The Joint Commission (TJC) Compliance

• TJC:  Employee Review and Easy Reference
  • Safety Management
  • Medical Equipment
  • Emergency Preparedness (Disaster)
  • Utilities
  • Security
  • Fire Safety
  • Hazardous Materials
  • Social Environment (patient care areas)
• About the Joint Commission on Accreditation of Healthcare Organizations
• VUMC Environment of Care (EOC)
• EOC Contacts
• Additional Healthcare Regulatory Agencies

TJC:  Employee Review and Easy Reference

Safety Management

1. Have you received training about Vanderbilt's Safety Program and how you can perform your job safety?
   • Yes, initial safety training is provided at Hearts and Minds orientation when employees are hired at Vanderbilt. Annually, staff participate in the Safety Fair and departmental safety training as a review.
2. What topics are included with your Safety Orientation and annual Safety Training?
   • General Safety and Vanderbilt policies, electrical and equipment safety, hazard communication (chemical safety), fire safety and emergency preparedness, bloodborne pathogens and isolation procedures, needles and sharps safety, personal safety and security, and fire safety
3. What are some general safety risks in your work area?
   • Some general safety risks found in all areas of the Medical Center include: spilled fluids, damaged electrical cords, broken furniture, etc.
4. What should you do if you notice a general safety risk such as those mentioned above?
   • Remove/confine the safety hazard and call the appropriate department
   • Facilities Management should be called for immediate repairs.
   • Clinical Engineering Services for medical equipment that is broken or damaged.
   • Environmental Services for non-hazardous spills if Service Associate is unavailable
   • Office of Clinical and Research Safety (OCRS) for hazardous spills.
5. What is an incident?
   • Any occurrence that is not consistent with the routine operation of VUMC.
6. What should you do if you are injured at work?
   • Report the injury to your supervisor; seek medical attention (if needed) through the Occupational Health Clinic or the ED; complete a first report of injury form.
7. How should you report an incident involving a patient or visitor?
   • Complete an Occurrence Report (MC 1518) within 24 hours of the incident.
8. What should you do if there is a serious incident or possible Sentinel Event?
   • Notify Risk and Insurance Management of incident as soon as possible.
9. How should the Occurrence report or first report of injury be written?
   • In clear, concise terms with no assumptions or "blame". Only pertinent information and factual data should be documented. Document complete details of incident.
10. What do you do if a visitor is involved in an incident?
    • Notify VUPD immediately of all visitor incidents involving theft. An incident or adverse occurrence report should be filled out for all incidents involving patients or visitors and sent to Risk and Insurance Management when completed. 
    • If the staff member discovering the incident feels that the visitor should go to the Emergency Department, this fact and reason must be noted on the incident report.
11. What should hospital personnel tell visitors that have had an incident?
    • Hospital staff should NOT inform visitors that Vanderbilt will the guarantor of any expenses incurred or make any statement indicating the hospital is responsible for the incident. Refer any questions to Risk and Insurance Management (936-0660).
12. Where can you smoke at VUMC?
    • Smoking is NOT permitted inside any Medical Center buildings or clinics.  There are no exceptions.
    • Designated smoking areas are listed in the VUMC Smoking Policy, SA 40-10.02.
13. Where can you find information about VUMC’s safety, infection control, operational and clinical requirements?
    • Access VUMC policies online at https://vanderbilt.policytech.com. 

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Medical Equipment

1. Who should you call about problems (failures/malfunctions) with medical equipment?
   • Call Clinical Engineering (formerly Biomedical Electronics) to report equipment problems.
2. How can you tell if equipment has been inspected by the Clinical Engineering department?
   • A current inspection sticker must be displayed on the equipment. Check the date on the sticker and never use equipment that is "out of date" for its check by BioMed.
3. How do you know if the medical equipment you are using is safe and working properly?
   • Whenever medical equipment is used, make sure the equipment is clean, and make sure the equipment is working properly.
4. What should you do if medical equipment breaks of does not function correctly?
   • Remove the equipment from service.
   • Notify your supervisor/manager
   • Send the equipment for repair.
5. What should you do if patient injury is caused by equipment failure?
   • Call Clinical Engineering and Risk Management as soon as possible. 
   • Secure the equipment so that it can be evaluated by Risk Management. It is vital that hospital personnel preserve and protect any equipment involved in a patient/employee/visitor incident for further examination and investigation.
6. Does your job require you to use medical equipment?
   • If you use medical equipment for your work at Vanderbilt, you must be able to describe or demonstrate operating and safety procedures for equipment use. For example, if you are expected to use a defibrillator, you should know how to turn the equipment off/on, how to use the equipment safely, and describe how and why you know that the equipment is working properly.

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 Emergency Preparedness (Disaster)

1. How do you know what your duties are in a disaster?
   • Review the VUMC Safety and Emergency Operations Manual and the Emergency Operations Quick Reference Guides for the Main Campus and the 100 Oaks Campus.
2. Does VUMC test the emergency preparedness/disaster plans?
   • Yes, all areas should participate in disaster drills at least twice every year. Off-site clinics must have one disaster drill annually.
3. What back up communications systems can be used if the medical center phones fail?
   • The red phones can be used if the regular phone system fails. Also pagers and 2-way radios can be used.
4. What is the overhead announcement used to alert Medical Center staff about a missing patient?
   • Code Pink – Missing Infant (younger than 12 months)
   • Code Purple – Missing Child (1-12 years)
   • Code Walker Adolescent - missing teen (13-17 years)
   • Code Walker Adult – missing adult (18 years or older)
5. What overhead announcement is used to tell staff that they should PREPARE for a disaster plan activation?
   • "YELLOW Alert for 'situation'"
6. What overhead announcement is used to tell staff to ACTIVATE the disaster plan for their area?
   • "ORANGE Alert for 'situation'"
7. What actions should you take if an "Orange Alert for Tornado" is announced?
   • Move patients, visitors, staff into interior areas away from exterior walls and windows.
   • Close windows and drapes
   • For patients that cannot be moved, cover patients with blankets and move bed so that patients' heads are turned away from windows.
8. What should you do if you receive a threatening phone call (or bomb threat)?
   • Do not hang up the phone.
   • Make detailed notes about the call and caller. Note the time.
   • Have someone call VUPD immediately from another phone.
   • Report the call to the AOC
   • Prepare to evacuate but wait until directed to do so.
   • Overhead announcement is Code Black.
9. What should you do if you encounter a suspicious package or letter?
   • Do not disturb, shake, or open the package.
   • Do not give the package to someone else to look at or remove the package from the area.
   • Call VUPD immediately.
   • Isolate the package or letter.

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 Utilities

1. How do you know what to do if there is a utility failure (water, electricity, natural gas, suction)?
   • Information about managing utility failures is found in the VUMC Safety and Emergency Operations Manual and the VUMC Emergency Operations Quick Reference Guide for the Main Campus and the 100 Oaks Campus.
2. Who should you contact if there is a utility failure in your work area?
   • Call Facilities Management to report utility failures (2-2041)
   • Call Respiratory Therapy (Adult 835-5978, Pediatric 835-5955) for Medical gas (oxygen) failure and then call Facilities Management (2-2041).
   • Notify Telecommunications for phone failure
3. If the lights go out in the Medical Center, what should you do?
   • Wait 8-10 seconds; the emergency generator will turn on the power.  Check that all essential equipment is plugged into red outlets and all life support equipment is properly functioning. Disconnect or turn off non-essential equipment that may be plugged into emergency power (red outlets). Examples of non-essential equipment include: fans, personal portable equipment.
4. What should you do if you get stuck in the elevator?
   • Stay calm
   • Use the elevator phone or emergency alarm to call for assistance.
   • Do NOT try to climb out of the elevator.

 Security

1. How do you contact VUPD in the event of an emergency?
   • On Campus: 911 or "O" for operator.
   • Off-site practices - 911 for local emergency services
2. How do you contact VUPD for non-emergency issues (escorts, security information, reports of criminal incidents not in progress)?
   • Call 322-2745
3. How do you enter the hospital during non-business hours (9pm - 6am)?
   • As a VUMC employee, you are able to enter the Medical Center at any entrance with ID card access.
   • The only public entrances into VUH/VCH are through the respective Emergency Departments. (To further ensure the safety of staff and patients, the ED’s have metal detectors which are monitored by Security 24 hours/day.)
4. If you work in a security sensitive area (pediatrics, handling money or pharmaceuticals), what measures are in place to control access and provide additional security?
   • Security-sensitive areas may be secured from public access
   • Special procedures may be in place to verify staff access (i.e. card swipe in doors, special ID access for Pyxis)

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 Fire Safety

1. What should you do in the event of a fire?
   • R.A.C.E.
     • Remove anyone from the immediate fire area; 
       Alert others and pull the manual fire alarm pull station; 
       Confine the fire by closing doors; 
       Extinguish or Evacuate
2. When should you begin evacuating in a fire situation?
   • The fire response plan for some buildings (Oxford House, Medical Arts, and most off-site clinics) is evacuation. If your office is in one of these buildings and the fire alarm is activated, you must evacuate the building.
   • The fire response plan for most patient care buildings is called “defend in place.” If there is danger from smoke or fire in your work area, evacuate that “smoke compartment.” When escaping from fire or smoke danger, evacuate beyond the fire/smoke rated doors.
     If your area is not in immediate danger, wait for further instructions.
3. What does the term “smoke compartment” mean in terms of fire safety?
   • A smoke compartment is a building space enclosed by smoke barriers on all sides, top and bottom.
   • In terms of fire safety, an easily recognizable feature of a smoke compartment is the fire/smoke doors. These are the doors that either remain closed and are automated closing devices or drop to close when the fire alarm is activated.
4. Your manager tells you to evacuate - where do you begin?
   • Evacuate horizontally first. Evacuate into the next “smoke compartment” (beyond the smoke/fire rated doors) or further away if there is still danger from smoke or fire.
   • Evacuate vertically to the ground floor if you don’t have a safe horizontal alternative. Use the stairs; NOT the elevator for vertical evacuation.
   • Evacuate those closest to danger first, then
     1. Ambulatory Patients and visitors
     2. Non-ambulatory patients
     3. Critical patients on life support
5. If you hear the fire alarm and the overhead announcement indicates that the fire is NOT in your work area, what should you do?
   • Clear corridors
   • Close doors
   • Prepare for further actions (possibly receiving patients from evacuated areas or evacuating if your area is endangered)
6. What is the overhead announcement in the Medical Center to make sure staff know about a potential fire?
   • Red Alert, "location"
7. When would it be important to shut off the medical gas to a room or an area? Who is responsible to shut off the med gas?
   • The oxygen to a room or area should be shut off if there is a fire in the immediate area. The Charge nurse or area manager is responsible for shutting off the med gas.
8. What is the best way to get help in a fire situation?
   • Activate the closest manual pull station!
   • If you do not hear the alarm or you feel that you need to call someone else, call VUPD.
   • If you are at an off-site clinic, call 911.
9. Do you know where the pull stations and fire extinguishers are in your work area?
   • If you don't know, go look for them!
10. Do you know the evacuation routes to take if you have to evacuate your work area?
    • You should know at least two routes to evacuate your work area. Your group should have a plan to meet at a remote site to make sure everyone is accounted for.
11. How do you operate a fire extinguisher?
    • P.A.S.S.
      • Pull the pin in the nozzle of the extinguisher; 
        Aim the nozzle of the extinguisher at the base of the fire; 
        Squeeze handles together; 
        Sweep from side to side - covering the fire.

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 Hazardous Materials

1. What does "Right to Know" mean?
   • You have the "right to know" about the chemical hazards you work with or may be exposed to at work.
2. What is an MSDS?
   • MSDS stands for Material Safety Data Sheet. An MSDS is a fact sheet about a chemical; providing information about the manufacturer, safe handling and storage procedures, first aid and spill procedures, etc.
3. Where can you find material safety data sheets for chemicals used in your department?
   • For every hazardous chemical used in your department, there should be a paper copy of the material safety data sheet available for you to review. You should know where the paper copy is maintained. If you don't know, ask your supervisor.
4. What hazardous materials could you possibly be exposed to in your work area?
   • Do you work with any of the following materials: cleaning agents, chemotherapeutic drugs, compressed gases, laboratory chemicals, radioactive materials or x-ray producing equipment, blood or body fluids, infectious wastes, etc?
5. What should you do if there is a hazardous material spill in your area?
   • Evacuate anyone in the immediate area,
   • Isolate the spill area, closing doors as you leave
   • Notify VUPD, Environmental Health & Safety, Facilities Management
   • Obtain an MSDS of the spilled chemical
6. What should you do if you spill a chemical on your skin and clothing?
   • Remove the contaminated clothing. 
   • Immediately wash the affected skin area with copious amounts of water.
   • Go to Occupational Health or the Emergency Department for evaluation and treatment (if necessary).
   • Complete a first report of injury and report the incident to your supervisor.
7. Do you know how to manage a
   • Blood or Body fluid spill?
   • Chemotherapeutic drug spill (if you work in pharmacy or an oncology area)
   • Mercury spill
   • Radioactive material spill
   • If you work with these agents, you MUST know how to manage a spill.  Refer to the VUMC Emergency Operations Quick Reference Guides for the Main VUMC Campus and the One Hundred Oaks Campus.

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Social Environment (For patient-care areas)

1. What special accommodations are made in your work area to ensure patient privacy?
   • List special accommodations such as private rooms, privacy curtains/screens, individual telephones for each patient
2. What special accommodations are made in your work area to provide a care site that is suitable for the patient's age, developmental level and clinical status?
   • List the special patient care features that make your unit unique. For example, the Peds area has a classroom, children's videos, the Child Life Center, special decorations and furnishings that cater to children. The Subacute Unit has a community room where entertainment activities are planned. 

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About The Joint Commission:

Vanderbilt University Medical Center is accredited by The Joint Commission (TJC).

The Joint Commission is an independent, not-for-profit organization charged with establishing standards and accrediting health care organizations. TJC evaluates and accredits nearly 19,000 health care organizations and programs in the United States.

TJC accreditation is recognized nationwide as a symbol of quality that reflects an organization's commitment to meeting certain performance standards. To earn and maintain accreditation, an organization must undergo an on-site survey by a TJC survey team at least every three years.

Vanderbilt University Medical Center's last accreditation survey was in 2012.  The next TJC survey will be unannounced and take place between February, 2015 and August, 2015. Since the survey is unannounced, faculty and staff within the organization will be informed of a survey via an overhead announcement using the VUMC standard emergency preparedness terminology: Yellow and Orange Alert. The overhead announcement that will be used to alert staff that surveyors are on-site is “Orange Alert - Survey.”

TJC's standards address the organization's level of performance in key functional areas, such as patient rights, patient treatment, and infection control. The standards focus not simply on what the organization has, but what it does. Safety-related standards are established in many of the chapters. However the primary safety emphasis is under the Environment of Care chapter.

TJC Environment of Care standards are pivotal for the ongoing operation and improvement efforts in making Vanderbilt University Medical Center a safe and healthy environment for patients, visitors, staff and employees. All work must be conducted in such a manner as to ensure your safety and the safety of others around you, and to protect the environment.

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VUMC Environment of Care

Introduction

The Vanderbilt University Medical Center Safety Program is dedicated to continual improvement of health, safety and environmental compliance at this institution. To foster this improvement, there are Safety and Health policies, procedures, and guidelines that closely align the Environment of Care (EC) philosophy established by TJC and the needs of the Medical Center.

 The Joint Commission's Environment of Care (EC) function has 20 primary standards. The standards are briefly summarized below. TJC’s requirement for ongoing training for EC issues was moved from the EC chapter to the HR chapter. That information is also included below. A complete copy of The Joint Commission's standards (Comprehensive Accreditation Manual for Hospitals) is available to Vanderbilt faculty and staff through the Eskind Library website.

EC.01.01.01: The hospital plans activities to minimize risks in the environment of care.

Note: One or more persons can be assigned to manage risks associated with the management plans described in this standard.

1. Leaders identify an individual(s) to manage risk, coordinate risk reduction activities in the physical environment, collect deficiency information, and disseminate summaries of actions and results. 
   Note: Deficiencies include injuries, problems, or use errors.
2. Leaders identify an individual(s) to intervene whenever environmental conditions immediately threaten life or health or threaten to damage equipment or buildings.
3. The hospital has a written plan for managing the following: The environmental safety of patients and everyone else who enters the hospital’s facilities.
4. The hospital has a written plan for managing the following: The security of everyone who enters the hospital’s facilities.
5. The hospital has a written plan for managing the following: Hazardous materials and waste.
6. The hospital has a written plan for managing the following: Fire safety
7. The hospital has a written plan for managing the following: Medical equipment
8. The hospital has a written plan for managing the following: Utility systems

EC.02.01.01: The hospital manages safety and security risks.

1. The hospital identifies safety and security risks associated with the environment of care that could affect patients, staff, and other people coming to the hospital's facilities.
2. The hospital takes action to minimize or eliminate identified safety and security risks in the physical environment.
3. The hospital maintains all grounds and equipment.
4. The hospital identifies individuals entering its facilities.
5. The hospital controls access to and from areas it identifies as security sensitive.
6. The hospital has written procedures to follow in the event of a security incident, including an infant or pediatric abduction.
7. When a security incident occurs, the hospital follows its identified procedures.
8. The hospital responds to product notices and recalls.

EC.02.01.03: The hospital prohibits smoking except in specific circumstances.

1. The hospital develops a written policy prohibiting smoking in all buildings. Exceptions for patients in specific circumstances are defined.
2. If the hospital decides that patients may smoke in specific circumstances, it designates smoking areas that are physically separate from care, treatment, and service areas.
3. The hospital takes action to maintain compliance with its smoking policy.

EC.02.02.01: The hospital manages risks related to hazardous materials and waste.

1. The hospital maintains a written, current inventory of hazardous materials and waste that it uses, stores, or generates. The only materials that need to be included on the inventory are those whose handling, use, and storage are addressed by law and regulation.
2. The hospital has written procedures, including the use of precautions and personal protective equipment, to follow in response to hazardous material and waste spills or exposures.
3. The hospital implements its procedures in response to hazardous material and waste spills or exposures.
4. The hospital minimizes risks associated with selecting, handling, storing, transporting, using, and disposing of hazardous chemicals.
5. The hospital minimizes risks associated with selecting, handling, storing, transporting, using, and disposing of radioactive materials.
6. The hospital minimizes risks associated with selecting and using hazardous energy sources.
7. The hospital minimizes risks associated with disposing of hazardous medications.
8. The hospital minimizes risks associated with selecting, handling, storing, transporting, using, and disposing of hazardous gases and vapors.
9. The hospital monitors levels of hazardous gases and vapors to determine that they are in safe range.
10. For managing hazardous materials and waste, the hospital has the permits, licenses, manifests, and material safety data sheets required by law and regulation.
11. The hospital labels hazardous materials and waste. Labels identify the contents and hazard warnings.

EC.02.03.01: The hospital manages fire risks.

1. The hospital minimizes the potential for harm from fire, smoke, and other products of combustion.
2. If patients are permitted to smoke, the hospital takes measures to minimize fire risk.
3. The hospital maintains free and unobstructed access to all exits.
4. The hospital has a written fire response plan.
5. The written fire response plan describes the specific roles of staff and licensed independent practitioners at and away from a fire's point of origin, including when and how to sound fire alarms, how to contain smoke and fire, how to use a fire extinguisher, and how to evacuate to areas of refuge.

EC.02.03.03: The hospital conducts fire drills.

1. The hospital conducts fire drills once per shift per quarter in each building defined as a health care occupancy by the Life Safety Code. The hospital conducts quarterly fire drills in each building defined as an ambulatory health care occupancy by the Life Safety Code.
2. The hospital conducts fire drills every 12 months from the date of the last drill in all freestanding buildings classified as business occupancies and in which patients are seen or treated.
3. When quarterly fire drills are required, at least 50% are unannounced.
4. Staff who work in buildings where patients are housed or treated participate in drills according to the hospital’s fire response plan.
5. The hospital critiques fire drills to evaluate fire safety equipment, fire safety building features, and staff response to fire. The evaluation is documented.

EC.02.03.05: The hospital maintains fire safety equipment and fire safety building features.

1. At least quarterly, the hospital tests supervisory signal devices (except valve tamper switches). The completion date of the tests is documented.
2. For hospitals that use Joint Commission accreditation for deemed status purposes: At least quarterly, the hospital tests water-flow devices. Every 6 months, the hospital tests valve tamper switches. The completion date of the tests is documented.
3. Every 12 months, the hospital tests duct detectors, electromechanical releasing devices, heat detectors, manual fire alarm boxes, and smoke detectors. The completion date of the tests is documented.
4. Every 12 months, the hospital tests visual and audible fire alarms, including speakers. The completion date of the tests is documented.
5. Every quarter, the hospital tests fire alarm equipment for notifying off-site fire responders. The completion date of the tests is documented.
6. For automatic sprinkler systems: Every week, the hospital tests fire pumps under no-flow conditions. The completion date of the tests is documented.
7. For automatic sprinkler systems: Every 6 months, the hospital tests water-storage tank high- and low-water level alarms. The completion date of the tests is documented.
8. For automatic sprinkler systems: Every month during cold weather, the hospital tests water-storage tank temperature alarms. The completion date of the tests is documented.
9. For automatic sprinkler systems: Every 12 months, the hospital tests main drains at system low point or at all system risers. The completion date of the tests is documented.
10. For automatic sprinkler systems: Every quarter, the hospital inspects all fire department water supply connections. The completion dates of the inspections are documented.
11. For automatic sprinkler systems: Every 12 months, the hospital tests fire pumps under flow. The completion date of the tests is documented.
12. Every 5 years, the hospital conducts water-flow tests for standpipe systems. The completion date of the tests is documented.
13. Every 6 months, the hospital inspects any automatic fire-extinguishing systems in a kitchen. The completion dates of the inspections are documented.
14. Every 12 months, the hospital tests carbon dioxide and other gaseous automatic fire-extinguishing systems. The completion date of the tests is documented.
15. At least monthly, the hospital inspects portable fire extinguishers. The completion dates of the inspections are documented.
16. Every 12 months, the hospital performs maintenance on portable fire extinguishers. The completion date of the maintenance is documented.
17. The hospital conducts hydrostatic tests on standpipe occupant hoses 5 years after installation and every 3 years thereafter. The completion date of the tests is documented.
18. The hospital operates fire and smoke dampers 1 year after installation and then at least every 6 years to verify that they fully close. The completion date of the tests is documented.
19. Every 12 months, the hospital tests automatic smoke-detection shutdown devices for air-handling equipment. The completion date of the tests is documented.
20. Every 12 months, the hospital tests sliding and rolling fire doors for proper operation and full closure. The completion date of the tests is documented.
21. For hospitals that use Joint Commission accreditation for deemed status purposes: Documentation of maintenance, testing, and inspection activities for fire alarm and water-based fire protection systems includes the following:
    • Name of the activity
    • Date of the activity
    • Required frequency of the activity
    • Name and contact information, including affiliation, of the person who performed the activity
    • NFPA standard(s) referenced for the activity
    • Results of the activity

EC.02.04.01: The hospital manages medical equipment risks.

1. The hospital solicits input from individuals who operate and service equipment when it selects and acquires medical equipment.
2. The hospital maintains either a written inventory of all medical equipment or a written inventory of selected equipment categorized by physical risk associated with use (including all life-support equipment) and equipment incident history. The hospital evaluates new types of equipment before initial use to determine whether they should be included in the inventory.
3. The hospital identifies the activities, in writing, for maintaining, inspecting, and testing for all medical equipment on the inventory.
4. The hospital identifies, in writing, frequencies for inspecting, testing, and maintaining medical equipment on the inventory based on criteria such as manufacturers’ recommendations, risk levels, or current hospital experience.
5. The hospital monitors and reports all incidents in which medical equipment is suspected in or attributed to the death, serious injury, or serious illness of any individual, as required by the Safe Medical Devices Act of 1990.
6. The hospital has written procedures to follow when medical equipment fails, including using emergency clinical interventions and backup equipment.

EC.02.04.03: The hospital inspects, tests, and maintains medical equipment.

1. Before initial use of medical equipment on the medical equipment inventory, the hospital performs safety, operational, and functional checks.
2. The hospital inspects, tests, and maintains all life-support equipment. These activities are documented.
3. The hospital inspects, tests, and maintains non–life-support equipment identified on the medical equipment inventory. These activities are documented.
4. The hospital conducts performance testing of and maintains all sterilizers. These activities are documented.
5. The hospital performs equipment maintenance and chemical and biological testing of water used in hemodialysis. These activities are documented.
6. For hospitals that use Joint Commission accreditation for deemed status purposes: Qualified hospital staff inspect, test, and calibrate nuclear medicine equipment annually. The dates of these activities are documented.

EC.02.05.01: The hospital manages risks associated with its utility systems.

1. The hospital designs and installs utility systems that meet patient care and operational needs.
2. The hospital maintains a written inventory of all operating components of utility systems or maintains a written inventory of selected operating components of utility systems based on risks for infection, occupant needs, and systems critical to patient care (including all life-support systems). The hospital evaluates new types of utility components before initial use to determine whether they should be included in the inventory.
3. The hospital identifies, in writing, inspection and maintenance activities for all operating components of utility systems on the inventory.
4. The hospital identifies, in writing, the intervals for inspecting, testing, and maintaining all operating components of the utility systems on the inventory, based on criteria such as manufacturers' recommendations, risk levels, or hospital experience.
5. The hospital minimizes pathogenic biological agents in cooling towers, domestic hot-and cold-water systems, and other aerosolizing water systems.
6. In areas designed to control airborne contaminants (such as biological agents, gases, fumes, dust), the ventilation system provides appropriate pressure relationships, air-exchange rates, and filtration efficiencies.
7. The hospital maps the distribution of its utility systems.
8. The hospital labels utility system controls to facilitate partial or complete emergency shutdowns.
9. The hospital has written procedures for responding to utility system disruptions.
10. The hospital's procedures address shutting off the malfunctioning system and notifying staff in affected areas.
11. The hospital's procedures address performing emergency clinical interventions during utility system disruptions.
12. The hospital's procedures address how to obtain emergency repair services.
13. The hospital responds to utility system disruptions as described in its procedures.

EC.02.05.03: The hospital has a reliable emergency electrical power source.

1. The hospital provides emergency power for the following: Alarm systems, as required by the Life Safety Code.
2. The hospital provides emergency power for the following: Exit route and exit sign illumination, as required by the Life Safety Code.
3. The hospital provides emergency power for the following: Emergency communication systems, as required by the Life Safety Code.
4. The hospital provides emergency power for the following: Elevators (at least one for nonambulatory patients).
5. The hospital provides emergency power for the following: Equipment that could cause patient harm when it fails, including life-support systems; blood, bone, and tissue storage systems; medical air compressors; and medical and surgical vacuum systems.
6. The hospital provides emergency power for the following: Areas in which loss of power could result in patient harm, including operating rooms, recovery rooms, obstetrical delivery rooms, nurseries, and urgent care areas.

EC.02.05.05: The hospital inspects, tests, and maintains utility systems.
Note: At times, maintenance is performed by an external service. In these cases, hospitals are not required to possess maintenance documentation but must have access to such documentation during survey and as needed.

1. The hospital tests utility system components on the inventory before initial use. The completion date of the tests is documented
2. The hospital inspects, tests, and maintains the following: Life-support utility system components on the inventory. These activities are documented.
3. The hospital inspects, tests, and maintains the following: Infection control utility system components on the inventory. These activities are documented.
4. The hospital inspects, tests, and maintains the following: Non–life-support utility system components on the inventory. These activities are documented.

EC.02.05.07: The hospital inspects, tests, and maintains emergency power systems. Note: This standard does not require hospitals to have the types of emergency power equipment discussed below. However, if these types of equipment exist within the building, then the following maintenance, testing, and inspection requirements apply.

1. At 30-day intervals, the hospital performs a functional test of battery-powered lights required for egress for a minimum duration of 30 seconds. The completion date of the tests is documented.
2. Every 12 months, the hospital either performs a functional test of battery-powered lights required for egress for a duration of 1 1/2 hours; or the hospital replaces all batteries every 12 months and, during replacement, performs a random test of 10% of all batteries for 1 1/2 hours. The completion date of the tests is documented.
3. Every quarter, the hospital performs a functional test of stored emergency power supply systems (SEPSS) for 5 minutes or as specified for its class (whichever is less). The hospital performs an annual test at full load for 60% of the full duration of its class. The completion dates of the tests are documented.
4. Twelve times a year, at intervals of not less than 20 days and not more than 40 days, the hospital tests each emergency generator for at least 30 continuous minutes. The completion dates of the tests are documented.
5. The emergency generator tests are conducted with a dynamic load that is at least 30% of the nameplate rating of the generator or meets the manufacturer’s recommended prime movers’ exhaust gas temperature. If the hospital does not meet either the 30% of nameplate rating or the recommended exhaust gas temperature during any test in EC.02.05.07, EP 4, then it must test each emergency generator once every 12 months using supplemental (dynamic or static) loads of 25% of nameplate rating for 30 minutes, followed by 50% of nameplate rating for 30 minutes, followed by 75% of nameplate rating for 60 minutes, for a total of 2 continuous hours.
6. Twelve times a year, at intervals of not less than 20 days and not more than 40 days, the hospital tests all automatic transfer switches. The completion date of the tests is documented.
7. At least once every 36 months, hospitals with a generator providing emergency power for the services listed in EC.02.05.03, EPs 5 and 6, test each emergency generator for a minimum of 4 continuous hours. The completion date of the tests is documented.
8. The 36-month emergency generator test uses a dynamic or static load that is at least 30% of the nameplate rating of the generator or meets the manufacturer’s recommended prime movers' exhaust gas temperature.
9. If a required emergency power system test fails, the hospital implements measures to protect patients, visitors, and staff until necessary repairs or corrections are completed.
10. If a required emergency power system test fails, the hospital performs a retest after making the necessary repairs or corrections.

EC.02.05.09: The hospital inspects, tests, and maintains medical gas and vacuum systems. Note: This standard does not require hospitals to have the medical gas and vacuum systems discussed below. However, if a hospital has these types of systems, then the following inspection, testing, and maintenance requirements apply.

1. In time frames defined by the hospital, the hospital inspects, tests, and maintains critical components of piped medical gas systems, including master signal panels, area alarms, automatic pressure switches, shutoff valves, flexible connectors, and outlets. These activities are documented.
2. The hospital tests piped medical gas and vacuum systems for purity, correct gas, and proper pressure when these systems are installed, modified, or repaired. The completion date of the tests is documented.
3. The hospital makes main supply valves and area shutoff valves for piped medical gas and vacuum systems accessible and clearly identifies what the valves control.

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.

1. Interior spaces meet the needs of the patient population and are safe and suitable to the care, treatment, and services provided.
2. Lighting is suitable for care, treatment, and services
3. The hospital maintains ventilation, temperature, and humidity levels suitable for the care, treatment, and services provided.
4. Areas used by patients are clean and free of offensive odors.
5. The hospital provides emergency access to all locked and occupied spaces.
6. The hospital keeps furnishings and equipment safe and in good repair.

EC.02.06.05: The hospital manages its environment during demolition, renovation, or new construction to reduce risk to those in the organization.

1. When planning for new, altered, or renovated space, the hospital uses one of the following design criteria:
   • State rules and regulations
   • Guidelines for Design and Construction of Health Care Facilities, 2010 edition, administered by the Facility Guidelines Institute and published by the American Society for Healthcare Engineering (ASHE) When the above rules, regulations, and guidelines do not meet specific design needs, use other reputable standards and guidelines that provide equivalent design criteria.
2. When planning for demolition, construction, or renovation, the hospital conducts a preconstruction risk assessment for air quality requirements, infection control, utility requirements, noise, vibration, and other hazards that affect care, treatment, and services.
3. The hospital takes action based on its assessment to minimize risks during demolition, construction, or renovation.

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

1. Staff and licensed independent practitioners can describe or demonstrate methods for eliminating and minimizing physical risks in the environment of care.
2. Staff and licensed independent practitioners can describe or demonstrate actions to take in the event of an environment of care incident.
3. Staff and licensed independent practitioners can describe or demonstrate how to report environment of care risks.

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

1. The hospital establishes a process(es) for continually monitoring, internally reporting, and investigating the following:
   • Injuries to patients or others within the hospital’s facilities
   • Occupational illnesses and staff injuries
   • Incidents of damage to its property or the property of others
   • Security incidents involving patients, staff, or others within its facilities
   • Hazardous materials and waste spills and exposures
   • Fire safety management problems, deficiencies, and failures
   • Medical or laboratory equipment management problems, failures, and use errors
   • Utility systems management problems, failures, or use errors
2. Based on its process(es), the hospital reports and investigates the following: Injuries to patients or others in the hospital’s facilities.
3. Based on its process(es), the hospital reports and investigates the following: Occupational illnesses and staff injuries.
4. Based on its process(es), the hospital reports and investigates the following: Incidents of damage to its property or the property of others
5. Based on its process(es), the hospital reports and investigates the following: Security incidents involving patients, staff, or others within its facilities.
6. Based on its process(es), the hospital reports and investigates the following: Hazardous materials and waste spills and exposures.
7. Based on its process(es), the hospital reports and investigates the following: Fire safety management problems, deficiencies, and failures.
8. Based on its process(es), the hospital reports and investigates the following: Medical/laboratory equipment management problems, failures, and use errors.
9. Based on its process(es), the hospital reports and investigates the following: Utility systems management problems, failures, or use errors.
10. The hospital conducts environmental tours every six months in patient care areas to evaluate the effectiveness of previously implemented activities intended to minimize or eliminate environment of care risks.
11. The hospital conducts annual environmental tours in nonpatient care areas to evaluate the effectiveness of previously implemented activities intended to minimize or eliminate risks in the environment.
12. The hospital uses its tours to identify environmental deficiencies, hazards, and unsafe practices.
13. Every 12 months, the hospital evaluates each environment of care management plan, including a review of the plan’s objectives, scope, performance, and effectiveness.

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

1. Representatives from clinical, administrative, and support services participate in the analysis of environment of care data
2. The hospital uses the results of data analysis to identify opportunities to resolve environmental safety issues.
3. Annually, representatives from clinical, administrative, and support services recommend one or more priorities for improving the environment of care.

EC.04.01.05: The hospital improves its environment of care.

1. The hospital takes action on the identified opportunities to resolve environmental safety issues.
2. The hospital evaluates changes to determine if they resolved environmental safety issues.
3. The hospital reports performance improvement results to those responsible for analyzing environment of care issues.

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Safety Training and Knowledge Requirements

HR.2.20 
Staff members, licensed independent practitioners, students and volunteers, as appropriate, can describe or demonstrate their roles and responsibilities, based on specific job duties or responsibilities, relative to safety.

The human element is the most critical factor in any process, determining whether the right things are done correctly. The best policies and procedures for minimizing risks in the environment where care, treatment, and services are provided are meaningless if staff, licensed independent practitioners, if applicable, students, and volunteers don not know and understand them well enough to perform them properly.

It is important that everyday precautions identified by the health car organization for minimizing various risks, including those related to patient safety and environmental safety are properly implemented. It is also important that the appropriate emergency procedures be instituted should an incident or failure occur in the environment.

Elements of Performance 
Staff members, licensed independent practitioners, students, and volunteers, as appropriate, can describe or demonstrate the following:

1. Risks within the hospital’s environment
2. Actions to eliminate, minimize, or report risks
3. Procedures to follow in the event of an incident
4. Reporting processes for common problems, failures, and user errors.

HR.2.30 
On-going education, including in-services, training, and other activities, maintains and improves competence.

Elements of Performance 
The following occurs for staff, students, and volunteers who work in the same capacity as staff providing care, treatment and services

1. Training occurs when job responsibilities or duties change
2. Participation in ongoing in-services, training, or other activities occurs to increase staff, student or volunteer knowledge of work-related issues
3. Ongoing in-services and other education and training are appropriate to the needs of the population(s) served and comply with law and regulation
4. Ongoing in-services, training, or other activities emphasize specific job-related aspects of safety and infection prevention and control
5. Ongoing in-services, training or other education incorporate methods of team training, when appropriate
6. Ongoing in-services, training, or other education reinforce the need and ways to report unanticipated adverse events
7. Ongoing in-services or other education are offered in response to learning needs identified through performance improvement findings and other data analysis
8. Ongoing education is documented

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EOC Contacts

Chad Fitzgerald 
Chief Regulatory Officer
Vice President of Health System Emergency Operations
Chair, Medical Center Safety Committee
Phone: 615-343-9566
email: chad.fitzgerald@vumc.org 
https://www.vumc.org/qps/ 

Kevin Warren
Senior Director
Office of Clinical and Research Safety
Phone: 615-322-0925
Email: kevin.warren@vumc.org 
www.vumc.org/safety

Charles DeFrance, Major
Vanderbilt University Police Department
Phone: 615-322-3286
Email: charles.e.defrance@vanderbilt.edu 
police.vanderbilt.edu

Rick Clark 
Administrative Director, Clinical Engineering
Phone: 615-322-3440
Email: rick.clark@vumc.org