Are You Ready for an Ambulatory Survey?
Part II: The Environment of Care and Life Safety
As with the hospital setting, ambulatory surgery centers, office practices, hospital-based ambulatory services, and other services that may be a part of a hospital’s network or may be completely independent, must meet many of the same environment of care and life safety requirements noted in the NFPA LSC 101, 2012 and NFPA 99, 2012, the Health Facilities Code. This means all aspects of the physical environment, including accuracy of temperature and humidity and ventilation in our Operating and Procedure room locations, how we use hazard chemicals, manage the medical gas system, and maintain a consistent approach to fire safety, to name a few, are important.
Here are tips for success
Regardless of the accrediting organization you use, the principles are the same and the care provided in ambulatory sites must meet the same requirements.
Point # 1: ASSURE ACCURACY OF UTILITY SYSTEMS CONTROLLING TEMPERATURE, HUMIDITY AND VENTILATION. Usually linked to the Infection Control CoP, the impact of consistent compliance with current ASHRAE ventilation, temperature and humidity continues to be the number one element of performance related to Utility Systems scored for Ambulatory settings. If you have an internal Building Automation System (BAS), make sure that you are reviewing ranges and communicating your adjustments routinely to department staff in those procedure areas; in you have a manual system, be prepared to provide real-time data and speak to your monitoring and correction process.
Point # 2: HIGH RISK MEDICAL EQUIPMENT. Assure a risk assessment of all medical equipment is current and accurate, identify high risk equipment, and make sure that all new equipment finds its way to the master equipment inventory. Surveyors may ask for a copy of your high-risk inventory to validate 100% PM required compliance for all high-risk equipment. A reminder also to address the Alternate Equipment Maintenance process as well.
Point # 3: FIRE ALARM AND LIFE SAFETY RELATED DOCUMENTATION. This appears twice in the Ambulatory top ten scored observations. Surveyors are looking for the accuracy of fire related inventory, being timely with required testing timeframes and assuring that repairs are documented in addition to retesting of those fire alarm and sprinkler device systems.
Point # 4: FIRE SAFETY RISKS. What is the frequency of your fire risk assessment? Roles and responsibilities at the point of and away from the fire are clearly defined in the Fire Safety plan. There is variation as to when drills are actually conducted. Proper management of storage locations to manage increased combustible loads is monitored.
Pint # 5: HAZARDOUS MATERIAL MANAGEMENT. Too often we lose sight of where we are actually using chemicals and hazmat type materials that are considered caustic or corrosive. Have we checked the Safety Data Sheet (SDS)? What is the required first aid and if indicated, is there an EYE-WASH station within 10 seconds or 55ft of access to the affected employee? What is the knowledge base of staff related to Spill Management and Cleanup process? Is appropriate PPE available? Ongoing education, training and drills are key to identify gaps.
Avoid Ambulatory Survey Findings
Remember that all accreditation requirements are based in Centers for Medicare and Medicaid (CMS) standards. The Environment of Care includes our approach to the general maintenance and safety of the built environment in addition to how we manage the life safety(fire) components as well. From our approach to managing aspects of building life safety, can we defend in place in a fire emergency and have we educated staff on how to protect and keep our patient’s safe in any type of an emergency? Environment of Care and Life Safety rounding will prevent some of the typical requirements for improvements (RFIs) that organizations receive:
- Failure to demonstrate required pressure relationships for critical, high-risk areas, such as the OR, GI Lab, Decontamination areas: (-) pressure in an area requiring (+) pressure and vice versa.
- Medical equipment that is missing organizational asset tags for inventory identification; equipment missing the required preventive maintenance documentation.
- Accuracy of inventory and meeting required timeframes for testing of fire alarm signaling devices, sprinkler testing, standby-emergency power and the medical gas system.
- Failure to properly segregate full, empty and in-use medical gas cylinders.
- Protecting the means of egress; clear corridors and access aisles.
- Managing our fire and smoke barriers: no penetrations above ceiling, door latching, ceiling barriers are smoke-tight.
Examples of Survey Findings:
- Evidence that equipment identified as high-risk (defibrillator) has not received (PM) preventive maintenance 100% of the time.
- The annual fire alarm testing for several devices was outside of the current annual timeframe: inventory of pull stations and smoke detectors is not accurate compared to the prior year.
- Multiple sprinkler pipes are observed having IT lines tethered to the sprinkler piping.
- Medical gas directional labeling is missing for medical air, vacuum on piping above ceiling. NFPA 99, 2012 requires labeling to be visible every 20-25ft.
- Evidence that the eye-wash stations are not being checked weekly in compliance with OSHA/ANSI standards.
- The GI Lab Decontamination room demonstrated positive pressure relationship to the adjacent space when the required pressure relationship is negative.
- Hazardous storage room is missing a door closer and did not positively latch.
Stay Ahead of the Curve
Managing the environment is everyone’s job! The more eyes the better when looking at areas from a safety perspective. Remember to communicate regularly with Facilities to address identified concerns. Never assume that someone has put in the work-order!!!! Keep policies and procedures up to date and assure that your facility has a robust approach to assessing risk in the environment in order to keep patients safe in your ambulatory settings.