By Jim Twyeffort, Regulatory Compliance Consultant
In coordination with ASHE, the Joint Commission has launched a new resource, the Physical Environment Portal.
The portal was designed to address the areas that frequently come up as non-compliant during surveys over the past few years. The first standard to be addressed is Utility Systems, or EC.02.05.01. In the portal for this standard, you can find examples of how you can improve compliance for EC.02.05.01.
Standards include:
- EP 15: Air pressure, filtration and air changes in critical care areas such as the OR
- EP 8: Label utility system controls for partial or complete emergency shutdown
- EP 1: Design and installation of utilities to meet patient care and operational needs
Each of these is equally important to improve, but having control of your building means you have the proper labeling and critical mapping for your facility. Often, this can be overlooked – whether it’s because it’s an antiquated system or managed by the same senior technician for decades, who carries institutional knowledge of the facility utility system and often doesn’t provide written records.
However, when it comes to an emergency shutdown, the right labeling can ensure patient safety and care and minimize the impact to patients.
In my previous life as a director of plant operations, I encountered such an issue and learned that, without the appropriate labeling, our issues were magnified and of larger magnitude because it was a guessing game when it came to shutting off valves. Will this impact the entire system, a floor or a portion of the floor? Will this cause an improper shutdown, creating a catastrophic event? If you don’t have the right critical mapping of your facility and labeling, you’ll only know if you have to shut it off.
If you have a computerized maintenance management system (CMMS), you can easily implement a labeling project for your team. First, you can set up inspections to evaluate the current state of labeling. Following that, you can set up a labeling project to ensure that it adheres to Joint Commission Standards. In addition to the Joint Commission standards, the NFPA also has strict requirements for labeling. They outline several aspects of your labels, including key colors, naming conventions and the direction of flow arrows.
A space management solution, or CAFM, can complement your CMMS solution by offering a centralized location to host your Life Safety and utility management critical mapping drawings. In turn, you can plot full-size drawings or even print Life Safety drawings to place in your Statement of Condition (SOC) and critical mapping for your Joint Commission survey.
With the appropriate equipment labeling in place, you can ensure that you are able to react quickly to any issue that may arise, reducing your risk to causing damage to critical and expensive equipment as well as continuing to ensure quality patient care.
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