ANTHC :: Accreditation

Accreditation Services

We maintain competency in the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the Accreditation Association for Ambulatory Health Care (AAAHC) accreditation processes and can provide many Environment of Care related services including:

Training opportunities for Safety and Infection Control Officers.
Conducting comprehensive surveys of healthcare facilities including mock accreditation surveys.
Assisting facilities in developing policies and procedures, Environment of Care Management Plans, and Infection Control Surveillance Plans.
Helping keep you up to date on the latest accreditation requirements.

Joint Commission on Accreditation of Healthcare Organizations

The JCAHO has released a new document titled Surge Hospitals: Providing Safe Care in Emergencies. Click on the image to the right to see this document.

To see a one-page summary of the topics in this document, follow the link below:
Summary of Surge Hospitals

JCAHO Documents (courtesy of Gary Slack)

The following Environment of Care (EC) documents and presentations are provided courtesy of Gary Slack, PE, CCE, President of Healthcare Engineering Consultants.

The following presentations were given by Gary at the December JCAHO course in Anchorage. They are listed in the order presented and are available in PowerPoint or PDF formats.

Select your format		Description
		Introduction - An introduction to the 2006 JCAHO survey process, scoring guidelines, changes made in 2005 and expected changes for 2006, focus areas for 2006, and survey strategies to remember.
		Performance Improvement - A summary of the performance improvement and measurement expectations of the JCAHO. A discussion of the components of the annual management plan evaluation is also covered.
		Risk Assessment - A review how to complete a risk assessment for global issues (e.g. safety management) and specific issues (need to refrigerator temperature tests), how to complete a failure mode effects analysis, and how to perform a root cause analysis.
		Regulatory Compliance Part 1 - A brief presentation on the regulatory issues that must be addressed at your facility.
		Regulatory Compliance Part 2 - A more in-depth presentation on the regulatory issues applied to each EC management area.

The documents below are available in Word and PDF formats.

Select your format		Description
Environment of Care (EC) - General
		EC Scoring Sheets - A summary of the scoring requirements for each element of performance in each of the EC areas.
		Pre-Construction Risk Assessment - Use this tool to pro-actively address any infection control and safety related issues that may arise during construction activities.
Performance Improvement:
		Performance Measure Worksheet - Use this document to create a "dashboard" of all of your EC performance measures to track accomplishments.
		Quarterly Summary Report - Use this document to report all of your EC performance measures. You may choose to color-code each of the performance measures to indicate if the goals have been met. This is a good way to keep your governing body updated.
		Writing your Annual Evaluation - This document suggests content and formatting for your annual EC reports.
Risk Assessment:
		Performing Specific Risk Assessments - Risk assessments can be performed to prioritize your resources. This document will walk you through the process to perform and document a risk assessment for global issues (an entire EC area) or specific issues (for example, refrigerator logs).
		Risk Management Cycle - Use this document to plan and track your annual risk reduction activities. It follows the "Plan, Teach, Implement, Monitor, Respond, Improve" approach.
Survey Preparation:
		EC Survey Preparation Packet (2005) - The purpose of this preparation packet is to provide healthcare staff with a coordinated tool to prepare for an actual Joint Commission scheduled or unscheduled survey, related to the ?€œEC?€ standards.
		Required Survey Documents - A comprehensive list of documents that will be required to have on hand during a survey.
		Likely EC Tracers (2005) - The nine most probable topics to be covered during an EC "tracer."
		Interview Responsibility Grid - Use this simple table to determine who is the designated speaker and backup for each of your EC areas during the EC interview session.
		EC Interview Questions - A list of potential questions and topics that may be covered during the EC interview portion of your survey.
		Tracer Simulation Tracking Sheet - Conduct your own environment of care "tracer" using these common topics.
		Survey Planning Process Document Review - Don't give the surveyor the "deer in headlights" look. Make sure you have all of the documents JCAHO will want to see during the survey.
EC.1 - Safety Management
		Global Risk Assessment Sample - A sample risk assessment that examines the impact to safety from different risk elements. This is an Element of Performance under EC.1.10.
EC.2 - Security Management
		Global Risk Assessment Sample - A sample risk assessment that examines the impact to security from different risk elements. This is an Element of Performance under EC.2.10.
EC.3 - Hazardous Materials and Waste Management
EC.4 - Emergency Management
		Disaster Recovery Checklist - This checklist can help you quickly identify the status of your facility immediately following an emergency.
EC.5 - Fire Safety Management
		Fire System Component Test Schedule - This document summarizes the testing schedule for all of the components of your fire system including tamper switches, fire pump, pull stations, and fire extinguishers.
		Above the Ceiling (ATC) Policy - A sample policy for contractors and other "outside" companies that may be performing work "above the ceiling."
		Above the Ceiling (ATC) Permit - A sample permit for requesting access "above the ceiling."
		Life Safety Specialist Building Tour Checklist - Even if your facility is not visited by a Life Safety Specialist, you can use this form to document and track the components of your fire safety system.
EC.6 - Medical Equipment Management
		Medical Air Quality Requirements - A brief summary of medical air quality requirements from USP and NFPA 99.
		Clinical Alarm System Effectiveness - Make sure your clinical alarm systems are effective and maintained by following this four-step process.
		Medical Gas System Preventive Maintenance (PM) Recommendations - Not sure how often the components of your medical gas system should be checked? Use this document to set up your PM schedule.
EC.7 - Utility Systems Management
		Building Management Program (BMP) Data Collection Sheet - Use this score sheet to collect information on your BMP and determine your rate of compliance.
		Waterborne Pathogens Policy - A sample policy related to managing pathogenic biological agents in cooling towers, potable and aerosolizing systems, and to provide a safe environment for patients, staff, and visitors.
		Airborne Pathogens Policy - A sample policy that outlines a preventive maintenance program to ensure air filtration, air exchange, and pressure relationships are properly maintained for ventilation systems in the hospital so that airborne contaminants are effectively controlled.
		BMP Quarterly Effectiveness Summary - Use this form to track your BMP compliance rate over time.
EC.8 - Appropriate Environment