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You are so beautiful, to me…

In the interest of a little summertime reading, I wanted to diverge a bit from the usual rant-a-minute coverage (rest assured, the ranting will continue next week—too much going on in the world) and cover a couple of “lighter” topics (though one does have to do with my favoritest topic—risk assessments).

First up, we have Soliant Healthcare’s list of the 20 most beautiful hospitals in the U.S. (as a music lover, I find that I am an absolute sucker for lists—go figure!); while I have not had the opportunity to do any work at the listed facilities (and have done some work at places I think measure up pretty well from a design perspective, etc.), I can say that the buildings represented on the list are pretty easy on the eye. I don’t know if anyone out there in the Mac’s Safety Space blogosphere works at any of the listed facilities, but congratulations to you if you do or did!

The other item for this week focuses on the pediatric environment; from my experiences, a lot of community hospitals have really scaled back their pediatric care facilities, mostly because demand is not quite what it used to be. Where there might once have been dedicated pediatric units, now there are a handful of rooms used for pediatric patients when they need in-hospital care, but not much in the way of dedicated spaces.

If you happen to be in a position in which your dedicated pedi spaces are not quite as dedicated as they once were, you might find it useful to perform a little risk assessment based on a toolkit provided by the University of California, San Francisco, and endorsed by a couple of professional groups. While the focus is more towards the home environment, I think it’s helpful to simply ask the questions and be able to rule out the concerns outlined in the toolkit. Any time you have to “run” with an environment that has to function for different patients, risk factors, etc., it never hurts to be able to pull a risk assessment out of your back pocket when a surveyor starts jumping ugly because they don’t agree with what they’re seeing or how you’re managing something.

The National Center for Missing & Exploited Children used to provide some risk assessment guidance for healthcare professionals, but in looking at their website, it appears to me that they are confining guidance to law enforcement, media, and families. (Some of the stuff for families is interesting and worth sharing in general.) Since they’re an at-risk patient population, you never know when your efforts to provide an appropriate environment for infants, children, and teens will come under survey scrutiny—and it never hurts to periodically review your efforts to ensure that your plan is current.

Reefing a sail at the edge of the world…

What to do, what to do, what to do…

A couple of CMS-related items for your consideration this week, both of which appear to be rather user-friendly toward accredited organizations. (Why do I have this nagging feeling that this is going to result in some sort of ugly backlash for hospitals?)

Back in May, we discussed the plans CMS had for requiring accreditation organizations (AOs) to make survey results public, and it appears that, upon what I can only imagine was intense review and consideration, the CMS-ers have elected to pull back from that strategy. The decision, according to news sources, is based on the sum and substance of a portion of Section 1865 of the Social Security Act, which states:

(b) The Secretary may not disclose any accreditation survey (other than a survey with respect to a home health agency) made and released to the Secretary by the American Osteopathic Association or any other national accreditation body, of an entity accredited by such body, except that the Secretary may disclose such a survey and information related to such a survey to the extent such survey and information relate to an enforcement action taken by the Secretary.

So, that pretty much brings that whole thing to a screeching halt—nice work of whoever tracked that one down. Every once in a while, law and statute work in favor of the little folk. So, we Lilliputians salute whomever tracked that one down—woohoo!

In other CMS news, the Feds issued a clarification relative to the annual inspection of smoke barrier doors (turns out the LSC does not specifically require this for smoke doors in healthcare occupancies) as well as delaying the drop-dead date for initial compliance with the requirements relating to the annual inspection of fire doors. January 1, 2018 is the new date. If you haven’t gotten around to completing the fire door inspection, I would heartily recommend you do so as soon as you can—more on that in a moment. So, good news on two fed fronts—it’s almost like Christmas in August! But I do have a couple of caveats…

I am aware of 2017 surveys since July in which findings were issued because the inspection process had not been completed, and, based on past knowledge, etc., it is unlikely that those findings would be “removable” based on the extended initial compliance date. (CMS strongly indicates that once a survey finding is issued in a report, the finding should stay, even if there was compliance at the time of survey.) So hopefully this will not cause too much heartburn for folks.

The other piece of this is performance element #2 under the first standard in the Life Safety chapter. (This performance element is not based on anything specifically required by the LSC or the Conditions of Participation—yet another instance of our Chicagoan friends increasing the degree of difficulty for ensuring compliance without having a whole mess of statutory support, but I digress.) The requirement therein is for organizations to perform a building assessment to determine compliance with the Life Safety chapter—and this is very, very important—in time frames defined by the hospital. I will freely admit that this one didn’t really jump out at me until recently, and my best advice is to get going with defining the time frame for doing those building assessments; it kind of “smells” like a combination of a Building Maintenance Program (BMP) and Focused Standards Assessment (FSA), so this might not be that big a deal, though I think I would encourage you to make very sure that you clearly indicate the completion of this process, even if you are using the FSA process as the framework for doing so. In fact, that might be one way to go about it—the building assessment to determine compliance with the Life Safety chapter will be completed as a function of the annual FSA process. I can’t imagine that TJC would “buy” anything less than a triennial frequency, but the performance element does not specify, so maybe, just maybe…

Civilization and its discontents

A bit of a hodge-podge this week, with the thematic element of security being the tie that binds, so to speak. There continues to be a lot of news (or it certainly seems that way to me) lately about various security concerns, from violence in the workplace to incursions by unauthorized persons into restricted and/or sensitive areas. We have spent a fair amount of time on these subjects this year (and I somehow suspect that this won’t be the last time for discussion in this realm), but I did want to share some resources with you in case you missed them in the deluge of this, that, and the other thing. (I sometimes marvel that I manage to capture anything, given the fire hose of information constantly spewing into the ether, but I digress.) So, in (relative) brief:

Hospitals & Health Networks (H&HN) published a very interesting story last week about efforts by Milwaukee-based Aurora Health Care to use a clinical approach to reducing assaults in their workplace, including establishment of a Behavioral Emergency Response Team (BERT)—I think you’re going to become very familiar with this term. At any rate, a lot of valuable information, so if you’ve not yet checked it out, I would encourage you to do so (“Violence in the Hospital: Preventing Assaults Using a Clinical Approach“).

In the comment section at the end of the H&HN article, an individual left a comment regarding a public health film titled “One Punch Homicide” that might be of benefit as a preventive measure. I have yet to watch the documentary in its entirety—the trailer is pretty intense—then again, there’s nothing not brutal about violence. The film runs about 90 minutes, but, as information, if nothing else, it’s worth a look:

As our final thought for this week’s adventure, our friends in Chicago are covering the dangers of tailgating. (I guess since the featured videos are Massachusetts-sourced, the concept of tailgating takes on a whole ‘nutha dimension.) As you will recall, a few months earlier, there was an incident involving an interloper at a hospital in Boston. Since then, the security folks have been hard at work coming up with inventive ways to get folks to use those eyes in the back of their head.

Since it is impossible to determine how much influence anything from Chicago might have on the survey front, I would encourage you (I’m very encouraging this week, aren’t I?) to check out the blog by Dave Corbin, director of security and parking at Brigham and Women’s Hospital in Boston, and maybe show these videos to your EOC Committee and maybe others in your organization—this is one of those things that is scary because it’s true (“Leading Hospital Improvement: New Campaign Illustrates Need for Staff Training on Dangers of Tailgating”).

Hope the summer is treating you well—keep it cool and keep it tuned to

We hold these truths…

In the wake of the high-rise fire in London a few weeks ago, those of you with high-rise facilities are probably going to experience some intensified attentions from your local fire folks (it’s already started in Houston). Any time there is a catastrophic fire with loss of life, it tends to result in an escalation in the interests of the various AHJ’s overseeing fire safety. While I suspect that your facilities are not at risk to the extent the conditions at the Grenfell Tower appear to have been, it is very likely that your locals are going to want to come out and kick the tires a little more swiftly/demonstrably than they have in the past. And, since we are responsible for a fair number of folks who are not (or at least less than) capable of getting themselves out in a fire, I think there is a very strong possibility that scrutiny will extend to non-high-rise facilities as well. I think we can say for pretty much certain that the regulatory folks probably didn’t miss this as a news story, and it’s not a very big leap to want to apply any lessons learned to how their areas of responsibility would fare under intensified scrutiny.

As a related aside, one of the challenges that I periodically face in my consulting engagements is the pushback of “it’s always been like this and we’ve never been cited” or something similar. My experience has been that a lot of times, the difference between a good survey and a not-so-good survey can be the surveyor taking a left turn instead of a right, etc. We have certainly covered the subject of imperfect buildings and how to find them (they are, after all, everywhere you look), so I won’t belabor the point, but this probably means that the focus on the physical environment is going to continue apace, if not (and I shudder at the thought) more so. We’ve got a lot of work ahead of us, folks—let’s get those sleeves rolled up!

Finally, as a head’s up, there’s going to be a webinar in August hosted by HC Info on strategies for meeting the CMS guidance (almost makes it sound helpful, doesn’t it) relative to the management of legionella risk that we covered a few weeks back. (Apparently space is limited, so you might want to get right on this:

Something (nothing official, just an intense feeling) tells me that this is likely going to be a significant survey focus over the next little while, so I’m in favor of gathering as much expert information, etc. as possible. Again, while I have no reason to think that most folks are not appropriately managing these types of risks, I also know that the survey expectation bar appears to have been raised to an almost impossible-to-attain level. To echo the motto of the Boy Scouts—Be Prepared!

But I got the crystal ball, he said!

And he held it to the light…

In their (seemingly) never-ending quest to remain something (I’m not quite sure what that something might be, but I suspect it has to do with continuing bouts of hot water and CMS), our friends in Chicago are working towards modifying the process/documentation for providing post-survey Evidence of Standards Compliance (for the remainder of this piece, I will refer to the acronymically inclined ESC). The aim of the changes is to “help organizations focus on detailing the critical aspects of corrective actions take to resolve” deficiencies identified during survey. Previously, the queries included for appropriate ESC submittals revolved around the following: identifying who was ultimately responsible for the corrective action(s); what actions were completed to correct the finding(s); when the corrective actions were completed; and, how will you sustain compliance (that is, as they say, the sticky wicket, to be sure).

The future state will be (more or less) an expansion of those concerns, as well as including extra-special consideration for those findings identified as higher-risk Requirements For Improvement (RFIs) based on their “position” in the matrix thingy in your final report (findings that show up in the dark orange and red areas of the matrix). The changes are roughly characterized as delving “deeper into the specifics” of the original gang of four elements, so now we have the following: assigning accountability by indicating who is ultimately responsible for corrective action and sustained compliance (not a big change for that one); assigning accountability for leadership involvement (only for the high-risk findings—whew!) by indicating which member(s) of leadership support future compliance; corrective actions for the findings of noncompliance—this will combine the “what you did” with the “when you finished it”; for high-risk findings, you will also have to provide information on the corrective actions as a function of preventative analysis (this sounds like a big ol’ pain in the rumpus room, don’t it?); and , finally, an accounting of how you will ensure sustained compliance, which will have to include monitoring activities (including frequency), the type of data to be collected from the monitoring activities, and how, and to whom, the data will be reported.

In the past, there was always the lurking (almost ghoulish) presence of what’s going to happen if you have repeat findings from survey to survey, and this new process sounds like it might be paving the way for more obstreperous future survey outcomes. But I’d like to know a little bit more about what might be considered a repeat finding—does it have to be the same condition in the same place or is it enough to get cited for the same standard/performance element combo. If the former is the case, then I “get” them being a little more fussy about the process (in full recognition that every organization has some repeat-offender tendencies), but if it’s the latter, then (insert deity of choice) help us all, ‘cause it’s probably going to get more ugly before we see improvement. Or maybe it will just be repeats in the high-risk zone of the matrix—I think that’s also pretty reasonable, though I do think they (the Chicagoans) could do a little better in ensuring consistent approaches/interpretations, particularly when it comes to ligature risks.

All that said, I stand on my thought (and let me tell you, that’s not an easy task) that there are no perfect buildings, no perfect physical environments, etc., and that’s pretty much supported by what I’ve seen being cited during surveys—the rough edges are where the greatest number of findings can be generated. And since they only have to find one instance of any condition in order to generate an RFI, the numbers are not in favor of the folks who have to maintain the physical environment. If you’re interested in the official notice, the links below will take you the announcement article, as well as a delightful graphic presentation—oh boy!

Horrors beyond contemplation

It is impossible to capture, or even comment on, the events that transpired at the Bronx-Lebanon Hospital Center in New York at the end of last month with anything less than abject horror. There have been lots of news stories about the various events that contributed to what happened, so I will let you investigate the causative factors on your own. But having checked out the available information, I can’t help but feel almost powerless when it comes to being able to provide any sort of guidance relative to the compliance aspects of preparing for such an event.

I think I can say, without much fear of contradiction, that this is likely to create an additional focal point for TJC surveys this year (so, keeping count, we have ligature risks; management of environmental conditions including temperature, humidity, air pressure relationships; intermediate- and high-level disinfection activities; workplace violence, including active shooter). But I still keep coming back to Sentinel Event Alert #45, “Preventing violence in the health care setting,” and I keep pondering the import of that one word: preventing.

Much as we have discussed in the past with a whole bunch of topics, at what point can we say that we have reduced the risk associated with X, Y and/or Z to the full extent possible? It would be an amazing thing to be able to put in place measures and strategies that could actually prevent something (really anything) bad from happening, but I have yet to encounter many instances in which prevention is actually achieved. Do we work towards that as a goal every moment of every day? Absolutely! But I don’t know how you “prevent” what happened at Bronx-Lebanon.

Until we have sufficiently sophisticated early detection for armed persons, aberrant behavior, etc. (we can’t have metal detectors at the front door of everyone’s home, can’t do a behavioral health assessment at everyone’s front door either), the purpose of looking at this is to ensure that there is an appropriate response, be it de-escalation or run, hide, fight. From what I gather, the response at Bronx-Lebanon was in keeping with appropriate levels of preparedness. As is usually the case with human beings, I suspect that there will be valuable lessons learned in reviewing what happened, but the fact of the matter is that this could have been so, so much worse.

At any rate, we know this is likely to be a focus during survey (information from a survey just this past week indicates a very significant focus on the management of violent events), and I think one of the most important preparation activities is to share information with the healthcare safety community. To that end, I wanted to alert you to an opportunity to do just that: next week, on Thursday, July 20, 2017, HCPro will present a webinar, “Emergency Preparedness for SNFs: How to Plan for, Respond to, and Recover From an Armed Intruder/Active Shooter Event.” While the title indicates a focus on skilled nursing facilities (SNFs), the general concepts are very much applicable to all healthcare environments and, truthfully, couldn’t be more timely.

I’ve worked in healthcare long enough to recall a time when this level of violence occurred in environments other than health care, but I think we have to operate under the thought that it is only a matter of time before our organizations come face-to-face with the reality of 21st Century existence. Although I wish it were otherwise, not focusing on preparing is no longer an option.

If brevity is the soul of wit…

Hope everyone enjoyed a festive and (most importantly) safe Independence Day—with any luck, today (July 5) does not mark the end of summer (as some do say) so much as it marks the beginning of the end of spring (up here in the Northeast, spring was loath to depart, but it does seem that pre-autumn weather has finally made a commitment to spending some time in the northern hemisphere).

I was looking recently at past blog posts for a reference to the CMS stance on law enforcement interactions with patients as a function of restraints and patient rights—always a fun topic—and I noted that the posts used to be a mite briefer than tends to be the case of late. (You can be the judge of whether my decline in brevity has left me soulless or witless.) I absolutely recognize that there’s been a lot of stuff to cover over the past 18 months with the firestorms of compliance that swept the healthcare environment, which has (no doubt) promoted some of the “volume” of bloggery. But it has caused me to wonder whether I am consuming the compliance elephant in sufficiently small bites to be of use to you folks out there in the field. As near as I can tell, the purpose of this whole thing (as much as I enjoy having a place to pontificate) is to provide information and thoughts on what is happening at the moment to you, my faithful audience of safety folk. And (as near as I can tell) it never hurts to ask one’s audience whether this works for you—please feel free to give me an e-dope slap if you think the “Space” has gone intergalactic in a less-than-useful way. At any rate, I am going to experiment with smaller bites of information in the coming weeks so you’ll have more time for other things—perhaps outdoors…

As far as news goes, things are relatively quiet as we observe the anniversary of CMS’s adoption of the 2012 Life Safety Code. Hopefully you all have done your NFPA 99 risk assessments; polished off those door inspections and are speeding towards the completion of activities relating to initial compliance with the Emergency Preparedness Final Rule. Health Facilities Management This Week discussed some prepublication EC/LS standards relating to the testing of emergency lighting systems; inspection and testing of piped medical gas and vacuum systems; and updating pertinent NFPA code numbers. The pre-pub stuff is aimed at behavioral health care, laboratory, nursing care center, and office based surgery accreditation programs. You can find the details here:

(I guess some of those links are about as brief as I am…)

Thanks, as always, for tuning in—I really appreciate having you all out there at the other end of the interweb…see you next week!

Plan be nimble, plan be quick

As we have discussed (pretty much ad nauseum) in this hallowed hall of electrons, there is likely to be a renewed (and I don’t mean renewed in a healthful way, this would be more like a subscription to a magazine that someone sent you as a prank) interest/scrutiny in how you and your organization are complying with all these lovely (and pesky, can’t forget pesky) new emergency management considerations. But there is one word of caution that I wanted to inject into the conversation, and while it probably doesn’t “need” to be said, I try not to leave any card unplayed when it comes to compliance activities.

Over the years (officially 16 of consulting—time flies!) I have found that sometimes (OK, maybe more frequently than sometimes), the prettiest plans, policies, procedures, etc. end up falling to the ground in demonic spasms because they did not accurately reflect the practice of the organization. The general mantra for this is “do the right thing, do what you say, say what you do,” but sometimes it’s tough to figure out exactly what constitutes “the right thing” (as opposed to “The Right Stuff,” natch). When it comes to emergency preparedness, response, recovery, etc. probably the single most important aspect of the plan (at least I think it’s an aspect—if you can think of a better descriptor, please sing out!) is that it is flexible enough to be able to react to minute-by-minute changes that are (frequently) the hallmark of catastrophic events. I think anyone who has worked in healthcare for any length of time has seen what happens to a rigid structure, be it policy, plan, expectations, buildings, flora and fauna—whatever, when things get to swirling around in intense fashion—things start to pull apart (figuratively and/or literally) and sustaining your response becomes that much more difficult.

So, as we “embrace” the challenges of the changes, I would encourage you to think about how you’ll maintain (and test during exercises) that flexibility of response that will give you enough wiggle room to weather the storms (of outrageous and other fabulous fortune). Exercise scenarios can push (or be pushed) in any number of directions (strangely, it is very much like real life)—make sure you take full advantage of those folks in the Command Center—if they’re not sweating—turn up the heat!

Is this the survey we really want?

Moving on to the type of pain that can only be inflicted at the federal level, a couple of things that might require an increase in your intake of acid-reducing supplements…

As it appears that CMS doesn’t love that dirty water (and yes, my friends, that is a shameless local plug, but it is also a pretty awesome tune), now their attentions are turning to the management of aerosolizing and other such water systems as a function of Legionella prevention. Now, this is certainly not a new issue with which to wrestle, which likely means that the aim of this whole thing, as indicated in the above notification—“Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water”—is something with which we are abundantly familiar. But I will admit to having been curious about the implied prevalence in healthcare facilities as that’s the type of stuff that typically is pretty newsworthy, so I did a quick web search of “Legionella outbreaks in US hospital.” I was able to piece together some information indicating that hospitals are not doing a perfect job on this front, but the numbers are really kind of small in terms of cases that can be verifiably traced back to hospitals. When you think about it, the waters could be a bit muddy as Legionella patients that are very sick are probably going to show up at your front door and there may be a delay in diagnosis as it may not be definitively evident that that’s what you’re dealing with. At any rate, sounds like a zero-tolerance stance is going to be, but the Survey & Certification letter does spell out the instructions for surveyors:

Surveyors will review policies, procedures, and reports documenting water management implementation results to verify that facilities:


  • Conduct 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.
  • Implement a water management program that considers the ASHRAE industry standard and the CDC toolkit, and includes control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens.
  • Specify testing protocols and acceptable ranges for control measures, and document the results of testing and corrective actions taken when control limits are not maintained.

I have little doubt that you folks already have most, if not all, of this stuff in place, but it might not be a bad idea to go back and review what you do have to make sure that everything is in order. And if you are interested in some of the additional information (including some numbers) available, the following links should be useful:

Moving on to the world of emergency management, during the recent webinar hosted by CMS to cover the Emergency Preparedness final rule, one of the critical (at that time, more or less unanswered) questions revolved around whether we could expect some Interpretive Guidelines (basically, instructions for surveyors in how to make their assessments) for the EP Final Rule. And to what to my wondering eyes should appear, but those very same Interpretive Guidelines.  I will feely admit that the setup of the document is rather confusing as there are a lot of different types of providers for which the Final Rule applies and not all the requirements apply to all of the providers, etc., so it is a bit of a jumble, to say the least. That said, while I don’t think that I am sufficiently well-versed with the specific EM requirements of the various and sundry accreditation organizations (HFAP, DNV, CIHQ, etc.), I can say that those of you using TJC for deemed status purposes should be in pretty good shape as it does appear that one of the early iterations of the TJC EM standards was used in devising the Final Rule, so the concepts are pretty familiar.  A couple of things to keep in mind in terms of how the CMS “take” might skew a little differently are these:


  • You want to make sure you have a fairly detailed Continuity of Operations Plan (CoOP); this was a hot button topic back in the immediately post-9/11 days, but it’s kind of languished a bit in the hierarchy of emergency response. While the various and sundry performance elements in the TJC EM chapter pretty much add up to the CoOP, as a federal agency, it is likely that CMS will be looking for something closer to the FEMA model (information about which you can find here), so if you have a CoOP and haven’t dusted it off in a while, it would probably be useful to give it the once over before things start heating up in November…
  • As a function of the CoOP, you also want to pay close attention to the delegation of authority during an emergency, primarily, but not exclusively the plan of succession during an emergency (I found the following information useful and a little irreverent—a mix of which I am quite fond). It does no good at all for an organization to be leaderless in an emergency—a succession plan will help keep the party going.
  • Finally, another (formerly) hot button is the alternate care site (ACS), which also appears to be a focus of the final rule; the efficacy of this as a strategy has been subject to some debate over the years, but I think this one’s going to be a source of interest as they start to roll out the Interpretive Guidelines. At least at the moment, I think the key component of this whole thing is to have a really clear understanding (might be worth setting up a checklist, if you have not already) of what you need to have in place to make appropriate use if whatever space you might be choosing. I suspect that making sure that you have a solid evaluation of any possible ACS in the mix: remember, you’re going to be taking care of “their” (CMS’) patients, so you’d better make sure that you are doing so in an appropriate environment.

And then came the last days of May…

There’s been a ton of activity the past few weeks on both the Joint Commission and CMS sides of the equation (and if you are starting to feel like the ref in a heavyweight prize fight who keeps getting in the line of fire, yup, that’d be you!) with lots of information coming fast and furious. Some of it helpful (well, as helpful as things are likely to be), some perhaps less so than would be desirable (we can have all the expectations we want as to how we’d ask for things to be “shared,” but I’m not thinking that the “sharers” are contemplating the end users with much of this stuff). This week we’ll joust on TJC stuff (the June issue of Perspectives and an article published towards the end of May) and turn our attentions (just in time for the solstice—yippee!) to the CMS stuff (emergency preparedness and legionella, a match made in DC) next week.

Turning first to Perspectives, this month’s Clarifications & Expectations column deals with means of egress—still one of the more frequently cited standards, though it’s not hogging all the limelight like back in the early days of compliance. There are some anticipated changes to reflect the intricacies of the 2012 Life Safety Code® (LSC), including some renumbering of performance elements, but, for the most part, the basic tenets are still in place. People have to have a reliable means of exiting the (really, any) building in an emergency and part of that reliability revolves around managing the environment. So, we have the time-honored concept of cluttah (that’s the New English version), which has gained some flexibility over time to include crash carts, wheeled equipment, including chemotherapy carts and isolation carts that are being used for current patients, transport equipment, including wheelchairs and stretchers/gurneys (whichever is the term you know and love), and patient lift equipment. There is also an exception for fixed (securely attached to the wall or floor) furnishings in corridors as long as here is full smoke detector coverage or the furniture is in direct supervision of staff.

Also, we’ll be seeing some additional granularity when it comes to exiting in general: each floor of a building having two remote exits; every corridor providing access to at least two approved exits without passing through any intervening rooms or spaces other than corridors or lobbies, etc. Nothing particularly earth-shattering on that count. We’ll also be dealing with some additional guidance relative to suites, particularly separations of the suites from other areas and subdividing the areas within the suite—jolly good fun!

Finally, Clarifications & Expectations covers the pesky subject of illumination, particularly as a function of reliability and visibility, so head on over to the June Perspectives for some proper illuminative ruminations.

A couple of weeks back (May 24, to be exact), TJC unveiled some clarifications. I think they’re of moderate interest as a group, with one being particularly useful, one being somewhat curious and the other two falling somewhere in the middle:

ED occupancy classifications: This has been out in the world for a bit and, presumably, any angst relating to how one might classify one’s ED has dissipated, unless, of course, one had the temerity to classify the ED as a business occupancy—the residual pain from that will probably linger for a bit. Also (and I freely confess that I’m not at all sure about this one), is there a benefit of maintaining a suite designation when the ED is an ambulatory healthcare occupancy? As suites do not feature in the Ambulatory Occupancy chapters of the LSC, is it even possible to do so? Hmmmm…

Annual inspection of fire and smoke doors: No surprise here, with the possible exception of not requiring corridor doors and office doors (no combustibles) to be included. Not sure how that will fly with the CMSers…

Rated fire doors in lesser or non-rated barriers: I know this occurs with a fair degree of frequency, but the amount of attention this is receiving makes me wonder if there is a “gotcha” lurking somewhere in the language of the, particularly the general concept of “existing fire protection features obvious to the public.” I’m not really sure how far that can go and, given the general level of obliviousness (obliviosity?) of the general public, this one just makes me shake my head…

Fire drill times: I think this one has some value because the “spread” of fire drill times has resulted in a fair number of findings, though the clarification language doesn’t necessarily get you all the way there (I think I would have provided an example just to be on the safe side). What the clarification says is that a fire drill conducted no closer than one hour apart would be acceptable…there should not be a pattern of drills being conducted one hour apart. Where this crops up during survey is, for example, say all your third shift drills in 2016 were conducted in the range of 5 a.m. to 6 a.m. (Q1 – 0520; Q2 – 0559; Q3 – 0530; Q4 – 0540), that would be a finding, based on the need for the drills to be conducted under varying circumstances. Now, I think that anyone who’s worked in healthcare and been responsible for scheduling fire drills would tell you (at least I certainly would) that nobody remembers from quarter to quarter what time the last fire drill was conducted (and if they think about it at all, they’re quite sure that you “just” did a fire drill, like last week and don’t you understand how disruptive this is, etc.) If you can’t tell, third shift fire drills were never my favorite thing to do, though it beats being responsible for snow removal…

So that’s the Joint Commission side of the equation (if you can truly call it an equation). Next time: CMS!