Hazel Hawkins Memorial is a full service, not-for-profit hospital located in Hollister, CA. Founded in 1907, the hospital offers a full range of inpatient and outpatient services including: emergency services, stroke care, surgical services, radiology and diagnostic imaging services, laboratory services, palliative care, physical, speech and occupational therapy, respiratory care, and a birthing center.
Frank Gee manages the facilities for the hospital’s main campus in Hollister and 15 outpatient clinics throughout San Benito County. In his role as the Director of Plant Operations and Engineering responsible for all facility maintenance operations, Mr. Gee oversees adherence to safety and engineering standards and compliance with applicable regulations, laws, and codes.
In 2018 The Joint Commission (TJC), a US-based accrediting body that establishes and enforces standards to ensure the safety and quality of healthcare facilities, performed a site survey of Hazel Hawkins.
Survey findings
“At the time, we were using manual methods to record temperature and humidity conditions,” said Mr. Gee. “The survey showed that this created gaps in the records of environmental conditions. The results of this particular survey focused on the relative humidity of our surgical suites, which include two operating rooms (ORs) in the main hospital and three in our Ambulatory Surgery Center (ASC). Hazel Hawkins’ ORs do not run 24/7; they are often closed on weekends and at night. With minimal staffing in the surgical suites to write down continuous data, conditions were not always recorded. TJC wanted to see the humidity in the ORs and sterile rooms monitored continuously and unconditionally.”
Relative humidity must be controlled in ORs and sterile rooms to mitigate the growth of microorganisms, prevent electrostatic discharge (ESD), and ensure ideal working conditions for OR personnel. Humidity can affect sterile supplies and electro-medical devices in ORs.
“The relative humidity can never go beyond 60% because the risk of infection increases,” said Mr. Gee. “Even during a procedure, surgeons are compelled to consider discontinuing that procedure if the relative humidity goes beyond 60%. In addition, modern surgery can include robotics and other devices that can be negatively affected by electrostatic discharge if the relative humidity goes below 30%.”
At the survey, TJC surveyors issued an “Accreditation Survey Findings Report”. The report contained Requirements for Improvement (RFI) on monitoring humidity in the surgical suites, temperatures for drug storage refrigerators, and temperatures for blanket warmers. When a hospital receives survey findings, it must respond by submitting an Evidence of Standards Compliance (ESC) Report for each RFI.
The standards cited from TJC publication “Evidence of Standards Compliance” (ESC) included:
- EC.02.05.01 – 15: In critical care areas designed to control airborne contaminants (such as biological agents, gases, fumes, dust), the ventilation system provides appropriate pressure relationships, air-exchange rates, filtration efficiencies, temperature and humidity. Note: For more information about areas designed for control of airborne contaminants, the basis for design compliance is the Guidelines for Design and Construction of Health Care Facilities, based on the edition used at the time of design (if available).
- ESC: MM.03.01.01 – 2: The hospital stores medications according to the manufacturer’s recommendations or, in the absence of such recommendations, according to a pharmacist’s instructions. Note: This element of performance is also applicable to sample medications.
An in-house continuous monitoring implementation team of hospital managers was created to respond to the RFI. “The challenge was that we needed to take immediate corrective actions and submit our report within 90 days,” said Mr. Gee. “So we were under some significant time constraints.”
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