- Conduct gap analysis per JCI FMS standards
- Map legal requirements
- Review all existing documentation
- Implements strategies to close gaps
- Inspect facilities to identify deficiencies
- Conduct mock audit
1) Important Areas
- Legal compliance
- Safety
- Security
- Hazardous material
- Emergencies
- Fire safety
- Medical equipment
- Utility systems
1.1 Legal Compliance
Ensure the organisation complies with relevant laws, regulations and facility inspections requirements.
- ensure all departments are in compliance to relevant laws and regulations by carrying out updates and review in accordance to established procedures.
1.2 Safety
Ensure that buildings, grounds, equipment and systems do not pose hazards to the occupants.
- review all hazard identifications and risk assessments to ensure sufficient coverage
1.3 Security
Ensure property and occupants are protected from harm and loss.
- strict enforcement to no-smoking
1.4 Hazardous Material
Ensure that handling, storage and use of hazardous waste are controlled and hazardous waste is safely disposed.
1.5 Emergencies
Ensure that response to epidemics, disater and emergencies is planned and effective
- develop and maintained standing operating procedures in response to a) mass disaters & emergencies, b) management of infectious diseases and c) management of casualties suspected/exposed to biological and biochemical agents.
1.6 Fire Safety
Ensure property and occupants are protected from fire and smoke.
- implements a plan to test the evacuation plan at least twice a year.
- ensure staff participation in at least one emergency preparedness test per year.
- ensure the involvement of doctors and nurses as well.
1.7 Medical and Utility Equipment
Ensure that equipment is selected, maintained and used in a manner to reduce risks.
2. System Tracer - FMS
The surveyor will identify the following:
- Identify areas of concern and strengths in the hospital's FMs process.
- Identify or determine the action necessary to address any identified areas of concern.
- Assess or determine the hospital's actual degree of compliance with relevant standards.
The duration will take about 60
to 90 minutes in which 30% of the session will be spent in group
discussion activity after the surveyor has finished reviewing the
documents relating to the FMS evaluation plan for risks and safety in
the environment including minutes of meeting.
Discussion Guidelines
- Plan - what specific environment of care risk have been identified by the hospital?
- Teach - How roles and responsibilities for staff/volunteers have been communicated by the hospital?
- Implement - What procedures and controls the hospital implement to minimize the impact of risk to the patients, visitors and staff?
- Respond - What procedures does the hospital implement to respond to an FMS incident/failure. How, when and to whom are FMS problems, incidents, and/or failures reported within the hospital?
- Monitor - How is FMS performance monitored by the hospital? What monitoring activities have taken place within the last 12 months?
- Improve - What FMS issues are currently being analyzed? What actions have been taken as a result of FMS monitoring activities
The surveyor will observe the
implementation of those particular management processes determined to be
potentially vulnerable or will trace a particular risk in one or more
FMS risk categories that the hospital manages by doing the following:
• Beginning where the risk is encountered or first occurs (that is, a starting point might be where a particular safety or security incident occurs, a particular piece of medical equipment is used, or a particular hazardous material enters the hospital).
• Having staff describe or demonstrate their roles and responsibilities for minimizing the risk, the actions they should take if a problem or incident occurs, and how to report the problem or incident.
• Assessing any physical controls for minimizing the risk (for example, equipment, alarms, and building features).
• Beginning where the risk is encountered or first occurs (that is, a starting point might be where a particular safety or security incident occurs, a particular piece of medical equipment is used, or a particular hazardous material enters the hospital).
• Having staff describe or demonstrate their roles and responsibilities for minimizing the risk, the actions they should take if a problem or incident occurs, and how to report the problem or incident.
• Assessing any physical controls for minimizing the risk (for example, equipment, alarms, and building features).
• Assessing the emergency management plan for mitigation, preparedness, response, and recovery strategies and actions and responsibilities for each priority emergency (see FMS.6 and FMS.6.1 for more information on the emergency management plan).
• Assessing the emergency management plan for responding to utility system disruptions or failures (such as having an alternative source of utilities, notifying staff how and when to perform emergency clinical interventions when utility systems fail, and obtaining repair services).
• Reviewing the implementation of relevant inspection, testing, or maintenance procedures of any equipment, alarms, or building features that are available for controlling the particular risk.
• Asking others in the hospital who have a role in responding to the particular problem or incident to describe or demonstrate their role and reviewing the condition of any equipment they use when responding.
• Assessing the emergency management plan for responding to utility system disruptions or failures (such as having an alternative source of utilities, notifying staff how and when to perform emergency clinical interventions when utility systems fail, and obtaining repair services).
• Reviewing the implementation of relevant inspection, testing, or maintenance procedures of any equipment, alarms, or building features that are available for controlling the particular risk.
• Asking others in the hospital who have a role in responding to the particular problem or incident to describe or demonstrate their role and reviewing the condition of any equipment they use when responding.
If the risk moves around in the
hospital’s facility (for example, a hazardous material or waste), the
surveyor(s) will follow the risk from “cradle to grave.”
3. Document Review
DOCUMENTS/MATERIALS NEEDED
• Documents, such as plans, policy and procedures, test and maintenance reports (as identified in [a] through [f ] of the intent statement for FMS.2), that describe the plans for the following:
• Documents, such as plans, policy and procedures, test and maintenance reports (as identified in [a] through [f ] of the intent statement for FMS.2), that describe the plans for the following:
(a) Safety and security (FMS.4)
(b) Hazardous materials (FMS.5)
(c) Disaster preparedness (FMS.6)
(d) Fire safety (FMS.7)
(e) Medical equipment (FMS.8)
(f) Utility systems (FMS.9)
(b) Hazardous materials (FMS.5)
(c) Disaster preparedness (FMS.6)
(d) Fire safety (FMS.7)
(e) Medical equipment (FMS.8)
(f) Utility systems (FMS.9)
• Facility Improvement Plan (described in the intent statement for FMS.4 through FMS.4.2)
4. Facility Tour
The purpose of the facility tour is to address issues related to the following:
• The physical facility
• Medical and other equipment
• Patient, visitor, and staff safety and security
• Infection prevention and control
• Emergency preparedness
• Hazardous materials and waste
• Staff education
Prior to the facility tour, the surveyor(s) will have reviewed the Facility Improvement Plan and the safety plan(s) described in FMS.2. They will then visit different areas of the facility to check the implementation of these plans.
The surveyor(s) will also review selected portions of the facility inspection report prepared by the hospital.
The surveyor(s) will visit patient care areas as well as non–patient care areas of the facility. In all areas, the surveyor(s) will observe the facility and interview staff to learn how the hospital manages the facility to accomplish the following:
The surveyor(s) will visit patient care areas as well as non–patient care areas of the facility. In all areas, the surveyor(s) will observe the facility and interview staff to learn how the hospital manages the facility to accomplish the following:
• Reduce and control hazards and risks
• Prevent accidents and injuries
• Maintain safe conditions
• Maintain secure conditions
• Implement emergency response plans
Note: In some survey agendas, two surveyors will visit separate sections of the facility at the same time. The hospital should be prepared to have staff available to guide and assist each surveyor on the tour of the facility.
The non–patient care areas visited by the surveyor(s) include the following:
• The boiler room
• The emergency power generator
• The loading/receiving dock
• Central storage areas or warehouse
• Central sterile supply department• The boiler room
• The emergency power generator
• The loading/receiving dock
• Central storage areas or warehouse
• Laboratory
• The laundry, if applicable
• Food service/kitchen
• Oxygen storage rooms
• Hazardous materials storerooms
• Areas designated as hazardous, such as locker rooms, clean and soiled linen rooms, and oxygen storage rooms
• The bottoms of laundry and garbage chutes
• The morgue
• Heating and air-conditioning equipment rooms to evaluate storage practices and utility systems maintenance
• The roof
Reference: JCIA Hospital Survey Guide, Version 2. & JCIA Hospital Standards 4th Edition.
