Maintaining a Safe Environment of Care – conformance to Joint Commission Standards and avoiding accreditation citations Reply

Joint Commission accreditation is intended to ensure that hospitals provide the highest level of performance and service to their patients. The Joint Commission’s accreditation process seeks to help organizations identify and resolve problems and to inspire them to improve the safety and quality of care and services provided. The process focuses on systems critical to the safety and the quality of care, treatment, and services.

Joint Commission publishes a list of the top deficiency citations about every 6 months. The top ten citations for the first half of 2014 were recently highlighted in the December 2014 issue of the New England Healthcare Engineers’ Society (NEHES) newsletter. One of the top ten citations is specifically related to management of hazardous materials and waste. The Joint Commission Standards include Environment of Care Standard EC.02.02.01, the management of hazardous materials and waste. This standard includes several elements of performance to ensure that hospitals are maintaining a safe environment for their patients, health care professionals, and support staff. Hospitals must be able to demonstrate that they do the following:

– Maintain a written, current inventory of hazardous materials and waste that it uses, stores, or
generates
– Have written procedures, including the use of precautions and personal protective equipment, to
follow in response to hazardous material and waste spills or exposures
– Implement its procedures in response to hazardous material and waste spills or exposures
– Minimize risks associated with selecting, handling, storing, transporting, using, and disposing
of hazardous chemicals, radioactive materials (radiation, x-rays), hazardous energy sources
(lasers, MRIs), and hazardous gases and vapors
– Minimize risk associated with disposing of hazardous medications
– Monitor levels of hazardous gases and vapors to determine that they are in safe range
– Have the permits, licenses, manifests, and MSDSs required for managing hazardous materials and
waste
– Label hazardous materials and waste, identifying the contents and hazard warnings

Demonstrating conformance to this standard includes compliance with several regulations, covering a diverse range of hazardous materials and hazardous waste sources, or “streams.” In addition, there is overlap among the many applicable regulations: OSHA, EPA, DOT, NRC, DOE, state regulations, and local bylaws.

In order to reduce risk, hospitals should consider getting a third party inspection, or audit, to assist on both compliance with applicable hazardous materials and hazardous waste regulations, and conformance to the Joint Commission Environment of Care standard. If you would like to find out more, please contact CAPACCIO’s William Potochniak, PE, at wpotochniak@capaccio.com or Jill Vernes, CHMM, TURP, at jvernes@capaccio.com.

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