ConstructionInfection protection
By Gregory W. Weigle, P.E., FACHE
The best time to review your compliance procedures is when policies are revised or re-written. Recently, the Joint Commission formalized the Guidelines for Design and Construction of Health Care Facilities requirement for performing an infection control risk assessment (ICRA) when commencing a construction project. The release of this new "old" standard offers the perfect opportunity to review your strategy to ensure compliance with ICRA and interim life safety measures (ILSM).
The Joint Commission Environment of Care (EC) Standard EC.02.06.05 states, "An organization must manage its environment during demolition, renovation or new construction to reduce risk to those in the organization." There are three elements of performance (EP) for this standard:
- The use of the Guidelines for Design and Construction of Hospitals and Health Care Facilities (2001 Edition).
- Life Safety standard LS.01.02.05.01 - the compatible standard for life safety risk during construction.
- A pre-construction risk assessment occurs for hazards that affect care, treatment and services and that action is taken upon its assessment.
Guideline for an ICRA
Although the 2001 edition of the Guidelines is referenced, the 2006 edition is what most facility managers and designers are currently using and will also be cited for the purposes of this article. The Guidelines, in Section 1.5 (Planning, Design, and Construction), require an ICRA be performed by the owner for the risk of transmission of water and airborne contaminants.
The owner makes the assessments' design and mitigation (measures during construction) recommendations known to the design team.
This section further defines that a panel must conduct the assessment, the specifics as to what the assessment should entail, and that regular monitoring and updates must occur.
Note that the owner is emphasized and is deemed to be the "expert" for the intent and purpose of guiding the practice of the design team and the contractor. It is important to understand the clear implication that there exists a limitation in responsibility (scope) for controlling the spread of infection with respect to the roles of the design team and contractor.
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An ICRA assessment tool. (Click for PDF version) |
The ILSM requirement
The aforementioned Life Safety Standard LS.01.02.01 requires the following of the hospital:
- Develop an ILSM policy
- Perform an evaluation (or assessment) to see what elements of protection are compromised
- Identify the appropriate measures (mitigations) to be taken
- Monitor the mitigations (surveillance)
- Educate and train the players involved
- Incorporate any other prescriptive actions defined by the National Fire Protection Association's NFPA 101, the Life Safety Code.
- Documentation of certain elements
- Develop measures of success
Non-compliance with this standard invokes a "Situational Decision Rule" (CON04) by the Joint Commission. This is a "conditional accreditation" and the organization has 45 days in which to respond with their corrective action. This may affect their new accreditation pyramid where decisions are based upon the impact on patient care. The situational decision rule category is the second most serious condition on the pyramid.
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An ILSM assessment tool. (Click for PDF version) |
Similarity and synergy
Although the ICRA requirement deals with human safety resulting from infection and the ILSM deals human safety from fire, there are similarities between the means and methods of both. For ILSM and ICRA alike, policies, assessment matrices, monitoring and surveillance tools, have been well documented and can be found on the American Society for Healthcare Engineering Web site at www.ashe.org and other industry Web sites.
The idea of a combined ILSM and ICRA surveillance tool and assessment panel is also not new and has been discussed before. However, it is always prudent to review your organizations approach to compliance with these standards, especially in a year when the Joint Commission has revised their standards. For those responsible for managing Joint Commission compliance, synergies should be identified in strategies to effect compliance with regulatory standards.
There are three main elements of the ICRA and ILSM standards which have similarity and thus have potential for synergy in an organization's compliance strategy:
- The standards assessment
- The means or measures of compliance to the standards
- The implementation assurance (or monitoring, surveillance and documentation) of the standards
Whether you are assessing infection control or life safety, the main objective to be accomplished in the assessment is to ascertain the degree of risk that the construction activity presents to the organization. Most are probably familiar with assessment tools for both ICRA and ILSM.
For an ILSM assessment, a tool might be a matrix with conditions compromising life safety systems down one side and the eleven interim measures across the top of the matrix (see Figure 1). For each condition, there will be checks in the measures deemed necessary to implement to minimize the risk to the organization from that condition.
Similarly, an ICRA assessment matrix tool may define patient risk groups down the side and list type of construction (or maintenance) activities across the top with a construction class listed where the risk groups and construction types intersect. The construction class defines the precautions (measures) to be employed to minimize the risk to the organization from that condition. In both assessments the goal is clearly to define how much risk exists due to the proposed construction activity.
In the example of the assessment matrices in Figure 2, measures are cited to mitigate the corresponding defined risk. Although these measures are not explicitly the same for each assessment, there are common elements that may provide control for the spread of disease or fire. For example, a barrier may be required to limit the spread of dust or smoke. Ensuring that the barrier is sealed to meet a fire rating will also enable it to control dust from leaching beyond the limits of construction.
Cleanliness of the construction area both reduces the combustible load and the amount of dust that can migrate outside of the area. The personnel working in the construction area can be trained in both areas thus will be more effective in their work practices to limit both hazards. Proper ventilation is another measure that may be required for HEPA filtration to minimize infection and may also be needed to control smoke or the environment. Analyzing requirements at the onset will ensure that services can be constructed to perform dual roles in order to maximize effectiveness and value of the temporary utility to the owner.
The best of assessments and control measures mean nothing to the regulatory auditor if there is no evidence that the plan was carried out as prescribed. Strategies should begin with the monitoring and/or surveillance of the affected areas. As previously acknowledged, "Monitoring Checklists" have already been presented that combine measures of ILSM and ICRA. It is important to have a clear understanding of who is responsible for the assessment, the frequency of the assessment, the reporting of the assessment and the follow-up or corrective action for deficiencies discovered in the assessment.
The person(s) that performs the assessment must first be properly trained. They must understand how to use the assessment tool(s), what actions are to be taken when deficiencies are found, and who should be notified about the deficiencies. Some infractions (a ceiling tile not replaced) may not require an immediate action, but a non-working HEPA filtration unit may require the stoppage of activities until that condition is corrected. Throughout this process, communicate is of paramount importance. Reporting and documentation must be clear, concise and understood by the assessor.
Synergy in strategies
In addition to the surveillance of ICRA and ILSM measures, there are other opportunities to combine compliance strategies. The starting point for this discussion is the management plan and policies of the organization. Certainly an infection control policy and interim life safety policy are separate intents; however, the processes of implementation may have common elements.
The individuals who are charged with conducting assessments are similar, the tools used to comply may be similar (the monitoring surveillance tool), the consequences of non-compliance have a similar impact, and reporting in the organization should be parallel if not the same. Having the plans and policies reviewed concurrently and by the same common players ensures consistency.
All stakeholders involved in the assessment should be included at the planning stage - designers, contractors, facility managers, safety officers, risk managers, and the managers of the affected areas. In addition, an infection control professional and hospital epidemiologist should be included to provide the missing pieces to perform an ICRA. The design professionals must develop life safety plans which can be used in the ILSM assessment.
If your state doesn't require an infection control plan, adding infection control plans to the drawing set provides a common methodology to perform either assessment. The organizations assessment tools can be added to the drawings as a schedule or in the notes. With construction documents as part of the drawing set, a meeting in which both assessments are discussed with the appropriate representatives formalizes the assessment. Recording meeting minutes ensure accuracy and communication between for both the infection control and environment of care (EOC) Committees.
The implementation period for both ILSM and ICRA measures is from the time the risk activity is commenced until the time it ceases to exist. Having ILSM and ICRA as a standing agenda item on the appropriate monitoring committees (IC or EOC) and documenting discussion of the surveillance activities memorializes the organizations management of these requirements for regulatory compliance. When the activity ceases, it should be documented it in the committee minutes.
Inclusion of these issues (from the committees' minutes and actions) in the annual review of the management plans reflects the organizations understanding of the importance of the problem(s). If the monitoring activities reflect that either of these issues were problematic and required more intervention than is reasonably expected, the organization may wish to develop a performance improvement (PI) initiative. All of the above information will be critical (and welcomed) in performing the PI initiative.
A hazardous activity
Construction is a hazardous activity and presents many risks to a hospital organization. It is a complex contractual arrangement of many participants that must be managed properly to ensure success for the institution and a safe environment for patients and occupants. The requirement of regulatory compliance is simply the evidence that you are doing just that for your organization.
Gregory W. Weigle, P.E., FACHE, is a principal consultant at KLMK Group LLC in York, Pa. He can be reached via e-mail at gweigle@klmkgroup.com.
