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The exodus is here: Are you prepared?

Some say not so much.

First off, many thanks to the standards sleuths out there that assisted on solving last week’s missing EP caper; it’s nice to know that I am not merely orating into the void (oration being a somewhat hyperbolic description of this blog—lend me your eyes!).

Now, on to our continuing coverage of emergency management stuff.

The ECRI report outlining the Top 10 Patient Safety Risks for 2018 (if you missed it last week, you can download it here), does make mention of all-hazards emergency preparedness as #7 on the Top 10 list, though I have to say that their description of the challenges, etc., facing hospitals was whatever word is the opposite of hyperbolic (I did a quick search for antonyms of hyperbolic, but nothing really jumped out at me as being apropos for this discussion), pretty much boiling down to the statement that “facilities that were prepared for…disasters fared better than those that were not.” And while there is a certain inescapable logic to that characterization, I somehow expected something a bit weightier.

That said, the ECRI report does at least indicate that there may have been hospitals that were prepared, which is a little more generous than hospital preparedness was described in the report from our friends at the Johns Hopkins Bloomberg School of Public Health Center for Health Security (you can find the report here). The opening of the Hopkins report goes a little something like this: “Although the healthcare system is undoubtedly better prepared for disasters than it was before the events of 9/11, it is not well prepared for a large-scale or catastrophic disaster.” Now that is a rather damning pronouncement, and it may be justified, but I’m having a bit of a struggle (based on reading the report) with what data was used in making that particular pronouncement. I’m not even arguing with their recommendations—it all makes abundant sense to me from a practical improvement standpoint—and I think it will to you as well. But (I’m using a lot of “buts” today), I’m having a hard time with the whole “is not well prepared” piece (in full recognition that it is healthcare as a single monolithic entity that is not well prepared). Could hospitals be better prepared? Of course! Will hospitals be better prepared? You betcha! Could hospitals have more and better access to a variety of resources (including, and perhaps most importantly, cooperation with local and regional authorities)? Have the draconian machinations of the federal budgeting process limited the extent to which hospitals can become prepared? Pretty sure that’s a yes…

Could the nation (or parts therein) experience catastrophic events that significantly challenge hospitals’ ability to continue to provide care to patients? Yup. Will the nation (or parts therein) experience catastrophic events that significantly challenge hospitals’ ability to continue to provide care to patients? Probably, and perhaps (given only the weather patterns of the last 12 months or so) sooner rather than later. There have always been (and there always will be) opportunities for hospitals to improve their level(s) of preparedness (preparedness is a journey, it is not a destination), including building in resiliency to infrastructure, resources, command leadership, etc. And while I appreciate the thought and preparation that went into the report, I can’t help but think that somehow this is going to be used to bludgeon hospitals on the regulatory front. In preparation for that possibility, you might find it useful to turn your emergency management folks loose on a gap analysis relative to the recommendations in the report (again, I can’t/won’t argue with the recommendations—I like ’em), just in case your next accreditation surveyor tries to push a little in this realm.

The mystery of the disappearing EP and other tales

I have no way to be certain of the numbers, but I do know of at least one organization that fell victim in 2017 to an Element of Performance (EP) that has since gone “missing.” Once upon a time, EC.02.05.03 (having a reliable emergency electrical source) had an EP (#10, to be precise) that, among other things, required hospital emergency power systems (EPS) to have a remote manual stop station (with an identifying label, natch!) to prevent inadvertent or unintentional operation. (I’m not really sure how a big ol’ stop button that’s labeled would prevent somebody from inadvertently operating the emergency power system; it would surely help if the inadvertent operation happened, but prevention…)

So, to follow this back to the applicable NFPA citation NFPA 110-2010, we find “(a)ll installations shall have a remote manual stop station of a type to prevent inadvertent or unintended operation located outside the room housing the prime mover, where so installed, or elsewhere on the premises where the prime mover is located outside the building.” The Explanatory Material goes on to indicate that “(f)or systems located outdoors, the manual shutdown should be located external to the weatherproof enclosure and appropriately identified.” So, that all seems pretty straightforward, don’t you think.

Well, recently (last week) I was working with a hospital that had not bumped into EC.02.05.03, EP 10 and, since I had not yet committed the standard and EP numbers to memory (every time things get changed, I swear to myself that I will not memorize the numbers, but somehow it always ends up happening…), we went to look at the online portal to the standards. And we looked, and looked, and looked some more, and could not find the EP for the remote manual stop. I just figured that I had sufficiently misremembered where this EP, so my plan was to look at survey reports that I know included RFIs for not having the remote manual stops and go from there. So, I looked it up in the survey report, checked the online portal and, guess what? No more EP 10 (in the interest of the complete picture, this EP also requires emergency lighting within 10 seconds at emergency generator locations and a remote annunciator (powered by storage battery) located outside the emergency power system location). Now, from a strict compliance standpoint, as the 2010 edition of NFPA 110 is the applicable code edition based on adoption of the 2012 Life Safety Code® (and I did check the 2013 and 2016 editions, each of which contain the same requirements), I can only guess that the requirements contained in EP 10 are still actionable if your (or anybody else’s) AHJ sees fit to cite a deficiency in this regard, so it’s probably worth keeping a half an eye out for further developments if you have not yet gotten around to installing the lighting, remote stop, and annunciators for your emergency power system equipment locations.

Also, just to alert you to (yet) another offering from ECRI, this past week saw the unveiling of the Top 10 Patient Safety Concerns (download the white paper here). There are a few items on the list that should be of interest to you folks (in bold):

  1. Diagnostic errors
  2. Opioid safety across the continuum of care
  3. Care coordination within a setting
  4. Workarounds
  5. Incorporating health IT into patient safety programs
  6. Management of behavioral health needs in acute care settings
  7. All-hazards emergency preparedness
  8. Device cleaning, disinfection, and sterilization
  9. Patient engagement and health literacy
  10. Leadership engagement in patient safety

I haven’t delved too much into the latest emergency preparedness stuff (ECRI’s take, as well as the Johns Hopkins report), but I’ve queued that up on my reading list for this week, just as soon as I dig out from our most recent wintry spectacular—currently raging outside my window, so I’m going to send this on its way before the power gets too dodgy…

Cylindrical musings and nudging as a compliance strategy

Howdy, folks. After surviving the battering of this past weekend’s tumultuous weather in the Northeast (I got to experience it twice—once in Indiana and again back home), I’m going to be (relatively) brief for this week’s missive.

First up, hopefully most of you are familiar with the TED Talks concept (all the info you need about that you can find here) and NPR has a weekly program that kind of crystallizes some of the TED offerings in their TED Radio Hour. This past weekend (no TV, so we had to huddle around the radio, just like in olden times), the program revolved around the use of gentle pushes or nudges to change behaviors (you can hear that broadcast here). As safety professionals, I think we are all acquainted with the various attempts to get folks to do our bidding when it comes to safe practice (that sounds a little authoritarian, but it’s kinda what we’re up against) and I thought the entire program really gave me some food for thought in how we might come at compliance from a slightly different perspective. I thought some of the ideas were fascinating and definitely worth sharing, so if you have a spare 55 minutes or so (the webpage above does break it out into the individual sections of the broadcast—I think it’s all good, but whatever description seems most interesting to you would be a good starting point), you might give it a whirl…

I also want to bring you some hopeful news on the cylinder storage segregation front; when this whole focus started, quite a few folks were cited for storing non-full (empty or partial) cylinders in the same location as full cylinders. I don’t know when The Joint Commission posted the updated FAQ on cylinder storage, but, and I quote, “Full and partially full cylinders are permitted to be stored together, unless the organization’s policy requires further segregation.” I know this whole thing was the bane of a lot of folks’ existence, particularly after we had to work so diligently to get folks to secure the cylinders properly, only to have this little paradigm shift towards the edge of darkness. I believe that this will make things somewhat simpler in the execution (make sure your policy reflects the allowance for full and partials to be stored together—they’ll be looking to review that policy).

As a final, non-safety note, I just flew cross-country and was able to watch Gary Oldman’s performance as Winston Churchill in Darkest Hour. I’ve always been something of a history buff, with World War II as a central theme and must tell you that I thought it was a really great performance and a fine movie (or is it a film?). It really points out the power of consensus and the use of the spoken word to galvanize folks (which kind of ties back to the nudging—though Sir Winston’s nudge packed a lot of wallop). At any rate, I thought it was very well done (no surprise about the Best Actor Oscar) and probably my favorite since Lincoln (the movie, not the car or President…though Lincoln in the Bardo was a very interesting book…).

’Tis the season…for more emergency management goodness!

Recognizing the somewhat hyperbolic nature of this week’s headline (you need only listen to current news/weather feeds to be able to determine that emergencies are not quite as seasonal as perhaps they once were…), I did want to share one more emergency management-related nugget with you (I do try to mix things up, but until I start seeing some “hard” survey results—or some regulatory panjandrum makes some sort of announcement, I’m going to keep seeding this space with various and sundry bits of stuff), this coming to us from the left coast, aka California.

While I have little doubt that you Californians in the audience are familiar with the California Department of Public Health (CDPH—four scary letters, though perhaps not as scary as OSHPD for the facilities folks in Cali) requirements for workplace emergency plans (which is highlighted in this month’s CDPH Occupational Health Watch), I think that there might well be some useful information for folks in other parts of the country (I have found, over some few years of experience, that regulatory tsunamis can start in California and find their way to all manner of locales). To be honest (and why else would we be here?), the plan elements required (or at least the ones the surveyors want to see) by the usual regulatorily-inclined suspects, are frequently not quite as useful from an operational preparedness/mitigation/response/recovery standpoint (they provide a useful structure for the aforementioned quartet, but when it comes down to doing the do, again, sometimes not so much).

At any rate, the Cal/OSHA Emergency Action Plan requirements, provide (at least in my mind—feel free to disagree) a good basic sense of the pieces to have in place that are not necessarily as patient-focused. When the fecal matters starts impacting the rapidly rotation turbine blades, it’s important to have a structure in place that addresses the employee aspect, particularly for those of you with offsite non-clinical operations (billing, finance, HR, etc.: a lot of folks don’t have enough space at the main campus for all the moving pieces that constitute a healthcare organization). So, here’s the California stuff (and please feel free to share any good stuff your state might have on the books—this is all about getting prepared and staying prepared—every little bit helps):

(b) Elements. The following elements, at a minimum, shall be included in the plan:

(1) Procedures for emergency evacuation, including type of evacuation and exit route assignments;

(2) Procedures to be followed by employees who remain to operate critical plant operations before they evacuate;

(3) Procedures to account for all employees after emergency evacuation has been completed;

(4) Procedures to be followed by employees performing rescue or medical duties;

(5) The preferred means of reporting fires and other emergencies; and

(6) Names or regular job titles of persons or departments who can be contacted for further information or explanation of duties under the plan.

(c) Alarm System.

(1) The employer shall establish an employee alarm system which complies with Article 165 (link to that info here).

(2) If the employee alarm system is used for alerting fire brigade members, or for other purposes, a distinctive signal for each purpose shall be used.

(d) Evacuation. The employer shall establish in the emergency action plan the types of evacuation to be used in emergency circumstances.

(e) Training.

(1) Before implementing the emergency action plan, the employer shall designate and train a sufficient number of persons to assist in the safe and orderly emergency evacuation of employees.

(2) The employer shall advise each employee of his/her responsibility under the plan at the following times:

(A) Initially when the plan is developed,

(B) Whenever the employee’s responsibilities or designated actions under the plan change, and

(C) Whenever the plan is changed.

(3) The employer shall review with each employee upon initial assignment those parts of the plan which the employee must know to protect the employee in the event of an emergency. The written plan shall be kept at the workplace and made available for employee review. For those employers with 10 or fewer employees the plan may be communicated orally to employees and the employer need not maintain a written plan.


I hope this provides you with some useful (and perhaps even thoughtful) information as we roll through emergency year 2018. I am hoping for a time of minimal impact for communities this year (I think we had just about enough last year), but the oddness of the weather patterns over the past couple of months gives me pause. (I live in the Boston area and Houston and its environs had snow before we did!)

Emergency Management Monkeyshines: All Things Must Pass…

Sometimes like a kidney stone, but nonetheless…

Before we dive into this week’s “content,” I have a thought for you to ponder as to the nature of basing future survey results on the results of surveys past (rather Dickensian, the results of surveys past): Recognizing that authorities having jurisdiction (AHJ) always reserve the right to disagree with any decision you’ve ever made or, indeed, anything they (or any other AHJ) have told you in the past, how long are existing waivers and/or equivalencies good for? Hopefully this ponderable will not visit itself upon you or your organization, but one must be prepared for any (and every) eventuality. Which neatly brings us to:

In digging around past emails and such, I noticed that I had not visited the Department of Health and Human Services Healthcare Emergency Preparedness Gateway in rather a while and what to my wondering eyes should appear but some updated info and a link to CMS that I think you’ll find useful. So, the current headlines/topics:

  • Considerations for the Use of Temporary Care Locations for Managing Seasonal Patient Surge
  • Pediatric Issues in Disasters Webinar
  • 2017 Hurricane Response – Resources for Children with Special Health Care Needs
  • Supporting Non-resident/Foreign Citizen Patients
  • A new issue of The Exchange newsletter
  • A link to the CMS Emergency Preparedness Final Rule surveyor training (you can find the information available to providers here). Unfortunately, the post-test is not available to providers, but sometimes it’s like that.

It is my intent over the next little while to check out the education package, so I will let you know if I have any grave reservations about the content, etc., or if I think you need to earmark it for priority viewing.

So, kind of brief this week, but I’m sure there’ll be more to discuss in the not too distant future. And so, with the end of wintah on the horizon, I wish you a moderately temperate week!

There’s no such thing as someone else’s code: Infection control and the environment (again…)

Periodically, I field questions from folks that require a little bit (well, perhaps sometimes more than a little) of conjecture. Recently, I received a question regarding the requirements in ASHRAE 170-2008 regarding appropriate pressure relationships in emergency department and radiology waiting rooms (ASHRAE 170-2008 says those areas would be under negative pressure, with the caveat that the requirement applies only to “waiting rooms programmed to hold patients awaiting chest x-rays for diagnosis of respiratory disease”).

Right now, that particular question is kind of the elephant in the room from a regulatory perspective; there is every indication that The Joint Commission/CMS are working their way through ASHRAE 170-2008 and have yet to make landfall on this particular requirement—as far as I know—feel free to disabuse me of that notion. The intent of the requirement (as I interpret it) is to have some fundamental protections in place to ensure that an isolated respiratory contagion does not have the capacity of becoming a legitimate outbreak because of inadequate ventilation. Now, you could certainly use the annual infection control program risk assessment to identify whether your waiting rooms are “programmed to hold patients awaiting chest x-rays for diagnosis of respiratory disease” based on the respiratory disease data from the local community (and you might be able to obtain data from a larger geographic area, which one might consider a “buffer zone”).

Best case scenario results in you being able to take this completely off the table from a risk standpoint, next best would be that you introduce protocols for respiratory patients that remove them from the general waiting rooms (depending on the potential numbers, you may not have the space for it), worst case being that you have to modify the current environment to provide appropriate levels of protection. The notation for this requirement does provide some relief for folks with a recirculating air system in these areas, which allows for HEPA filters to be used instead of exhausting the air from these spaces to the outdoors, providing the return air passes through the HEPA filters before it introduced into any other spaces.

Knowing what I do about some of the ventilation challenges folks have, I suspect that it may make more sense to pursue the HEPA filtration setup than it would be to try to bring each of the spaces under negative pressure, but (going out on a limb here) that might be a question best answered by a group of knowledgeable folks (including an individual of the mechanical engineering persuasion) as a function of the (wait for it…) risk assessment process.

Ultimately, it comes down to what the Authority Having Jurisdiction chooses to enforce; that said, it might be worth having someone work through your state channels or by putting the question to the Standards Interpretation Group at Joint Commission (I suspect that their response would not be not particularly instructive beyond the usual “do a risk assessment” strategy, but there is a new person running the Engineering group at TJC, so perhaps something a little more helpful might be forthcoming). At any rate, as noted above, I’ve not heard of this being cited, but I also know that if there’s an outbreak tied to inadequate ventilation somewhere, this could become a hot topic pretty quickly (probably not as hot as ligature risks at the moment, but you never know…).

When the tough get going: Emergency Management and other considerations

First off (and apologies for the short lead time on this), but next week (February 13), CDC is hosting a webinar on the importance of assessing for environmental exposures during emergencies (and in general). While this is likely to be some useful information as a going concern, you can also earn CEUs for tuning in. A summary of the program as well as registration information, etc., can be found here. Overall, I think hospitals had a pretty good track record of emergency response in 2017, but somehow these things never seem to get easier over time…

Another issue that I see starting to gain a little traction in the survey world is dealing with concerns relating to medical gas and vacuum systems; for the most part (I’m sure there are some exceptions, but I can’t say that I’ve run into them), folks in hospitals tend to rely on contracted vendors to do the formal inspection, testing, and maintenance of medical gas and vacuum systems, which tends to keep an in-depth knowledge of the dirty details at (more or less) arm’s length. A couple of weeks ago, I received some information from Jason Di Marco of Compliant Healthcare Technologies (many thanks to Jason!) that I thought would be worth sharing with you folks. Of primary interest is a downloadable guide to medical gas systems (available here in exchange for your email address) that really gives a good overview of the nuts and bolts (as it were) of your med gas system. Jason also publishes a blog on the critical aspects of medical gas and vacuum system inspection, testing, maintenance, compliance, etc., where I found a fair amount of useful information. Again, I can see the regulatory compliance laser focus starting to turn in the direction of all the systems covered under NFPA 99 and I can also see some of those prickly surveyor types trying to pick at the knowledge base of the folks managing these processes. So, in the interest of never having too much information, I would suggest getting a little more intimate with your medical gas and vacuum systems.

You don’t have to be a weather(person)man to tell: Kicking off survey year 2018!

Your guess is as good as mine…

Just a couple of brief items (relatively—you know how I do go on, but I will try) of interest. I don’t know that there’s a common theme besides an effort to anticipate in which direction the survey winds might blow in 2018:

  •  Previously in this space, I’ve mentioned the work of Matt Freije and his team at HCInfo as they have done yeoman’s (yeoperson’s?) work in the field of water systems management and the “fight” against In response to last year’s letter of intent by CMS to take a more focused look at how hospitals and nursing homes are providing appropriately safe water systems for their patients, Mr. Freije has developed a checklist to help folks evaluate their current situations and has posted the checklist online for comment, suggestions, etc. I’m having a hard time thinking that this might not become something of a hardship for folks arriving late to the party, so if you’ve not yet embraced poking around this subject (and even if you have), you’d do well to check out the checklist.
  •  A couple of inspection items relative to the ongoing rollout of the various and sundry changes wrought by the adoption of the 2012 Life Safety Code®, some of which have yet to migrate in detail to the accreditation organization publications (at least the ones that I’ve seen), but have popped up during recent CMS surveys:
    • Make sure you fire alarm circuit breakers are clearly marked in red (check out NFPA 72 for the skinny on this).
    • Make sure your ILSM/fire watch policy/process reflects the appropriate AHJs—you need to make sure that you know for sure whether your state department of public health, et al, want to be notified. They do in California, and probably elsewhere.
    • In NFPA 25, chapters 5 and 13 indicate some monthly inspections of gauges, valves for condition, appropriate position (open or closed) and normal pressures—again, they’re not specifically listed in the accreditation manuals yet, but I suspect that they’ll be coming to a survey report near you before too long.
    • A final note for the moment in this category, NFPA 70 (2011 edition) 400.10 indicates that “flexible cords and cables shall be connected to devices and to fittings so that tension is not transmitted to joints of terminals.” Keep an eye on power strips, particularly in your IT and communications closets for those dangling power strips (and some of them aren’t so much dangling as they are pulled across open spaces, etc. I suspect you know what I mean.) I know the folks who manage this stuff think that we are just being pains in the butt, but now you may have a little codified leverage.
  •  In my post a couple of weeks ago, I don’t think I played the personal protective equipment (PPE) card with sufficient gravity; part of folks’ understanding of the hazards of using chemicals is recognizing the importance of actually using appropriate PPE as identified on the product SDS. When you think about it, the emergency eyewash station is not intended to be the first line of defense in the management of exposures to chemical hazards, but rather what happens when there is an emergency exposure. If the use of PPE is hardwired into the process, then the only time they’ll need to use the eyewash equipment is when they do their weekly testing. At that, my friends, is as it should be.


What it is ain’t exactly clear: Hazardous materials management and the SAFER matrix

I was recently asked to ponder the (relative—all things are relative) preponderance of findings under the Hazardous Materials and Wastes Management standard (EC.02.02.01 for those of you keeping track). For me, the most interesting part of the question was the information that (as was apparently revealed at the Joint Commission Executive Briefings sessions last fall) findings under EC.02.02.01 frequently found their way to the part of the SAFER matrix indicating a greater likelihood of causing harm (the metric being low, moderate, and high likelihood of harm) than some of the other RFIs being generated (EC.02.06.01, particularly as a function of survey issues with ligature risks, also generates those upper harm-level likelihood survey results). Once upon a time, eyewash station questions were among the most frequently asked (and responded to in this space), so it’s almost like replaying a classic

Generally speaking, the findings that they’ve earmarked as being more likely to cause harm are the ones relating to eyewash stations (the most common being the surveyors over-interpreting where one “has” to have an eyewash station the remainder pretty much fall under the maintenance of eyewashes—either there’s a missing inspection, access to the eyewash station is obstructed during the survey, or there is clearly something wrong with the eyewash—usually the protective caps are missing or the water flow is rather anemic in its trajectory). All of those scenarios have the “potential” for being serious; if someone needs an eyewash and the thing doesn’t work properly or it’s been contaminated, etc., someone could definitely be harmed. But (and it is an extraordinarily big “but”) it’s only when you have an exposure to a caustic or corrosive chemical, which loops us back to the over-interpretation. OSHA only requires emergency eyewash equipment when there is a risk of occupational exposure to a corrosive chemical (the ANSI standard goes a bit further by indicating eyewash equipment should be available for caustic chemicals as well as corrosives). A lot of the findings I’ve seen have been generated by the clinical surveyors, who are frequently in the company of hospital staff that aren’t really clear on what the requirements are (you could make the case that they should, if only from a Hazard Communications standard standpoint, but we’ll set that aside for the moment), so when the clinical surveyor says “you need an eyewash station here” and writes it up, the safety folks frequently don’t find out until the closeout (and sometimes don’t find out until the survey report is received). The “problem” that can come to the fore is that the clinical folks don’t perceive the eyewash finding as “theirs” because it’s not a clinical finding, so they really don’t get too stressed about it. So, the surveyor may ask to see the SDS for a product in use and if the SDS indicates that the first aid for eye exposure is a 15- or 20-minute flush with water, then they equate that with an eyewash station, which in a number of instances, is not (again, strictly speaking from a regulatory standpoint) “required.” Sometimes you can make a case for a post-survey clarification, but successful clarifications are becoming increasingly rare, so you need to have a process in place to make your case/defense during the survey.

The other “batch” of findings for this standard tend relate to the labeling of secondary containers (usually the containers that are used to transport soiled instruments); again, in terms of actual risk, these conditions are not particularly “scary,” but you can’t completely negate the potential, so (again) the harm level can be up-sold (so to speak).

In terms of survey prep, you have to have a complete working knowledge of what corrosive chemicals are in use in the organization and where those chemicals are being used (I would be inclined to include caustic chemicals as well); the subset of that is to evaluate those products to see if there are safer (i.e., not corrosive or caustic) alternatives to be used. The classic finding revolves around the use of chemical sprays to “soak” instruments awaiting disinfection and sterilization—if you don’t soak them, then the bioburden dries and it’s a pain to be sure it’s all removed, etc.; generally, some sort of enzymatic spray product is used—but not all of them are corrosive and require an eyewash station. Then once you know where you have corrosives/caustics, you need to make sure you have properly accessible eyewash equipment (generally within 10 seconds of unimpeded travel time from the area of exposure risk to the eyewash) and then you need to make sure that staff understand what products they have and why an eyewash is not required (strictly speaking, there really aren’t that many places in a hospital for which an eyewash station would be required) if that is the case—or at least make sure that they will reach out to the safety folks if a question should come up during survey. Every once in a while there’s a truly legit finding (usually because some product found its way someplace where it didn’t belong), but more often than not, it’s not necessary.

You also have to be absolutely relentless when it comes to the labeling of secondary containers; if there’s something of a biohazard nature and you put it in a container, then that container must be properly identified as a biohazard; if you put a chemical in a spray bottle, bucket, or other container, then there needs to be a label (there are exceptions, but for the purposes of this discussion, it is best managed as an absolute). Anything that is not in its original container has to be labeled, regardless of what the container is, the reason for doing it, etc. The hazard nature of the contents must be clear to anyone and everyone that might encounter the container.

At the end of the day (as cliché an expression as that might be), it is the responsibility of each organization to know what’s going on and to make sure that the folks at the point of care/point of service have a clear understanding of what risks they are likely to encounter and how the organization provides for their safety in encountering those risks. We are not in the habit of putting people in harm’s way, but if folks don’t understand the risks and (perhaps most importantly) understand the protective measures in place, the risk of survey finding is really the least of your worries.

It’s knowing (hoping) that this can’t go on forever: A little bit of regulatory mishegas…

It being only the third week of the New Year, it’s a little early for any trends to fully manifest themselves, so a couple of odds and ends to get you caught up on (or, upon which to get you caught up, for any hard-core grammarians in the crowd…).

The latest issue of Health Facilities Management has a couple of articles (and a risk assessment available to ASHE members—gotta love a new risk assessment) that should prove of some value/interest over the next little bit:

  •  ASHE issues update on CMS ligature-risk policy – this is basically a recap of the CMS memo issued in December (details here) but also includes mention of an environmental ligature risk tool (updated to include a worksheet for EDs) that is available to ASHE members. I’m not sure if the “hand in glove” relationship between ASHE and TJC will remain the same with the departure of George Mills, but there is every reason to feel that ASHE’s position as an advocacy group will continue. In that light, probably a good idea to check out the ligature risk tool and adopt any elements that you may not have yet considered. I still feel that you have to rule everything in as a risk until you can start ruling stuff out, but I also think that we should be checking out any and all available resources.
  • An interesting article on airflow in the OR; to be honest, I love this kind of digging around into the corners of what makes the surgical environment such a bear from a compliance standpoint and where regulatory scrutiny might be headed as a function of increasing attention to the infection control impact of the environment. I’m not suggesting you have to mimic the study, but it might help you anticipate some pointed survey questions or requests.
  • Also in the latest issue of HFM, there’s an update on the CMS interpretations relative to rolling latches and related concerns as well as a request for volunteers to assist in gathering information, policies, etc. on how folks are keeping things quiet at night.

Moving on to our friends from Chicago, in the continuing unfolding of information regarding the management of ligature risks, the latest issue of Joint Commission Online includes further guidance relating to “other” (my quotation marks) behavioral health environments such as residential treatment, partial hospitalization, intensive outpatient and outpatient treatment programs. The guidance indicates that these settings are not required to be ligature resistant, but then goes on to indicate that a risk assessment should be conducted in these environments, and then policies and procedures implemented to address how to manage patients in these settings that may experience and increase in symptoms that could result in self-harm or risk of suicide. The piece also indicates that the expert panel met again in December and there will be additional guidance relating to suicide risk assessment and safe monitoring of high-risk patients. And so the conversation continues…