Courtemanche & Associates: Preparing for Joint Commission
TJC Building Tour
1.Statement of Conditions
2000 Life Safety Code
Doors: rated <3/4" undercut,
Fit, positive latching, Astragal
NFRCorridor doors < 1" undercut
Double corridor doors <1/8 “gap
Floor Assemblies
Sprayed on fire proofing
Compartments
Fire / smoke wall penetrations
Exits
Labeled / Illuminated
2 Remote
Clear of Obstruction
Horizontal
2. National Patient Safety Goals
Clinical Alarm Systems
Infusion Pumps
3. Safety Plans
Worker Safety
Patient Safety
Inpatient psychiatric units
Patient suicide risks
4. Security Plans
Identification
Infants / Children Abduction Drills
Lock-down capability
5. No Smoking
6. Fire Prevention Plans
Extinguishers
Number and type
Monthly check
Annual Test / PM
Secured visible
Auto Systems(Lab, Kitchen, etc.)
Every 75 feet
Sprinklers
Sprinkler System (all/part/not)
Storage 18" Below Head
Spare Heads and Wrench
Fire Alarms
Tested / Operational
Covers All Areas
Smoke Detectors
Test all circuits
Annual PM
Fire Drills
Quarterly: each shift
Circuits / Extinguishers
Supervise away from point of origin
Annual fire training effectiveness eval
7. Emergency Management
Hazard Vulnerability Analysis – all sites
Collaborative Planning
Contingencies – alternate care sites
Role in Disaster- 4 phases
Role in Bioterrorism
Radiation / hazmat decontamination
8. Hazardous Material
Management Plans
2 Hour Firewall
Limited Quantities
Labeling, Handling, Storage
Proper Disposal (Manifest)
9. Construction
Pre-construction risk assessment (ICRA)
Interim Life Safety Measures
10. Utility Systems Plans
Emergency Power, HVAC, and H2O
Generator/ transfer switch checks
Testing Battery egress lighting
Staff knowledge medical gases
Labeling Medical Gases
Water Systems
Relief Valves on Boilers
Does Not Vent to Corridor
Damage Alarms
Shutdown plans
Contingency Plans
11. Medical Equipment Plans
Proper PM / Repair / Safety testing
Timely PM completion
Outdated / obscured PM stickers
Defibrillator staff testing process
No Space Heaters
Aggregate Data
12. Housekeeping
Handling / Storage
Laundry Chutes
Fire Safety
Security of trash compactor
Security of red bag trash
13. Central Supply
ETO Sterilizer
PM of sterilizers
Haz-Mat Procedures
14. Medication Areas
Security / Pyxis overrides
Control of Meds / Samples
Emergency Carts / Red boxes
Medication Carts security
Storage / Handling (Chemo)
Hood / Refrigerators
15. Admitting Areas
Patient Rights
Privacy: auditory
Advance Directives
Security of Patient Info
16. Dietary
Food Storage
Handling
Refrigerator / Dishwasher temps
Emergency release for refrig
Fire Safety
Auto Extinguishers
Emergency shut down procedures
Wire Mesh Filters
17. Resource Centers
Accessibility
Availability