Industry Update - June 2019

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


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

USP Releases New and Revised Chapters for Compounding

from HFM Magazine

The U.S. Pharmacopeia (USP) has published the new and revised USP Compounding General Chapters and made them available for free download.

The chapters published include:

The new & revised standards, in addition to General Chapter 800 published in February 2016, go into effect Dec. 1.

Health Facility Trends Fucturescan Focus


This collection of articles will help health care facilities professionals understand and prepare for new trends that experts anticipate emerging in the near future of our field.

ASHE Committee to Focus on Operational Excellence

from HFM Magazine

The American Society for Health Care Engineering’s (ASHE) new Operational Excellence Committee, formed in April of this year, has a goal of implementing ASHE’s operational excellence strategic imperative to more areas.

“The committee will implement the strategic imperative in a way that allows us to make a difference in member’s organizations,” says Jonathan Flannery, FASHE, senior associate director of advocacy at ASHE. “The whole effort here is to give our members the tools, resources and guidance to improve their operations across the board.”

Like ASHE’s Energy to Care initiative, which is a benchmarking and awards program focusing on helping hospitals save energy, the operational excellence imperative encompasses energy sustainability but goes much further. Though no formal products have yet to be delivered, expect Best Practice documents and monographs from this committee in the coming months and years.

Academic Research to Support Facility Guidelines Institute & ANSI/ASHRAE/ASHE Standard 170-2013


The purpose of this study was to conduct a literature review of ANSI/ASHE/ASHRAE Standard 170 Ventilation of Health Care Facilities to determine whether the 886 requirements defined in the Standard (Part 4 of the FGI Guidelines) are supported by engineering and/or scientific evidence. The authors and the Project Monitoring Subcommittee (PMS) assigned the requirements to one of three categories: rational inclusion, clinical inclusion and evidence-based inclusion.

Those requirements categorized for evidence-based inclusion were aligned with related citations. The authors provided opinions on whether the available evidence suggests that the requirement is a basic necessity or an enhanced requirement, requires a change to the Standard, is procedural or requires further investigation. Overall, 209 requirements (23.6%) were determined to be a basic necessity as supported by rational inclusion, clinical requirements or evidence and six requirements (0.7%) were considered to be enhanced practices. Twelve requirements (1.4%) were determined to be procedural and not subject to evidence. Evidence was found to support a change to the standard for eight requirements (0.9%). The remaining 651 requirements (73.5%) are recommended for further study.

FGI Guidelines Public Comment Period Ends June 30

from FGI Guidelines

The Facility Guidelines Institute (FGI) public comment period for 2022 documents closes June 30. Members of the public, particularly healthcare professionals that use the document in the field, are encouraged to submit edits to the 2018 Guidelines and provide input on 2022 drafts of the Guidelines for Design and Construction of Hospitals, Guidelines for Design and Construction of Outpatient Facilities, and Guidelines for Design and Construction of Residential Health, Care, and Support Facilities.

CMS Requests Comments on Co-Location Guidance


The public comment period for the Centers for Medicare & Medicaid Services (CMS) Guidance for Hospital Co-location with Other Hospitals or Healthcare Facilities closes July 2. The draft revisions are intended to provide clarity and guidance regarding what constitutes a co-location between hospitals or other health care entities. The draft addresses how the co-located facilities will be surveyed and clarifies contractual staffing requirements for co-located health care facilities. Once final, these will be used by CMS as surveyor tools. ASHE is requesting members share concerns and submit comments.

ASHE Task Force Helps Members to Overcome Blind Spots

from HFM Magazine

ASHE’s Member Tool Task Force is focused on helping those in the field overcome this effect. The tools created by this task force are the result of very knowledgeable people addressing complex topics. Here are a few suggestions on how to reduce the impact of the Dunning-Kruger Effect in one’s own performance efforts:

  1. Engage in continuous education opportunities. Plan time to read from a variety of sources.
  2. Participate in training opportunities that contribute to professional development even if one’s own role does not require ongoing education or other requirements.
  3. Begin each day or each project with the perspective of a learner. Be open to learning from others — even those outside of the facilities or engineering realm.
  4. Pay attention to challenges and lessons learned for valuable takeaways.
  5. Never underestimate the value of mentorship, and know that mentors can be found at all levels. Spend time with the plant supervisor who has worked at the facility for the past 20 years, and learn from team members. At the other end of the spectrum, offer to be a mentor to those new to the field. One’s own knowledge can be significantly improved when the person spends time educating others.
  6. Find experts in the field — from close to one’s own home base to the national level:
  • Engage with a local ASHE chapter.
  • Subscribe to Health Facilities Management magazine.
  • Be active on the MyASHE website, where one can ask questions and respond to those posted by other members. The more engaging the dialogue, the better the impact for all.

Technology Outpaces Exit Sign Requirements

from HFM Magazine

(…)The median number of failures for LED exit signs per campus, over an entire year, was zero (average = 1.3). Non-LED exit signs had higher failure rates, at a median of 10 for the year (average = 0); however, these findings were affected by a few campuses with extreme scores. This suggests an extremely low failure rate, particularly for LED signs.

This conclusion was echoed by many of those surveyed. Open comments by respondents argued that monthly inspections were an unnecessary burden. They also cited advancements such as LEDs and emergency power tie-ins that create a situation where current technology has outpaced the monthly inspection requirement.

(…)ASHE is working with the NFPA Codes and Standards Review Committee to develop a proposal to recommend the deletion of the requirement for visual inspections of exit signs within the 2021 edition of the Life Safety Code.

Prepublication Standards – New Element of Performance in the Life Safety Chapter

from Joint Commission

The Joint Commission has developed a new element of performance at Standard LS.01.01.01, EP 7 for hospitals, critical access hospitals, and ambulatory care organizations. This new requirement emphasizes the importance of providing basic building information (BBI) on the accredited organization’s statement of conditions (SOC).

National Health Care Facilities and Engineering Week


Facilities & Engineering Week will take place October 20–26, 2019. To celebrate, ASHE will be hosting two free members-only webinars as well as a social media contest. Perhaps sharing this ASHE endorsed video will liven up your week!

Clarification of Behavior Health In-Patient Electrical Outlets

from Joint Commission

The Joint Commission recently highlighted that temper-resistant receptacles (TRR’s) are required in behavior health in-patient environments. Although disagreement about the effectiveness of tamper resistant with arc fault and ground interruption exists, The Joint Commission clarifies their expectations that these devices are to be installed throughout the behavioral health unit, patient bedrooms and restrooms, corridors and common spaces. The Joint Commission states, “TRRs, provide a simple, affordable, reliable, and permanent solution to help prevent injuries”

CDPH Warns of Hot Summer Ahead


The California Department of Public Health’s Licensing and Certification Program has issued a reminder to health care facilities that, as the hot summer weather begins, they should have contingency plans in place to deal with the potential loss of air conditioning; ensure patients and residents are free of adverse conditions that may cause heat-related complications; and report extreme heat conditions that compromise patient health or require evacuation, transfer, or discharge of patients. More information and guidance are available in All Facilities Letter 19-21.

Report Findings Suggest Lawmakers Re-examine 2030 Hospital Seismic Mandate


Twenty-five years after California adopted stringent requirements to keep hospitals operational after an earthquake, a new report by the RAND Corporation suggests state lawmakers should consider policy alternatives that take into account the massive financial costs and reflect the way health care is now delivered.

USP 797 Pharmaceutical Compounding – Sterile Preparations


The United States Pharmacopeia Convention has updated the USP 797 standard. The publication date was June 1, 2019. The standard applies to all places where compounded sterile preparations (CSPs) are prepared (e.g., hospitals, clinics, pharmacies and emergency rooms) and to all persons, regardless of profession, whose work involves preparation of CSPs. The updated USP 797 standard's official implementation date is December 1, 2019. The standard emphasizes individual training and evaluation of those who compound sterile preparations. Contact is the most likely source of clinically significant microbial contamination during pharmaceutical compounding. Proper hand hygiene is critical and environmental sampling is stressed as part of comprehensive quality management.

The update includes several differences from the last edition of the 797 standard. The "low, medium, high" risk levels have been replaced by a two category system of classifying CSPs. Category 1 CSPs are those assigned a beyond-use date (BUD) of 12 hours or less at controlled room temperature, or 24 hours or less when refrigerated if made in accordance with all requirements for Category 1 CSPs. Category 2 CSPs are those that may be assigned a BUD of greater than 12 hours at controlled room temperature, or greater than 24 hours if refrigerated if made in accordance with requirements for Category 2 CSPs.

The updated standard also clarifies the requirements for sterile compounding cleanroom design and certification. Certification and recertification must be performed every 6 months. All certification and recertification records must be reviewed by the designated person(s) to ensure that the classified environments meet the minimum requirements. Corrective action plans must be implemented and documented in response to any out-of-range results.

ASHE will be releasing guidance for complying with USP 797 in the upcoming weeks.

New ASHE Career Center Hospital Facilities Job Portal


The American Society for Health Care Engineering (ASHE) recently launches a portal for industry career opportunities. This portal offers users access to nationwide hospital facility job openings, as well as reference checking, resume writing resources, and career coaching. “The ASHE Career Center offers professional services to help you build and manage your career for maximum potential for success.”