Comments on Revisions to Performance Improvement (EC9)
Note: ASHE comments are highlighted in yellow.
Current Standard: EC.9.10
The organization monitors conditions in the environment.
Revised Standard: EC.9.01.0
The [organization] collects information to monitor conditions in the environment.
Note: Incidents involving [patients] may be reported to appropriate staff
in quality assessment, improvement, or other functions.
However, at least a summary of such incidents is shared with the person
designated to coordinate safety management activities.
(see also EC.1.01.0) Note: Review of incident reports often requires
that legal processes be followed to preserve confidentiality. Opportunities
to improve care, treatment, and services or to prevent similar incidents
are not lost as a result of following the legal process.
Are “notes” advisory only or are they
enforceable code language? This note appears to have a requirement in addition
to the standard.
Current Standard: EC.9.10 Current EP 1:
The organization establishes and implements process(es) for reporting and investigating
the following*:
- Injuries to patients or others coming to the organization’s facilities as well as incidents of property damage
- Occupational illnesses and injuries to staff
- Security incidents involving patients, staff, or others coming to the organization's facilities or property
- Hazardous materials and waste spills, exposures, and other related incidents
- Fire-safety management problems, deficiencies, and failures
- Equipment-management problems, failures, and user errors
- Utility systems management problems, failures, or user errors
*Organizations have the flexibility to develop a single reporting method
that addresses one or more of the items listed.
TO
Revised Standard: EC.9.01.0: Revised EP 3:
The [organization] establishes and implements a process for investigating and
reporting: injuries to [patients] or others within the [organization]’s
facilities and grounds.
This is new language.” Grounds” is not
in the current standard/EP.
Current Standard: EC.9.10 Current EP 3:
The organization establishes and implements a process(es) for on-going monitoring
of performance regarding actual or potential risk(s) in each of the environment
of care management plans.
**The environment of care plans are for managing safety, security, hazardous
materials and waste, emergency management, fire safety, medical equipment,
and utilities.
Revised Standard: EC.9.01.0: Revised EP 1:
The [organization] continually monitors its performance in managing the risks
identified in each of the environment of care management plans.
The word continual might imply constant such as every
minute of every day. “On-going” might
be a better word.