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Well that stinks! Or maybe it doesn’t…

I guess we can file this under the “You never know what’s going to pique someone’s interest” category.

In last week’s Joint Commission E-Alert publication, there is a featured set of links to an updated FAQ regarding “Aromatherapy & Essential Oils” (for example, this one). When I first saw it, I was thinking that maybe it was going to discuss some of the intricacies of dealing with all this smelly stuff that seems to crop up in offices and other spaces (everywhere looks like a good place for a stick-up). But when I clicked through the link, I found the question revolved around whether or not aromatherapy and/or essential oils needed to be managed as medications. As usual, the response was “it depends” (admittedly, that is a very much shortened version of their response, but please feel free to click through to embrace the majesty of this FAQ), with the slightly more involved response being “it depends on how you’re using it.” I have to say that I am not typically a fan of a lot of these scents; some of the them just seem like iffy attempts at covering other odors and some of them just seem wrong, but I digress. I know there are (perhaps more than) a few organizations that have adopted a fragrance-neutral/fragrance-free environment (these days, you just don’t know how someone is going to react to various scent-sations—allergies abound), but I can definitely see some folks interpreting this as something of an endorsement of using scents as a strategic intervention.

In other news, TJC also announced the publication of a new book of safety lists, which (based on my past experiences with their book products), may or may not be the answer to your sticky challenges (I pretty much live in the “not” camp, but someone wants to try and convince me that we have a winner, I’m game). Alternatively, you might consider the 2019 edition of the HCPro Hospital Safety Trainer Toolbox, which promises so much more than a bunch of checklists. I personally kind of ebb and flow on the whole concept of checklists, primarily because I find they try to do too much (or perhaps promise too much is the more appropriate descriptor). I see those checklists that go on and on for pages and pages and I’m thinking how in (insert deity of choice)’s name do you operationalize something that big? To that point, I am often asked what I look for when I’m doing consultant survey work and my (admittedly somewhat glib) response is that I don’t look for anything in particular, but rather I look at everything. I suspect it goes back to my EVS days when I looked at things from top to bottom in a (more or less) circular fashion—pretty much looking for stuff that didn’t look right (it is very rare indeed that I find an instance of noncompliance that looks “right,” if you know what I mean). The corollary to that is that a surveyor (and I count myself among that august assemblage) is never more dangerous than when they are standing still—that’s when the little funky detail stuff comes into focus. All the divots, loaded sprinkler heads, dust animals (bunnies, dinosaurs, the lot), become more visible. A moving surveyor (unlike the moving finger…) is a very good thing!

Ready, Set, ICRA!

One of the more frequently recurring questions/concerns/vulnerabilities in my travels relates to when it is appropriate to do a (and I will use this term collectively) pre-construction risk assessment, inclusive of all the usual suspects: Noise, vibration, system shutdowns, etc. Clearly (and I know you know, because I see you knowing), the pieces of this puzzle that can get you into the most trouble in most rapid fashion are those relating to infection control and interim life safety measures.

My (moderately) tongue-in-cheek response to any questions about “when” you would employ has typically been “always” (I remember the first time the question came up at a conference and my response was the same—and I’m sticking to my guns on this). My general philosophy as it relates to risk assessments is that we always assess for risk and we implement only what is necessary to manage those risks.

At any rate, as your “homework” for this week (and I would very much like to hear how you folks are parsing this), please look over the list below and figure out where you’ve placed the dividing line for your risk assessment process (basically, where you’d do an assessment and where you wouldn’t), particularly as a function of the Chicago requirement to “when planning for demolition, construction, renovation, or general maintenance [my bolding], the hospital conducts a preconstruction risk assessment for air quality requirements, infection control, utility requirements, noise, vibration, and other hazards that affect care, treatment, and services.” I firmly believe that this balancing act is going to be become a key component of survey oversight. (I would be more than happy to be wrong about this, but somehow I think things are moving in this direction.)

So please look over these perky little definitions and let me know your thoughts:

43.2.2.1 Categories of Rehabilitation Work. The nature and extent of rehabilitation work undertaken in an existing building.

43.2.2.1.1 Repair. The patching, restoration, or painting of materials, elements, equipment, or fixtures for the purpose of maintaining such materials, elements, equipment, or fixtures in good or sound condition.

43.2.2.1.2 Renovation. The replacement in kind, strengthening, or upgrading of building elements, materials, equipment, or fixtures, that does not result in a reconfiguration of the building spaces within.

43.2.2.1.3 Modification. The reconfiguration of any space; the addition, relocation, or elimination of any door or window; the addition or elimination of load-bearing elements; the reconfiguration or extension of any system; or the installation of any additional equipment.

43.2.2.1.4* Reconstruction. The reconfiguration of a space that affects an exit or a corridor shared by more than one occupant space; or the reconfiguration of a space such that the rehabilitation work area is not permitted to be occupied because existing means of egress and fire protection systems, or their equivalent, are not in place or continuously maintained.

43.2.2.1.5 Change of Use. A change in the purpose or level of activity within a structure that involves a change in application of the requirements of the Code.

43.2.2.1.6 Change of Occupancy Classification. The change in the occupancy classification of a structure or portion of a structure.

43.2.2.1.7 Addition. An increase in the building area, aggregate floor area, building height, or number of stories of a structure.

Dance on a volcano: Keeping tabs on those that keep tabs on us…

As we’ve discussed in the past, the world in which we exist—and the stories and challenges contained therein—is never ending. And the subtext of that constancy revolves around our efforts to stay (as it were) one step ahead of the sheriff.

Part of me is railing against my chosen topic this week because I always feel like this space can (and, admittedly, does) have a tendency towards a Joint Commission-centric vision of the compliance universe, but while they may not be the largest primate in the compliance universe (once again violating all manner of metaphoric-mixing indignities), they are (more or less) the organization with the most robust customer-forward presence, through Perspectives to the FAQ pages to the topic-specific offerings we’re covering this week. All things being equal (which, of course, they never really are), I would encourage you to poke around a bit on these sites as there is a mix of stuff that is almost ancient, but some tools, etc. that you might find useful in demonstrating compliance.

The Physical Environment portal is kind of the granddaddy of this whole construct; it started out as a collaboration with the American Society for Health Care Engineering (and may very well continue to be so, but it’s kind of tough to tell) with the goal of providing information on the most frequently cited standards. Unfortunately (for me, but not so much for you), a lot of the information, including “surveyor insights,” is accessible only through your organization’s TJC extranet portal, but there is some stuff that’s worth a look. For example, there is a fire drill matrix that gives a sense of what areas should be considered for your high-risk fire drills (or would it be fire drills in high-risk areas…); the one on the matrix I found of some interest was Cath/EP lab making the high-risk list. I guess the overarching thought is to make sure you carefully consider those areas in which surgical fires a present as a risk.

There are also portals for emergency management, healthcare-acquired infections (I would keep a close eye on that one; lots of indication that this is the next “big thing” for survey), and workplace violence. Keep an eye on them: You never know what might pop up!

You’ve got to get in to get out: New safety adventures in ambulatory care

Hoping that this is more treat than trick, I had cause (albeit minimal) to reflect on what I see as a reasonably significant increase in EC findings being generated in the ambulatory care world. If we accept (and I certainly do) that one of the primary drivers to the survey process is the generation of findings, then it makes all the sense in the world to start “pushing” the survey process in those environments over which we have less control/influence/oversight. I talked a little bit about tools for the ambulatory setting back in January of this year (continuing our program of a self-referential October), and the good folks at ECRI are offering what they are terming a “deep dive” into safe ambulatory care (if you scroll about 1/3 of the way down the ECRI homepage, you’ll find the link to download the report for the low purchase price of some contact information).

The report breaks things down into four key areas: Diagnostic testing, medication safety, falls, and, safety & security. While I recognize the latter two may be of primary interest to this audience, I would encourage you to check out the information relating to diagnostic testing and medication safety. Everything in healthcare (and pretty much any and everywhere else) “exists” in the physical environment (thinking of concentric circles with the patient at the center and the physical environment being the outermost circle), so the interactions between “disciplines” can generate a lot of opportunities when it comes to the practical application of safety and the environment. Taking that with the (at times infuriating) “grayness” of what is required from a regulatory standpoint, it really prompts a level of vigilance that is unlikely to subside any time soon.

To close things out for this week/month, another resource that you might find of interest is a podcast dealing with all things water treatment; you’ve heard (metaphorically speaking) me speak of Matt Freije and the good work he’s spearheading at hcInfo.com and he appears on an episode of the ScalingUp podcast. I found it pretty interesting, but that may just be me. That said, I think the focus and attentions paid to water management plans during survey activities is going to continue to rise and I can see a future in which funky water values will drive Condition-level survey results. Now is the time to start educating ourselves to what it all means and I think this podcast is a good start for folks. Check it out!

And a happy and safe All Hallows Eve to you all…

Who remembers pop-o-matic Trouble?

In something of a variation on another bloggy evergreen, I ask the rhetorical question: To what, if any, extent have you included consideration of  board games in your physical environment risk assessments for behavioral health? As I think towards a generation (are they already here?) for which the glories of board games will be forever lost, our friends in Chicago offer the latest challenge in managing risks with our all-too-vulnerable patient populations (for those of you of a certain vintage, the description of a board game is very nearly worth the price of admission).

The article describes the quite inventive use of a plastic board game piece to defeat the reptilian tamper-resistant screws and suggest some alternative products that do not so easily surrender to such efforts. I don’t know that I’ve been privy to a lot of discussion relative to board games in the behavioral health setting, but I suppose this would come under the heading of “everything has an inherent, though perhaps not apparent, risk.” Based on some recent surveys, it seems that Joint Commission surveyors have been rather inventive in looking for physical environment elements that have not been specifically accounted for in the assessment process. The classic example is including medical beds in the risk assessment, but not specifically mentioning the risks associated with the ligature-resistance (or not) of the side rails, bed frame, etc. Sooooooo, if they have not yet been included in your risk assessment activities, it might be a good time to pull a little group together and ponder the use of board games (and perhaps other such items) as a function of the behavioral health physical environment risk assessment.

Should we think about Halloween candy as well?!?

Check and mate!

Sticker shock: Compliance your way (not someone else’s)!

As we continue our October re-visitation of some of your more evergreen topics and I was thinking that I had covered this particular topic recently, but it turns out it was rather a long time ago—2012, to be exact (my, my, my, how time flies!).

I guess the general thought/concern relates to whether any particular piece of equipment has to have a due date sticker or some variation thereof. And, interestingly enough, while this still surfaces from time to time, the requirement (or lack thereof) has not really changed in the last seven or so years. Is there a benefit to having a due date so line staff can include a visual when they are using a piece of equipment? Absolutely! If you use color-coded outdate stickers, can it make it easier to discern when something is in arrears? It sure can! Can an outdate sticker call into question the efficacy of your process if there are too many of the “wrong” color floating around? Yup!

If you’re going to use them, then by all means make full use of them. Make sure line staff understand what information is contained on the sticker. Make sure they understand that if a sticker gets removed during the cleaning process, that is an important piece of information to communicate to clinical engineering or whoever is responsible for maintaining the equipment. And, please—for the love of all that is good and practical—try to stay away from policies that speak to the necessity of a sticker being present; another evergreen survey truth is that non-compliance with an internal process is one of the toughest survey findings to clarify. Everything (and anything) you do that is not specifically required by code and regulation should make sense from an operational standpoint. If there’s a program element that has, shall we say, evolved (or mutated) over time and is giving you compliance fits, take it out, dust it off, and make sure that whatever it is brings value to the process. And if it doesn’t? Time to move on!

Crying my eyes out: The never-ending story of emergency eyewash equipment!

October seems to be shaping up into a “greatest hits” kind of month as we once again dig back into the closet of perennial findings—this week finds us in the realm of managing occupational exposure to chemicals.

With the information contained in the September issue of Perspectives, it looked like findings relating to hazardous materials and wastes (which were mostly related to eyewash stations) had dropped off the Top 10 list (it was the #9 most-frequently cited standard for 2018), which I saw as a good thing. Generally speaking, I’ve found that the knowledge-base of the surveyor corps relative to the management of occupational exposures to hazardous materials leaves a little bit to desire, and rather prone to over-interpretation of what does and what does not constitute an inappropriately managed risk. You could, of course, (and I certainly have) give voice to the thought that over-interpretation is something of a standard practice amongst the surveyors of the world and you’d get very little in the way of argument from me. But there are a couple of recent findings that kind of crystallized (at least for me), the intersection of over-interpretation and a limited knowledge of the practical/operational aspects of appropriate management of occupational exposure to hazardous chemicals.

So, we have the following:

  • A single container of bleach in a storage room becomes a finding of moderate risk because the pH level of bleach requires the installation of an eyewash station

Now, purely from a reasonable risk assessment standpoint (and in recognition of the very remote likelihood that the container of bleach is going to somehow vomit its contents), the mere presence/storage of a corrosive does not (in my mind) constitute a risk of occupational exposure. If someone is pouring the bleach into another container (which is not the case here—again, only storage), then the risk of occupational exposure comes into play. The image that I conjured up relative to this is the local grocery store—gallons upon gallons of bleach—and nary an eyewash in sight (and yes, while OSHA doesn’t really jump ugly relative to customer exposure, the risks to customer and in-house staff is probably about equal). I suppose the best course for a corrective action would be to remove the bleach and be done with it. That said, this seems a bit of a reach…

  • Two eyewash stations (one in a soiled utility room and one in a scope decontamination room) that were located at dirty sinks in these areas, increasing the risk of staff exposure to contamination

Now, my philosophy regarding the location of emergency eyewash equipment is that you want to install them in locations as close to the point of likely exposure as is possible/reasonable, which sometimes (maybe even often) means that you install them on the only sink in a soiled utility room, etc. And you do that because?!? You do that because, the emergency eyewash station is equipped with protective covers to ensure that the emergency eyewash does not get contaminated, so you can install them in the locations in which they would be of the greatest benefit in an emergency, which might very well be in a soiled location.

It seems that the mystery of eyewash stations will never be completely solved…

Wanna buy a watch? How about a patient watch?

It’s been a while (OK, more than a while: It would seem it’s been something more than a decade. My, how time flies!) since we’ve discussed the matter of using security officers to watch patients. I can absolutely say that it is often a topic of conversation when I meet with security folks over the course of consulting as it not infrequently has a significant impact on security staffing resources. As I have maintained for a very long time, it is very difficult to carry out security rounding, etc., when your security staff is eyeballing patients from a fixed post. If you’re interested in the “historical” perspective, please feel free to use the Wayback Machine to review the state of things in 2008!

If we have learned nothing else over the years, it is the truth in that old saw: “The more things change, the more things stay the same” (or variations thereof). I came across an article at the beginning of September referencing recent guidance from the International Association for Healthcare Security & Safety (IAHSS), which includes the advice of not to use security officers for patient sitting/watch activities. There are certainly any number of complexities that come into play—competency and education, “backfilling” security activities when security officers are caught up in patient care activities, etc. And with the increasing number and types of risks relating to security occurrences in hospitals, being able to effectively respond to those risks, should they occur, could make the difference in ensuring organizational viability. I personally (and particularly in those days in which I had operational responsibility for security) continue to believe that the use of security officers for “general” patient watches is an inappropriate use of resources. Sure, there will be those instances in which a security presence beyond a quick response is needed, but I can think of few more useless applications of security resources than a security officer watching a sleeping patient. Patients should receive care from caregivers, and not that security officers are uncaring, but their training and competence are “designed” for other duties.

As a quick closeout for this week (and perhaps it is the turning of the season that causes reflection on past experiences), for those of you that may be embarking on a managerial position for the first time or for those of you that have been managers for so long that your inception is lost in the mists of time (those mists, of course, are the result of the earth cooling), I ran across a piece that I think might be helpful or at least prompt some reflection on current and/or past experiences. “What I Wish I’d Known As A First Time Manager” offers 10 thoughts on those (sometimes tenuous) first steps into managerial bliss (yeah, right!). I don’t know that there’s anything particularly earth-shattering, but sometimes it’s nice to hear some practical thoughts in a place other than in your own mind. We are, after all, in this thing together, so improving one improves all—and if that’s not a pretty nifty raison d’être, I don’t know what is.

It’s a lot like you: The dangerous type of emergency risks!

I know we chatted just last week about emergency management concerns, but once again, there’s more news stuff relating to the management of utility systems (it’s not just about water features) during emergencies and it does appear that the consequences of inadequately managed risks can get you into trouble with more than just the usual regulatory suspects.

A USA Today story from a couple of weeks ago outlined the charges/arrests resulting from the deaths of a number of nursing home patients in the aftermath of hurricane Irma, back in 2017. The sticking point, as it were, was the failure of the facility to evacuate once they lost the ability to effectively cool the facility. The news story paints a bleak picture of negligence, failure to call 911, etc., but also provides some indication that 911 calls from the facility received no response. I imagine that some details will emerge during trials as to what may or may not actually have transpired, including the existence of a “fully functional hospital across the street” to which (apparently) evacuation was not an option. I still maintain the most important part of any emergency response plan (and if not the most important, one of the very, very most important) is having a very clear understanding of what the trigger points are that would result in a need to evacuate. The worst thing that can happen with evacuation is to wait so long that a safe evacuation is not possible. I guess we’ll (hopefully) see what circumstances led up to this circumstance.

On a related (somewhat) note, our friends at the CDC have collaborated with the American Water Works Association to develop an Emergency Water Supply Planning Guide to assist healthcare facilities in their efforts to prepare for, respond to, and recover from, a total or partial water supply interruption. The Guide is designed to help folks assess water usage, response capabilities, and water supply alternatives. I suspect that this might be especially useful to folks in areas that tend to experience drought conditions, so if you want to check out the CDC Guide, you can find it here, along with links to some other preparedness resources.

Closing out things for this week, I’d like to share with you folks an article that I found to be of interest; while I don’t personally have managerial oversight in my current role, I saw enough parallels to “back in the day” to prompt the thought that “I wish there was something like this available when I was starting out.” So, in case you’re starting out in the amazing field of management or are interested in what’s going on in management theory, I think this would be worth your while. There’s a quote from Warren Buffett that I think really captures the essence of the compliance wars: “What the human being is best at doing is interpreting all new information so that their prior conclusions remain intact.” I bet that everyone reading this knows at least one human being like that…

You can find the whole article here.

If you don’t signal, how will I know where you want to go? Emergency management and its discontents (Just What You Needed)!

Kind of a mixed bag this week, though it all fits under the heading of emergency management, so here goes nothing…

A few weeks ago, USA Today did a story on the preparedness levels of the United States based on an analysis of state-by-state metrics. The story was based on a study, the National Health Security Preparedness Index, prepared by the Robert Wood Johnson Foundation and covers a lot of ground relative to trends in preparedness, including governmental spending on preparedness and some other stuff. The reason I “noticed” this was the indication that my home state was “best prepared” for disasters, etc., but the overarching message was that, even in the face of some setbacks in individual regions, the nation continues to improve emergency preparedness. Of course, it being USA Today, there are color slides indicating where each state ranks among the fabulous 50, so if you thought there was no scorekeeping on this front…

OK, maybe not keeping score, but a certain accreditation agency is keeping an eye on all things relating to preparedness. In this blog post, Jim Kendig (field director for the Life Safety Code® surveyors at The Joint Commission, and a very knowledgeable fellow when it comes to this stuff) provides a really good overview of the Preparedness Index and describes it in terms of how the various pieces can (and do) fit together and provide the foundation for an effective emergency management program. I see no reason why we can’t expect something more of a deep dive in the coming survey cycle and I think you’ll find the information Jim shares to be really helpful.

As a final thought for this week, it is always the case that what constitutes a mass casualty incident varies from organization to organization, but if you want to catch a glimpse of how this gets framed within the context of one of the largest metropolitan areas on the planet, the Greater New York Hospital Association developed a Mass Casualty Incident Response Toolkit that you might find worth checking out. There’s a ton of information, tools/forms, and links to more tools/forms, etc., to review in this space, but I encourage you to give the materials a look-see. It does appear that the nature of what we can expect to show up at our collective front doors is shifting and anything that facilitates better positioning to deal with an emergency is worth our time and energies.