The Environment of Care
Complying with Accreditation Standards
By Kathy Dix
The “environment of care” is a broad term for a wide-ranging group of factors in the healthcare environment; however, it encompasses a large body of checkpoints that accrediting bodies use to determine a facility’s quality.
“We talk about the environment of care as referring to the elements and factors that contribute to creating the way the environment works for the patient, family, staff and others in the healthcare delivery system, in terms of certain key elements,” says Michael Jarema, associate director, department of survey methods and standards at the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). “We talk about light, privacy, space, how it’s configured, size, security issues, access to the interior and exterior, a layout that supports patient care and operations.”
“You should know that for ambulatory surgery centers (ASCs), they can use the Joint Commission survey process to also satisfy certification in the Medicare program,” says Michael Kulczycki, executive director of JCAHO’s ambulatory care accreditation program. “We have what’s called a ‘deemed status’ relationship with Medicare, and what that means is that an organization can request an accreditation survey and they will accept our survey in lieu of (CMS) coming out and doing one.
“There are a couple of differences from a ‘non-deemed status’ survey; one, the surveys we do as ‘deemed status’ are unannounced, and secondly, in addition to the JCAHO standards, there are about 28 items not currently covered under our standards that we look at,” he adds.
“The standards within the environment of care chapter address seven specific areas that the surveyors will look at depending on the type of organization,” Jarema explains. “There are two major distinctions — ambulatory healthcare occupancy and a business occupancy. We require an organization to have seven written plans for these areas, and then we will look at how they are addressing the implementation of those plans.”
The seven areas of focus are safety management — looking at safety risks — security management; hazardous materials and waste management; emergency management, such as disasters; fire safety — the area in which occupancy becomes a critical question; medical equipment management; and utilities management. “Utilities is everything from what you do in a case of electrical failure, how you manage piped-in gases, etc. Air quality would certainly be part of the review; we don’t have specific standards that say how many times air has to be turned over in a particular setting, but OSHA may very well, or the EPA very well may have requirements for those, and we say organizations have to be in compliance within the law,” says Jarema.
“Let me reinforce that point,” Kulczycki interjects. “Many times, people point to JCAHO for requiring a multitude of things — for example, requiring a certain air quality standard. We generally in many areas are not prescriptive, but we do have requirements that any organization is in compliance with applicable law and regulation. For example, a surgery center has to be in compliance with the Occupational Safety and Health Administration (OSHA), the Environmental Protection Agency (EPA), and the Food and Drug Administration (FDA) for the medical devices ... we’re not the ones coming up with all those detailed requests. The other example would be the National Fire Protection Association which defines many of the fire safety standards. What we say is that you have to be in compliance with it. But we don’t get into defining room size, air turnover, things like that. What we could conceivably do on survey is, if on observation, the surveyor sees something on the environment of care tour that doesn’t look appropriate, then he may ask the organization, ‘Show me your evidence that you’re in compliance with OSHA standards or EPA standards.’”
Certain areas of the environment of care are occasionally harder to comply with than others; JCAHO does a semi-annual data survey about that very issue. “What are the top 10 areas where organizations have problems maintaining compliance? In other words, they receive a requirement for improvement during the survey. In about 10 percent of all ambulatory surveys in 2003, the requirement that the organization implements the organization safety plan was an issue,” Kulczycki says.
Jarema confirms, “An ambulatory organization could conduct a proactive risk assessment, by doing a walking tour of their facility outside and inside, taking a look at equipment and trying to identify any potential risks. Perhaps there’s an unsecured piece of equipment, or an unsafe condition in the environment. Maybe in your waiting area, as a courtesy, the staff decided to have hot water and coffee available for clients and family members, but they’re also seeing pediatrics in this environment. Proactively, you would say ‘There’s a risk for injury and burns here, because our coffee and tea makers are exposed to children playing in the area, who could scald or burn themselves or cut themselves on broken glass.’”
Kulczycki adds, “That does also include outside the facility. In terms of looking at appropriate lighting, for example, if the organization is routinely open until 6 or 7 p.m., and patients are leaving after sundown, then the surveyor would be looking for adequate lighting and security outside the building.”
When facilities are considering accreditation, they need to keep in mind the difference in requirements between a business occupancy and an ambulatory healthcare occupancy, Jarema points out. “In an ambulatory healthcare occupancy, the facility needs to take additional precautions that are built in to the physical design of the facility and the plant itself, to ensure that the patients are in a safe environment, and that we can get those folks out, so that runs the gamut from fire suppression systems to other design requirements in the environment.”
Generally speaking, JCAHO requirements seem reasonable; Jarema confirms this impression. “I try to think, ‘Does this standard seriously improve the quality and safety of patient care, which is what the Joint Commission’s mission is all about?’ They shouldn’t seem arbitrary; they shouldn’t seem capricious. There should be some tie-in directly into the services and the processes that occur within an organization. I’m not going to sit here and tell you that 100 percent of our standards always are self-evident in that regard, but I would say the vast majority of them are, and the others have some good rationale and reasoning behind them. If I were building from scratch, I would probably reach for a copy of the Joint Commission standards and say, ‘This is what I need to design a good environment.’
Kulczycki adds, “We have evidence that shows at both the ASC level as well as office-based surgery facilities, many organizations buy our standards and we never see them come through the accreditation process, but they’re using our standards to give them a management and operational framework.”
The new JCAHO survey process has also engendered positive feedback; streamlining the standards and using “tracer methodology” to survey the facility “are leading organizations to really see how the accreditation process and ambulatory standards are directly tied to patient safety and patient care,” Kulczycki explains. “More importantly, because the new survey process involves all the caregivers and staff at organizations like an ASC, staff members themselves are seeing immediate linkages, because the staff members are being involved in the survey process.”
Tracer methodology is a new approach for JCAHO surveyors; for 50 percent to 60 percent of the time within the facility, the surveyor will use a patient chart as a road map through the organization. Following the chart through admitting, pre-, peri-and post-surgery, recovery and discharge education includes speaking with “rank-and-file” staff members. “They appreciate it, because in the past, they’ve been asked to follow procedure, or to be compliant with certain standards, without having a real appreciation of what it means and how it ties to patient safety,” says Kulczycki. “The new process really connects the dots for that staff person.”
Jarema adds, “It really pulls together the entire survey process, because as it relates to the environment of care, it’s not like, ‘Now we’re going to do the environment of care piece, and now we’re going to do the patient care piece, and then do something else.’” The surveyor will ask staff members about the equipment for a particular patient’s surgery, safety risks for the equipment and what training they’ve had in using it. They’ll ask how the patient can be evacuated if a fire occurs, how the gas systems would be shut off, and how the procedure would be closed if all lighting were lost.
“It’s integrated. You really tie all the standards and requirements back to the important reason everyone is there, and that is to deliver the highest possible and safest quality of care to that patient,” Jarema says.
The Centers for Medicare and Medicaid Services (CMS) form for certification is extensive — ASCs must satisfy multiple conditions. ASCs that wish to receive Medicare or Medicaid reimbursement can choose a deemed status review by JCAHO, which gives CMS confirmation that the ASC meets or exceeds federal requirements for coverage. The 10 requirements that must be met include:
- Compliance with state licensure law
- Governing body and management
- Surgical services
- Evaluation of quality
- Medical staff
- Nursing services
- Medical records
- Pharmaceutical services
- Laboratory and radiologic services1
Environment-of-care standards include the physical environment — operating, recovery and waiting rooms, and infection control — fire safety, emergency equipment and personnel.
If the ASC does become accredited under the JCAHO process, it is obligated to inform the appropriate state agency, which will supply the ASC with two forms. Only when those forms are submitted will CMS issue a Medicare provider number. CMS may, if it sees fit, conduct a sampling of validation surveys for ASCs who choose the “deemed status” alternative.
Environment of Care in Practice
The environment-of-care definition seems all-inclusive for some facilities. “You look at environmental observations and workplace safety, equipment, medication management,” says Grace Doherty, director of satellite and rehabilitation programs for outpatient services at Children’s Memorial Hospital in Chicago. “We look at infection control and supplies, point-of-care testing, compliance, medical gases, our hazardous surveillance, how we get rid of hazardous materials, crash carts and defibrillators, specific fire safety, security, access to information, staffing and competencies, what information gets reported, how we report it, safety, quality and performance improvement.”
The ambulatory area has created a unique “environmental rounding” that is held on a monthly basis, so the facility is survey-ready year-round. “We don’t have anything separate we do to prepare for this, because we’re in an ongoing preparedness mode,” Doherty explains. “By doing this on a monthly basis, and making sure all the staff is educated, this becomes innate.”
“We had an unannounced survey about six weeks ago and did particularly well, because of the readiness mode,” says Monica Heenan, RN, MPA, administrator of ambulatory services at the facility.
Ambulatory services has been practicing environmental rounding for at least three years, Doherty says. Staff members take turns each month, so they feel accountable. The manager will ensure that follow-up is done if staff members notice a problem. “We make everyone accountable for this. They take pride in their area, so we don’t have to worry. Anyone can walk in our doors at any time.”
There was no sentinel event that yielded the program; rather, the entire healthcare system “took it on as organizational initiative, to get away from gearing up for a survey to be in accreditation mode all the time,” says Heenan. “It was not only in the surgery center, but throughout our institution.”
Doherty says, “Doing this has also helped our parent/patient satisfaction survey, which we do through Press-Ganey. Because a lot of what we round for directly affects patient care and family, they’re very happy when they come to our facility. They feel safe, comfortable.”
When the surveyor visited recently, he immediately noticed the physical appearance. “Things were clean, well maintained, in order,” Heenan affirms. “There were no surprises in the things he looked at; the method by which he did it was slightly different, because he pulled about four charts, walked through where those patients would have gone, but he ended up covering everything they would ordinarily cover — crash carts, narcotic security, etc.”
Doherty adds, “He also questioned staff. A lot of staff felt prepared by doing these monthly roundings, because you identify an issue, amend it, fix it immediately after it’s identified.”
The staff members were able to discuss things they had improved, because they had been directly involved in the monthly environment- of-care rounds.
The rounds ensured that there were no particular areas difficult to keep compliant; it’s an “everyday thing,” Doherty says, just like brushing your teeth or taking a shower. “It’s part of their life.”
Heenan points out that there are minor changes every year, with the new national patient safety goals, for example. “Those are challenging at first, but we’ve been able to check on those very closely.” Support from physicians has been good; since the same attitude prevails in both the surgery center and the main hospital, physicians who work in both places see the consistency from site to site and realize they are not being asked to do anything they wouldn’t do at the main hospital.
Also, Doherty observes, “Because we are smaller than a main hospital, it’s pretty easy to keep our hands on top of things, and to communicate changes, and to do follow-through with all staff.”
New employees are informed of the monthly rounding during the interview process and orientation, and they are assigned a buddy the first time they participate. Because the facility is in a state of constant preparedness, there’s no “hustle and bustle. “All of us here at the hospital many years ago were always in the hustling and bustling mode, and it’s not fun. This is more comfortable; you feel non-threatened, and you get more done this way,” Doherty says.
Employees offer positive feedback, even express enthusiasm when their turn arrives to make the environment of care rounds. “I know it may sound PollyAnna-ish, but it really is part of their life, and it’s a learning experience, because they’re accountable for their areas, so they take pride in their area. And you can relate it to back to the parent satisfaction survey. That’s really nice, when we can draw it back to the rounding,” Heenan affirms.