To provide true value, the Environment of Care (EC) management plan should serve as a roadmap, guiding an organization’s operations to minimize risk and support strong performance in six key EC functional areas: safety, security, hazardous materials and waste, fire safety, medical equipment, and utilities. Effective management plans are required of all Joint Commission-accredited organizations except for those accredited under the office-based surgery and home care programs. Management plans shouldn’t detail how things are done, but should provide assurance that processes are in place to respond to risk. For example, an organization’s utilities management plan might say: Although Acme Hospital does not monitor for Legionella bacteria, there is a process in place whereby the organization can implement mitigation strategies when notified by the infection control department of a potential outbreak. This statement assures that the organization has a mitigation strategy and knows when to activate it. As your organization creates or revises its management plan, keep the following in mind:
- Don’t cite the standards in the plan. While the plan must address the pertinent EC standards and their elements of performance (EPs), you don’t need to repeat them. Your organization may annotate a copy of the plan with the standard numbers to ensure that the plan addresses every relevant EP. This can also help during survey because the surveyor can quickly see how your organization complies with specific standards.
- Determine a format for the plan. The format of the plan can be determined by your organization. The plan can be:
- Individual documents that address each aspect of the EC
- One set of consolidated plans that cover all your organization’s functions
- One document that covers the topic areas that apply to all management plans and adjunct plans that highlight the work specific to the functional areas
An overall plan could describe each function as it relates to the entire EC management process, and attachments can go into the details for each of the six functional areas.
- Have a consistent structure for the plan. This enables anyone to pick up the plan and know where to find certain information. For example, each plan could include a mission and vision statement, a description of plan scope, a list of objectives, a list of compliance details, and a brief discussion about how performance will be measured and how the plan will be evaluated.
- Cite supporting policies and how to access them. This might include cross-referencing the appropriate policies and procedures or providing a list of them in an addendum to the plan.
- Show compliance with the strictest authority having jurisdiction (AHJ). The EC standards require one fire drill per shift per year in freestanding business occupancies. However, if the local fire marshal requires more frequent drills, an organization must honor that requirement. If the local AHJ requires one drill every two years, an organization is still required to have one per shift per year according to The Joint Commission, which is then the strictest AHJ. When the AHJ is not The Joint Commission, the plan should state that your organization is meeting the stricter authority’s requirements.
- Reference related Joint Commission standards. Standards from other chapters of the accreditation manual might apply to EC efforts and should be referenced in the management plan. A plan that refers to other standards will yield a more complete picture of the management process for each EC area and will create a safer environment for patients.
- Have a plan for every site accredited by The Joint Commission and ensure that the plan applies to the setting. For example, if a hospital has several physician offices, each office should have a management plan that reflects the activities that occur at that location. The hospital’s primary plan can be adapted to different settings. While the hospital’s hazardous materials management plan might mention mitigation strategies for Legionella, the physician office should not address this topic unless it has such mitigation strategies in place.
For more information, see the June 2013 Perspectives or the June 2013 issue of Environment of Care® News. (Contact: George Mills, firstname.lastname@example.org)