ENVIRONMENTAL
COMPLIANCE AND IMPROVEMENT GUIDE
To improve
compliance with JCAHO Environment of Care Standards
Citations from JCAHO standards are © 2005
Joint Commission on Accreditation of Healthcare Organizations.
Any use of any or all of the Joint Commission standards and elements
of performance beyond this particular tool is strictly
forbidden
without the written permission of the Joint Commission. |
Please
note: this page is under development. Contact
(603) 795-9966,
if you have questions or suggestions.
Table of Contents
What is
JCAHO?
The
Joint Commission on the
Accreditation of Healthcare Organizations (JCAHO) sets
standards for healthcare organizations and issues accreditation to organizations
that meet those standards. JCAHO conducts periodic on-site surveys to
verify that "an accredited organization substantially
complies with Joint Commission standards and
continuously makes efforts to improve the care and
services it provides."
What is this
resource?
JCAHO
standards address an organization’s performance in key
functional areas. Each standard is presented as a series of
"Elements of Performance" (EP) -- expectations that establish
the broad framework that JCAHO surveyors use to evaluate a
facility's performance.
Some of the
standards refer to environmental issues. Many of the
environmentally relevant Elements of Performance fall under the
"Environment of Care" (EC) standard, but others are included in
the Human Resources (HR) and Leadership (LD) standards.
This Guide
relates each JCAHO Element of Performance to specific federal
regulations, to help facilities be in
compliance with both. The Guide also suggests
steps that facilities can take to
encourage environmental performance improvements.
A comprehensive
environmental program, including waste
minimization and pollution prevention initiatives, can
not only ensure compliance, but can also help
reduce the costs of compliance.
How does it
work?
Each page starts with the actual language of the JCAHO Element
of Performance, supplemented by a series of specific statements
that refers either to evidence that the organization is
complying with the standard, or to evidence that the
organization is improving its practices. Where
appropriate, the guide provides links, tips and tools that
enumerate specific management practices, materials, regulatory
requirements, and facility infrastructure relevant to that EP.
Environmental
issues are inherently complex, and the web of regulations and
practices that have evolved to deal with them can seem
overwhelming to the nonspecialist.
To
help make the information more user-friendly, each page is
organized using the following symbols to denote the type of
information available for each standard or Element of
Performance:
|
Evidence
of Standards Compliance. These
are statements and direct links* to applicable federal environmental
and workplace regulations. |
|
 |
Evidence of Environmental Improvement. These performance improvement initiatives go beyond what
is absolutely required, but typically ease the burden of
compliance, often save money, and satisfy JCAHO’s
accreditation requirements. |
|
 |
A recommended set of Tools and Resources that may be
particularly helpful for those looking for additional
information on specific topics, sample policies, or
guidance on how to deal with a particular problem. |
*Links to the
Code of Federal Regulations (CFR) will automatically select the
most recent version of the regulation available from the
Government Printing Office (GPO) website. (See note
below).
Who is it
for?
This
information is offered:
- to JCAHO
surveyors as a convenient reference for a complex set of
technical and regulatory issues
- to
healthcare organizations as a means for maintaining
accreditation and improving your relations with and effects
on the communities you serve
Please
contact us
This resource
was created by Hospitals
for a Healthy Environment to supplement the guidance
provided by the JCAHO standards. We are very
interested in your comments, and in finding ways to improve this
resource. Please direct your questions and suggestions to:
To begin
Proceed to the
Table of Contents
to access the
guidance for specific JCAHO Elements of Performance.
Please note: Users may sometimes
experience delays in retrieving documents from the GPO website.
Although it is a very convenient resource, the GPO website has a
potentially misleading peculiarity: a document search that
"times out" will return the same error message as an erroneous
citation. Clicking again on the same link that produces
the apparent error will often result in a successful retrieval.
If returning to the site at a less busy time is not a convenient
option for you, it may help to bypass the direct link and use
the
search tree provided on the GPO website, selecting the appropriate Title, Part, and
Section for the most recent version available.
The
following information will help you use the GPO search tree.
A standard citation format is used for all links to the Code of
Federal Regulations (CFR) :
if, for example, the citation reads "40 CFR 265.33", the
reference is to Title 40, Part 265, Section 33. These are
the numbers you will need to use the search tree.
The first
page of the search tree provides a table of all the yearly
revisions available for each Title. Ordinarily, you will
want the most recent revision, but it is not always available.
You may find it
convenient to check the boxes corresponding to the two or three
most recent versions of the desired Title. Clicking
"Continue" at the bottom of that page will then provide a second
page with a list of all the Parts for each of the revisions
checked. If the most recent revision for the desired Part
is not yet available on line, it will not appear as a live link
in the list. But if you have checked more than one box,
then scrolling down the second page will take you
to the list of Parts for the next most recent revision, and the
desired Part will generally be found available as a live link
there. Clicking that link will take you to a third page,
where you can select the desired Section and bring up the text
of the regulation.
