JC HVAC Overview

Joint Commission
Standards 2010
1
Hospital 2010
Accreditation Participation
Requirements Review:
HVAC Systems
2
Risk Mitigation Management
• Underpins Regulations
• Benefits
– Reduces Risk of Outbreak
– Prevents Unscheduled Shutdown
– Avoids Crisis Management
– Prevents Loss of Life
– Avoids Reimbursement Loss
– Improves Reputation
3
Key
All Elements of Performance (EP) must be

followed but indicates higher level of Joint
Commission concern and Surveyor attention
4
Environment of Care
• EC.02.05.01
– Hospital manages risks associated with utility
system
– Written plan for and record of all component
maintenance
– In operation the HVAC system delivers the
appropriate pressure relationships and IAQ
• EC.02.05.05
– Hospital inspects, tests and maintains HVAC
system (life support utility)
5
Environment of Care
HVAC System
– Every component should have:
• Plan for inspection, maintenance, testing
• Testing/measurement data should be on file
Environmental Conditions
– Focus on sensitive environments:
• OR, Cath Lab, Imaging Suite, AIIR, etc.
– Should monitor and record:
• Pressure, Temp, Humidity, Particulate Counts, etc.
6
Infection Prevention / Control
• IC.01.05.01
– HVAC is integrated into infection prevention
(IP) activities
• There should be awareness of the impact

of air quality in patient environments
– Exp. Studies directly connected Aspergillus
outbreaks to airborne contamination
7
Human Resources
• HR.01.04.01
– Staff orientation on appropriate (IP) duties is
documented
• Staff should be trained on how HVAC

maintenance impacts IP
– Training should be documented
– Promotes understanding of interpretation and
implications of testing data
8
Leadership
• LD.01.02.01
– Leadership ensures performance
improvement programs address IP problems
identified by infection preventionists
– * A second deficiency can be assigned if no
action is taken
• LD.04.04.01
– Leadership reprioritizes performance
improvement activities in response to
changes in environment
9
Leadership
• Responsibility
– As soon as Hospital Leadership is made
aware of a potential deficiency in HVAC
systems they become responsible for:
• Ensuring problems are addressed
• Prioritize improvement program based on change
in system performance or environment
– A second deficiency for inaction is only likely if

there are multiple primary deficiencies
10
National Patient Safety Goals
• NPSG.07.03.01
– Implement evidence practices to prevent HAI
due to MDRO
• NPSG.07.05.01
– Implement evidence practices to prevent HAI
due to SSI
• Sensitive Environments will get additional

scrutiny because of relationship to HAI
11
Performance Improvement
• PI.03.01.01
– Hospital improves performance on an ongoing
basis
• Even without a specific IP problem,

hospitals should strive to improve IAQ and
HVAC system performance
12
Overview
• Impact of HVAC system on HAI is difficult
to quantify but accepted as legitimate
• 2010 standards require:

– Component specific maintenance plans
– Documented system testing and maintenance
• Surveyors may focus on sensitive area

environmental conditions due to HAI risk
13
Mintie Services
• Inspection Preparation
– HVAC system rehabilitation
– Register cleaning, etc.
• Resources / Assistance for budget request

– Access to national facility and IP leadership
– Pre-project photos, etc.
• Visual and Photo documentation

– Creates record to provide during survey
– Reduces liability
14
Mintie Services
Support
RISK MITIGATION
MANAGEMENT
Industry leader, experience since 1940. 24 Hour Emergency

Response, Licensed and Certified Air Cleaning Specialists, Infection
Prevention Trained Crews, Patented Containment Technology. 15
Questions
• Corporate
323-225-4111
• Arizona
602-908-6400
• Los Angles
323-493-5141
• Orange County
323-819-4198
• San Diego
323-819-4198
• San Francisco / Sacramento www.mintie.com

707-291-7915
16

JC HVAC Overview

Uploaded by

Copyright:

Available Formats

JC HVAC Overview

Uploaded by

Document Information

Original Description:

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

JC HVAC Overview

Uploaded by

Copyright:

Available Formats

Joint Commission

All Elements of Performance (EP) must be

• There should be awareness of the impact

• Staff should be trained on how HVAC

– A second deficiency for inaction is only likely if

• Sensitive Environments will get additional

• Even without a specific IP problem,

• 2010 standards require:

• Surveyors may focus on sensitive area

• Resources / Assistance for budget request

• Visual and Photo documentation

Industry leader, experience since 1940. 24 Hour Emergency

• San Francisco / Sacramento www.mintie.com

You might also like