Earlier in 2024, The Joint Commission added a new aspect to the assessment of competency expectations. This aspect focuses on the competence required to inspect, test and manage certain aspects of the physical environment.
Historically, I think we would all agree that the Competency Assessment Session and HR file review of years past focused on those responsible for care, treatment and services of a clinical nature. Although we may remember days when the HR file for the Boiler Operator would appear on the list of requested files.
The review of the physical environment competency associated documents is now the responsibility of the EC-LS surveyor.
A recent article in The Joint Commission publication, EC News, focused the readers on key areas where competency assessment is expected.
The four areas where competence is expected are:
Hazardous Waste Materials Management:
Federal requirements require those persons responsible for the management of hazardous waste materials be certified via the Department of Transportation training program.
Fire Door Inspections:
Functional fire doors are a life-saving element of every organization’s Fire Safety Plan. Fire doors provide a critical barrier to limiting the spread of smoke and fire and creating a safer haven for those who cannot be easily evacuated. When we think of them from this perspective, ensuring personnel responsible for inspecting, testing and maintaining these doors, it becomes very evident that a clear working knowledge and demonstration of skills that reside at NFPA 80-2010 section 5.2.3.1 is essential.
Medical Gas Management:
Similar to the above thought process, medical gas management is essential for patient and staff safety. Performance of the inspection, testing and maintenance should only be performed by those people knowledgeable and skilled in this field. There may be several options for certification, but the American Society of Sanitary Engineers ( ASSE) certification seems to be highly respected.
Fire Alarm System Management:
Understanding the operations of the fire alarm system is essential to ensure its proper functioning. Inspection, testing and maintenance should be performed by person(s) knowledgeable in NFPA 72-2010 as evidenced by certification through organizations such as NICET, or the manufacturer of the installed system they are responsible for. Certification may also be available through your state or local authority, or other recognized certification organizations.
Establishing processes to ensure that all who provide care, treatment and services, both clinically oriented and non-clinically oriented is essential to creating a culture and environment that places patient and staff safety first.
Please contact us for questions or more information at 704-573-4535 or info@courtemanche-assocs.com.
Courtemanche & Associates specializes in Healthcare Accreditation and Regulatory Compliance Consulting Services. With over 30 years of being in business and 100+ years of healthcare experience amongst our consulting team, we are ready to assist with your accreditation and regulatory compliance needs.
