There are a couple of developments on the Joint Commission front. They’re deleting some 131 performance elements from across the accreditation manual; a few are EC-related, but none in the EM or LS chapters, I want to take a few moments to look at the tea leaves before I weigh—maybe I’ll include in our upcoming edition of portal chortlings—we’re about due for a fireside chat, but anyways…
This just in: The Clarifications and Expectations column penned by Mr. Mills is “on hiatus,” but scheduled to return in June 2016. Curiouser and curiouser…
Last week I was working with a client on answering a citation that had come up during a TJC survey (not their survey, but someone else’s—sometimes folks will share post-survey intel). The finding was related to the storage of toilet paper and paper towel in a housekeeping closet, based on (presumably) the notion of the housekeeping closet as a “soiled” area and the toilet paper and paper towel being “clean” supplies (remembering that when we use toilet paper, the rolls are right next to the toilet OMG…OMG…OMG!). Now I am reasonably certain that (much like some other conditions and/or practices I will note in a moment) there are no specific regulatory standards that speak to how and where one is to store paper supplies, etc., so, once again, we come up against the assumed role of the surveyor cadre in prescribing practices instead of assessing how well a risk is being managed. Are there housekeeping closets that are somewhat less reputable looking than others? Absolutely! Are there risks associated with storing paper products in housekeeping closets? Absolutely! Are there risks associated with storing paper products in clean utility rooms, including the potential for pests? Absolutely! Is this a discussion that could go on forever? Absolutely!
To paraphrase the late, great Lewis Allen (you probably know him just as “Lou”) Reed, I am sick of it. I am sick of seeing findings like “linen cart cover was not down,” “solid bottom shelf was not in place,” “materials stored under a sink,” “toilet paper and paper towel stored in a housekeeping closets,” “cardboard boxes in clean utility rooms.” The whole concept of the management of the physical environment is supposed to be based on managing the risks is that very same physical environment. Show me how whatever condition being cited is actually resulted in a risk that is being appropriate managed—not merely the possibility of a potentially increased risk if the planets are in the correct alignment, etc., etc., ad nauseum. Every time I think about the “war on cardboard,” I grind my whole being (not just my teeth); yes, there are places where cardboard ought not be broken down (sterile supply areas, etc.) but those locations are very limited. Show me that we’re not managing the cardboard appropriately. Show me real evidence (not online pictures) that we are legitimately dealing with cardboard critter condos. I absolutely, beyond any shadow of doubt, understand and recognize the risk potential of cardboard, but if there’s no evidence that the cardboard boxes are doing anything more than appropriately holding the contents of said boxes, how does that become a citable offence? When I think of the hundreds of thousands of dollars that have been wasted purchasing plastic bins that (channeling T. Swift here) never, ever, ever, ever (is that too many “evers”?) get cleaned…check ’em out if you don’t believe me. And never mind the kabillion of labor hours devoted to removing all the whatevers from those cardboard boxes and putting them in the plastic bins as opposed to delivering the box full of stuff and then throwing that every same box away when it is empty. In fact, I would submit to you that by getting rid of the cardboard, we have made it exponentially more difficult to manage expiring product. Old days: case with expiration date on it; when case is empty, throw case away—boom! New days: plastic bin almost empty so we dump more product in on top of the old stuff (Oh sure, we’re taking the old stuff out and then placing it in a bag on top of the new stuff to ensure the old stuff gets used first. Yup, that’s what’s happening, yes indeedy…) I’m sure each of you can think of some “practice” that’s being enforced in your organization that is based on not much in the way of logic (logic doesn’t seem to prevail as much as it used to—I can’t think that that’s a good thing). I think we need to take a stand. (“I’m rather unhappy about the current state and I’m not inclined to support it any longer” or the more pointed “I’m mad as hell and I’m not going to take it anymore.” We safety professionals are more inclined towards the genteel first versions when in polite conversation, but deep inside, you know what I’m talkin’ about!)
Okay, that’s probably enough on that topic for the moment (I’m going to guess that there may be one or two heads nodding in the affirmative at this point in my screed, though perhaps there are others that might disagree). If there’s such a strong feeling about this stuff, then the regulators should be very clear about those “clarifications and expectations.” There’s a process for reviewing the survey results before the final results are provided to each organization. Use it to remove these findings that are truly no more than surveyor bias (yeah, it’s like how tough it is to reverse an official decision in sports). Unless, of course, the purpose of the current survey process is to generate as many findings as humanly possible…nah—who’d believe that!
So join us next week as we add another section to our construction of the immortal portal cortile chortle…
Well, maybe ignore is a bit strong…
One of the recurring themes from my childhood was the not-infrequent exhortation from my mother: Don’t go looking for trouble (probably not an uncommon theme for everyone out there in the studio audience). But one of the more common themes that I’ve been running into are those instances in which trouble was lurking in the weeds, but folks weren’t necessarily successful in identifying/locating trouble spots. As near as I can tell, the worst thing that can happen during a survey (from a safety perspective) is when a surveyor identifies a condition or a practice about which you had no clue. It doesn’t happen a lot, but it does happen (usually followed by “Wow, I didn’t know that”).
There are a number of reasons for such a happenstance—sometimes folks really don’t know about something (though, dear reader, you are probably not in that number as we discuss a whole bunch of esoteric stuff). For instance, I still get a lot of folks who (and I have to believe that they are being completely candid) don’t know that hand sanitizer expires (or medicated lotion soap…or disinfectant wipes) or they are supremely confident that that is someone else’s concern (usually EVS when it comes to the many soaps, sanitizers, and disinfectants that populate the healthcare landscape). To my mind, it all goes back to the role of point of care/point of service folks (and I give the caregivers equal billing/accountability with the service-givers on this count) in being able to identify and report or otherwise manage risks in the physical environment.
But we as safety professionals have to be wicked diligent (as I pen this, it’s the day after the Boston Marathon, so that’s my gratuitous reference to Boston cultchah) in really working to ferret out all these little foibles, imperfections, etc. I think I’ve said this before in this forum (and no doubt will again), but whichever regulatory survey team shows up at your front/back/side door, they are going to find “stuff”—the human condition does not easily attain perfection, which leaves us vulnerable, vulnerable, vulnerable.
I recognize that everyone is stretched for time—too many meetings, too many spreadsheets, too many “too manys” to count—which only serves to “push” the maximization of the not-enough’s (not enough time, not enough resources, not enough support) in this adventure. Think of it as a challenge—there are folks out there doing stuff you would rather they not do—sometimes you only see the result (damaged walls and doors, unsealed penetrations, spills, thrills, chills) and we all have to be more effective in keeping on top of things.
Past lessons learned are a wonderful thing, but sometimes you have to go at things a little differently, so go out there and find some trouble spots. You’ll be glad you did!
Eventually, I will run out of these, but hopefully not before the EC portal is perfectly populated and otherwise polished off…
Late last week brought the announcement of new material being posted to The Joint Commission’s Environment of Care portal, this month’s offering focusing on those pesky compliance issues relating to ensuring that building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat. The performance elements chosen for additional coverage relate to unprotected openings in fire-rated walls and floors (Can you say “penetrations”? I thought you could!); fire doors have functioning hardware—positive latching, self- or auto-closing—and compliant gaps and undercuts; and making sure that openings in 2-hour fire-rated walls are rated for 1.5 hours.
I guess when it comes down to the perennial survey findings, after egress-related issues, the construction and maintenance of fire-rated barriers is something akin to an old friend. Depending on how many of these puppies (rated barriers—walls and floors; and fire doors), the likelihood of there being some sort of imperfection is fairly good, and since the Life Safety portion of the survey process devotes so much more time (than in the old days) to the inspection of these locations, I can’t say that it’s an overwhelming shock that those imperfections are being identified during the survey process. Interestingly enough, at least at the moment, there is no component of the new posting aimed at the organizational leadership element (yes, Virginia, there is no fireside chat this month on this topic) and the information on the portal page (say that 10 times fast) is a wee bit to the sparse end of the spectrum (there are a couple of links to the Joint Commission Resources webpage for some free downloads), though there is an “example of improved compliance” that provides a flowchart representation of the importance of barrier management as a function of protecting patients (and allowing for evacuation to exist as a last resort). I don’t know, it just seems like there’s something missing from this month’s update. (Mention of the BMP springs to mind. The spirit is represented in the free downloads—a pair of articles from EC News back in 2012, but no specific mention). I suppose one could make the case that there’s not a whole heck of a lot to be said about the practical aspects about maintaining rated assemblies, inclusive of walls, floors, doors, etc. Again, perfection for these life safety features is most elusive and often fleeting. So the question becomes: how do you “capture” these deficiencies as close to their genesis as you can?
One favorite concept of mine (and it gets a mention in the free downloads) is the bounty system as a function of your permitting process—I think (in case you really hadn’t noticed) that anything we can do to enlist the active participation of point of care/point of service staff in these activities—and what better way than to make a game of it? I guess it all comes down to a mix of reinforcing positive behaviors (for frontline staff who identify the miscreants without permits in return for cash and prizes—okay, maybe not so much) and discouraging negative behaviors (by giving the unpermitted miscreants the boot to give them time to ponder their wicked ways). I’ve never had the opportunity to actually operationalize an above the ceiling bounty system. Anyone out there have any success stories they could share? Or, indeed, if you have stories about bounty programs that didn’t quite make the mark, those are always worth sharing.
Not a really banger of a portal update this month (I wonder if the number of findings have been reduced yet—it will be interesting to see what type of impact the portal has on the number and nature of findings…), but I guess you can’t hit a home run at every at bat. Play ball!
Well, I don’t know that I’m disappointed, per se, but I was expecting The Joint Commission to add something new to its physical environment portal, but that appears not to be the case. I guess this calls for an extended drum roll…
But that’s not to say that our friends in Chicago have not been busy—anything but. In fact, it’s been quite a preponderance of stuff this past few days, starting with the 2015 Top 5 most-cited standards. Anyone who bet the under on findings in the physical environment came up a bit short, but surely that can’t be very much of a surprise. We’ve covered the particulars pretty much ad nauseum, but if there’s anybody out there in the studio audience that has any specific questions regarding our top 5, I would be happy to do so again.
So we have the following:
EC.02.06.01—Maintaining a safe environment
IC.02.02.01—Reducing infection risk associated with equipment, devices. and supplies
EC.02.05.01—Managing utility system risks
LS.02.01.20—Maintaining egress integrity
LS.02.01.30—Building features provided and maintained to protect from fire and smoke hazards
I suppose a wee bit of shifting in terms of the order of things, but I can’t say that there are any “shockahs” (after all, I am from Bawston) in the mix. Again, if someone has something specific they’d like me to discuss, I would be more than happy to do exactly that. Check out the online stuff; alternatively, you can also refer to the April edition of Perspectives.
But wait, there’s more…
We also have some new/updated resources for Life Safety Code® compliance, including guidance on how the facility tour is going to be administered, a comprehensive list of documents that would be included in the survey process, information regarding PFI change and equivalency requests, and a bunch of other stuff. You can find all this information online. Something tells me that, at some point, you may be able to link to all this stuff from the Portal (if that is not already the case, that’s what I would do).
And, to finish off a big week of new information, there is a new posting to help the Emergency Management cause. Namely, some resources having to do with the management of active shooter incidents, etc., featuring the joint resource for healthcare providers issued by the Departments of Homeland Security and Health and Human Services to assist with situational awareness and preparedness in the aftermath of the terrorist attacks in Brussels. The focus/intent being to use recent events as an opportunity to reinforce the importance of vigilance and security in our organizations. It is certainly an area for some concern (and, as always, an area of opportunity) and I think that it is very likely that this will continue to be a big piece of the survey puzzle when it comes to emergency management. The risks associated with acts of violence appear to be relatively unabated in society at large and it comes back to the healthcare safety and security professionals to ensure that our organizations are appropriately managing those risks to the extent possible and working towards an emergency response capability that keeps folks safe.
That’s the wrap-up for this week; not sure if any fireside chats are looming close on the horizon, but rest assured, we will keep you apprised of any and all portal-related activity.
If you asked a dog the question in the title above, would it say, “Woof”? (Though some might say kitchen…I sometimes do.)
I’ve been encountering a fair number of roof-related opportunities and I wanted to give the topic an airing. I’m not entirely certain what prompted my thinking about rooftops (it’s way beyond Christmas), but I can say that I’ve encountered a bit of a run on unsecured roof hatches/access doors in hospitals (and hotels, too—I suppose I spend as much time in hotels as I do in hospitals—a certain inescapable logic coming into play on that count).
I will admit that I’m no fan of hatches from a practical standpoint (being rather stout and not particularly tall in the physique department), but I’m kind of surprised at the number I’ve encountered that are not secured (and I’m not talking about something that’s sort of secured, though I’ve seen some not-particularly-well-secured hatches as well). I know it’s important for Facilities/Plant Ops staff to have access to roofs, as well as emergency responders, but leaving these types of locations without any security seems way beyond a reasonable strategy. We’re certainly no stranger to the stories of patients wandering off (and I suppose you can’t always predict who might be prone to wandering) and I don’t know that I would want to hang my hat on the “remote” likelihood of someone “stumbling” on to an unsecured roof hatch, so I would ask you to please be attentive to the hatches and “batten them down” if they should have any level of uncontrolled access.
But just so we’re clear, it goes beyond hatches. It is of critical importance that you have a very hardened perimeter for all your roof areas. I don’t know how many times I’ve found propped, unattended doors because someone didn’t feel comfortable “trusting” a vendor (e.g., window washers) with the key to the access door. And I think it is a very well-established truism that doors for which folks do not have keys tend to get propped (I bet we could distill that into some sort of mathematical equation) and the likelihood of the propping is in proportion (I’m guessing inverse, but maybe not) to the risks of leaving that door unsecured. It may even be worth considering having roof access doors and hatches on your “Elvis” list (i.e., that list of critical things to check when you know you’ve got surveyors in the building—oxygen cylinders, corridor clutter, etc.). It’s all part of making absolutely sure that no one is inadvertently put at risk (I don’t believe that folks would purposefully leave a roof door unsecured and unattended—and I hope there’s no one out there to challenge that belief with a real life example).
Finally, don’t forget about fall protection for the folks you allow on the roof, particularly if you have minimal or no parapets. Interestingly enough, our good friends at the Occupational Safety & Health Administration have a few choice thoughts regarding fall protection; you can start that journey here. Even if it’s somebody working for a contractor, if you have a fall, your organization is likely to be mentioned as prominently as the contractor—and if you ask me, that’s no way to get on the front page of the local newspaper. So, the secret word for the week is “protection”: protection of patients, protection of staff, protection of contractors—it’s all part of the mix.
Next up (unless my calendar is lying to me), we should have another fabulous edition of Portal Chortling, with perhaps a side of Fireside Chat. Stay tuned!
Or those wheels are going to be slipping all over the place…
This week’s offering is a little bit towards the random musings category, so hang on tight!
Friction vs. traction: I think that just about everyone in the safety community has experienced some level of pushback when they’ve tried to enact some change of process/expectation/behaviors to enhance the safety of their organization. And in so doing, you’ve discovered that the healthcare culture really does embrace change—it grabs change by the throat, throws it on the ground, and kicks it until it stops moving. This usually comes down to the classic “I’ve worked here for umpty-ump years and it’s never been a problem before,” etc., and while it doesn’t always seem so helpful in the moment, it does give you something in the way of useful feedback—they’ve actually noticed what you’re trying to do. For example, I can recall a time when the thought of physicians actually wearing ID badges seemed like a fantasy. And yet, as we speak, it is actually happening in a whole bunch of places (maybe not as much as we would like, but you’ve got to start somewhere). Now admittedly, a lot of the move towards the use of ID badges comes down to the proliferation of access control technology, the end result is that compliance became more convenient (in the ongoing battle between convenience and compliance, all too often convenience kicks compliance’s tailbone).
I would ask you to think about those stubborn deficiencies/behaviors that are perennially on your “needs attention” list and look at whether compliance is sufficiently convenient or has the operationalization of a compliance activity, say, the segregation of full and not full compressed gas cylinders, resulted in a process so complicated that it does not encourage compliance. In this case, I would say that more than 50% of the instances in which I find partially full or empty cylinders in the rack designated for full cylinders is because the racks for the “not full” cylinders were jammed with empties or partials and the only place left to safely store (remember, we’ve been nagging folks for about a decade on the proper storage of cylinders) the partial or empty cylinder is in the full rack. Perhaps the question that needs to be asked is whether there is enough space for the partial/empty cylinders; you can usually control the number of full cylinders being provided, but the number of partial/empties can ebb and flow over the course of a shift, a day, even over a week. I know it’s tough to get folks to own up to having put a cylinder in the wrong place (or damaged a wall, but that’s for another day), but I am fascinated by the action that results in someone doing something that they know they are not supposed to do. By the way, this is based on my firm belief that we’ve done enough education on this subject—and I would like to believe that the education that we’ve provided is sufficiently effective to at least get the message across. In looking at the misfiled cylinder as a failure mode—what happened in the process to result in the cylinder being in the wrong place. I can’t imagine that it’s being done purposely (it happens way too often—if it’s purposeful, we might just as well give up), but there has to be something we can discern from these instances/practices that we can use to encourage compliance—make it more convenient, as it were. So, don’t be afraid of a little friction as you pull these stubborn compliance issues apart. If things go too smoothly, there’s probably a workaround lurking somewhere in the background. Remember, it’s taking the path of “least resistance,” not “no resistance.”
The other random musing for the week is for those of you that may be in the middle of your post-survey process; be very judicious when you are creating your corrective actions plans. All too often, I see folks that have way overcommitted on their corrective action plans. Look very carefully at what the standard or performance element is actually requiring you to do and try to pick the route to compliance that work best operationally (meaning choose strategies that encourage compliance without overwhelming the participants—this is an analogue of the eternal question of how to eat an elephant). Don’t commit to daily activities if you can get where you need to be by doing it weekly; don’t commit to weekly if you can get where you need to be by doing it every other week; and so on. Also, I would advise trying to stay away from activities that don’t make sense—operationally, logically, etc. I tend to say that logic doesn’t always prevail, but I reserve that for direct dealings with regulatory surveyors. Once the surveyors are on their way, take the compliance results as data to make improvements—and focus on determining how you’ll measure those improvements. It puts you in a much better position to avoid those findings in the future (and at some point, the regulatory folks are no doubt going to get ugly when it comes to repeat offenses). As with so many things in the safety and compliance realm: this is a journey, not a destination. And on that quasi-Zen note, I bid you a safe week!
And so, the flying fickle finger of compliance finally points portally (via The Joint Commission’s Physical Environment Portal) in the direction of that most troublesome of standards, EC.02.03.05, and we return once again to the fireside of our intrepid duo, Messrs. George Mills of The Joint Commission and Dale Woodin of ASHE. There are two videos, one for the facilities audience and one for leadership (does anyone else find it fascinating that the duo dons neckwear for the leadership video?).
While I don’t want to engage in revealing any spoilers, in the video, EC.02.03.05 is described as being “most prescriptive” and “frustrating” and also notes that Mr. Mills has taken some pains to “tear apart” the standard in past “Clarifications and Expectations” columns in Joint Commission Perspectives. Yet, yet, yet, approximately 40% of hospitals continue to get cited for deficiencies relative to the myriad components represented in this standard. I personally would love to see how this actually breaks down in terms of which of the 20+ performance elements are the most problematic (I can’t imagine that there are some that “float” to the top more than any others), but the video does seem to indicate what the “problems” are:
- You have to have an inventory, by location, of each device class, meaning smoke detectors, heat detectors, pull stations, HVAC shutdown devices, water flows, tamper switches, fire extinguishers, etc. It seems to me that back in the day, there was a reluctance on the part of our Chicagoan friends to actually say the words that would indicate the need for an inventory. But it all comes down (or back—I think I’ve beaten this particular breathless equine once or twice in the past) to knowing that you inspected, tested, maintained, each device in the fire alarm system. So if you (or your vendor’s documentation) do not specifically indicate that each device was demonstrably inspected, tested, maintained, then (buzzer sound): you lose!
- The documentation has to be available “upon request”, so really, if you can’t produce the current documentation PDQ, then (buzzer sound): you lose! You can only get credit for those inspection, testing and maintenance activities for which you have available documentation—if you didn’t document it, you didn’t do it. Period. End of story.
Now I certainly recognize that a combination of findings under EC.02.03.05 would drive a finding under the Leadership standards (to be exact, LD.04.01.05 EP 4), based on past survey reports. But apparently there is indeed a magic number of EC.02.03.05 EP findings that will result in the Leadership finding—three or more EPs out of compliance, then (bell rings): you win a discussion with your boss as to how you allowed (and I’m using that term in its most pejorative sense) such a thing to happen. At that point, for example, it is way too late to admit that the fire alarm and sprinkler testing vendors have not given you very useful reports (and something tells me that that particular conversation is not as rare as it ought to be). From watching the video (and in providing a neckwear-enhanced video specifically for your organization’ s leaders and Mr. Mills indicates he had to edumacate his bosses too—we are not alone), there is a very clear expectation that you, the facility/safety professional, will make the effort to proactive communicate with your boss, particularly if you are experiencing service issues, etc., in getting these activities under control. You can certainly make the case that the protection of the entire organization can be compromised if your fire alarm and sprinkler systems are not appropriately maintained, so, really, any infrastructure concerns should be communicated in a timely fashion to the leadership of each organization to ensure that appropriate resources are allocated on an ongoing basis to make sure everything stays on an even keel.
At any rate, our duo takes great pains to point out that none of this stuff is new (the “seed” documents from NFPA 72, 25 and the like having been penned way back in the 20th century), but I do feel that the methodology for surveying has evolved/mutated over time. I mean, if it were really that simple, wouldn’t this go away? They also point out that ASHE has a fair amount of information to assist you in your compliance efforts (ASHE Focus on Compliance: you can be especially warm for their forms) and there’s even a PowerPoint presentation that The Joint Commission uses at the EC Base Camp presentations (you can link to the presentation on the left hand side of the portal page), which gives it the power of the Quadruple P—Portal PowerPoint Presentation! Ultimately, you’ve got to keep a really close eye on this stuff, aside from product expiration dates, the management of the various and sundry elements of EC.02.03.05 is among the most voluminous in sheer numbers—that’s a lot of spheres to keep up in the air—and you only have to drop a couple to earn that lovely chat with your boss. I am absolutely convinced we can make it happen, so let’s see what we can do to retire EC.02.03.05 from the top 10. (Or 20…wouldn’t that be a fine thing?)
Flexible Spending Account, Federal Student Aid, Food Services of America, Focused Standards Assessment.
So, I am forced to pick one. While I’m sure the lot of them is most estimable in many ways, I suppose the choice is clear: the freaking Focused Standards Assessment (kind of makes it an FFSA, or a double-F S A…what the…).
Just to refresh things a bit, the FSA is a requirement of the accreditation process in which a healthcare organization (I’m thinking that if you weren’t in healthcare, you probably would be choosing one of the other FSAs) reviews its compliance with a selected batch of Joint Commission accreditation requirements. The selections include elements from the National Patient Safety Goals, some direct and indirect impact standards and performance elements, high-risk areas, as well as the RFIs from your last survey—and I know you’ve continued to “work” those Measures of Success from your last survey. Ostensibly, this is very much an “open book” test, if you will—a test you get to grade for yourself and one for which there is no requirement to share the results with the teacher (in this case, The Joint Commission—I really don’t understand why folks submit their results to TJC, but some do—I guess some things are just beyond my ken…).
The overarching intent is to establish a process that enhances an organization’s continuous survey readiness activities (of course, as I see various and sundry survey results, I can’t help but think that the effectiveness of this process would be tough to quantify). I guess it’s somewhat less invasive than the DNV annual consultative visits, though you could certainly bring in consultants to fulfill the role of surveyor for this process if some fresh eyes are what your organization needs to keep things moving on the accreditation front.
I will freely admit to getting hung up a bit on the efficacy of this as a process; much like the required management plans (an exercise in compliance), this process doesn’t necessarily bring a lot of value to the table. Unless you actually conduct a thorough evaluation of the organization’s compliance with the 45 Environment of Care performance elements, 13 Emergency Management performance elements, 23 Life Safety performance elements (15 for healthcare occupancies, eight for ambulatory healthcare occupancies)—and who really has the time for all that—then does the process have any value beyond MBW (more busy work)? I throw the question out to you folks—the process is required by TJC, so I don’t want anyone to get in trouble for sharing—but if anyone has made good use of this process, I would be very interested in hearing all about it.
This is my last piece on the FSA process for the moment, unless folks are clamoring for something in particular. I had intended to list the EPs individually, but I think my best advice is for you to check them out for yourself. That said, I have a quick and dirty checklist of the required elements (minus the EP numbers, but those are kind of etched into my brain at this point). If you want a copy, just email me at firstname.lastname@example.org.
In the interest of time and space (it’s about time, it’s about space, it’s about two men in the strangest place…), I’m going to chunk the EM and LS risk areas that are now specifically included in the Focused Standards Assessment (FSA) process (previously, the risk areas were only in the EC chapter). Next week, I want to take one more chunk of your time to discuss now the FSA process (particularly as a function of what EPs the folks in Chicago have identified as being of critical importance/status). But for the moment, here are the add-ons for 2016:
- participation of organizational leadership, including medical staff, in emergency planning activities (you need to have a clear documentation trail)
- your HVA; (interesting that they’ve decided to include this one—they must have found enough folks that have let the HVA process languish)
- your documented EM inventory (I think it’s important to have a very clear definition of what this means for your organization)
- participation of leadership, including medical staff, in development of the emergency operations plan (again, documentation trail is important)
- the written EOP itself (not sure about this addition—on the face of it, it doesn’t necessarily make a lot of sense from a practical standpoint)
- the annual review of the HVA (my advice is to package an analysis of the HVA with the review of the EOP and inventory)
- annual review of the objectives and scope of the EOP
- annual review of the inventory
- reviewing activations of the EOP to ensure you have enough activations of the right type (important to define an influx exercise, as well as, a scenario for an event without community support)
- identification of deficiencies and opportunities during those activations—this means don’t try to “sell” a surveyor an exercise in which nothing went awry—if the exercise is correctly administered, there will always, always, always be deficiencies and/or opportunities. If you don’t come up with any improvements, the you have, for all intents and purposes, wasted your time… (Perhaps a little harsh, but I think you hear what I’m saying)
- Maintenance of documentation of any inspections and approvals made by state or local fire control agencies (I think you could make a case for having this information attached to the presentation of waivers, particularly if you have specific approvals from state or local AHJs that could be represented as waivers)
- Door locking arrangements (be on the lookout for thumb latches and deadbolts on egress doors—there is much frowning when these arrangements are encountered during survey)
- Protection of hazardous areas (I think this extends beyond making sure that the hazardous areas you’ve identified are properly maintained into the realm of patient spaces that are converted to combustible storage. I think at this point, we’ve all see some evidence of this. Be on the lookout!)
- Appropriate protection of your fire alarm control panel (for want of a smoke detector…)
- Appropriate availability of K-type fire extinguishers (this includes appropriate signage—that’s been a fairly frequent flyer in surveys of late)
- Appropriate fire separations between healthcare and ambulatory healthcare occupancies (a simple thing to keep an eye on—or is it? You tell me…)
- Protection of hazardous areas in ambulatory healthcare occupancies (same as above)
- Protection of fire alarm control panels in ambulatory occupancies (same as above)
I would imagine that a fair amount of thought goes into deciding what to include in the FSA (and, in the aggregate, the number of EPs they want assessed in this process has gotten decidedly chunkier—I guess sometimes more is more), so next week we’ll chat a bit about what it all means.
I apologize for not having gotten to this sooner, but sometimes the wind comes out of nowhere and you find yourself heading in a rather unexpected direction (I’ve never spent so much time in Texas!).
With the advent of each new year, our three-lettered friends in Chicago unveil the changes to the accreditation standards for the upcoming cycle. Most of the changes in the EC/LS/EM world (with a couple of fairly notable exceptions—more on those in a moment) have to do with a shift in focus for the Focused Standards Assessment (FSA) process as a function of the various specific risk areas (I will freely admit that this is a wee bit convoluted, but should not necessarily come as a surprise). At any rate, as part of the accreditation process, each organization is supposed to evaluate its compliance based on specific areas of concern/risk identified by The Joint Commission. Thus for 2016, some of the risks to be evaluated have gone away (at least for the moment) and other have been added to the mix:
Please remember: These are not going away entirely, they just don’t have to be included in your organization’s FSA process!
So, we bid adieu to specific analysis of the safety, hazardous materials, medical equipment, and utility systems management plans (leaving security and fire safety in the mix) and we say bonjour to the identification of safety and security risks (as you may have noted, I’m not indicating the specific standard and EP numbers—our friends get a little protective of their content, but if you really need to check out the numbers, please see your organization’s accreditation manual).
We say goodbye to implementing our hazardous material and waste spill/exposure procedures, the monitoring of gases and vapors, and proper routine storage and prompt disposal of trash; and say hello to the hazardous materials and waste inventory, the actual written hazmat and waste spill/exposure procedures, minimization of hazmat risks, ensuring that you have proper permits, licenses, etc., for hazardous materials, and labeling of hazardous materials.
We say howdy to a focused look at fire drills, including the critiques.
We greet a focus on the testing documentation relating to duct detectors, electromechanical releasing devices, heat detectors, manual fire alarm boxes and smoke detectors, as well as the documentation relating to fire dampers.
We say auf wiedersehen to focusing on the selection, etc., of medical equipment, the written inventory of medical equipment, SMDA reporting, inspection, testing and maintenance of non-high risk medical equipment, and performance testing of all sterilizers.
We say guten tag to the written utility components inventory, written frequencies for maintenance, inspection and testing of utility system components, written procedures for utility system disruptions, and minimization of pathogenic, biological agents in aerosolizing water systems.
We say konichiwa to a focus on the provision of safe and suitable interior spaces for patients and the maintenance of ventilation, temperature and humidity in all those other pesky areas (e.g., soiled utility rooms, clean utility rooms, etc.).
We say hola to a focus on whether or not staff (including LIPs) are familiar with their roles and responsibilities relative to the environment of care (I predict that this is one is going to start showing up on the top 10 list soon unless there is a dramatic shift in survey focus).
And we say “Hey-diddly-ho, good neighbor” to the use of hazard surveillance rounds to identify environmental deficiencies, hazards, and unsafe hazards, as well as ensuring that you have a good mix of participants in your EC Committee activities, particularly the analysis of data—clinical, administrative, and support services have to be represented.
Now, there are three standards changes that went into effect on January 1, 2016: one a shift to a different spot in the standards, one a fairly clarifying clarification, and one about which I am not quite sure what to make, though I somehow fear the worst…
The requirement for the results of staff dosimetry monitoring (CT, PET, nuclear medicine) to be reviewed at least quarterly shift from Safety to Hazardous Materials. The EP number remains the same (and I can give you 17 reasons for that…), but it’s only a shift in where it would be scored (another important reason for making sure that you have a solid relationship between your EOC Committee and your Radiation Safety Committee—I’m a great believer in having compliance information in a location where surveyors are more likely to encounter it: EOC Committee minutes).
The requirement for managing the risks associated with smoking activities was clarified to indicate that the risks have to be managed regardless of the smoking types (e-cigarettes and personal vaporizers are officially in the mix); I’m presuming that this is helpful to folks who have perhaps faced some resistance in this area.
And finally (we’ll cover the EM and LS changes next time—nothing particularly scary, but a little too voluminous for this rather dauntingly wordy blog post), the requirements based around the inspection, testing and maintenance of non-high-risk utility system equipment components has gone from a “C” Element of Performance (EP) to an “A” EP (they did remove the Method of Success requirement for a deficient finding in this area—I suspect that was as much for their own sanity as anything else. Plus, it never really made a great deal of sense to figure out how to monitor something over four months’ time that frequently occurs every six or 12 months). My sense is that they are making the change to increase the “cite-ability” of managing utility systems equipment; now they only need to find one instance of noncompliance for a finding. I don’t know that I’ve seen a ton of findings in this area, but I can’t honestly say that I’ve been doing a close count of the OFI section of the reports, so it may be that they’re seeing a trend with the non-high-risk utility equipment that makes them think we’re not doing as good a job managing as we should, but that is wholly and completely conjecture on my part. I will, of course, be keeping a close eye on this one; I have a sneaking suspicion that the focus on utility systems equipment is going to continue into the immediate future and this might just become another pressure point.
As a closing thought relative to the FSA and risk area discussion, I think we can reasonably intuit that (particularly since the FSA process, represents a process for self-reporting) the expectation is for folks to be looking very carefully at the requirements contained within the above-noted areas and that your compliance plans relative to those requirements will be well in hand come survey. For some reason, this shift “smells” like an approach that’s going to be that much more focused on organizational leadership when there are gaps (and ask anyone who’s had a bumpy survey these past couple of years—leadership gets dragged into the fray on a regular basis). The fact of the matter is that they will find something deficient in your facility—if they don’t, they didn’t look hard enough. It’s about having processes in place to recognize and manage those deficiencies appropriately (and yes, I recognize that I am running the risk of repeating myself). This is big-time crazy focus on this stuff—and we need to be continuously improving how we go about doing it (whatever “it” might be).
Back next week to cover the EM/LS stuff. Arrivederci for now!