Physical Environment

Citation

TJC APR.09.04.01

The hospital provides care, treatment, services, and an environment that pose no risk of an “...

The hospital is required to maintain an environment and provide services that do not pose an immediate threat to the health or safety of patients.

Citation

TJC EM.12.02.11

The hospital has a plan for managing essential or critical utilities during an emergency or d...

The standard addresses a hospital plan for maintaining essential or critical utility systems during an emergency or disaster incident.

Citation

TJC MM.15.01.01

The hospital safely prepares medications.

The standard addresses pharmacist supervision, sterile compounding policies, staff competency, compounding environments, storage, labeling, quality assurance, and radiopharmaceutical preparation oversight.

Citation

TJC NPG.08.01.01

The hospital reduces the risk for suicide.

Requires the hospital to screen, assess, document, monitor, and follow up on patients at risk for suicide, including environmental risk mitigation and discharge planning.

Citation

TJC NPG.11.01.01

The hospital manages security risks.

Requires the hospital to control access to security-sensitive areas, develop security incident policies including infant or pediatric abduction, monitor and investigate specified safety and security incidents, and coordinate care decisions for patients under legal or correctional restrictions.

Citation

TJC NPG.11.03.01

The hospital manages utility systems.

The hospital manages utility systems, including written procedures for utility disruptions and emergency backup policies for essential medication dispensing equipment and medication refrigeration.

Citation

TJC NPG.13.02.01

The hospital’s imaging services have a designated leader and follow current safe imaging prac...

Requires a designated radiation safety officer, adherence to recognized radiology safety standards, and current CT imaging protocols reviewed with clinical and physics input.

Citation

TJC NPG.13.03.01

The hospital manages imaging safety risks.

The hospital manages MRI, CT, PET, nuclear medicine, and fluoroscopy safety risks through access controls, signage, dosimetry monitoring, and annual medical physicist performance evaluations.

Citation

TJC PE.01.01.01

The hospital has a safe and adequate physical environment.

Requires the hospital to maintain a building, space, and premises that are constructed, arranged, and kept clean and orderly to support safe patient access and care.

Citation

TJC PE.03.01.01

The hospital designs and manages the physical environment to comply with the Life Safety Code.

Requires the hospital to design and manage its physical environment to comply with the Life Safety Code, including fire safety documentation, fire control plans, and construction-related safeguards.

Citation

TJC PE.03.02.01

The hospital protects occupants during periods when the Life Safety Code is not met or during...

Requires the hospital to implement interim life safety measures, including fire watches, alternative exits, surveillance, drills, and training, when Life Safety Code deficiencies cannot be immediately corrected or during construction.

Citation

TJC PE.04.01.01

The hospital addresses building safety and facility management.

Requires the hospital to comply with the Health Care Facilities Code and maintain essential equipment, ventilation, lighting, temperature control, and supplies in pharmaceutical, patient care, food preparation, and nuclear medicine areas.

Citation

TJC PE.04.01.03

The hospital manages utility systems.

Requires the hospital to manage utility systems, including emergency power and lighting in critical care areas, emergency gas and water supply, compliance with NFPA emergency power standards, and risk management during repairs or maintenance.