1. health and fitness

Getting “Survey Ready” in 2015 for the Physical Environment
April 23, 2015
Crowne Plaza Hotel
600 Metro Place North
Dublin, OH 43017
Overview
This one-day program will provide valuable information for those individuals who are responsible for creating
the best possible Environment of Care, Emergency Management and Life Safety programs and must
understand the 2015 Joint Commission survey methodology and changes to the standards. Information will be
provided so the attendees will be able to implement a practical, continuously compliant program for healthcare
facilities to achieve maximum performance while effectively preparing for unscheduled Joint Commission and
CMS surveys. Attendees will also receive specific guidance in how to understand and interpret the most
serious deficiencies that are common in surveys. Practical examples will include an explanation of “best
practices” that will help you move your own program to the top and guarantee success. Handout materials will
include scoring sheets and survey checklists as well as forms, worksheets and sample policies that can be
easily adapted to your own program. Sufficient time will also be provided during each section for questions and
discussion
Who Should Attend
Healthcare staff from hospitals, ambulatory care centers, clinics, nursing homes, mental health facilities and other
health-related organizations that are required to comply with the Joint Commission “Physical Environment”
standards.
Who will benefit from this training?
Accreditation coordinators, safety officers, risk managers, quality management and performance improvement
directors, facility and engineering managers, directors of security, staff with hazardous materials and emergency
management responsibilities, biomedical engineering managers, fire safety professionals in healthcare, infection
control practitioners, and administrative and clinical staff who manage others with Environment of Care, Emergency
Management and Life Safety responsibilities.
Benefits of Participation
 Understanding how the Joint Commission will evaluate and score the surveys during 2015
 Reviewing Changes to the 2015 standards that may affect your survey outcome.
 The specific responsibilities of each of the survey team members, including the expanded role of the Life
Safety Surveyor, based on new checklists and survey agendas required by the new Joint Commission field
manager.
 Achieve “Continuous Compliance” and overcome the most common deficiencies cited in the Environment of
Care, Emergency Management and Life Safety areas.
 Prepare for the “five vulnerabilities”: The Survey Planning Session, Life Safety Surveyor Documentation
Review, Facility Tour, the Physical Environment Interview and likely Physical Environment Tracers.
 Incorporate “best practices” to enhance your existing programs.
 Using proven ideas and techniques to achieve survey success.
Registration
The registration fee for this program is $200 per person for OHA members and Corporate Partner
representatives. The fee for participants from non-member organizations is $250 per person. Registration fees
include handout materials, lunch, beverage breaks and administrative costs. Full fee payment must accompany
registration. Send registration fee to OHA, 155 E. Broad Street, Suite 301 Columbus, Ohio 43215-3640.
You can access the online registration form at http://www.ohiohospitals.org
155 E Broad St. Floor 15  Columbus OH 43215  614-221-7614  www.ohanet.org  Page 1 of 3
Cancellation
A refund of registration fees will be made to registrants notifying OHA of cancellation three (3) working days
prior to the program date. A $40 processing fee will be assessed against each refund. No refund will be made
for cancellations received after that date. Substitutions are encouraged.
Overnight Accommodations
Registrants are responsible for making their own overnight arrangements. OHA has blocked a few rooms for
the night of April 22 at the hotel. The group rate is $129 plus taxes. The cutoff date for this rate is April 1, 2015.
Please make reservations by calling 614-764-2200. To visit their web page, go to Crowne Plaza Dublin ,
where you can find directions to the hotel, or make a reservation on-line. Please mention OHA in order to get
the group rate.
Services for Physically Challenged Individuals
The Ohio Hospital Association wishes to take reasonable steps to ensure no individual who is physically
challenged is discriminated against because of the absence of auxiliary aids and services. If special
arrangements are required for an individual to participate in this program, please contact OHA at (614) 2217614 at least 10 days prior to the scheduled date.
Continuing Education Credits
The Ohio Hospital Association (OLN-0017-P) is approved as a provider unit of continuing education by the
Ohio Board of Nursing through the approver unit at the Ohio League for Nursing (OBN-006-92) and provider
unit status is valid through June 30, 2017. Please contact OHA’s Center for Education at 614.221.7614 for
information on continuing education credits.
Agenda
8:00 a.m. Registration/Coffee & Pastries
8:30
The 2014 Survey Process
 Understanding the role of the surveyors
 The scoring system for 2015
● Direct and Indirect citations and “CFIs”
● The Situation Decision Rules
 Immediate Threat outcomes
● The most common survey deficiencies from 2014
9:15
Changes to the 2015 Standards
 Environment of Care
 Emergency Management
 Life Safety, including the CMS “Categorical Waivers”
● Other referenced documents, including the 2012 editions of NFPA 99 and
the Life Safety Code
10:00
Break
10:15
The Major Survey Vulnerabilities in 2015
 The Survey Planning Session
 The Life Safety Surveyor documentation review
 The Life Safety Surveyor facility tour
12:00 Noon – Lunch (provided)
1:00 PM The Major Survey Vulnerabilities in 2015
 The Physical Environment Interview
 The Physical Environment Tracers
OHA 155 E Broad St. Floor 15  Columbus OH 43215  614-221-7614  www.ohanet.org  Page 2 of 3
2:00
Best Practices and Programs in the Environment of Care (EC)
 Safety, security risk assessments
● Reporting to the safety committee, executive management and the
governing body
 Hazardous energy: lasers and MRI’s
 Hazardous medication disposal
 Hazardous gases and vapors, including compressed gas storage
 Fire prevention issues, including “silent” drills
 Medical equipment maintenance strategies and documentation for CMS, including new inventory and
alternate maintenance requirements
● Clinical alarm patient safety goal
● Revised utility inventory and classification requirements
 Water and air-borne pathogen programs
● Temperature, humidity and pressure relationship requirements
 PCRA, ICRA, MCRA and ILSM requirements
2:30
Break
2:45
Best Practices and Programs in Emergency Management (EM)
 The Emergency Operations Plan (EOP)
 Hazard vulnerability analysis
 Utility and consumable timeline charts
 The six critical emergency management elements
● Emergency privileging for volunteers
 Drills and evaluation requirements
3:30
Best Practices and Programs in Life Safety (LS)
 Building compartmentation
 Furniture and equipment in egress hallways
 Requirements for hazardous areas
● Construction areas
 Operational deficiencies
4:00
Questions and Discussion/Evaluations
4:15
Adjourn
Faculty
Gary Slack is the President of Healthcare Engineering Consultants and has over thirty years of experience in the
health care field in the areas of teaching, research, clinical engineering and technology and regulatory management.
He has worked with hundreds of healthcare institutions throughout the United States in both the public and private
sectors. He has conducted on-site consultations and seminar programs for the Public Health Service, Department of
Veteran’s Affairs and all branches of the military. He has also developed educational programs, including video and
Webinar presentations, for many healthcare organizations, and has served as a faculty member for Joint Commission
training programs, for the American Society for Healthcare Engineering, and other regional, state and national hospital
organizations.
He has published many articles and has written or contributed to five books that focus on Environment of Care and
medical equipment management and medical gas and vacuum system topics. Mr. Slack has also been active on
national technical committees, including the National Fire Protection Association and has served on the editorial
boards for OPUS Communications and the Health Care Safety Institute, and is a frequent contributor to the Decision
Health publication, EC Leader. He received Bachelor and Master degrees in electrical and biomedical engineering
from The Ohio State University and is a Registered Professional Engineer (PE), a Certified Clinical Engineer (CCE)
and a Health Safety Professional (HSP) at the Executive Level.
OHA 155 E Broad St. Floor 15  Columbus OH 43215  614-221-7614  www.ohanet.org  Page 3 of 3