Can’t get no protection…

I’m not sure if you folks follow my HCPro colleague David LaHoda’s OSHA Healthcare Advisor e-newsletter and blog, but there’s an item this week that I think bears bringing to your attention in case you didn’t see it.

Now I think we can all agree that there is a great deal of attention being paid (and rightly so) to issues of workplace violence and how can we be assured that we are doing all we can to protect the front line folks from assaults, etc. And I think many, if not most, of us recognize that acts of violence by patients are definitely not diminishing over time. The variables are wide-ranging—the economy, the reduction of behavioral health resources, etc.—and endlessly complex.  We must manage these variables in as proactive a manner as possible.

So, how are you folks out in the safety community addressing these types of concerns? What education are you providing and to what staff demographic groups are you targeting with that education? Are you mandating education in certain areas, or are you letting folks participate as they feel necessary? Who has a program that’s working well, and what monitoring and measures have you put in place to ensure that the program you have is getting the desired results? I think this is a dialogue that’s going to be with us for a while, so please weigh in on what you’re doing/facing/dreading.

As a final thought, back in the day before we had “standard precautions,” there was the term “universal precautions” based on the concept that you can’t tell whether a person is an infection risk just by looking at them, so you have to manage everyone as if they had the potential. Is it time for a truly “universal” approach to the potential for violence when it comes to patient management? What do you think?

Gaining some Perspectives on The Doors of Perception

I’m going to guess that you all out in the audience do not necessarily place The Joint Commission’s Perspectives periodical on your list of must-reads, but for the May and June 2012 issues (and who knows beyond that), you really owe it to yourself to grab a copy and prepare for some hard-hitting door and barrier conversation with our esteemed colleague, one Mr. George Mills, Director of the Engineering Department at The Joint Commission.

At any rate, I think we can point to an increasing level of frustration on the part of the various and sundry regulatory agencies (and us, don’t forget us) relative to the number of findings in the life safety (LS) chapter and the omnipresence of these issues in the most frequently cited standards during surveys. How do we make this go away? The answer to that question, interestingly enough, is adopting a risk-based strategy for the ongoing inspection and maintenance of whatever building component is in play – this month its doors.

Now, those of you who’ve been hanging around the pea patch for one or two cycles will immediately recognize the concept as being almost eerily similar to the Building Maintenance Program of days gone by (OK, maybe not so gone by). That said, I think that I can safely say that if you can adopt the strategies contained in this month’s Perspectives (starting on page six), you will have the power (and data-driven power at that) to ensure that your organization will not have to endure another RFI for door issues on your final survey report (but remember that you may still have to use the post-survey clarification process to rid yourself of those pesky RFIs. Still, it is so worth it).

The article has recommendations, a lovely form to use, the philosophy and concept behind the whole thing – really, it’s the complete package. One word of caution: Stuff that appears in Perspectives is traditionally held to be equivalent to anything in the standards manuals and FAQs. For all intents and purposes it’s a requirement, so you’d better get to the adoption of this strategy or having a most compelling risk assessment to indicate that you are achieving an equivalent level of safety for your facility and its occupants. Failure to do so will make things very difficult when attempting post-survey clarifications.

As noted in the article (and this has been a frequent touchstone in my consulting practice), the stuff The Joint Commission is finding is mostly minor in nature: doors not latching, missing ratings labels, excessive gaps and undercuts, etc. These is not big ticket stuff by any stretch of the imagination. And, to my way of thinking—odd though it may be at times—there is no reason we should have to be burdened with having to clean up all these little survey messes (not that I’m advocating big messes as an alternative – no no no). I think we’ve been provided a very implementable strategy for keeping things on the side of compliance, which is never a bad thing.

What do you folks think?

Taking care of business

Earlier today, I was conducting an EC/EM interview session with a very participative group and I was complimenting them on their ability to speak to improvement efforts in areas that are not necessarily in their scope of practice. Now, my experience has been that the folks most familiar/expert with the EC function being discussed tend to dominate the conversation (sometimes in a good way, sometimes not) and I thought it was cool that these folks were so familiar with what others in the group felt was important. To my compliment, the observation was made (and I thought this was absolutely the grandest definition of what a high-performance team can achieve) that they mind each other’s business. In that simple turn of phrase (not an exact quote – sometimes paraphrase is the best I can do), the whole concept of what the EC team can embrace and accomplish was crystallized: It’s not about what may or may not be “somebody else’s job” (or “not my job”); it’s actually using the team concept to make and sustain improvements. In the old days we used to call that type of organizational behavior “silos,” which is OK if you’re storing grains and such, but when the goal is organizational improvement, we want to be more like a snack mix with all sorts of nuts and fibrous bits.

And please keep in mind, it’s not necessarily about never having any issues to correct. As long as there are human beings in the mix, there will be corrections to make – be assured of that. But if you can harness the power of a group of committed individuals who accept responsibility, hold each other accountable, and care enough to “mind each other’s business,” you can accomplish so much. There’ll always be stuff to do, but think about the power of getting stuff done.

Brings a smile to my face – how ‘bout you?

Dry your eyes – but don’t dry those wipes!

A quick note of interest from the survey world –

A recent survey resulted in a hospital being cited under the Infection Control standards (IC.02.02.01 on low-level disinfection, to be exact). In two instances, someone had the temerity to forget to close the cover on a container of disinfectant wipes. Can you believe such risky behavior still exists in our 24/7 world of infection prevention? It’s true, my friend, it is true!

The finding went on to say that, as the appropriate disinfection of a surface depends on wet contact with the surface being disinfected, leaving the cover open would partially dry out the next wipe, impairing the ability of the wipe to properly disinfect the surface. Now, I suspect that the person to use that next wipe might somehow intuit that the moisture content in the wipe was not quite where it needed to be and maybe, just maybe, go to the lengths of (wait for it) – pulling out an additional wipe (or two, or three). Now my experience has been that sometimes those wipes are not what I would call particularly well-endowed in the moisture department. And  the use instructions for these products usually indicate that you should use as many wipes as it takes to ensure that the surface to be disinfected stays wet long enough for disinfection to occur.

I’ve always been a pretty big fan of the slowly-becoming-less common sense, so I’m not quite sure how we’ll be dealing with this one – thoughts, anyone?

Do you remember? Or even yesterday…

Way back in September of last year, we were chatting about the importance of appropriately managing conditions in the patient environment, primarily the surgical environment. For those wishing for a refresher, you can find that post here. (I talked about how I’ve noticed recent citation in surveys regarding the surgical environment, including the maintenance of temperature and humidity, ensuring appropriate air exchange rates, and making sure that your HVAC systems are appropriately maintaining pressure relationships, etc.)

One of the things I didn’t really cover back then was when you have documented out-of-range values. Could be temperature, could be humidity, could be those pesky air exchanges and/or pressure relationships. The fact of the matter is that we live in an imperfect world and, more often than not, our success comes down to how effectively we manage those imperfections. And that can, and does, come down to how well we’ve prepared staff at the point of care/service to be able to respond to conditions in the environment. But, in order to get there, you have to undertake a collaborative approach, involving your infection preventionist and the folks in the surgical environment.

The management of risk in the environment doesn’t happen because we have (or don’t have) nifty technology at our disposal; it’s because we can work collaboratively in ways that no building automation system or self-regulating HVAC equipment can. This idea has become an increasingly important part of the survey process. We know that more folks are harmed by hospital-acquired infections and other related conditions and I’ve seen it become a fairly significant survey vulnerability. So, let’s start talking about this stuff with the end users and make sure that we’re ahead of the curve on the matters of the care environment.

Panic in Detroit – Panic at the Disco – Panic at the Surgery Center…Fire in the Hole!

I’m presuming (and please don’t attempt to disabuse me of this notion) that you are all dutifully conducting security risk assessments on a regular basis. As you conduct them, I’m sure you find risks of some events that are greater than some other areas. So, I to ask: When you’ve completed your security risk assessment, do you identify specific strategies, including the use of technology, for minimizing those risks to the extent possible? If you’re not including that facet in the risk assessment process, you might want to consider doing so.

Recently, I was looking at a survey report in which an ambulatory surgery center was cited during a TJC survey because they had not installed a panic alarm “at the registrar’s desk in order to obtain immediate assistance in an emergent or hostile situation.” Now, as with so many things that have been popping up during surveys, I don’t disagree with the concept of having panic alarms at those customer service/interaction points where unhappy folks (or folks of any ilk) can experience the need to vent their frustrations, etc. But in that disagreement, I think I’d first be looking at what tools have been provided to staff to actively manage, if not de-escalate, these negative encounters. I would much prefer to avoid having to use a panic alarm by appropriately managing the encounter, much like I would just as soon not “need” to have an emergency eyewash station.

I’m a great believer in the proactive management of risk, but I’m also a great believer in implementing risk management and response strategies that make operational sense. So, the question to the studio audience is: Where have you installed panic alarms and where have you not installed panic alarms, and why? There’s always the risk that some surveyor will disagree with your strategy, but if that strategy was derived through thoughtful analysis of the involved risks, does that not meet the intent of all this?

I like the concept of best practice as much as anyone, but I also recognize that there is a tremendous amount of variability in the safety landscape. Just because something works in one place does not necessarily mean that it will work in all cases—that’s the mystical, magical, and ultimately mythical power of the panacea. One size doesn’t fit all—never has, never will. But if we’re going to be held to that type of an expectation, how does that help anyone? Ok, jumping down from soapbox for now, but rest assured, you’ll see me back up here before too long.

Shock the monkey (part x + y to the 10th power) – here we go again…

OK, so now it appears that we’re going to have to rethink how we schedule preventative maintenance (PM) activities on our critical equipment, particularly if that criticality affects patient health and safety. I believe that we’ve already chatted a bit about the whole clarification of PM frequencies and where CMS stands on the issue (in case you hadn’t noticed, they’re pretty much standing on your head).

In issuing the clarification (and I will freely admit that I missed this at first – check it out at: https://www.cms.gov/Surveycertificationgeninfo/downloads/SCLetter12_07.pdf), the Feds have decided that, in the matter of critical equipment, the frequency will reflect manufacturer recommendations, AND NOTHING ELSE! Let me repeat that: AND NOTHING ELSE!

For example, PM’ing defibrillators on an annual basis (despite what your experience might indicate) is a big freaking no-no! Isn’t that special? Yeah, I thought so, too.

Maybe this isn’t anything to you folks, but I know of at least one hospital that got cited during a recent survey, so when there’s one, there’s usually others (these things almost never happen in isolation). So, if you think you may be taking advantage of logic and common sense approaches to the management of the risks associated with the use of medical equipment, think again (hopefully this won’t shift again, but if history tells us anything.)

Shoo beedoobee – splattered, splattered!

In the never ending discourse on the subject of emergency eyewash stations, I’d like to take a moment to remind folks that it appears that the TJC surveyors have access to the ANSI Emergency Eyewash and Shower Equipment Standards and they have become very diligent in ferreting out (apologies to the ferrets in the audience – I don’t mean to offend) practices that are not consistent with the “recommendations” contained therein. And so, let me say this:

If your organization has chosen to maintain your emergency eyewash stations on a lesser frequency than weekly, then you had best conducted a risk assessment to demonstrate that you are ensuring the same level of safety that you would if your were maintaining them on a weekly basis. Water temperature, water pressures, “cleanness” of the flushing liquid, whether access to the equipment is obstructed – these all need to be considered in the mix, because, and I can tell you this with a great deal of certainty, if you are doing these inspections less than weekly, you will be cited during survey. If you have not conducted the risk assessment to demonstrate that the lesser frequency is appropriate, then you will have to move to the weekly program. (Sort of a “you can pay me now or you can pay me later” kind of deal.) But rest assured that eyewash stations are definitely in the mix, so make like a Boy Scout (do I really need to finish that thought? I didn’t think so…)

By the way, I’ve also caught wind of the invocation of AAMI standards when it comes to the placement of emergency eyewash equipment in the contaminated section of central sterile. (Also, don’t forget to keep those pressure relationships in check. Clean central sterile should never be negative to dirty central sterile). Now I will freely admit that I am not as conversant with the AAMI standards as I am with, say, OSHA standards, and perhaps even the ANSI standards dealing with this stuff. Again, the rhetorical question becomes: How many rocks do we need to turn over before we can safely determine that there isn’t some funky consensus standard lurking in the weeds that is not in strict concurrence with accepted practice? Why can’t these guys just get along…jeez!

She’s a laughing, giggling whirly bird – oh heli!

Interesting development on the survey front in the last couple of weeks. I’m not at all sure what it means, but I thought I would share it with you all, make of it what you will.

During a recent survey in the Sunshine State, a hospital was cited for not having the “recommended (maximum) rotor circumference signage on the pad nor the other recommended signs that are recommended by the FAA” (signs such as “MRI in use,” etc.). Now we could certainly have a good time parsing the whole “recommended signs that are recommended” phraseology, but I keep coming back to that word “recommended.”   How far do we have to go to ensure that we have somehow accounted for every recommendation for every possible risk that we might encounter?. Yeah, beats me, too, but in the interest of furthering the applicable knowledge base, let’s step to the web for some edification:

First I draw your attention to the Advisory Circular issued by the FAA back in 2004. I can’t seem to lay my mitts on anything more contemporary than this, but if you find something more recent, please share.

Now, as we scan the first page of this most comprehensive document, we see a little statement that I think makes the TJC survey citation a little more squishy than I would prefer: “This AC is not mandatory and does not constitute a regulation except when Federal funds are specifically dedicated for heliport construction. “ To me, “not mandatory” sounds like a really big case of the “we don’t have to’s,”  what do you think?

Turning to Chapter 4, Hospital Heliports (this is on page 95 of the document), I will freely admit that there’s a lot of interesting/cool information. (Did you know that the FAA recommends Portland Cement Concrete for ground level facilities—who knew? Do you have Portland Cement Concrete for your ground level facilities? I certainly hope so). Anyway, the chapter describes a lot of important stuff about hazards and markings, including MRI impact, etc.

I’m going to guess that you’ve been having helicopters fly in and out of your airspace on a regular basis, and in all likelihood, some of you are already up to speed on this.  For those of you for whom this might be virgin territory, my advice would be to consult with the folks actually doing the flying and find out what they want to see with your helicopter setup. This would constitute what I euphemistically refer to as a risk assessment. You may have encountered that term once or twice here in Mac’s Safety Space. I can’t imagine that you’d not have heard by now if the pilots using your pad have issues. (I’ve never found them to be shy about safety—nor should they be.) Still, it’s never a bad idea to reach out periodically to make sure that everything is both hunky and dory; it’s really the least we can do.

Update: Link correction for CMS memorandum on LSC

I have been alerted that the link below did not work. I have corrected that link, but I’ll provide it here too:

Click here to directly access the CMS memorandum the changes regarding the Life Safety Code®.

(Ref: S&C-12-21-LSC)