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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.

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 January 2008 Joint Commission (JC) 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 2008 JC survey process, scoring guidelines, changes made in 2007 and expected changes for 2008 and 2009, focus areas for 2008, and survey strategies to remember.
		Survey Planning Session and Statement of Conditions - How to prepare for the Joint Commission Environment of Care Survey Planning Session including a discussion of management plans, annual evaluations and other documentation. Also discussion of the Statement of Conditions and Building Maintenance Program.
		Facility Tour - A review of the topics typically reviewed by the Joint Commission during hte facility survey.
		EC Interview - Covers how to present your data during the EC interview and what surveyors may ask about in each management area including smoking policy, risk assessment, anc changes to the emergency management standard.
		EC Tracer - Discussion of the EC tracer methodology and likely EC tracer topics.

The documents below are available in Word and PDF formats. Some of these documents were presented by Gary at the January 2008 course.

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. Updated for 2008.
		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 Improvement Dashboard - Use this document to create a "dashboard" of all of your EC performance measures and track accomplishments on a regular basis.
		Performance Improvement Examples - This document provides guidance on how to select indicators for each of the EC management areas. Examples are also provided.
		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 Self Assessment Tool (2008) - This tool can be used to assess your policies and procedures for compliance with JC standards by management area.
		EC Survey Preparation Packet (2008) - 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 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.
		EC Tracer Simulation Tracking Sheet - Conduct your own environment of care "tracer" using these common topics. Updated for 2008.
		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
		Behavioral Health Risk Assessment - A sample risk assessment that examines multiple risk elements that might be seen in a behavioral health environment.
		Safety 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
		Security 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
		Tabletop Simulation - During the EC interview, the surveyor may conduct a tabletop exercise. Use this document so you know what to expect and how to prepare.
		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."
		Statement of Conditions Policy - A sample policy for designating who is responsible for the SOC and how often it is updated.
		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 components of your fire safety system.
		Building Tour Life Safety Specialist Checklist - Want to know what your Life Safety Specialist is looking for during the building tour? Use this checklist to find out.