February 17, 2010 | | Comments 0
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Stick to required policies in your physical environment program

Sometimes you hear about Joint Commission surveyors requesting to see certain policies in your physical environment program.

Joint Commission standards are not very prescriptive when it comes to the identification of specific policies. The only required policies are:

  • Environment of care management plans
  • Written security response policy
  • Smoking policy
  • Hazardous materials spill response policy
  • Fire response plan
  • Medical equipment maintenance, inspection, and testing policy (including frequencies for those activities)
  • Medical equipment failure response policy
  • Utility systems equipment maintenance, testing, and inspection (including frequencies)
  • Utility systems disruption response policy
  • Emergency operations plan
  • Interim life safety measures policy

Beyond that, you would only need to have other policies as indicated by your own programmatic elements.

Now it may be that a surveyor is a fan of “canned” manuals that have a policy for every element of performance in the standards, and if it helps for you to have that, so be it. I’ve not encountered too many organizations that need to rely that much on policy-driven programs, but everybody gets to make his or her own way in the world.

The more policies you have, the more policies you have to manage, which takes time away from managing safety in the physical environment. In my judgment, the paper chase is not necessarily the best use of time.

Entry Information

Filed Under: Emergency managementEnvironment of careLife Safety Code


Steve MacArthur About the Author: Steve MacArthur is a safety consultant with The Greeley Company in Danvers, Mass. He brings more than 30 years of healthcare management and consulting experience to his work with hospitals, physician offices, and ambulatory care facilities across the country. He is the author of HCPro's Hospital Safety Director's Handbook and is contributing editor for Briefings on Hospital Safety. Contact Steve at stevemacsafetyspace@gmail.com.

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