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Indoor Environment Report — October 2004

JCAHO enhancing its HVAC standard

Starting next year, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) is implementing a refinement of its environment of care standards for HVAC systems in healthcare facilities.

Beginning in January, hospitals must label controls for a partial or complete emergency shutdown.

This is a refinement of JCAHO’s Standard EC.7.10, which focuses on management of healthcare facilities’ utility risks. This standard requires healthcare facilities to establish and maintain a utility systems management program to promote a safe, controlled, and comfortable environment that:

  • Ensures operational reliability of utility systems
  • Reduces the potential for organization-acquired illness to be transmitted through the utility systems
  • Assesses the reliability and minimizes potential risks of utility system failures

Performance of this standard means facilities should develop and maintain a written management plan describing the processes it implements to manage the effective, safe, and reliable operation of utility systems. Hospitals must also design and install utility systems that meet the patient care and operational needs of the services in their buildings.

In addition, the standard mandates that hospitals establish risk criteria for identifying, evaluating, and creating an inventory of operating components of systems before the equipment is used. These criteria address life support, infection control, support of the environment, equipment support, and communication.

While hospitals should develop appropriate strategies for all utility systems equipment on the inventory for ensuring effective, safe, and reliable operation of all equipment in the inventory, they may use may use different strategies as appropriate.

Equally important, hospitals must identify and implement emergency procedures for responding to utility system disruptions or failures that address the following:

  • What to do if utility systems malfunction
  • Identification of an alternative source of hospital-defined essential utilities
  • Shutting off the malfunctioning systems and notifying staff in affected areas
  • How and when to perform emergency clinical interventions when utility systems fail
  • Obtaining repair services

In addition, they must design, install, and maintain ventilation equipment to provide appropriate pressure relationships, air-exchange rates, and filtration efficiencies for ventilation systems serving areas specially designed to control airborne contaminants (such as biological agents, gases, fumes, and dust).

Specially designed areas include operating rooms, special procedure rooms, delivery rooms for patients diagnosed or suspected of having airborne communicable diseases (for example, pulmonary or laryngeal tuberculosis), patients in “protective environment” rooms (for example, those receiving bone marrow transplants), laboratories, pharmacies, and sterile supply rooms.

A related standard — Standard EC.7.30 — provides guidance on maintenance, testing, and inspection of utility systems.

For more information, contact JCAHO at www.jcaho.org.

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