Safety Management Crosswalk – 2008 to 2009

2008 Standard / Element of Performance / 2009 Standard
EC.1.10 / Safety Risk Management
1 / Management Plan / EC.01.01.01 – 3
2 / Safety leadership appointment / EC.01.01.01 – 1
3 / Intervention authority / EC.01.01.01 – 2
4 / Proactive risk assessments / EC.02.01.01 – 1
5 / Procedures based on risk / EC.02.01.01 – 3
6 / Safety policy review / N/A
8 / Safety recall process / EC.02.01.01 – 11
9 / Grounds and equipment / EC.02.01.01 – 5
EC.1.20 / Maintains Safe Environment
1 / Environmental tours / EC.04.01.01 – 12, 13
2 / Patient areas / EC.04.01.01 – 12
3 / Non-patient areas / EC.04.01.01 – 13
EC.1.30 / Smoking Policy
1 / Policy in buildings / EC.02.01.03 – 1
2 / Outpatient/ youth prohibition / N/A
3 / Exceptions to policy / EC.02.01.03 – 1
4 / Building requirements / EC.02.01.03 – 4
5 / Smoking cessation education / N/A
6 / Compliance monitoring / EC.02.01.03 – 6
7 / Strategies for violations / N/A
HR.2.20 / EC Training for Staff
1 / Hospital environmental risks / EC.03.01.01 – 1
2 / Actions to eliminate or minimize risks / EC.03.01.01 – 1
3 / Actions after incident occurs / EC.03.01.01 – 2
4 / Incident reporting processes / EC.03.01.01 – 3

Security Management Crosswalk – 2008 to 2009

2008
Standard / Element of Performance / 2009 Standard
EC.2.10 / Security Risk Management
1 / Management Plan / EC.01.01.01 – 4
2 / Responsibility appointment / N/A
3 / Proactive risk assessment / EC.02.01.01 – 1
4 / Procedures based on risk / EC.02.01.01 – 3
5 / Identification policy, procedure / EC.02.01.01 – 7
6 / Access to sensitive areas / EC.02.01.01 – 8
7 / Security incident procedures / EC.02.01.01 – 10
8 / Abduction procedures / EC.02.01.01 – 9
9 / VIP/ media procedures / N/A
10 / ED vehicular access / N/A

Hazardous Materials Management Crosswalk – 2008 to 2009

2008 Standard / Element of Performance / 2009 Standard
EC.3.10 / Hazardous Materials Management
1 / Management Plan / EC.01.01.01 – 5
2 / Accurate inventory (OSHA) / EC.02.02.01 – 1
Cradle-to-grave processes for:
3 / Chemicals / EC.02.02.01 – 5
4 / Chemotherapeutics / EC.02.02.01 – 5
5 / Radioactive materials / EC.02.02.01 – 6
6 / Medical waste, sharps / N/A
7 / Adequate space/ safe handling / EC.02.02.01 – 5, 6
8 / Hazardous vapor monitoring / EC.02.02.01 – 9, 10
9 / Emergency spill procedures / EC.02.02.01 – 3, 4
10 / Permits and licenses / EC.02.02.01 – 11
11 / Manifest forms / EC.02.02.01 – 11
12 / Hazardous waste labeling / EC.02.02.01 – 12
13 / Effective separation / N/A
N/A / Personal protective equipment / EC.02.02.01 – 3
N/A / Hazardous energy sources / EC.02.02.01 – 7
N/A / Hazardous medication disposal / EC.02.02.01 – 8

Emergency Management Crosswalk – 2008 to 2009

2008 Standard / Element of Performance / 2009 Standard
EC.4.11 / Emergency Management
1 /

LD/ medical staff involvement

/

EM.01.01.01 – 1

2 /

Hazard vulnerability analysis

/

EM.01.01.01 – 2

3 /

Prioritization of hazards

/

EM.01.01.01 – 3

4 /

Needs communication to area

/

EM.01.01.01 – 4

5 /

Mitigation

/

EM.01.01.01 – 5

6 /

Preparedness

/

EM.01.01.01 – 6

7 /

Response

/

EM.02.01.01 – 5, 8

8 /

Recovery

/

EM.02.01.01 – 4

9 /

Inventory of assets, resources

/

EM.01.01.01 – 8

10 /

Monitoring assets, resources

/

EM.02.02.03 – 6

11 /

Annual effectiveness evaluation

/

EM.03.01.01 – 1, 2, 3

EC.4.12 /

Emergency Operations Plan

/
1 /

Written “all hazards” ICS plan

/

EM.02.01.01 – 1, 2, 3

2 /

Incident command structure

/

EM.02.01.01 – 2

3 /

ICS organizational chart

/

EM.02.01.01 – 2

EM.02.02.07 – 4

4 /

ICS activation authority

/

EM.02.01.01 – 5, 6

5 /

ICS activation phasing

/

EM.02.01.01 – 5

6 /

96-hour capability

/

EM.02.01.01 – 3

7 /

Alternative care sites

/

EM.02.01.01 – 7

EC.4.13 /

Emergency Communications

/
1 /

Notification to staff

/

EM.02.02.01 – 1

2 /

Staff communication

/

EM.02.02.01 – 2

3 /

External authority notification

/

EM.02.02.01 – 3

4 /

Ext. authority communication

/

EM.02.02.01 – 4

Policy for communication with: /
5 /

Patients/ families

/

EM.02.02.01 – 5

6 /

Community/ media

/

EM.02.02.01 – 6

7 /

Vendors and suppliers

/

EM.02.02.01 – 7

8 /

Regional emergency centers

/

EM.02.02.01 – 8

9 /

Command center names/roles

/

EM.02.02.01 – 9

10 /

Community resources/ assets

/

EM.02.02.01 – 10

11 / Incoming patients (names) /

EM.02.02.01 – 11

12 / Local and federal agencies /

EM.02.02.01 – 12

13 / Alternative care sites /

EM.02.02.01 – 13

14 / Back-up communications /

EM.02.02.01 – 14

N/A / Advance preparation for communications / EM.02.02.01 – 17

Emergency Management Crosswalk – 2008 to 2009 (continued)

2008 Standard / Element of Performance / 2009 Standard
EC.4.14 / Resource and Asset Strategy
1 /

Obtaining emergency supplies

/

EM.02.02.03 – 1

2 /

Replenishing medical supplies

/

EM.02.02.03 – 2

3 /

Replenishing pharmaceuticals

/

EM.02.02.03 – 1

4 /

Obtaining non-medical supplies

/

EM.02.02.03 – 3

5 /

Staff support activities

/

EM.02.02.07 – 5

6 /

Staff family support needs

/

EM.02.02.07 – 6

7 /

Local asset sharing

/

EM.02.02.03 – 4

8 /

Regional asset sharing

/

EM.02.02.03 – 5

9 /

Evacuation (horiz and vertical)

/

EM.02.02.11 – 3

10 /

Patient transportation

/

EM.02.02.03 – 9

11 /

Patient information to new site

/

EM.02.02.03 – 10

N/A /

Advance preparation for assets

/

EM.02.02.03 – 12

EC.4.15 /

Safety and Security

/
1 /

Safety/ security operations

/

EM.02.02.05 – 1

2 /

Role of community security

/ EM.02.02.05 – 2, 3
3 /

Hazmat management

/ EM.02.02.05 – 4
4 /

Decontamination methods

/ EM.02.02.05 – 5
5 /

Patient wandering (LTC only)

/ EM.02.02.11 – 4
6 /

Control of facility access

/ EM.02.02.05 – 7
7 /

Control of in-house movement

/ EM.02.02.05 – 8
8 /

Emergency traffic control

/ EM.02.02.05 – 9
N/A /

Advance preparation for safety/ security

/ EM.02.02.05 – 10
EC.4.16 /

Staff Roles/ Responsibilities

/
1 /

Staff roles for critical areas

/

EM.02.02.07 – 2

2 /

Staff training for assignments

/ EM.02.02.07 – 3, 7
3 /

LIP role during emergencies

/ EM.02.02.07 – 8
4 /

Personnel identification means

/ EM.02.02.07 – 9
N/A /

Advance preparation for staff

/ EM.02.02.07 – 10
EC.4.17 / Management of Utilities

Alternative means for:

/
1 /

Electricity

/

EM.02.02.09 – 2

2 /

Potable water needs

/

EM.02.02.09 – 3

3 /

Non-potable needs

/

EM.02.02.09 – 4

4 /

Fuel for building/ transport

/

EM.02.02.09 – 5

5 /

Essential utilities (HVAC, MG)

/

EM.02.02.09 – 7

N/A / Medical gas and vacuum systems /

EM.02.02.09 – 6

N/A / Advance utility preparation /

EM.02.02.09 – 8

Emergency Management Crosswalk – 2008 to 2009 (continued)

2008 Standard / Element of Performance / 2009 Standard
EC.4.18 / Clinical/ Support Activities
1 /

Patient clinical activities

/

EM.02.02.11 – 2

2 /

Vulnerable patient services

/

EM.02.02.11 – 4

3 /

Patient hygiene/ sanitation

/

EM.02.02.11 – 5

4 /

Mental health services

/

EM.02.02.11 – 6

5 /

Mortuary services

/

EM.02.02.11 – 7

6 /

Tracking patient information

/

EM.02.02.11 – 8

N/A /

Advance patient preparation

/

EM.02.02.11 – 11

EC.4.20 /

Emergency Drills

/
1 /

Two drills per year

/

EM.03.01.03 – 1

2 /

One influx drill per year

/

EM.03.01.03 – 2

3 /

Community non-support test

/

EM.03.01.03 – 3

4 /

Community-wide drill

/

EM.03.01.03 – 4

6 /

Realistic and HVA-driven

/

EM.03.01.03 – 5

8 /

Competent, trained monitor

/

EM.03.01.03 – 6

Drill monitoring of:

/
9 /

Communication

/

EM.03.01.03 – 7

10 /

Resource mobilization/ alloca

/

EM.03.01.03 – 8

11 /

Safety and security

/

EM.03.01.03 – 9

12 /

Staff roles/ responsibilities

/

EM.03.01.03 – 10

13 /

Utility systems

/

EM.03.01.03 – 11

14 /

Patient clinical/ support activit

/

EM.03.01.03 – 12

15 /

Identification of deficiencies

/

EM.03.01.03 – 14

16 /

LD/ physician critique input

/

EM.03.01.03 – 13

17 /

Plan changes based on results

/

EM.03.01.03 – 16

18 /

Drills evaluate improvements

/

EM.03.01.03 – 17

19 / Drill report to safety committee /

EM.03.01.03 – 15

N/A / Privileges to LIP’s / EM.02.02.13 (all EP’s)
N/A / Privileges to Volunteer Staff / EM.02.02.15 (all EP’s)

Fire Prevention Crosswalk – 2008 to 2009

2008 Standard / Element of Performance / 2009 Standard
EC.5.10 / Fire Safety Management
1 /

Management plan

/

EC.01.01.01 – 6

2 /

Proactive fire protection

/

EC.02.03.01 – 1

3 /

Fire system testing program

/

EC.02.03.05

4 /

Fire response plan

/

EC.02.03.01 – 9

5 /

Acquisitions, decoration policy

/

LS.02.01.70 – 1

EC.5.20 /

Life Safety Code Compliance

1 /

NFPA 101 compliance

/

LS.01.01.01

2 /

e-SOC completion

/

LS.01.01.01 – 2

5 /

Sufficient PFI progress

/

LS.01.01.01 – 3

6 /

SOC responsibility assignment

/

LS.01.01.01 – 1

EC.5.30 /

Fire Drills

1 /

Quarterly/ shift hospital drills

/

EC.02.03.03 – 1

2 /

Annual/ shift clinic drills

/

EC.02.03.03 – 2

4 /

Unannounced drills

/

EC.02.03.03 – 3

5 /

Staff drill participation

/

EC.02.03.03 – 4

6 /

Drill critique

/

EC.02.03.03 – 5

7 /

Annual response evaluation

/

N/A

8 /

Staff knowledge during drills

/

EC.02.03.03 – 5

EC.5.40 /

Fire Component Tests

1 /

Supervisory/ tamper switches

/

EC.02.03.05 – 1, 2

2 /

Alarm notification devices

/ EC.02.03.05 – 3, 4
3 /

Off-premises trans. eqmt.

/ EC.02.03.05 – 5
4 /

Fire pumps

/ EC.02.03.05 – 6
5 /

Water tank level alarms

/ EC.02.03.05 – 7
6 /

Water tank level alarms (cold)

/ EC.02.03.05 – 8
7 /

Main drain tests

/ EC.02.03.05 – 9
8 /

Fire department connections

/ EC.02.03.05 – 10
9 /

Fire pumps

/ EC.02.03.05 – 11
10 / Kitchen systems / EC.02.03.05 – 13
11 /

Gaseous extinguishing systems

/ EC.02.03.05 – 14
12 /

Portable fire extinguishers

/ EC.02.03.05 – 15, 16
13 /

Occupant hoses

/ EC.02.03.05 – 17
14 /

Smoke/ fire dampers

/ EC.02.03.05 – 18
15 /

HVAC smoke detectors

/ EC.02.03.05 – 19
16 /

Horizontal/ vertical fire doors

/ EC.02.03.05 – 20
N/A /

5-year standpipe test

/ EC.02.03.05 – 12

Fire Prevention Crosswalk – 2008 to 2009

2008 Standard / Element of Performance / 2009 Standard
EC.5.50 /

Interim Life Safety Measures

1 /

ILSM policy

/

LS.01.02.01 – 3

2 /

Applicability of measures

/

LS.01.02.01 – 5 to 14

3 /

ILSM implementation

/

LS.01.02.01 – 4

N/A / Fire watch implementation / LS.01.02.01 – 1
N/A / Alternate exit signage / LS.01.02.01 – 2

Medical Equipment Management Crosswalk – 2008 to 2009

2008 Standard / Element of Performance / 2009 Standard
EC.6.10 / Management of Risk
1 / Management Plan / EC.01.01.01 – 7
2 / Acquisition process / EC.02.04.01 – 1
3 / Inventory risk criteria / EC.02.04.01 – 2
4 / Maintenance strategies / EC.02.04.01 – 3
5 / Test intervals determination / EC.02.04.01 – 4
6 / Recall/ hazard process / EC.02.01.01 – 11
7 / SMDA process/ reporting / EC.02.04.01 – 5
8 / Equipment failure procedures / EC.02.04.01 – 6
EC.6.20 / Maintenance documents
1 / Current, accurate inventory / EC.02.04.01 – 2
2 / Initial equipment tests / EC.02.04.03 – 1
3 / PM tests – life support / EC.02.04.03 – 2
4 / PM tests – nonlife support / EC.02.04.03 – 3
5 / Sterilizer tests / EC.02.04.03 – 4
6 / Dialysis water tests / EC.02.04.03 – 5
Prev PSG / Clinical alarms
Prev PSG / Infusion pump “free flow”
PSG / OR fires (ambulatory facility)
IM.3.10.10 / Aggregation of data / IM.1.01.01
HR.3.10.8 / Staff, vendor competency / HR.01.06.01 – 1, 2

Utility Systems Management Crosswalk – 2008 to 2009

2008 Standard / Element of Performance / 2009 Standard
EC.7.10 / Utility Risk Management
7 /

Management plan

/

EC.01.01.01 – 8

8 /

Systems meet needs

/

EC.02.05.01 – 1

9 /

Inventory criteria

/

EC.02.05.01 – 2

10 /

Maintenance strategies

/

EC.02.05.01 – 3

11 /

Define test intervals

/

EC.02.05.01 – 4

12 /

Utility failure procedures

/

EC.02.05.01 – 9

13 /

Utility distribution diagrams

/

EC.02.05.01 – 7

14 /

Shutdown control labeling

/

EC.02.05.01 – 8

15 /

Waterborne pathogen policy

/

EC.02.05.01 – 5

16 /

HVAC policy, testing

/

EC.02.05.01 – 6

N/A /

Emergency shutoff/ notification

/

EC.02.05.01 – 10

N/A /

Emergency clinical procedures

/

EC.02.05.01 – 11

N/A /

Emergency repair services

/

EC.02.05.01 – 12

N/A /

Utility failure response

/

EC.02.05.01 – 13

EC.7.20 /

Emergency Power Source

/
1 /

Alarm systems

/

EC.02.05.03 – 1

2 /

Exit route illumination

/

EC.02.05.03 – 2

3 /

Emergency communications

/

EC.02.05.03 – 3

4 /

Exit sign illumination

/

EC.02.05.03 – 2

5 /

Blood, bone, tissue storage

/

EC.02.05.03 – 5

7 /

Emergency care areas

/

EC.02.05.03 – 6

8 /

Elevators (at least one)

/

EC.02.05.03 – 4

9 /

Medical air compressors

/

EC.02.05.03 – 5

10 /

Medical/ surgical vacuum

/

EC.02.05.03 – 5

11 /

Life support equipment areas

/

EC.02.05.03 – 6

14 /

Operating rooms

/

EC.02.05.03 – 6

15 /

Recovery rooms

/

EC.02.05.03 – 6

16 /

OB delivery rooms

/

EC.02.05.03 – 6

17 /

Newborn nurseries

/

EC.02.05.03 – 6

EC.7.30 /

Utility System Testing

/
1 /

Current, accurate inventory