RSSRecent Articles

Hanging on in quiet desperation is the safety way

Thought I’d something more to say…

Beware the alligator roll: One quick item for your consideration (I’ve been “sitting” on this one for a little bit). When one considers ligature risks in the environment (as with all risks), one of the evergreen truisms is that risks are very often in the eye of the beholder. So, the question then becomes at what height does a ligature point become a risk that transcends what might be considered a minimal risk. There is certainly information from various sources that self-harm (mostly asphyxiation) can occur at any height—individuals have fixed a ligature to a low pipe and around their neck and then spun their body to twist the ligature until they were asphyxiated, often described as an “alligator roll” or “crocodile roll” (depending on your reptilian preferences). Our friends in Chicago recently updated one of their FAQs on the subject to reinforce consideration of the potential for at-risk patients to harm themselves. If there’s one thing I’ve learned over the years, it’s that persons wishing to harm themselves are often quite creative in how they make use of elements in the physical environment. That said, as creative as folks might be, they usually are not able to “create” while someone is watching; for example, I’m not aware of anyone using the alligator roll to harm themselves while someone was watching them. To me, this pinpoints the criticality of the assessment process and ensuring that folks who are at serious risk for self-harm are put under observation. There is no such thing as a completely risk-free environment and we need to make sure that the assessment process takes into account that “reality.”

As a closing thought for this Thanksgiving week, while the fall is probably my favorite time of year, there always seems to be a component of melancholy to experience (i.e., endure), usually in the form of reflection. There’s also the element of missing folks near and dear who are no longer with us in the corporeal sense (I rely a great deal on the memories of the dearly departed), but I try to remember to be thankful for all that has come before, as well as what we have now. It’s hard not to think of it all as a continuum, but that may just be me. So, as we close in on the end of Year 2 of the Time of COVID, I want to thank each and every one of you for your support and interest in the safety profession as well as this little slice of whatever it is. I appreciate everything you folks do, day in and day out, and my hope is for us all to get through this together. A most joyous and restful Thanksgiving to you and your families—enjoy the spirit of community to the extent that you can!

Tired of being tired? Me too!

A couple of quick items this week. As is frequently the case, I keep something of a digital scrapbook of ideas for the blog in my draft email folder. If I see a news item or some such that I think might be worth sharing, I’ll set it aside with the intent of using it at a later date. As things are wont to do, competing priorities, breaking news, etc., will sometimes push other items out of the way and I try to remember to go back and dig out stuff that continues to be at least somewhat timely—and sometimes what was kind of fresh in the moment can become even more significant over time.

For example, way back in June 2020 (if that doesn’t make me sound like an old codger, I don’t know what would), our friends in Chicago released an issue of its Quick Safety newsletter providing some thoughts regarding the challenges in promoting well-being during a crisis. At that point, I don’t know that many would have predicted that we would still be in the thick of it almost 18 months later and, anecdotally (doing client work and overhearing conversations as I travel), it does seem that folks are reaching the point of wearing out. I have no reason to think that is not the case for you folks as well, so this might be something you’d want to share with your organization—or maybe even at the Thanksgiving table.

Item #2 for this week kind of spins off the whole conversation regarding the management of workplace violence—the importance of being able to rapidly summon assistance in an emergency. Panic alarms are intermittently used in healthcare, but I think that, as part of being able to manage workplace violence, they are going to become ever more prevalent, particularly in remote locations—both within the “four walls” of your organization and in any community settings (clinics, business offices, etc.). In exchange for a wee bit of information, you can download a white paper from the good folks at Patient Safety & Quality Healthcare that discusses some of the considerations. Before you know it, budget season will be upon us and this might be something to think about adding to the mix.

Putting the O(SHA) back in OMG…

I’m sure you were right there with me last week pondering the potential impact of the Emergency Temporary Standard issued by our friends at the Big O (see the news release) in efforts to get ahead (and stay ahead) of COVID. As I travel, I’m not sure that this is going to be as successful as they’d like it to be. I still observe folks in airports, on public transportation, etc., who are surprised when they are reminded that masks are mandated in a lot of confined public environments. As somewhat of an editorial aside, I “get” that someone might forget to slide their mask back up after they’ve eaten, etc., but I don’t get the mindset that has masks buried at the bottom of their handbag, etc. I freely admit that my OCD slides to the fore when it comes down to mask wearing; when I’m traveling, the mask goes on in the car and doesn’t come off again until I get to my hotel room. I figure it’s worked well so far, so I’m going to stay the course for a while longer—maybe once we have a solid 12 months of vaccinations (and who knows when that might be…).

At any rate, under the ETS, covered employers must develop, implement, and enforce a mandatory COVID-19 vaccination policy, unless they adopt a policy requiring employees to choose to either be vaccinated or undergo regular COVID-19 testing and wear a face covering at work.

The ETS also requires employers to do the following:

  • Determine the vaccination status of each employee, obtain acceptable proof of vaccination status from vaccinated employees, and maintain records and a roster of each employee’s vaccination status.
  • Require employees to provide prompt notice when they test positive for COVID-19 or receive a COVID-19 diagnosis. Employers must then remove the employee from the workplace, regardless of vaccination status; employers must not allow them to return to work until they meet required criteria.
  • Ensure each worker who is not fully vaccinated is tested for COVID-19 at least weekly (if the worker is in the workplace at least once a week) or within seven days before returning to work (if the worker is away from the workplace for a week or longer).
  • Ensure that, in most circumstances, each employee who has not been fully vaccinated wears a face covering when indoors or when occupying a vehicle with another person for work purposes.

But in looking at all this stuff, I’m thinking healthcare (for the most part) has already embarked on this journey and when I started poking around the FAQs, FAQ 2J speaks very specifically to whether, in light of the existing Healthcare Emergency Temporary Standard (29 CFR 1910.502), and the answer (at the moment; more on that in a bit) is no, the protection of healthcare workers is already in play based on the existing ETS. But the potential “twist” is that if the Healthcare ETS were to expire/no longer be in effect, etc., before the expiration of this latest ETS, then the protection of healthcare workers would shift over. I don’t know that anything is jumping out at me from a practical standpoint that might represent a gap of protection if that shift were to occur, but if someone has different take on this, I’d be pleased as punch if you’d share it with us.

Sooooo…I think we’re OK for the moment, at least in terms of regulatory expectations, but keep an eye on things as they shift in and out of view/focus. If I sense a sea-change, I will do my best to keep you informed.

At the risk of “dating” this post, I’d like to conclude this week’s offering with a shout out to the veterans of our Armed Services. Not that they don’t deserve a shout out every week, but it just seems important to “push” Veterans’ Day a little bit this year. We are all the better for your service and I thank each and every one of you!

You probably already knew this…

I know we talked a bit about fire drills not so long ago, but somehow I seem to have missed this particular “clarification” while I was dodging the COVID-19 virus last summer and I wanted to make sure that you folks who may not have had much time for bedtime reading last (last) summer, I figured it couldn’t hurt to get this one out there (especially since these clarifications seem to be generating some findings).

In the July 2020 issue of Perspectives, there is an article that discusses some of the “asks” (OK, I suppose they’re somewhat more authoritative than asks…) that could come into play during survey when your fire drill program is being evaluated. One of the items applies particularly to folks who are using the two-shift model (as opposed to a three-shift model) with the enjoinder to schedule drills when administrative staff are on site so they can participate in the drill(s)—and have the opportunity to respond acceptably to the drill. So that’s something that could be queried during a survey (if you’ve adopted the two-shift).

The next item concerns the scheduling of drills across quarters. Now I think that this kind of flies in the face of the whole randomized scheduling, but, for example, if you conduct a first-shift drill in February, then the expectation is that the subsequent drills would be in May, August, and November, using the “every three months, plus or minus 10 days” definition. So, if you were to conduct a first-shift drill in January and then a first-shift drill in June (with the intent being to “mix things up”), that would result in a finding. It’s been a long time since I’ve conducted a fire drill, but I suspect I would have been in arrears relative to this expectation.

The Perspectives article also includes some guidance relative to what things to look at during fire drills. For instance, making sure that (when the fire alarm system is activated) locked egress doors unlock appropriately; as well as making sure that you evaluate the component of your fire response plan that deals with the management of visitors, particularly at the point of origin for the fire.

In the end, I don’t know how helpful it was to “release” this particular information when a lot of folks were trying to figure out how to ensure staff didn’t lose sight of the importance of fire drills while still maintaining the social distancing norms of the day. I think we’ve all come to grips (more or less) with the whole hour of separation between drill times, but it almost seems like a case of moving the compliance target just out of reach every time you think you’ve “grasped” the brass ring (somehow the whole “compliance as carousel” vision seems to be more telling every time I think about it). I guess there’s always an opportunity or two floating around, but sometimes I wish they floated within the immediate field of vision…

Now that this has come to light, I think I’m going to go back and check some of those issues of Perspectives to see if there’s any more revelatory content. Until next time!

Deck the halls with boughs of noncombustible construction…

It hardly seems possible that we are rushing headlong into the depths of November (October being almost as I write this), though I will note (as you would no doubt verify) that some of the big box stores have had “those” decorations out on the showroom floor for a couple of weeks. Strange that they don’t have a section of trimmings for hospitals…mayhap one day some illustriously inventive individual will come out with a line of Life Safety Code®-compliant holiday decorations for the healthcare market. To sleep, perchance to dream…

At any rate, it would seem that once again it is time to prepare for the onslaught of non-UL-listed trees and lights and all manner of unauthorized décor modifications (if you don’t believe me, check this out). I think that if I were in a position of waiting on a survey that’s more than 45 days late, I would very much plan on seeing our friends from Chicago before the end of the year and I would spend a wee bit of time coaching the more festive members of your organization in the do’s and don’ts of noncombustible decorations. As I’ve maintained right along, I absolutely understand that there is a therapeutic value (and perhaps never more so than this upcoming season) in having our places look festive during the holidays. Folks are exhausted and are probably not going to react well to any overly Scrooge-y dictates—work with them—if you have any money in your budget, maybe put together some examples of what can be done with code-compliant materials. I think, sometimes, the most powerful message of all is the one you show—and leave the telling to others…

To close the thought on those well within the survey window—the goal of the survey process is to generate findings, particularly in the physical environment—if you have a circuit breaker labeled as “spare” and it’s in the “on” position, they’re gonna find it and write it. If you have some schmutz on a sprinkler head, they’re gonna find it and write it. Something parked in front of an electrical panel—yup! Something parked in front of a fire alarm pull station—you betcha! Doors not latching—oh yeah! There are no perfect buildings and if all they can find are these types of imperfections, that’s what your survey report will look like.

Effective rounding is the only thing that’s going to keep these types of things under control; I’m sure there’s lots of rounding going on—make sure they’re effectively managing the conditions that are most likely to be discovered during survey. You know what to look at (everything!). Get folks out of the habit of looking “for” things—it sometimes leads to missing other things that didn’t make the “checklist.”

Everybody’s talking: I can’t hear a word they’re saying…

Something of a mixed bag of stuff this week, which is sometimes the case, particularly with the ever-shifting compliance landscape. First up, an update to one of TJC’s safety alerts dealing with the management of behavioral health patients in the ED, mostly as it relates to strategies of keeping things moving, and if they’re not moving, keeping things on a (relatively) even keel when inpatients beds are limited supply (which is pretty much all the time, though the degree to which that impacts ED patient flow is distinctly variable). If you’ve not had a discussion relative to the management of behavioral health patients in your ED (and I would certainly understand that pandemic response might just have caused a re-prioritization of discussions and conversations of all manner and variety), it’s probably worth checking out the updated materials with a small group and seeing if there are any improvement opportunities to be had. As with all such things, it’s never really about a “one size fits all” approach, but, in recognition that interpretations of compliance on the part of surveyors is often based on published content, at the very least it puts you in a better position having had the conversation about the “suggestions.” There are no magic bullets for any of this stuff and what works in some areas, works not so well in others, but it never hurts to see what’s in the minds of others (so to speak).

Closing out the week with a couple of COVID-related resources for your consideration. One of the hallmarks of the last 15-18 months of pandemic response has been the modification of existing facilities to support the medical management of infectious patients, etc. While there may have been some “casting about” for answers at the outset/onset of the pandemic, adjustments were made and life went on. But what if you had a facility that was specifically designed for such an event? I don’t know that anyone was sitting that “pretty,” but there’s been a lot of thought put into the design of the next iteration of healthcare facilities. For a glimpse of where things could be headed, there was an article in Health Facilities Management in July that discusses a lot of design considerations. My thought is that some of these might be useful in planning how to manage things in the shorter term (I somehow suspect that we are not all going to get new facilities any time soon) and if you’ve got some renovations in the not-too-distant future, you might find something useful to discuss with the architecture planning folks. For good or ill, we’ve never had so much practical experience as it relates to the management of pandemics, so let’s put it to good use. And just as I finished typing this post, the October 2021 issue of Health Facilities Management showed up in my inbox, featuring an article entitled “Designing The Post-Pandemic Hospital,” so there’s more information to consider. Much of it I suspect you already know, but it’s always good to see that you are not alone in thinking about this stuff.

Another component of pandemic response is the management of medical waste in the time of COVID; as with all such things, guidance is very fluid, but it’s worth bookmarking the Healthcare Environmental Resource Centers COVID medical waste page. There’s some state-specific information on the page as well as a link to a page where you can check on regulations in your home state. I suspect that the information contained therein will be in a near-constant state of update, so checking in on a regular basis is probably a good idea.

Not just dentists need drills…

There’s an interesting article on the history of fire drills in the latest issue of Health Facilities Management if you’ve not checked it out. I had the chance to do some work at St. Anthony’s Hospital a while back—it remains a beautiful building even despite its somewhat tragic past. At any rate, in acknowledgement that any specific requirement in the Life Safety Code® tends to be the result of a tragedy (not locking egress doors is one that springs very quickly to mind), it’s a fairly simple task to trace the origin of fire drills back to this hospital fire.

But it seems that some of the lessons of history have been lost to the mists of time (wait, what?!?) and fire drills have come to be considered (not by you or me, but by some) to be rather burdensome. Even OSHA only “recommends” fire drills (though I suspect that that is more of a “one size fits all” recommendation: if you can’t mandate it for all, you can’t mandate it for any), though I suspect you would have to do some very fancy footwork to convince any surveyor from the big O that fire drills were not a most important component of any occupational safety program. I do know that the interpretation of certain accrediting agencies as to what does or does not constitute “unexpected times and under varying conditions”, has made the scheduling of fire drills more burdensome (between you, me and the lamppost, the only person who remembers when the last fire drill—regardless of the shift—was conducted is the person charged with scheduling them), but one of the prerogatives of being an AHJ is to be as burdensome as one likes. If you’re a member of ASHE, they’ve updated their fire drill matrix to help identify fire drills that are too temporally proximal. Check out the details here.

So, I guess the question I have boils down to this: in the (unlikely) event that fire drills are removed as requirements in healthcare occupancies (I think it even less likely that business occupancies would be absolved of the requirement for fire drills), would you still conduct them as a “best practice”? I will freely admit that I am a wee bit torn about how I would respond to that. I am generally in favor of the provision of “live” education to staff (I know computer-based learning is somehow less intrusive, but I think I prefer education to be intrusive; not “in your face” intrusive, but not so far off that mark) and I always tried to use fire drills as an opportunity to interface with line staff on a myriad of topics. But the thought of fewer things that I would “have” to do has a certain appeal. At the end of the day, I don’t think I’d turn my back on fire drills as a means of providing education to staff, but I suspect it would be an uphill battle if word ever got out that fire drills were no longer mandatory…if that were to ever happen.

As we relive our lives in what we tell you…

While it is always my intent to be amazingly timely in posting things, sometimes items that I’ve earmarked for sharing end up languishing in my draft emails folder. And, as I was poking around trying to decide what to run with this week, I came upon an item that, while a little long in the tooth in terms of when it was published, should still provide some food for thought (and action) as we navigate the waters of preparedness. There are always things to do and events to plan for, but you’ll probably want to review the document to look over the updates.

As usual, there’s nothing that I see that makes me crazy, but I also know that, in the hands of some surveyors, what looks like flexibility to folks with practical experience can become “the only way.” So you might want to check out the review tool being used in a certain Midwest state very close (so close they are the same) to our friends from Chicago. At some point, I suspect that the conversations during survey are going to turn to “What about the next one?” (as we venture further into the realm of emerging infectious diseases, or EID), so it’s probably a good idea to start planning along those lines. Hopefully the next one doesn’t get here for a very, very long time, but…

A couple of general thoughts regarding some of the changes:

Play nicely with others: collaboration versus isolation. In one of those ever-shifting dualities brought on by the pandemic, there’s been a lot of “distancing” (social or otherwise) that has only (at least to my mind—feel free to disagree) increased the degree of difficulty when it comes to meaningful collaboration. At least now we can get folks to “visit” from time to time, but a lot of the most difficult situations, conditions, etc., over the last year or so were very much accomplished “on the fly.” I think we all try to live by the “stronger together” ethic, but I guess it just proves the point that the whole 96-hour thang is very dependent on the event(s). That said, if you are accredited by our friends in Chicago, be very certain that you have met the requirements for evaluating emergency response activities, have a documented review of your emergency inventory, reviewed your HVA, evaluated your emergency response plan/emergency management plan/emergency operations plan. It doesn’t have to be complicated, but there is some indication that shortfalls will be cited. Please take an hour this week and make sure all those little duckies are in neat rows.

The umbrella can provide protection for a lot of different events: we did touch on this earlier in the year, but I’m glad to see that guidance is being provided to surveyors that it is not necessary to have response plans/protocols for every possible event. That said, you want to make sure that you have a good cross-section of folks participating in the planning process, particularly with the whole EID issue. Infection control and prevention folks are amazingly important when it comes to planning for emergencies (but after the last 12 months or so, you really didn’t need me to tell you that), but there are other folks in your organization that have a part to play in the planning. I think one of the critical performance metrics going forward will be the general concept of continuity as it impacts operations across the continuum of care. Your planning must key on how the place stays in business over the long haul (recognizing we’re still “hauling” to a fair degree…) and you really want to include consideration of continuity as a specific evaluation element. We now know that we can appropriately to a really long event, but the hows and whys are going to be key as we move out of response into recovery mode.

I think you folks “got this,” but it never hurts to look preparedness in the eye from time to time.

The Matrix Unloaded…Overloaded: Somehow stuff keeps happening…

Interesting read in the October 2021 Perspectives relative to some Life Safety chapter considerations that have earned a place in the Consistent Interpretation column. The thing that really caught my eye was the potential for these conditions to show up in the upper right hand corner of Ye Olde (SAFER) Matrix—a fate that befalls only a few choice conditions. I’m not so sure these are the conditions I would have thought could “bump” up into that corner, but I guess it’s all subject to interpretation. Fortunately, they don’t appear to be cited very frequently (from a high of just over 12% to a low of just over 0.5%) so perhaps it’s more a question of the frequency in which these conditions might be identified during a survey. While you’re definitely going to want to look at the details, the types of things identified in the article are things like: missing fireproofing; “missing” sprinkler heads; issues with two-hour walls, particularly occupancy separations; proper fire protection rated components in opening protectives (so, no 20-minute fire doors in 2-hour rated walls); painted-over door labels (How many of these would you need to have to push a high-risk/high-frequency finding? Beats me…).

Again, nothing that gets cited with any great frequency is in the mix (the performance element under which the door label issue would be cited “sits” at about a 10% finding rate), and, as I think about it, none of these are things I see with any frequency, though I suppose you could make the case that some of this extends into the territory of “if you look long enough and hard enough, there’s always one.” For example, in all likelihood, if you have fireproofed steel in your facility, there will be a section of fireproofing that was knocked off/removed/damaged, etc.; same thing with the painted-over door labels—there’s probably one somewhere (which causes me to reflect on the nature of environmental surveys as scavenger hunts). Definitely something to keep an eye on (and encourage your line staff to be on the lookout for them too).

To conclude with a little more LS goodness, I’ve been sitting on this one for a little bit (OK, maybe a little more than a little…since February), but as the intense chaos of the pandemic ebbs and flows (but never really subsides to any great degree), Health Facilities Management published a short article on the importance of the risk assessment process to ensure appropriate management of the risks associated with rapid-cycle facility modifications to accommodate all sorts of shifts in volume, acuity, patient types, etc. While some of the risk assessment would probably have to be retrospective (unless your policy specifically prohibits retrospective review), it might be worth going back to look at modifications to egress and, perhaps, fire protection features when you were creating COVID units from thin air. There are almost always lessons to be learned and the more we can hard-wire into the process moving forward, the safer we’ll all be in the long run.

That’s all for now. See you next week!

Don’t let weighing in weigh you down…

In what I would term an interesting move (I don’t know that I would go so far as to call it unprecedented, but it might well could be), our friends in Chicago are rearranging the deck chairs in the Emergency Management chapter. It does seem like it’s more of  a consolidation than a wholesale rewrite, but the strategy of setting up new standard and performance element numbers makes this potentially a big deal (as we know, surveyors tend to focus on the stuff that has changed since the last survey visit, so if you’re using the existing numerical indicators, you’ll likely need to change—or get rid of them entirely). I suspect this may have more to do with trying to align the existing EM standards et al. with the CMS requirements (It will be interesting to see if they end up developing a crosswalk—probably when it’s adopted).

While I can’t say that I’ve digested the whole thing, it does seem like they removed a lot of the specifics relating to the management of LIP volunteers (including an allowance for organizations to forego the use of volunteers, a strategy they had never really “approved”; I know a couple of instances in which organizations were cited for declining to use volunteers), but it makes me wonder what degree of specificity is going to come into play when they start surveying to this.

That said, I don’t see anything that’s giving me heartburn; since CMS based Appendix Z on much of the TJC standards from 2007-ish, what was once old (and abandoned) is now fresh and new and cutting edge. I have the same hopes for myself over time…

At any rate, the critical processes are still represented. I think it will show over time that some of the specificity of the current standards pushed folks to do things that didn’t necessarily make sense from an organizational standpoint, but I guess we’ll have to wait until the final version is out and about and able to take care of itself. I’m guessing substantive changes are not likely to be made at this point, but they are asking for comments, so if you’ve got a mind to say something, I would encourage you to do so.

Next week we’ll chat a little bit about some recent interpretive dances from the perspective of Perspectives. Stay tuned!