcare providers

Cell Phones in Hospitals (April 3, 2007)
Ad hoc studies have shown there is no interference from cell phones on medical devices and there are also reports of interference from cell phones on medical devices. The ad hoc reports are just that. They are not rigorous scientific studies. Holding a cell phone next to a device and putting it into operation might show that nothing untoward happens but that is only valid for that observation. ASHE recommends a risk assessment by qualified personnel at the hospital to weigh all the pros and cons. Even if the conclusion is to allow cell phones, they still should not be used closer than 3 feet from life support/critical care equipment.

CMS and The Joint Commission Define Installation Criteria of Alcohol-Based Hand Rub Dispensers (March 21, 2007)

Click here for the complete Advisory.

Joint Commission Expanded Scope of Service for Life Safety Code Specialists
The Joint Commission announced in the January 2007 Joint Commission Perspectives that effective January 1, 2008, the Joint Commission will expand the scope of the Life Safety Code® Specialist to include:

  1. Adding a Life Safety Code Specialist to the survey team for one day for all critical access hospital and hospital surveys
  2. For Hospitals and critical access hospitals with more than 750,000 square feet, the Life Safety Code Specialist surveys will be extended from one day to two days in 2008

ASHE encourages hospitals to design, build and maintain their facilities to protect patients, visitors and staff from fire, smoke and products of combustion. The process of evaluating and maintaining features of fire protection, fire suppression and alarm systems should be systematic and on-going, and not based on when and what type of inspection will take place. Click here for ASHE's Regulatory Advisory.

CMS Guidance on Alcohol-based Skin Preparations in Anesthetizing Locations
On January 12, 2007 the Centers for Medicare and Medicaid Services (CMS) issued a Memorandum to State Survey Agency Directors supporting the use of alcohol-based skin preparations in anesthetizing locations. Specifically, the Memorandum addresses "risk reduction techniques to permit safe use of alcohol-based skin preparations in inpatient or outpatient locations in hospitals, Critical Access Hospitals (CAH) or Ambulatory Surgery Centers."

ASHE encourages healthcare organizations that use alcohol-based or flammable skin preparations in anesthetizing locations to immediately implement and monitor their compliance with the risk reduction methods outlined in the CMS Memorandum and the Temporary Interim Amendment (TIA) to NFPA 99. To view ASHE's Advisory and link to the CMS Memo and NFPA TIA please click here.

Due Date for eSOC™ is Extended
In 2004, the Joint Commission announced that the Statement of Conditions™ process would migrate to an electronic version effective January 1, 2007. This would affect the required Part 2, Basic Building Information (BBI) and Part 4, Plan for Improvement (PFI). Since August 2005, the eSOC (electronic Statement of Conditions™ compliance document) has been available to organizations via the Joint Commission extranet to allow ample time to migrate from the existing paper process to an electronic process. During this time, two concerns have been identified and shared with the Joint Commission by the American Society for Healthcare Engineering (ASHE) as well as letters written directly to the Joint Commission's Standards Interpretation Group. In response to these concerns, the Joint Commission is working on an interface to assist the user in their conversion of those items remaining in their current electronic format to the Joint Commission eSOC, and create a solution to a security issue related to access to the eSOC. In light of the time needed to effect these changes, the Joint Commission has extended the due date to convert from paper or in-house electronic format to the eSOC to July 1, 2007. During this transition period, the Joint Commission requires:

  • All accredited organizations, which have buildings that require a Statement of Conditions, to have created an electronic Basic Building Information (eBBI, which is Part 2 of the SOC/eSOC) by January 1, 2007.
  • All new life safety code deficiencies required to be managed using the Statement of Conditions should be managed using the electronic Plan for Improvement (ePFI, which is Part 4 of the SOC/eSOC) beginning no later than January 1, 2007.
  • Any life safety code deficiency that is currently identified in an existing Part 4 (paper, spreadsheet, other), and that is scheduled to be completed after December 31, 2006, should be entered into the eSOC. After discussion with ASHE, the Joint Commission agreed to make the effective date July 1, 2007.

This was first reported in the November 3, 2006 edition of ASH*E*Flash


JCAHO Triennial Extended Run Test For Emergency Generators
Effective 1/1/07 the Joint Commission (JCAHO) has revised EC Standard 7.40 adding the requirement that "The organization tests each emergency generator at least once every 36 months for a minimum of four continuous hours". JCAHO will begin surveying for compliance with this new requirement on 7/1/07. In announcing the field review of the proposed revision, the JCAHO stated that this proposed revision is "Based on recent briefings by experts and debriefing with organizations that have sustained extended electrical utility power outages". Many ASHE members took advantage of the opportunity to comment on this proposed new requirement ultimately leading to the final requirement.

Advisory Archive