EC.9.10: The "other" EOC standard

Dear Medical Staff Leader,

When consulting with clients, I frequently ask them how they are complying with EC.9.10, one of the lesser known environment of care (EOC) standards. Many times I receive blank looks because they are not aware of this standard.

While the seven well-known EOC standards usually are well attended, EC.9.10 does not receive as much attention, even though it requires hospitals to monitor and improve their environments.

Unlike the first seven standards, EC.9.10 does not require a written management plan. Therefore, it is often overlooked. This can easily get a hospital in trouble because Joint Commission surveyors will ask just as many questions about EC.9.10 as they will about the first seven standards. In addition, they will want to see documentation indicating compliance with the standard. So, let’s look at what you need to do to comply.

EC.9.10: Monitoring conditions in the environment

• You must have a process for reporting incidents involving:
  • Injuries to patients
  • Property damage
  • Staff illness and injuries
  • Security incidents
  • Hazardous spills
  • Fire safety problems
  • Medical equipment problems
  • Utility problems
• Leadership must assign a person to monitor and respond to conditions in the environment. The assigned person:
  • Collects information indicating opportunities for improvement in the environment
  • Coordinates hazard notices and recall reports
  • Prepares summaries of deficiencies, problems, failures, and user errors related to the environment of care. (NOTE: The person designated to coordinate safety management activities [see EC.1.10] must review at least a summary of the incidents involving patients.)
  • Prepares summaries of results of performance improvement (PI) activities
  • Participates in hazard surveillance
  • Helps develop safety policies
• Each EOC management plan’s performance must be monitored on an ongoing basis.
• The objectives, scope, performance, and effectiveness of each EOC management plan must be evaluated annually.
• EOC monitoring and response activities must be communicated to the hospital’s patient safety program.

EC.9.20: Analyzing EOC issues and recommendations to solve them

Hospitals need to make sure:

• Representatives from administration and clinical and support services are involved in the process of resolving EOC issues
• A multidisciplinary improvement team meets at least every other month to address issues in a timely manner and approve recommendations as appropriate
• EOC issues are communicated to hospital’s leadership
• One or more PI activity is recommended and communicated to hospital leaders based on the ongoing PI monitoring of each management plan (HINT: Each management plan must have at least one PI monitoring activity!)

EC.9.30: Improving the environment

Hospitals need to make sure:

• Appropriate staff participates in implementing recommendations and monitoring the effectiveness of those recommendations
• Monitoring results are communicated to hospital leaders

Brad Keyes, CHSP 
Consultant 
The Greeley Company