Preparing a surgery center policy and procedure manual to get you through a Joint Commission survey is set up quite differently from AAAHC or an AAAASF policy and procedure manual. To comply with the Joint Commission standards for surgery center accreditation you must provide written plans for managing risks and safety issues & to demonstrate that you are monitoring the plan’s effectiveness through documentation. During your Environment of Care session with your Joint Commission’s Inspector you will need to show all of your written plans and your evaluation of the environment.
Key elements of the Joint Commission Environment of Care Plan include:
● Safety and Security which must address the risks in the physical environment, access to security sensitive areas, product recalls and smoking.
● Hazardous materials and waste to address risks associated with hazardous chemicals, radioactive materials, hazardous energy sources, hazardous medications and hazardous gases and vapors.
● Fire and Safety issues to address risks from fire, smoke, and other products of combustion; fire response plans, fire drills, management of fire detection; alarm, and suppression equipment and systems; and measures to implement during construction or when the Life Safety Code cannot be met.
● Medical equipment addresses selection, testing and maintenance of medical equipment and contingencies when equipment fails.
● Utilities addresses inspection and testing of operating components control of airborne contaminants, and management of disruptions.
I created an Environment of Care Plan Book with all of the essential elements required to meet the conditions of the Joint Commission Inspection. You can call or email me for more details. In blog posts to come I will break down components of the Environment of Care to give you an understanding of how to get through this session with the Joint Commission.
Here’s to your success,