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Hanging on in quiet desperation is the safety way: Thought of something more to say!

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, guidance and/or equivalencies good for? Answer: It depends (with more permutations that you can shake a stick at…).

Last week, we chatted a little bit about the whole water management thing, including mention of what CMS is telling surveyors to look for, but I thought it might be useful to extract some of the specifics from that missive (if you missed it last week, it’s here). So, here we have:

Expectations for Healthcare Facilities

CMS expects Medicare and Medicare/Medicaid certified healthcare facilities to have water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems.

Facilities must have water management plans and documentation that, at a minimum, ensure each facility:

  • Conducts a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g., Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system.
  • Develops and implements a water management program that considers the American Society of Heating, Refrigerating, and Air-Conditioning Engineers (ASHRAE) industry standard and the CDC toolkit.
  • Specifies testing protocols and acceptable ranges for control measures, and document the results of testing and corrective actions taken when control limits are not maintained.
  • Maintains compliance with other applicable federal, state, and local requirements.

Note: CMS does not require water cultures for Legionella or other opportunistic waterborne pathogens. Testing protocols are at the discretion of the provider.

Healthcare facilities are expected to comply with CMS requirements and Conditions of Participation to protect the health and safety of its patients. Those facilities unable to demonstrate measures to minimize the risk of LD are at risk of citation for noncompliance.

Expectations for Surveyors and Accrediting Organizations

Long-term care (LTC) surveyors will expect that a water management plan (which includes a facility risk assessment and testing protocols) is available for review but will not cite the facility based on the specific risk assessment or testing protocols in use. Further LTC surveyor guidance and process will be communicated in an upcoming survey process computer software update. Until that occurs, please use this paragraph as guiding instructions.

Just so you know, I chose to use some of the text in bold font because I think that’s probably the most important piece of this for folks moving forward (kind of makes me think that, just perhaps, there have been citations for folks not actively pursuing water cultures). But it does establish the expectation that a piece of the required risk assessment is going to include something that relates to whether you choose to culture, how often, and how you came to make that determination. I think this helps folks manage some of the ins and outs of this process, but I still feel like this could end up being a source of consternation as surveyors “kick the tires” in the field.

 

Wagging the dog: Can Accreditation Organizations influence each other?

In last week’s issue of HCPro’s Accreditation Insider, there was an item regarding the decision of the folks at the Healthcare Facilities Accreditation Program (HFAP) to update their Infection Control standards for acute care hospitals, with the intent of alignment with CMS expectations (you can find the article here) We’ve certainly covered the concerns relative to Legionella and the management of risks associated with aerosolizing water systems and this may only be a move to catch up on ground already covered by other accreditation organizations (our friends in Chicago already require the minimization of pathogenic biological agents in cooling towers, domestic hot- and cold-water systems, and other aerosolizing water systems), but I’m thinking it might also be something of a “tell” as to where survey focus might be drifting as we embark upon the second half of 2018. Certainly, waterborne pathogens are of critical importance to manage as a function of patient vulnerability (ideally, we want folks to get better during their hospital stays), so it makes perfect sense for this to be on the radar to some degree. At this point, the memorandum from CMS outlining their concerns has been with us for about a year, with an immediate effective date, so hopefully you are well-entrenched in managing those water systems. If this one is still on your to-do list, I think it’s probably advisable to making it a priority to get it to your “to-done” list. But you should definitely check out the latest “clarification” from CMS. While the memo indicates that this does not impose any new expectations or requirements, it does make it a little clearer as to what surveyors are supposed to be checking.

As I think Mr. Gershwin once opined about summer and the easiness of living, it would be nice to be able to set a spell and take one’s shoes off, but vigilance is always the order of the day.

On a somewhat lighter note, I just finished reading Our Towns – A 100,000 Mile Journey Into The Heart of America, which outlines the efforts of a number of (mostly smallish) municipalities across the United States in positioning themselves for a positive future (positive positioning—I kind of like that). The focus is mostly on the socioeconomics of different parts of the country, with a focus on how diversity can be employed in bettering a community (that’s probably a little ham-handed as a descriptor, but you can find an excerpt here if you like). As my work allows me to travel to a lot of places, while I haven’t been to a lot of the same destinations as the Fallows, I do recognize a lot of the stories and a lot of the challenges facing folks lately (and I think you might, too). I would describe the tone of the book as hopeful, so if you’re looking for something to read at beach/pond/summer cottage, etc., you might consider giving Our Towns a shot.

 

A quiet week in Lake Forgoneconclusion: Safety Shorts and Sandals!

But hopefully no open-toed sandals—maybe steel toed sandals…

Just a couple of quick items as we head out of the Independence Day holiday and into the heat of the summah (and so far, scorching has been the primary directive up here in the Northeast—hope it’s cooler where you are, but I also hope it didn’t snow where you are either…but I guess if you were in Labrador last week, all bets are off).

When last week’s musings on the ligature risk stuff in the July Perspectives went to press (or when I finished my scribbling), the new materials had not yet made their way to TJC’s Frequently Asked Questions page, though I thought that they might—and that’s exactly what has happened. To the tune of 17 new FAQs for hospitals, so if you haven’t yet laid eyes on the July Perspectives, head on over to the FAQ page and immerse yourself in the bounty (that’s a somewhat weird turn of phrase, but I’m going to stick with it).

While you’re there, you should definitely poke around at some of the other stuff on the FAQ page. There are lots and lots of recommendations for risk assessment types of activities, so if you’re looking for some risk minimization opportunities, you might find some useful thoughts. Of particular note in this regard is the practical application of safety practices in those organizational spaces for which your oversight is somewhat more intermittent; I’m thinking offsite physician practices or medical office buildings and similar care locations. Depending on where you are and where they are, it might not be quite so easy to keep a really close eye on what they’re doing. And while I tend to favor scheduling surveillance rounds with folks in general, I also know that if you don’t stop by from time to time, you might not catch any lurking opportunities (and they do tend to be lurksome when they know you’re coming for a visit). In a lot of the survey results I’ve seen over the last 18 months or so, there’s still a pretty good chunk of survey findings generated during the ambulatory care part of the survey process. Safety “lives” at the point of care/service, wherever that may be—definitely more ground to cover now that in the past. At any rate, I think you could use the FAQ stuff as a jumping off point to increase the safety awareness of folks throughout—and you can do that independently of anyone’s vacation schedule (including your own).

Hope you and yours had a most festive 4th!

Will it go ’round in circles? More managing the physical environment relative to suicide risk!

Hopefully you have already gotten a chance to look through the July 2018 issue of Perspectives for the latest reveals on how (at least one accrediting body) is working through the issues relating to ensuring each organization has a safe environment for the management of behavioral health patients. There is a fair amount of content (this comes to us in the form of FAQs—presumably these will find their way to the official FAQ page, if they have not yet done so) and splits up into three general categories: inpatient psych units, emergency departments (ED), and miscellaneous. (I’m going to guess that the FAQs relative to managing at risk patients in acute care settings is going to merit their own FAQ edition, so I guess we’ll have to stay tuned.)

I don’t know that I would term anything to be particularly surprising (lots of emphasis on the various and sundry risk assessment processes that comprise an integrated approach to such things), though they do make some efforts to describe/define, going so far as to indicate that only patients with “serious” suicidal ideation (those with a plan and intent) need to be placed under “demonstrably reliable monitoring” (aka 1:1 monitoring), with the further caveat that the monitoring be linked to immediate intervention, which means something in terms of competency, education, experience, etc. Clearly (and I completely agree with this) there is an expectation relative to who does the monitoring that probably doesn’t include a rookie security officer or other newbie. I personally have advocated for a very long time the use of folks who are specifically prepared for these types of activities, so maybe that idea is going to approach something of a standard. We shall wait and see.

Another interesting item is the indication that if you (and, yes, I mean you!) designate a room in your ED as a “safe room,” then the expectation (at least for TJC) is that room (or rooms if there are more than one) would be ligature resistant. Makes sense, but I think it does represent something of a caution for those of you looking at designating safe rooms in your EDs (and perhaps extending to the inpatient side of things—probably in the next installment). I guess the other interesting thing (and this probably doesn’t apply to all) relates to freestanding EDs: the recommendations (you can check out the November 2017 issue of Perspectives for the particulars if you’ve not yet done so) for EDs would apply. I understand that this is rather a big deal in general and is very close to endlessly complex in the practical application of the management of risks. I think this is one “ball” we’re going to be keeping an eye on for the next little while.

To end this week in the truth is stranger than almost anything category, I was looking through an email (devoted to all things culinary) and I noted a headline: “We’re All Using Clorox Wipes Wrong, Apparently” and I said to myself, “Dwell times have entered the vernacular of the American household” (I’m not saying it’s anything more than a toehold, but still) and darned if I wasn’t pretty much spot on. The other “revelation” is the absence of bleach in some of the kitchen wipe products identified in the article (I think I knew that, but I can’t really say when I might have acquired said knowledge). There’s also some information on what surfaces should be cleaned with certain kitchen wipes, etc. At any rate, I thought it worth sharing, at least as an example of how our work can span all demographics.

Happy Independence Day to all!

Education < / = / > Achievement: Don’t Let Survey Prep Get in the Way of Good Sense

I’d like to start off this week with an interesting (and hopefully instructive) tale from the field:

I was doing some work recently at an organization that is facing down the final six months of its survey window. This was my first visit to the facility and I was working on getting a sense of the place as well as identifying the usual list of survey vulnerabilities. As we’ve discussed before, one of the things that’s always in the mix, particularly with the gang from Chicago, is the care and feeding of emergency eyewash stations. This particular organization has adopted the strategy of having folks at the department level perform the weekly testing (a sensible approach from my standpoint—I think the most important piece of the weekly testing is helping to ensure that folks who might actually need the eyewash in an emergency actually know how the darn thing works), but the documentation form had two columns: one for the date and one for the signature of the person doing the test. The sheet did not, however, have any instructions on it, which prompted me to inquire as to how folks would know what (and why) they are checking, since the purpose is not just to run the water. The response to my inquiry was rather noncommittal, which is not that unusual, so I continued to collect data relative to the process. So, over the course of the facility tour, we found a couple of eyewashes with missing caps and no clear indication on the testing form that this had been identified as an issue. OK, not crazily unusual, but pointing towards a process that could use some tweaking. A couple of eyewashes with obstructed access provided a little more data.

Then we made our way to the kitchen. No real compliance issues with the eyewash itself, but I noted that they were checking the eyewash station on a daily basis and recording the temperature at that same frequency. Now, the ANSI standard does not require daily verification of eyewash flushing fluid temperature, so I asked about this particular practice (BTW: Nowhere else had we seen this practice—at least not yet …) and was informed another hospital in the region had been cited for not doing the daily temp checks (I have not been able to verify that this was an actual survey finding, but sometimes believing is enough … to cause trouble). And then we headed over to the lab and ran into a similar practice (they were just verifying the temps during the weekly test) and the feedback there was that a College of American Pathologists (CAP) surveyor had told them a story about an individual that had suffered eye damage because the (low temperature) water from the eyewash interacted with a chemical. This was not written up as a finding, but was relayed as an anecdotal recommendation.

The “funny” thing about all this (actually, there are a couple of process gaps) is that each of the eyewash stations in question are equipped with mixing valves, which pretty much mitigates the need for daily or weekly temperature checks (you want to check the temp when you’re doing the annual preventive maintenance activity). But the more telling/unfortunate aspect of this is that (independent of each other) these folks had unilaterally adopted a process modification that was not in keeping with the rest of the organization (it has been said, and this is generally true, that you get more credit for being consistently wrong than inconsistently right). Now, one of the big truisms of the survey process is that is almost impossible to push back when you are not compliant with your own policy/practice. And while I absolutely appreciate (particularly when the survey window is closing) wanting to “do the right thing,” it is of critical importance to discuss any changes (never mind changes in the late innings) with the folks responsible for the EOC program. While I pride myself on not telling folks that they have to do something that is not specifically required by code or regulation, some of the regulatory survey folks don’t share that reticence. The other potential dynamic for these “mythical” requirements is when a surveyor tells an organization something that doesn’t show up in the actual report. I run into this all the time—they may “look” at the finding in the report, but what they sometimes react to is what the surveyor “said.” Compliance has way more than 50 shades of whatever color you care to designate and what works/worked somewhere else doesn’t always work everywhere, so folks make these changes without knowing what is actually required and end up increasing the potential for a survey finding.

And healthcare isn’t the only pursuit in which incomplete communications (or making sure that communications are as complete as they can be) can have an impact. At the moment, I am reading An Astronaut’s Guide to Life on Earth by Col. Chris Hadfield (this, apparently, is going to be the summer for reading astronaut memoirs, be that as it may) and I came across a passage in which Hadfield describes a debriefing following a practice spacewalk in which one of the instructors noted that while Hadfield has a “very clear and authoritative manner,” he encouraged the folks participating in the debrief to not be “lulled into a feeling of complete confidence that he’s right.” As soon as I saw that, I was able to tie it back to the management of surveyors who speak in a “very clear and authoritative manner” and sometimes turn out not to be worthy of complete confidence that the surveyor is correct. If you are doing something that, in good faith and the extent of your knowledge, is the “right thing” and somebody (even me!) comes along and says you’re not doing that right, never be afraid to ask to see where it says that in the code/regulation, etc. (BTW: I’m not giving you permission to be obnoxious about it!) Surveyors (same for consultants) see a lot of stuff and sometimes compliance becomes a fixed idea, or process, in their head, but that doesn’t mean it’s the only way. And if you hear something that makes you think you have a vulnerability (something you’ve heard through that pesky grapevine), talk it out before you make any changes. That gives everyone in your organization a fighting chance at compliance.

As a final note, if you’ve forgotten about Col. Hadfield’s most notable performance (beyond the astronaut thing), check it out:

Documentary evidence: Sounds like you’re going to have to push a little more paper next survey!

A few weeks ago, our friends in Chicago upped the ante in releasing the updated documentation list for the Life Safety portion of the survey (you can find it—and I really, really, really suggest that you do so sooner rather than later—by logging into your Joint Commission portal and the clicking through the following internal links: > Survey Process, > Survey Activity Guide, > Additional Resources). And this is definitely a case of the list having shifted towards documentation of activities and conditions for which folks have been struggling to get in line. Now, from anecdotal discussions with folks, there’s not always a ton of time available for document review. So, in a lot of instances, the focus is on inspection, testing and maintenance of fire alarm and suppression systems equipment, emergency and standby power supply systems, medical gas and vacuum systems, with some “drift” into fire drills and other more or less standard areas of concern/coverage, including the management plans (sometimes—and those don’t appear to have earned a mention on the updated list).

However, according to that same updated document list, looks like a lot of focus on inventory lists (operating components of utility systems; high-risk operating components on your inventory, infection control components); “embracing” (you can think of that as reviewing and adopting) manufacturer recommendations for inspection, testing and maintenance of utility systems or outlining the Alternative Equipment Maintenance program being used. And the same types of things for medical equipment—inventory, high risk equipment, consideration of manufacturer recommendations, etc. It also appears that there will be focus on sterilizer inspection, testing, and maintenance; compliance of your hyperbaric facilities (if you have them) with Chapter 14 of NFPA 99-2012; testing manual transfer switches in your emergency power supply system. Let’s see, what else…oh yes, for those of you with recently (I’m guessing that pesky July 6, 2016 date is the key point in time) constructed or renovated procedural areas, you need to make sure that you have (and are testing) task lighting in deep sedation and general anesthesia areas (the annual testing requirement is for a 30-minute test).

I’m sure there’s other stuff that will pop to the surface as we move through this next phase of the survey process; I’m curious about how much in-depth looking they’re going to be able to do and still be able to get to the lion’s share of your building (unless they start using unmanned drones…). I’m also curious that they don’t specifically indicate the risk assessment identified in Chapter 4 of NFPA 99-2012 (it has been asked for during CMS surveys), but that may be for the next iteration. Part of me can’t help but think back to those glory days when we wished for adoption of the 2012 Life Safety Code®; I guess we can take full advantage of the operational flexibilities inherent in suite configuration and a couple more things, but it never really seems to get any easier, does it?

At any rate, please hop on your organization’s TJC portal and give the updated list a look. If you see something that gives you hives, sing out: we’re all here to help!

With a purposeful grimace and a terrible sound: Even more emergency management!

As much as I keep promising myself that I’ll poke at something more varied, the news of the day keeps turning back in the direction of emergency preparedness, in this case, just a little bit more on the subject of continuity of operations planning (COOP).

Late last week, our friends in Chicago proffered the latest (#41) in their series of Quick Safety (QS) tips, which focuses on elements of preparedness relating to COOPs (nobody here but us chickens). Within the QS tip (small pun intended), our Chicagoan overlords indicate that “continuity of operations planning has emerged as one of the issues that…need to address better in order to be more resilient during and after the occurrence of disasters and emergencies.” The QS also indicates a couple of best practice focus areas for COOPs:

  • Continuity of facilities and communications to support organizational functions.
  • A succession plan that lists who replaces the key leader(s) during an emergency if the leader is not available to carry out his or her duties.
  • A delegation of authority plan that describes the decisions and policies that can be implemented by authorized successors.

Now, I will freely admit that I always thought that this could be accomplished by adopting a scalable incident command structure, with appropriate monitoring of critical functions, inclusive of contact information for folks, etc. And, to be honest, I’m not really sure that having to re-jigger what you already have into something that’s easy for surveyors to discern at the 30,000-foot survey level is going to make each organization better prepared. I do know that folks have been cited for not having COOPs, particularly as a function of succession planning and delegation of authority (again, a properly structured HICS should get you most of the way there). So, I guess my advice for today is to figure out what pieces of your current EOP represent the COOP requirements and highlight them within the document (I really, really, really don’t want you to have to extract that stuff and create a standalone COOP, but if that helps you present the materials, then I guess that’s what you’d have to do…but I really don’t like that we’ve gotten to this point). At any rate, the QS has lots of info, some of it potentially useful, so please check it out here.

As a closing thought: I know folks are working really diligently towards getting an active shooter drill on the books, with varying degrees of progress. As I was perusing various media offerings, I saw an article outlining the potential downsides of active shooter-type drills. While the piece is aimed at the school environment, I think it’s kind of an interesting perspective as it relates to the practical impact of planning and conducting these types of exercises. It’s a pretty quick read and may generate some good discussion in your “house.”

The other shoe is starting to fall: Moving beyond ligature risks!

Well, it does seem like there are a couple of compliance themes asserting themselves in 2018, concerns related to emergency management (relatively simple in terms of execution and sustainability) and concerns relating to the management of behavioral health patients and the management of workplace violence (relatively complicated in terms of execution and sustainability). I think we can say with some degree of certainty that there are some commonalities relative to the latter two (beyond being complicated to work through) as well as some crossover. And while I wish that I had a ready solution for all of this, if I have learned nothing else over the last 39+ years, it is that there are no panaceas when it comes to any of this stuff. And with so many different regulatory perspectives that can come into play, is it enough to do the best you can under the circumstances? As usual, the answer to that question (at least for the moment) is “probably not.”

In last week’s Hospital Safety Insider, there was a news item regarding OSHA citations for a behavioral health facility in Florida for which inadequate provisions had been made relative to protecting staff from workplace violence. As near as I can make out from the story, the violence was being perpetrated mostly in patient encounters and revolved around “failing to institute controls to prevent patients from verbal and physical threats of assault, including punches, kicks, and bites; and from using objects as weapons.” Now, in scanning that quote (from information released by the Department of Labor), it does seem rather daunting in terms of “preventing” patients from engaging in the listed activities. This is one of those really clear division between federal jurisdictions—OSHA is driving the prevention of patients from engaging in verbal and physical threats while CMS is (more or less) driving a limited approach to what I euphemistically refer to as the “laying on of hands” in the management of patients. That said, I think it’s worth your while to take a look at the specific correction action plan elements included in the DOL release—it may have the makings of a reasonable gap analysis if you have inpatient behavioral health in your facility. It appears that the entity providing some level of management at the cited facility was also cited at another facility back in 2016 for similar issues, so it may be that some of this is recurrent in theme, but I think it probably makes sense to take a look at the details to see if your place has any of the identified vulnerabilities.

Wanting to end this week’s installment on an upbeat note, as well as providing fodder for your summer reading list, I was recently listening to the id10t podcast and happened upon an interview with astronaut Leland Melvin, who navigated a number of personal and profession barriers to become the first person to play in the NFL and go into space as an astronaut. His book, Chasing Space, is a fun and thought-provoking read and really captures the essence of what we, as safety professionals, often face in terms of barrier management. I would encourage you to check out the book as well as the interview. As a side note, I’m not sure if you folks would all be familiar with Chris Hardwick and his Nerdist empire, but I think he’s become a most winning and empathetic interviewer, and since I’ve never been afraid to embrace my inner (and outer) nerd, I will leave you with that recommendation (and please, if you folks have stuff that you’re reading and think would be worth sharing with our little safety community, please do—fiction, non-fiction—a good read is a good read!)

Not enough rounding in the world: Compliance and readiness in the face of everyday chaos…

As I was engaged in my walk this morning (the sun just starting to cast its light on the Rockies!), I was pondering the complexities of the healthcare environment as a function of compliance. One of the truisms of my practice is that I am good at finding those points where things don’t quite gel. Sometimes (most times, to be honest), it’s relatively minor stuff (which we know is where most of the survey findings “live”) and every once in a while (mostly because my eyes are “fresh” and can pick out the stuff that’s happened over time; as I like to say, squalor happens incrementally), you find some bigger vulnerabilities (maybe it’s a gap in tracking code changes or a process that’s really not doing what you need it to do). So, after tooling around for a couple of days, folks will inevitably ask me “what do you look for?” and I will stumble through something like “I try to find things that are out of place” or something like that.

This morning, I had something of an epiphany in how that question actually informs what I do: it’s not so much what I look for, it’s what I look “at.” And that “at,” my friends, is everything in a space. One of the process element that gets drilled into housekeeping folks (I’m pretty sure this is still the case, it definitely was back in 1978 when I started this journey), is to check your work before you go on to the next thing, and that means going back over everything you were supposed to do. I’ve had conversations with folks about what tools I’ve seen that have been effective (and I do believe in the usefulness of tools for keeping track of certain problematic or high-risk conditions), but only in very rare circumstances have I “relied” on a tool because I have an abject fear of missing something critical because I had a set of queries, if you will. I would submit to you that, from a compliance standpoint, there are few more complex environments in which to provide oversight than healthcare. It is anything but static (almost everything except for the walls can move—and does!) and in that constant motion is the kernel of complication that makes the job of facilities safety professional infinitely frustrating and infinitely rewarding.

So, I guess what I’m advising is not to limit your vision to “for,” but strive for “at everything—and if you can impart that limitless vision to the folks who occupy your organization’s environment, you will have something quite powerful.

 

There’s always someone looking at you: More emergency preparedness!

Once again, we tread the halls of emergency preparedness in search of context for some recent developments. I guess it is not inappropriate that this has become a more frequently touched upon subject, but I am hopeful that the weather patterns of last summer remain a distant memory, though the current situation in Hawaii does give one pause as a function of shifting likelihoods. At any rate, sending positive thoughts and vibrations to the folks in our 50th state in hopes that the tectonic manifestations will slow to a reasonable level.

First up, a couple of words about the recent unveiling of NFPA 3000 Standard for an Active Shooter/Hostile Event Response (ASHER) Program. I have no doubt that any number of you have been working very diligently towards establishment of an ASHER Program within your organizations. And I suspect that you have encountered some of the same resistors when it comes time to try and actually conduct a practical exercise to see how effective (or not) the response might be (I can’t think of too many other exercise scenarios that could be more potentially disruptive to normal operations, but I think therein lies the most compelling reasons for wanting/needing to exercise this scenario). I’ve participated in/monitored a couple of these exercises and I will tell you firsthand that it’s tough to get really good results on that first try. Folks are nervous and tentative and there’ll be a whole host of folks who won’t be as inclined to participate in the exercise as you might want (and really don’t seem too concerned when they fall victim to the shooter—there is nothing quite like the indifference that can be experienced during these types of exercises), but you really must forge on. To my mind, beyond the likely survey scrutiny driven by the Sentinel Event Alert, this type of scenario falls squarely in the realm of “most likely to experience, least well prepared to respond” and the longer it takes to begin making substantive changes to your response plan—based on actual data generated through exercises—the further behind the curve it will be if there is an event in your community (an event that has become increasingly likely, pretty much no matter where you are).

As to the standard, I don’t know that NFPA 3000 brings anything particularly new to the party, but it does provide a codified reference point for a lot of the work we’re already doing. You need only to check out the table of contents for the standard to see some familiar concepts—risk assessment, planning/coordination, resource management, incident management, training, etc. I do think that where this will become most useful as a means of further integration of our preparedness and planning activities with those of our local community(ies). We need to be/get better prepared to respond to the chaos that is integral to such an event and hopefully this will provide common ground for continued program growth.

As an aside relative to all things EM, there is an indication that our friends from Chicago are starting to kick the tires a little more frequently when it comes to ensuring that all the required plan elements are in place. There is a truism that the survey tends to focus more on what has changed than on what has remained the same, as we’ve noted in the past, TJC has added a few things to the mix, so you want to make sure you have:

  • Continuity of operations planning, including succession planning and delegation of authority during emergencies
  • A process for requesting (and managing) an 1135 waiver to address care and treatment at an alternate care site
  • A plan/process for sheltering patients, staff, and visitors during an emergency, as applicable
  • Evidence that all your outlying clinic, etc., settings have participated in your emergency response exercises or actual events

I know there are instances in which some of these might not apply, but you need to be very diligent in outlining how and why these elements would not be applicable to your organization. I think the only one noted above that really could be dependent on your organization is if you don’t have any care locations outside of your main campus. But beyond that, all those other elements need to be in a place that the surveyors can find them. And don’t be afraid to reiterate the language in the applicable individual performance elements—fleshing out the process is a good idea, but you want them to be able to “see” how what you have in your plan reflects what is being required. I continue to maintain that hospitals do a very good job when it comes to emergency management, but there is also always room for improvement. I don’t want our improvement processes to get derailed by a draconian survey result, so make sure the “new” stuff has been captured and added to your Emergency Operations Plan (EOP).