Standard Analysis Worksheet

EC.02.05.01 The hospital manages risks associated with its utility systems. 1st Quarter 2nd Quarter 3rd Quarter 4th Quarter

In-Depth Data
Defciency

Required
Category
Non- Non- Non- Non- Overall
EP Description Compliant compliant Compliant compliant Compliant compliant Compliant compliant Compliance
The hospital designs and installs utility systems that
1 A SLD meet patient care and operational need 87.50% 12.50% 87.50% 12.50% 93.00% 7.00% 96.50% 3.50% 91.13%
Written inventory of operating components of utility
2 C SLD systems 100.00% 0.00% 79.50% 20.50% 84.50% 15.50% 100.00% 0.00% 91.00%
Written documentation of inspection and maintenance
3 C SLD activities for all operating components 100.00% 0.00% 100.00% 0.00% 84.50% 15.50% 100.00% 0.00% 96.13%
Written documentation of intervals for inspecting,
4 C SLD testing and maintaining operating components 100.00% 0.00% 100.00% 0.00% 84.50% 15.50% 98.30% 1.70% 95.70%
Written documentation of activities and frequencies
for inspecting, testing and maintaining equipment in
5 A SLD accordance with manufacturer's recommendations 100.00% 0.00% 100.00% 0.00% 84.50% 15.50% 98.30% 1.70% 95.70%
Qualified individual utilizes written criteria to support
6 A SLD alternative methods 100.00% 0.00% 100.00% 0.00% 84.50% 15.50% 98.30% 1.70% 95.70%
Written documentation of operating components with
7 C SLD alternative equipment maintenance program 100.00% 0.00% 100.00% 0.00% 84.50% 15.50% 98.30% 1.70% 95.70%
Utility system controls are labeled for partial or
8 A SLD complete emergency shutdowns 93.54% 6.46% 83.50% 16.50% 90.00% 10.00% 95.00% 5.00% 90.51%
Written procedures for responding to utility system
9 A SLD N disruptions 88.88% 11.12% 100.00% 0.00% 100.00% 0.00% 90.00% 10.00% 94.72%
Electricity Yes Yes Yes Yes
Natural Gas Yes Yes Yes Yes
Medical Air Yes Yes Yes Yes
Vacuum Yes Yes Yes Yes
HVAC (Heating, Ventilation, Air Conditioning) Yes Yes Yes Yes
Water Yes Yes Yes Yes
Sanitation No No No Yes
Communication Systems Yes Yes Yes Yes
Information Technology Yes Yes Yes Yes
Elevator No
Procedures address shutting off the malfunctioning
10 A SLD system and notifying staff in affected areas 100.00% 0.00% 100.00% 0.00% 94.50% 5.50% 94.50% 5.50% 97.25%
Procedures address performing emergency clinical
11 A SLD interventions during utility system disruptions. 95.00% 5.00% 100.00% 0.00% 100.00% 0.00% 100.00% 0.00% 98.75%
Procedures address how to obtain emergency repair
12 A SLD services 100.00% 0.00% 100.00% 0.00% 94.50% 5.50% 94.50% 5.50% 97.25%
Hospital responds to utility system disruptions as
13 A SLD described in its procedures 92.30% 7.70% 83.33% 16.67% 93.50% 6.50% 95.45% 4.55% 91.15%
Minimizes pathogenic biological agents in cooling
towers, domestic hot-and cold water systems, and
14 A CLD other aeroloizing water systems 95.60% 4.40% 86.67% 13.33% 87.00% 13.00% 95.00% 5.00% 91.07%
Appropriate pressure relationships, air-exchange
rates, and fltration efficiencies in areas designed to
15 A CLD Y control airborne contaminants 76.54% 23.46% 74.56% 25.44% 64.26% 35.74% 77.20% 22.80% 73.14%
Air Pressure Relationship 59.57% 40.43% 46.81% 53.19% 34.04% 65.96% 57.45% 42.55% 49.47%
KPI Analysis Air-exchange Rates 79.30% 20.70% 88.60% 11.40% 80.25% 19.75% 85.90% 14.10% 83.51%
Filtration Efficiencies 90.74% 9.26% 88.26% 11.74% 78.50% 21.50% 88.26% 11.74% 86.44%

16 A SLD Utility systems have maps of distribution 100.00% 0.00% 100.00% 0.00% 93.00% 7.00% 100.00% 0.00% 98.25%

109.94% 8.81% 107.42% 11.33% 100.60% 18.15% 110.18% 8.57%

Standard Analysis Worksheet
Non-
Element of Compliance Compliance
Performance Percentage Percentage
1 91.13% 8.88%
2 91.00% 9.00%
3 96.13% 3.88%
4 95.70% 4.30%
5 95.70% 4.30%
6 95.70% 4.30%
7 95.70% 4.30%
8 90.51% 9.49%
9 94.72% 5.28%
10 97.25% 2.75%
11 98.75% 1.25%
12 97.25% 2.75%
13 91.15% 8.86%
14 91.07% 8.93%
15 73.14% 26.86%
16 98.25% 1.75%

EC.02.05.01 Element of Performance Compliance Rate

100.00%

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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Non-Compli ance Percenta ge Compl ia nce Percentage
 10.00%

Standard
0.00% Analysis
1 2
Worksheet
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Non-Compli ance Percenta ge Compl ia nce Percentage
In-depth Data Worksheet
EC.02.05.01 EP 15 Air Pressure Relationships - Daily Verifcation of Appropriate Air Pressure for In Use Rooms
1st Quarter 2nd Quarter 3rd Quarter 4th Quarter Total
Non- Non- Non- Non- Non- Overall
Measurement Compliant compliant Compliant compliant Compliant compliant Compliant compliant Compliant compliant Compliance
OR 1 (2) 174 6 157 23 148 34 157 25 636 88 87.85%
OR 2 (2) 170 10 164 16 153 29 155 27 642 82 88.67%
OR 3 (2) 149 16 176 12 92 17 92 0 509 45 91.88%
AHU 1

OR 4 (2) 147 11 123 12 120 14 156 0 546 37 93.65%

PACU (2) 152 7 147 9 143 13 129 27 571 56 91.07%
Clean Core 1 (4) 312 48 337 27 301 59 303 57 1253 191 86.77%
OR 5 (2) 152 0 154 0 156 0 156 2 618 2 99.68%
OR 6 (2) 152 0 154 0 156 0 156 2 618 2 99.68%
OR 7 (2) 152 0 154 2 156 1 156 0 618 3 99.52%
OR 8 (2) 152 0 154 1 156 2 156 0 618 3 99.52%
AHU 2

OR 9 (2) 152 3 154 2 156 0 156 1 618 6 99.04%

Ciculation Corridor 1 (2) 152 0 154 4 156 1 156 0 618 5 99.20%
Circulation Corridor 2 (2) 152 0 154 0 156 3 156 0 618 3 99.52%
OR Sterile Storage (3) 270 2 273 0 276 0 273 3 1092 5 99.54%
Clean Core 2 (4) 360 0 360 4 368 0 368 0 1456 4 99.73%
Clean Core 3 (4) 360 0 364 0 362 6 368 0 1454 6 99.59%
Clean Core 4 (4) 227 1 228 3 232 2 234 0 921 6 99.35%
AHU 3

IR 1 (2) 180 0 176 0 179 1 175 0 710 1 99.86%

IR 2 (2) 151 1 152 2 155 1 155 1 613 5 99.19%
IR Sterile Storage (1) 90 0 91 0 92 0 92 0 365 0 100.00%
Endo 1 (2) 166 0 172 1 181 3 183 1 702 5 99.29%
Endo 2 (2) 152 1 148 6 156 0 153 3 609 10 98.38%
Endo 3 (2) 152 0 154 0 154 2 156 0 616 2 99.68%
Endo 4 (2) 152 0 154 0 154 2 151 5 611 7 98.87%
AHU 4

Endo Sterile Storage (2) 180 0 182 0 184 1 184 0 730 1 99.86%
Endo Decontamination (2) 180 0 182 0 183 1 180 4 725 5 99.32%
Vascular 1 (2) 158 0 161 0 140 0 143 0 602 0 100.00%
Vascular 2 (2) 152 0 154 0 156 0 156 0 618 0 100.00%
Vascular Sterile Storage (1) 180 0 182 0 184 0 184 0 730 0 100.00%
L&D OR 1 (2) 178 2 179 3 182 2 182 2 721 9 98.77%
L&D OR 2 (2) 180 0 181 1 182 2 184 0 727 3 99.59%
L&D OR 3 (2) 149 0 161 0 175 0 173 0 658 0 100.00%
L&D Sterile Storage (1) 90 0 91 0 92 0 92 0 365 0 100.00%
AHU 5

ICU Isolation 1 (2) 178 6 173 5 184 3 184 1 719 15 97.96%

ICU Isolation 2 (2) 176 4 182 0 184 1 184 0 726 5 99.32%
NICU Isolation 1 (2) 179 1 176 3 184 2 184 0 723 6 99.18%
NICU Isolation 2 (2) 177 9 182 5 184 4 184 1 727 19 97.45%
Medical Isolation A (2) 152 0 154 0 156 1 156 0 618 1 99.84%
Medical Isolation B (2) 180 0 182 0 182 2 184 0 728 2 99.73%
AHU 6

Post-Op Isolation C (2) 176 0 182 1 180 0 178 0 716 1 99.86%

Post-Op Isolation D (2) 180 0 182 0 184 0 184 1 730 1 99.86%
Pharmacy 180 0 168 14 167 17 179 2 694 33 95.46%
Laboratory A 160 1 133 9 150 6 164 0 607 16 97.43%
Laboratory B 176 0 182 0 180 0 178 0 716 0 100.00%
AHU 7

Laboratory C 158 0 161 0 140 0 143 0 602 0 100.00%

Central Sterile - Clean (5) 450 3 455 5 460 1 460 2 1825 11 99.40%
Central Sterile - Dirty (6) 348 102 536 10 526 32 549 3 1959 147 93.02%
59.57% 40.43% 46.81% 53.19% 34.04% 65.96% 57.45% 42.55% 17.02% 82.98%
In-depth Data Worksheet
Air Pressure Relationships - Daily Verifcation of Appropriate Air Pressure for In Use Rooms
Non- Non-
Compliance Compliance Compliance Compliance
Measurement Percentage Percentage Measurement Percentage Percentage
OR 1 (2) 87.85% 12.15% OR 1 87.85% 12.15%
OR 2 (2) 88.67% 11.33% OR 2 88.67% 11.33%
OR 3 (2) 91.88% 8.12% OR 3 91.88% 8.12%
OR 4 (2) 93.65% 6.35% OR 4 93.65% 6.35%
PACU (2) 91.07% 8.93% PACU 91.07% 8.93%
Clean Core 1 (4) 86.77% 13.23% Clean Core 1 86.77% 13.23%
OR 5 (2) 99.68% 0.32% Pharmacy 95.46% 4.54%
OR 6 (2) 99.68% 0.32% Central Sterile - Dirty (6) 93.02% 6.98%
OR 7 (2) 99.52% 0.48%
OR 8 (2) 99.52% 0.48%
OR 9 (2) 99.04% 0.96%
Ciculation Corridor 1 (2) 99.20% 0.80% EC.02.05.01 EP 15 Areas of Non-compliance
Circulation Corridor 2 (2) 99.52% 0.48% 100.00%
OR Sterile Storage (3) 99.54% 0.46%
Clean Core 2 (4) 99.73% 0.27% 98.00%
Clean Core 3 (4) 99.59% 0.41%
Clean Core 4 (4) 99.35% 0.65% 96.00%
IR 1 (2) 99.86% 0.14%
IR 2 (2) 99.19% 0.81% 94.00%
IR Sterile Storage (1) 100.00% 0.00%
Endo 1 (2) 99.29% 0.71%
92.00%
Endo 2 (2) 98.38% 1.62%
Endo 3 (2) 99.68% 0.32%
Endo 4 (2) 98.87% 1.13% 90.00%
Endo Sterile Storage (2) 99.86% 0.14%
Endo Decontamination (2) 99.32% 0.68% 88.00%
Vascular 1 (2) 100.00% 0.00%
Vascular 2 (2) 100.00% 0.00% 86.00%
Vascular Sterile Storage (1) 100.00% 0.00%
L&D OR 1 (2) 98.77% 1.23% 84.00%
L&D OR 2 (2) 99.59% 0.41%
L&D OR 3 (2) 100.00% 0.00% 82.00%
L&D Sterile Storage (1) 100.00% 0.00%
ICU Isolation 1 (2) 97.96% 2.04%
80.00%
ICU Isolation 2 (2) 99.32% 0.68% OR 1 OR 2 OR 3 OR 4 PACU Cl ea n Core 1 Pha rma cy Centra l Steril e
NICU Isolation 1 (2) 99.18% 0.82% Non-Compl i a nce Percenta ge Compl i a nce Percenta ge - Di rty (6)
NICU Isolation 2 (2) 97.45% 2.55%
Medical Isolation A (2) 99.84% 0.16% OR 1, OR2, OR 3, OR 4, PACU and Clean Core 1: 1989 system that has a very extensive PM system due to the age of the equipment; 129 OR cases in the past year
Medical Isolation B (2) 99.73% 0.27% have been re-scheduled, moved or post-poned due to a malfunctioning system and approximately $53k in repairs.
Post-Op Isolation C (2) 99.86% 0.14% Pharmacy: Staff error due to not having the system on when required or propping door open. Manager follow-up and staff education and accountability.
Central Sterile Supply: Multiple issues - department error by not monitoring one pressure relationship from the dirty side into a staff work area, an electrical
Post-Op Isolation D (2) 99.86% 0.14% mechanical door holder that was removed from a door entering the area from the corridor, and staff propping the door once the electrical mechanical door holder
Pharmacy 95.46% 4.54% was removed, and corrective maintenance needs. Corrective action taken immediatly and documented; manager follow-up and staff education and accountability.
Laboratory A 97.43% 2.57% Other Areas Noted: Corrective action taken immediately and documented; not a trending issue.
Laboratory B 100.00% 0.00%
Laboratory C 100.00% 0.00%
Central Sterile - Clean (5) 99.40% 0.60%
Central Sterile - Dirty (6) 93.02% 6.98%
 Key Performance Indicator Dashboard
Environment of Care & Life Safety Key Performance Indicators 1st Quarter 2nd Quarter 3rd Quarter 4th Quarter
Non- Non- Non- Non- Overall
Standard Description Compliant compliant Compliant compliant Compliant compliant Compliant compliant Compliance

EC.02.05.01 The hospital manages risk associated with its utility systems. 76.54% 23.46% 74.56% 25.44% 64.26% 35.74% 77.20% 22.80% 73.14%

LS.02.01.20 The hospital maintains the integrity of the means of egress. 98.70% 1.30% 96.23% 3.77% 95.36% 4.64% 99.48% 0.52% 97.44%

EC.02.06.01 The hospital establishes and maintains a safe, functional environment. 93.68% 6.32% 96.61% 3.39% 91.50% 8.50% 94.39% 5.61% 94.05%
The hospital maintains fire safety equipment and fire safety building
EC.02.03.05 features. 100.00% 0.00% 98.75% 1.25% 97.59% 2.41% 99.32% 0.68% 98.92%

Building and fire protection features are designed and maintained to

LS.02.01.10 minimize the effects of fire, smoke, and heat. 96.40% 3.60% 98.72% 1.28% 95.33% 4.67% 98.72% 1.28% 97.29%

The hospital provides and maintains building features to protect

LS.02.01.30 individuals from the hazards of fre and smoke. 96.19% 3.81% 93.65% 6.35% 89.05% 10.95% 95.99% 4.01% 93.72%

LS.02.01.35 The hospital provides and maintains systems for extinguishing fres. 93.68% 6.32% 96.61% 3.39% 91.50% 8.50% 94.39% 5.61% 94.05%

EC.02.02.01 The hospital manages risks related to hazardous materials and waste. 98.77% 1.23% 98.77% 1.23% 96.53% 3.47% 95.04% 4.96% 97.28%
The hospital inspects, tests, and maintains medical gas and vacuum
EC.02.05.09 systems. 100.00% 0.00% 99.35% 0.65% 100.00% 0.00% 98.93% 1.07% 99.57%

EC.02.05.07 The hospital inspects, tests, and maintains emergency power systems. 99.53% 0.47% 98.12% 1.88% 100.00% 0.00% 98.12% 1.88% 98.94%
*Bolded standards are examples of non-compliance for an organization with a goal of 95% or greater.
 Key Performance Indicator Dashboard
Non-
Standard
Compliance
Percentage
Compliance
Percentage
Environment of Care Life Safety
EC.02.05.01
Overall Compliance Overall Compliance
Utility Mgmt 76.54% 23.46%
LS.02.01.20
Egress 97.44% 2.56%
EC.02.06.01
Safe & Functional 5.79% 4.38%
Environment 94.05% 5.96%
EC.02.03.05
Fire Safety Equipment 98.92% 1.09%
LS.02.01.10 94.21% 95.63%
Fire Safety Design 97.29% 2.71%
LS.02.01.30
Fire Safety Maintenance 93.72% 6.28%
LS.02.01.35
Extinguishment 94.05% 5.96% Compl ia nce Percenta ge Compl i a nce Percentage
Non-Compl i a nce Non-Compl i ance
EC.02.02.01 Percenta ge Percentage
Hazmat 97.28% 2.72%
EC.02.05.09
Medical Gas & Vacuum 99.57% 0.43%
EC.02.05.07
Emergency Power 98.94% 1.06%
Environment of Care 94.21% 5.79%
Life Safety 95.63% 4.38%

Key Performance Indicators for Environment of Care & Life Safety

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Key Performance Indicator Dashboard

Key Performance Indicators for Environment of Care & Life Safety

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90.00%

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EC.02.05.01 LS.02.01.20 EC.02.06.01 EC.02.03.05 LS.02.01.10 LS.02.01.30 LS.02.01.35 EC.02.02.01 EC.02.05.09 EC.02.05.07
Util i ty Mgmt Egres s Safe & Fi re Safety Fi re Safety Fi re Safety Extingui s hment Hazmat Medi cal Gas & Emergency
Functiona l Equi pment Des i gn Ma i ntena nce Vacuum Power
Envi ronment
Non-Compl ia nce Percenta ge Compl i a nce Percenta ge