Today’s blog post is the third in a series of posts of questions and answers from the JCR Annual Ambulatory Care Conference of November 2013. The Joint Commission “panel of ambulatory experts” responded to these questions regarding compliance issues during sessions held at the conference.
This installment focuses on the ‘environment of care.’ To answer our customer’s questions, we welcome guest blogger, John Maurer, SASHE, CHFM, CHSP. A Joint Commission staff engineer, John provides support for customers seeking insights specific to the ambulatory care environment and is a member of The Joint Commission’s Department of Engineering.
Q: Are there any standards regarding keeping the anesthesia equipment on all day and changing the equipment filter between each case?
A: There are no standards that address how long anesthesia equipment may be kept on. Changing filters on equipment and other maintenance activities would be defined by the manufacturer and should be defined in the policies governing inspection and maintenance activity, per EC.02.04.01 and implemented in accordance with EC.02.04.03.
Q: What are the challenges with generators?
A: One challenge The Joint Commission often sees is with the documentation required in EC.02.05.07. This is relative to generators and automatic transfer switches (ATSs) and how they are maintained in ambulatory settings. Generators are expected to be tested at least monthly for a minimum of 30 minutes under whatever the connected load to the generator is for the facility. This applies to any type of generator that is being used to supply emergency power in accordance with the elements noted in EC.02.05.03. Some organizations have self-testing generators that will conduct the necessary tests automatically, which is acceptable. Other organization may use a service company to perform the required tasks. Regardless of the method used to perform the required inspection and testing of generators, the information must be made available to the surveyor(s) at the time of survey.
Q: Does The Joint Commission have a job description for a safety officer, infection control officer, or a performance improvement officer?
A: The Joint Commission expects organizations to define qualifications and competencies based on the needs and services provided. Please see the HR chapter (HR.01.02.01) for further information regarding this topic.
Q: If an ambulatory care center does its laundry in-house, what guidelines do you recommend we follow? Also, do you recommend inspection? If so, by whom?
A (on guidelines): Many organizations have their own laundry service. Design and engineering issues are addressed in the 2010 edition of the “Guidelines for Design and Construction of Health Care Facilities,” section 3.1-5, as administered by the Facilities Guidelines Institute (FGI). This applies to new, renovated, or altered spaces as referenced in EC.02.06.05, EP 1, however, and existing spaces should be maintained as they were designed. FGI recommends the hot water for laundry service to be 160oF, with provisions that may allow for lower temperatures ).
A (on inspections): A maintenance and inspection program is required per EC.02.05.01 and EC.02.05.05, and should be developed by using evidence-based guidance, such as the Center for Disease Control’s “Guidelines for Environmental Infection Control in Health-Care Facilities,” 2003 edition, and the equipment manufacturer’s recommendations. As to ‘who performs the maintenance and inspection?’ this should be determined by the organization, which may choose to use a combination of staff and equipment vendors, for example.