Audit

EC.01.01.01 The hospital plans activities to minimize risks in the environment of care. Note 1: One or more persons can be assigned to manage risks associated with the management plans described in this standard. Note 2: For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital complies with the 2012 edition of NFPA 99: Health Care Facilities Code. Chapters 7, 8, 12, and 13 of the Health Care Facilities Code do not apply. Note 3: For further information on waiver and equivalency requests, see https://www.jointcommission.org/life_safety_code_information_resources/ and NFPA 99-2012: 1.4.

Rationale for EC.01.01.01
Risks are inherent in the environment because of the types of care provided and the equipment and materials that are necessary to provide that care. The best way to manage these risks is through a systematic approach that involves the proactive evaluation of the harm that could occur. By identifying one or more individuals to coordinate and manage risk assessment and reduction activities—and to intervene when conditions immediately threaten life and health—organizations can be more confident that they have minimized the potential for harm. Risks in the environment include safety and security for people, the handling of hazardous materials, the potential for fire, and utility systems.

Written management plans help the organization manage risks. These plans are not the same as operational plans, but they do provide a framework for managing the environment of care. These plans should also address the scope and objectives of risk assessment and management, describe the responsibilities of individuals or groups, and give time frames for specific activities identified in the plan.
Note: It is not necessary to have a separate plan for each of the areas identified in the standard; they may all be contained in a single document.

EP1 - Leaders identify an individual(s) to manage risk, coordinate risk reduction activities in the environment of care, collect information on deficiencies, and disseminate summaries of actions and results. Note 1: This information is disseminated to individuals with responsibility for the issues being addressed. Note 2: Deficiencies include injuries, problems, or use errors.

EP4 - The organization has a written plan for providing a safe environment for everyone who enters the organization’s facilities. Note: Facilities include both leased and owned spaces.

EP5 - The organization has a written plan for providing a secure environment for everyone who enters the organization’s facilities. Note: Facilities include both leased and owned spaces.

EP7 - The organization has a written plan for managing the following: Fire safety.

EP9 - The organization has a written plan for managing the following: Utility systems.

EC.02.01.01 The hospital manages safety and security risks.


Rationale for EC.02.01.01
Safety and security risks are present in most health care environments. These risks affect all individuals in the organization—individuals served, visitors, and those who work in the organization. It is important to identify these risks in advance so that the organization can prevent or effectively respond to incidents. In some organizations, safety and security are treated as a single function, although in others they are treated as separate functions.

Safety risks may arise from the structure of the physical environment or the performance of everyday tasks, or be related to situations beyond the organization’s control, such as the weather. Safety incidents are most often accidental. On the other hand, security incidents are often intentional. Security protects individuals and property against harm or loss. Examples of security risks include workplace violence, theft, and unrestricted access to medications. Security incidents are caused by individuals from either outside or inside the organization.

EP 1 - The organization implements its process to identify safety and security risks associated with the environment of care that could affect individuals served, staff, and other people coming to the organization’s facilities. Note: Risks are identified from internal sources such as ongoing monitoring of the environment, results of root cause analyses, results of proactive risk assessments of high-risk processes, and from credible external sources such as Sentinel Event Alerts.

EP3 - The organization takes action to minimize identified safety and security risks associated with the physical environment.

EP5 - The organization maintains all grounds and equipment.

EP8 - The organization controls access to and from areas it identifies as security sensitive.

EP11 - The organization acts in accordance with product notices and recalls. (See also MM.05.01.17, EPs 1–4)

EP13 - For opioid treatment programs: The organization establishes procedures for handling physical or verbal threats, acts of violence, inappropriate behavior, or other escalating and potentially dangerous situations. This includes situations in which security guards or police need to be summoned.

EC.02.06.01 The hospital establishes and maintains a safe, functional environment. Note: The environment is constructed, arranged, and maintained to foster patient safety, provide facilities for diagnosis and treatment, and provide for special services appropriate to the needs of the community.


Introduction to Standard EC.02.06.01
Features of the organization’s space influence the outcomes and satisfaction of individuals served and promote safety. The physical space also affects families, staff, and others in the organization.

These features of the environment of care include the following:
- Quality of natural and artificial light
- Privacy
- Size and configuration of space
- Security for individuals served and their belongings
- Clear access to internal and external doors
- Level of noise
- Space that allows staff to work efficiently

When designed into and managed as part of the environment, these elements create safe and suitable surroundings that support the dignity of the individual served and allow ease of interaction. The physical environment balances an individual’s rights against his or her needs and safety and the environment in which care, treatment, or services are provided. In particular, the leaders consider the safety, rights, and security of the individual served when approving the use of structural restraints.

The standards do not specifically address all of these features. However, organizations may wish to consider these aspects of the environment when they design and manage spaces. Decisions on what features to pursue should be based on data, such as information about the satisfaction of the individual served, data collected from staff, and evidence-based design guidelines.

EP1 - Interior spaces meet the needs of the individuals served for safety and suitability for the care, treatment, or services provided.

EP4 - The organization provides outside areas for use by individuals served, based on the individual's needs and suitable to the individual's age or other characteristics. Note: Outdoor areas may include facility grounds, nearby parks and playgrounds, and adjacent countryside.

EP5 - The organization provides storage space to meet the needs of the individual served.

EP8 - Waiting and reception areas are adequate in size and number and staffed according to the needs of the individuals served.

EP9 - Restrooms are adequate in size and number for people using the facility.

EP10 - For opioid treatment programs: The use of physical space, including bathrooms, reflects the special needs of female patients.

EP11 - Lighting is suitable for care, treatment, or services.

EP12 - Lighting is controlled by the individuals served, consistent with care, treatment, or services provided.

EP19 - Drinking fountains or water coolers are available for the individuals served.

EP20 - Areas used by individuals served are safe, clean, and comfortable.

EP24 - Furnishings and equipment should reflect the ability and needs of the individual served.

EP25 - Door locks and other structural restraints (such as fences) have the following characteristics:
- They are consistent with the organization's mission, program goals, program policy, and law and regulation.
- They provide the least-restrictive environment.
- They meet the needs of the individual served.
- They provide for emergency access to locked, occupied spaces.

EP26 - The organization keeps furnishings and equipment safe and in good repair.

EP36 - For opioid treatment programs: The program has private, individual offices available for counseling.

EC.02.06.03 The organization establishes and maintains a safe and functional dining environment when food is provided.

EP1 - The dining environment encourages eating and socialization.

EP2 - Dining areas are free from loud and distracting noises.

EP3 - Dining areas are arranged to seat small groups.

EP4 - Consistent with program goals, facilities for preparing snacks and meals for special occasions are available.

EP5 - The facilities for serving snacks, preparing meals, and engaging in recreational activities support the participation of the individuals served.

EC.02.06.05 The hospital manages its environment during demolition, renovation, or new construction to reduce risk to those in the organization.
Note: These elements of performance are applicable to all occupancy types.


Rationale for EC.02.06.05
In addition to fire safety, there are other hazards and risks resulting from demolition, renovation, or new construction that must be addressed. It is important to plan and conduct risk assessments before construction begins. Authoritative guidelines and state regulations can provide valuable information to guide demolition, renovation, or new construction.

EP1 - The organization uses design criteria when planning for new, altered, or renovated space that are consistent with applicable local, state, and federal law and regulation.

EP2 - When planning for demolition, construction, renovation, or general maintenance, the organization conducts a preconstruction risk assessment for air quality requirements, infection control, utility requirements, noise, vibration, and other hazards that affect care, treatment, and services. Note: See LS.01.02.01 for information on fire safety procedures to implement during construction or renovation.

EP3 - The organization takes action based on its assessment to minimize risks during demolition, construction, renovation, or general maintenance.

EC.03.01.01 Staff and licensed independent practitioners are familiar with their roles and responsibilities relative to the environment of care.


Rationale for EC.02.06.05
In addition to fire safety, there are other hazards and risks resulting from demolition, renovation, or new construction that must be addressed. It is important to plan and conduct risk assessments before construction begins. Authoritative guidelines and state regulations can provide valuable information to guide demolition, renovation, or new construction.

EP2 - Staff can describe or demonstrate actions to take in the event of an environment of care incident.

EC.04.01.01 The hospital collects information to monitor conditions in the environment.

EP1 - The organization establishes a process(es) for continually monitoring, internally reporting, and investigating the following:
- Injuries to individuals served or others within the organization’s facilities
- Occupational illnesses and staff injuries - Incidents of damage to its property or the property of others in locations it controls
- Security incidents involving individuals served, staff, or others in locations it controls
- Fire safety management problems, deficiencies, and failures
Note 1: All the incidents and issues listed above may be reported to staff in quality assessment, improvement, or other functions. A summary of such incidents may also be shared with the person designated to coordinate safety management activities.
Note 2: Review of incident reports often requires that legal processes be followed to preserve confidentiality. Opportunities to improve care, treatment, or services, or to prevent similar incidents, are not lost as a result of following the legal process.

EP2 - Based on its process(es), the organization reports and investigates the following: Problems and incidents related to each of the environment of care management plans.

EP3 - Based on its process(es), the organization reports and investigates the following: Injuries to individuals served or others within the organization’s facilities.

EP4 - Based on its process(es), the organization reports and investigates the following: Occupational illnesses and staff injuries. Note: This requirement applies to issues in the workplace, such as back injuries or allergies. It does not apply to communicable diseases.

EP5 - Based on its process(es), the organization reports and investigates the following: Incidents of damage to its property or the property of others in locations it controls.

EP14 - The organization monitors environmental deficiencies, hazards, and unsafe practices.

EP15 - Every 12 months, the organization evaluates each environment of care management plan, including a review of the plan’s objectives, scope, performance, and effectiveness. Note: By evaluating the management plans, the organization can make sure that they remain relevant and useful guides for managing the environment of care. A review of the plans' scope includes a determination of whether any new services, programs, or sites added in the past year need to be addressed by the plans or if new hazards have been introduced into the environment that now need to be covered. A review of the plans' effectiveness could be accomplished through a review of incident reports as well as evaluation of other known problems that are not found on the incident reports (such as problems identified in the critique of a fire drill). A review of the plans' objectives would include a determination of whether the previous year's objectives were met and if any new objectives should be established to address problems identified in the review of the plans' effectiveness.

EC.04.01.03 The hospital analyzes identified environment of care issues.

EP2 - The organization uses the results of data analysis to identify opportunities to resolve environmental safety issues.

EC.04.01.05 The hospital improves its environment of care.

EP1 - The organization takes action on the identified opportunities to resolve environmental safety issues.

Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.