Industry Update - January 2019

by Joe Brothman, Director, EHS & EM, UCI Health


Click here to access the full PDF version of this month's update.

2019 Joint Commission Survey Activity Guide

The Joint Commission released their annual Survey Activity Guide to prepare organizations for the various Joint Commission accreditation surveys. This toolkit goes over what to expect during a survey, how to prepare and how to respond to requests for information and deficiency identification.

AHA Urges USP to Delay <797> & <800> Dates

The American Hospital Association (AHA) in December urged the United States Pharmacopeial Convention (USP) to delay by at least 18 months the effective dates for its general chapter <797> pharmaceutical compounding and general chapter <800> hazardous drug handling in health care settings, as well as proposed revisions to general chapter <797>. “USP guidelines play a critical role in keeping our hospital staffs and the patients they care for safe,” AHA wrote. “However, we reiterate concerns we have previously shared regarding the compliance challenges that these two sections create.”

Specifically, the proposed changes to general chapter <797> may impact or modify efforts by hospitals and health systems to comply with chapter <800>; the guidelines involve large capital investments, in some cases the construction of entirely new buildings; and the timeline has resulted in high demand for contractors and supplies, making it challenging for all facilities to comply by the effective date, AHA stated. The current implementation date is Dec. 1, 2019.

FGI Process Begins for 2022 Guidelines

On Nov. 1, 2018, the Facility Guidelines Institute (FGI) opened the public proposal period for the 2022 Guidelines for health and residential care facilities with the launch of a new online proposal platform.

Public participation in the Guidelines revision process is vitally important. The first opportunity for input is during the proposal period, which will remain open through June 30. During this time, any change to the text can be recommended. The second opportunity follows the release of the draft 2022 documents in 2020, when the public may comment on the new language.

ASPR TRACIE Webinar January 29th

During this webinar, public and private partners will share how they have used ASPR's Healthcare and Public Health Risk Identification and Site Criticality (RISC) Toolkit, version 1.0. The toolkit contains an objective, data-driven, all-hazards risk assessment tool with the potential to inform emergency preparedness planning, risk management activities, and resource investments. Developed with the input of a team of healthcare partners and risk management subject matter experts, the RISC Toolkit is designed to help healthcare facility owners and operators identify risks in an easy-to-follow format using objective national-level data. After providing a brief description of the tool, the speakers will discuss how they have implemented the RISC toolkit and share success stories and lessons learned. Attendees will have a chance to ask questions at the end of the webinar.

HHS Releases Health Care Cybersecurity Guidelines

A Department of Health and Human Services task group recently released cybersecurity guidelines for the health care field, as mandated by the Cybersecurity Act of 2015. The main document explores and recommends practices to help mitigate key cybersecurity threats to the field. The four-volume publication also includes technical documents geared to information technology and IT security professionals, and resources to help health care organizations assess and improve their policies and procedures. Chantal Worzala, AHA vice president for health IT and policy, served on the panel of more than 150 experts from government and health care that developed the guidelines over the past two years. For more on the initiative, visit

Resources to Help Children With Emotional Disturbance During Disasters

New resources are available from the Substance Abuse and Mental Health Services Administration to help providers who care for children with serious emotional disturbances, including those caused by disasters. The resources define “serious emotional disturbance,” address emotional disturbances during disasters, highlight disasters’ emotional impact on children and teens, clarify complex trauma and how it can impact children, and explain causes of post-traumatic stress disorder in children and teens.