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In the realm of possibility: More listening, less posturing!

An interesting anomaly that I encounter periodically is the time-honored “first opinion,” particularly when it exists outside of a second opinion. All too often I hear clients tell me that  “X told us we have to do something a particular way,” often with a wake of disruption because whatever strategy, etc., that was identified didn’t take into full consideration elements of organizational culture, resources, practice, etc. But what I don’t understand is when I look at Environment of Care committee minutes, etc., I don’t see any discussion about whether the recommendation(s) were useful, germane, etc., to appropriately manage whatever the condition might be. I think it is very important to use any survey activity (regulatory, consultative) as an opportunity to identify best practices and ensure that policy and practice are in alignment. That way, you’ll have some experience in being able to sort out what is truly required from a regulatory perspective and what is solely in the land of surveyor interpretation.

In all the years I’ve been involved in healthcare safety, the one defining truth I’ve found is that compliance is rarely a black and white endeavor. And while I absolutely understand that managing anything as a “black and white” is a whole lot easier to police, from an operational standpoint, absolutes (either positive or negative) are not always easily, or practically, implemented.

The other dynamic is (and this is very much the case with response to regulatory surveys) that often we “over-promise,” particularly in terms of frequency of monitoring. Don’t set yourself up for failure, for example, by indicating in a corrective action plan that there will be weekly inspections of electrical panels for inappropriately configured circuit breakers. Unless you know that folks are mucking around in the panels on a frequent basis, is there really a compelling reason to embrace an inspection frequency that is not a regulatory requirement? I would tend to think: Not so much.

As we have established beyond any reasonable doubt, there will always (always, always, always) be imperfections in the environment, but don’t go crazy trying to chase all these things yourself (or have your staff do the chasing). As I’ve said any number of times (before any number of audiences), all this stuff “lives” at the point of care/point of service and if you can’t get the folks that “live” in those areas to help feed the gaping maw of work order system, you are managing a process that is not as efficient as it might otherwise be. With the ongoing impact of the “do more with less” mantra, it’s not so much about working smarter (though there is certainly an element of that), but about working collaboratively. Everyone is caregiver—everyone is a steward of the environment—and by judicious application of only what is actually required by code and/or regulation, you can start to break down the barriers between mutually assured noncompliance and an environment that appropriately supports care. Compliance is the byproduct of consistently doing the right thing.

Update: Defunct Links to/in the FAQ-niverse!

Greetings, fellow travelers!

With special thanks to Claire Rebouche for bringing this to my attention, it appears that the links to the new ligature risk FAQs that appeared in this week’s blog post no longer direct you to the content of the latest information (I swear to you that the links were working Monday), but rather direct you to the FAQ homepage. Now, that wouldn’t be such an awful thing if the latest FAQ (for the record, TJC describes it thusly: “Ligature Risks – Assessing and Mitigating Risk For Suicide and Self-Harm”) were readily discernible, but alas (at least for the moment), this particular FAQ is among the missing.

Rest assured, top people are working on trying to find out what’s going on, and hopefully this is but a temporary circumstance (I figure if we can’t find the information, the surveyors might be having a tough time as well—helps to level the playing field). One other thing to note is that where previously the ligature-related FAQs could be found in the EC section of the FAQ homepage, they’ve all been moved to the NPSG section (and, interestingly enough, increased the number of FAQs dealing with ligatures to just over 20), so you may want to keep an eye on any changes in that section (from a practical standpoint, I understand the shift, but I don’t know that they couldn’t have shown up in both sections as a transition, though perhaps they did—I don’t spend a lot of time monitoring the NPSG section of the FAQ page).

At any rate, what I suspect may be happening is that, in their efforts to “clean up” the FAQ page, it would seem that some of the internal links are no longer working, so I’m hoping that we’re just working through a funky transition period and everything will be up and running soon.

That said, there are a couple of other new items relative to the management of this at-risk patient population that I want to share (while they are still available): this one and this other one, which deal with how the process for managing at-risk patients can result in catastrophic gaps in care. I think they’re pretty straightforward in terms of information, but with everything else going on this week, I would encourage you to check ’em out sooner rather than later.

Déjà vu all over again: A new ligature resistant FAQ!

Using the Hospital FAQ page as the baseline, I reckon we’ve got about a dozen FAQs dealing with ligature resistance with this latest offering. For some reason, the “visual” I get from all of this FAQing is the difference between looking at something from a distance (for example, a celestial body) and seeing that same thing up close and personal. What started out as a sphere of incomprehensibility has become (slowly, ever so slowly, over time) a much more nuanced endeavor—an endeavor that continues to represent survey vulnerabilities for accredited organizations.

One of the interesting things to me is how the narrative has evolved over the last couple of years relative to how hospitals are to deal with all the intricacies of managing ligature risks as a survey vulnerability (which is different than managing the risks to patients, but more on that in a moment). This FAQ reveals some specifics as to what you are required to include in the mitigation strategy for those risks that are not yet removed/resolved/corrected/adjudicated, etc. Now, I don’t know that this is truly ground-breaking stuff, but I think this is cray-cray important because this is what the surveyors are going to be looking for, both in terms of structure, but also as a function of an ongoing process. I’m not going to quote verbatim from the FAQ. I know youse guys are excellent readers and such, so a quick summary:

  • Leaders and staff have to know what risks are currently in the mix and somebody has to be responsible for telling them (and documenting that they were told…)
  • Identification of patients at risk for suicide/self-harm, with appropriate risk-based interventions
  • A process for ongoing assessments and reassessments of organization-defined at-risk behavior
  • Staff education re: management of patient risk and implementation of appropriate interventions
  • Ensuring this whole program/process is integrated into the organization’s quality assurance/performance improvement (QAPI) program (sounds like it might be a good time to include this as a standing agenda item at your QAPI committee meetings)
  • Making sure that any equipment that poses a risk, but is necessary for safe treatment of behavioral health patients (the example given is medical beds with siderails on a geriatric unit), is considered, as a risk, in the patients’ overall suicide/self-harm risk assessments, with appropriate interventions to minimize the identified risks

As I reflect over the seemingly endless amount of survey angst that this topic has wrought over the past couple of years, I keep coming back to the reality that while we can always do better (would we have done as much as quickly without enduring survey bludgeoning?), there is minimal data to support that, while not perfect, hospitals were not doing a good job in managing these at-risk patients. Purely from a risk management perspective, this would be a subject of great interest and concern to any healthcare organization as the burden of managing these patients has shifted over time. I suppose it ultimately gets filed under the “abdication of responsibility” that comes with the disenfranchising of difficult patient demographics and the subsequent “arrival” of those patients in the acute care settings, but it seems to me that (and yes, I recognize that this is part of doing business in healthcare) a little more collaboration during this process (as opposed to pointing fingers and assigning “blame”) might have yielded a better end-product. Hopefully, at some point, we will be given credit for the good work that has been done (and quantified), but I don’t think we are quite there yet.

Don’t Call It A Comeback: The Statement of Conditions breathes again!

Not a whole lot going on in the July 2019 issue of Perspectives, but it appears that a little more consideration will need to be paid to the Statement of Conditions (SOC) and Basic Building Information (BBI) sections of The Joint Commission’s web portal for hospitals and other healthcare organizations. The article in Perspectives indicates that we can expect some changes to the questions asked in the BBI section, though the only specific indication thus far is that the questions relating to square footage of your buildings will be aimed at obtaining greater specificity of information, ostensibly to aid in the planning of survey visits. The impression I always had when it came to the square footage ranges was that they tended to “look” at the upper end of the range information, sometimes “encouraging” additional survey days when they might not necessarily have been warranted. My consultative recommendation to folks was to use the comment section to indicate the precise (or would “exact” be the more appropriate descriptor?) square footage so there would be minimal potential for extra survey days. Should be interesting to see how this all shakes out over the next few months as more “reveals” make themselves known.

In other news, the next edition (2022—can you imagine!?!) of the FGI Guidelines for the Design of Healthcare Facilities is in the development pipeline and the good folks at FGI are looking for comments/suggestions to aid in that development, but the window for doing so is quickly closing. You can check out the skinny here, but please know that the comment, etc., period ends on June 30. So if you have some burning thoughts/suggestions for how we will be managing our future facilities (including renovation activities), now is the time for all good safety professionals to come to the aid of their craft (or something like that…).

To close out this week’s chatter, I would encourage you to (yet again!) check out Tim Richards’ blog regarding medical gas certifications and qualifications. As you’ve no doubt noticed, the ongoing codification of everything has really “leaned” into staff competencies and qualifications, sometimes to the point of really muddying the waters as to what really is required. When it comes to medical gas stuff, I don’t know that you’ll be surprised, but it might be useful information to share with your boss (or your boss’s boss). Check it out here.

Wishing each of you a most festive and safe Independence Day!

One size fits all…or one size fits none

In a world in which the economies of scale don’t always economize, I keep running into situations and/or conditions that result from trying to make something do too much. The classic example (other than those one-size-fits-all bunny suits in ORs across this great land of ours—I always end up looking like late-model Elvis, Vegas edition) is the temperature log that is used for food refrigerators, medication refrigerators, etc. As a general rule of thumb, unless the temperature range for each of the refrigerators being monitored is the same (and never mind trying to mix Fahrenheit and Celsius), then you are just asking for trouble. “Pushing” staff to have to discern between competing “out of range” temperature values requires an almost infinite amount of attention, and while there is, in certain instances, some overlap (food is usually 33-40 degrees F and medication 36-46 degrees F, so 36-40 works for both), it just makes so much more sense to limit confusion to the extent possible. And, to my mind, that means individualized temperature logs. One quick note regarding temperature logs for freezers, if your log doesn’t have a temperature “safe” range clearly indicated, I’ve been seeing a lot of mix-ups regarding those pesky negative numbers. For instance, if you establish a target of -15 degrees or colder, -10 degrees would be considered an -out-of-range value, but in talking with the folks doing the monitoring, they “think” of “10” being less that “15,” kind of missing the whole negative number dynamic. I won’t say that this is happening everywhere, but I have run into it in a couple of instances, so that’s something to keep an eye on.

Turning to the Oddities page, I was cruising through The Joint Commission’s FAQ page (admittedly, looking for blog fodder) and came across something of a puzzle; in the text of the FAQ dealing with the “old” requirement of the building assessment as a function of the Statement of Conditions (the old Part 3, which is no longer available) and has not been since 2007. But if you look at the text of LS.01.01.01, the second performance element indicates that a building assessment is required (at time frames to be determined by each organization) to determine compliance with the Life Safety chapter of the Joint Commission manual. I guess the thing that struck me about this happenstance is that the FAQ would have a good opportunity to indicate that the building assessment has evolved (or mutated—your pick) into its present day purpose  as an exercise in assessing your building for compliance with the LS chapter. Maybe they just haven’t gotten around to updating this FAQ (it is a ways down the FAQ page), and I suppose it is no more than a curiosity.

Making stock, taking stock: Emergency inventory madness!

In trolling The Joint Commission’s FAQ page for interesting tidbits to share, I came across the entry regarding the thought process around the establishment of an emergency inventory. Some interesting takes on certain aspects of the emergency inventory concept—it doesn’t “have” to be centralized, in recognition of “just in time” purchasing and the importance of being able to use stock with a shelf-life (it would not be good to have your EM supplies expire because they were earmarked solely for emergency response).

The FAQ goes on to recommend tracking assets and inventory for a year to ascertain what your organization’s capabilities and needs might be. But I’m trying to figure out how that “recommendation” (recognizing that the FAQs can be invoked at the level of standards-based requirement) dovetails with the “requirement” for an annual “review” (I remain stymied by the use of “review” as opposed to evaluation; it may just be me, but a review doesn’t have the same action level as an evaluation but perhaps they are to be considered synonymous) of the inventory of resources and assets needed during an emergency. My thought would be that you would be looking at how resources and assets are managed on an ongoing basis and that information used to ensure that the organization has what it needs and has the ability to procure additional resources and assets should it experience a prolonged emergency.

I think the key thing to keep in mind (as when one is addressing each of the TJC-anointed critical functions) is to ensure that for each exercise or actual implementation, there is a process in place for evaluating performance in each of those areas. Someone should be looking at:

  • Communications
  • Staff roles and responsibilities
  • Safety/security
  • Utilities
  • Patient care activities
  • The management of resources and assets

And those someones (whoever they may be) need to be particularly forthcoming because (as we have learned over the years) it is not so much about what went right as it is about what opportunities can be identified to make the next time better. Too many times I’ve encountered folks that are reluctant to “air out the dirty laundry.” Identifying potential vulnerabilities is never a bad thing (true, it can make for some difficult discussions), it is the only thing.

He held his head in his hands: Outpatient/Offsite Vulnerabilities

Being something of a quiet week on the compliance front (as we embrace the “dog days” of summer—and spring’s got 10 or so days to go), I wanted to use a recent Joint Commission announcement relative to Environment of Care standards relating to fluoroscopy as they apply to outpatient/office-based surgery practices (which seems rather more logical than not, particularly when one reflects on the Conditions of Participation requirements relating to the management of imaging equipment). You can find the particulars here, but I don’t think that there’s anything that’s going to come as a surprise. To my mind, why would the expectations be any different based on where the equipment “lives”? Just as there must be continuity of care, there must also be continuity of compliance.

Now one could certainly disagree as to how much of a sea change this represents relative to the survey process, but (and I’m going out on a limb here, but it’s a very, very stout one) I think the next significant survey “beachhead” (mixing all sort of metaphors today) is going to be all those pesky little physician practices and clinics and such that dot the landscape and are covered by the “umbrella” of hospital operations (you know, offsite locations that have become “departments of the hospital”). If we accept the premise that the primary goal of the survey process is to generate as many findings as possible (and I accept that premise—the evidence doesn’t really point to much else), then the likelihood of the regulatory folks looking for areas with greater levels of vulnerability seems, again, rather more logical than not.

At any rate, my best advice to those of you with these types of sites is to really kick the tires when you’re rounding. As you are no doubt aware, there can be a lot of resistance when compliance comes to the hinterlands (think about how much angst fire drills can generate!), but the stakes for non-compliance have never been greater and, for the record, one can never be too safe…or too compliant!

Secret Club for Members Only: Some FAQing for your reading pleasure

This week finds us (once again) visiting with our friends from Chicago as they stand astride the accreditation world like some ancient colossus. (I am hopeful that my purple prose will subside at this point, but sometimes the fingers take me in odd directions.)

First up, we have some additional guidance relative to how one might go about managing compressed gas cylinders, particularly those pesky oxygen cylinders that can cause so much grief during survey. So now we have a Joint Commission performance element that establishes the expectation that each organization will have a policy regarding the storage of oxygen and other compressed gas cylinders, said policy is to include the amount of gas at which segregation of full and empty cylinders would take place. You may recall that the initial “take” required full cylinders to be segregated from empty and partially full cylinders, but that “interpretation” of NFPA 99 has shifted a bit to allow for the storage of partially full cylinders in the company of full cylinders.

And now, we have a new FAQ that provides some guidance relative to how one might go about determining the amounts representative of full/partial/empty, depending on whether the cylinder(s) you are using have an integral pressure gauge. The FAQ also introduces the concept of “depleted volume content,” which ( as near as I can tell), is the amount of gas left in the cylinder that requires storage with the empty (as opposed to the full) cylinders. There is also a (maybe) handy table that walks you through the various segregatory considerations—I’ll let you parse those in your spare time.

My takeaway is that you need to make sure that if your current policy (if you don’t have one, it is a standards-based requirement, so best get on it) doesn’t pretty closely mirror how things shake out in this FAQ, you should consider modification of current policy/practice or be prepared to discuss how what you’re doing to be in compliance with the NFPA 99-2012 requirements. The other “thing” I noticed is the discussion of the labeling of empty cylinders as a function of the segregation process—if you have the empties in a separate rack that is labeled as such, then you should be fine. But if you have a single rack with full and empty cylinders cohabitating, then the empty cylinders have to be labeled; unfortunately, this does not appear to allow for the marking of the rack itself (I’ve seen red tape and red paint to identify the empty “slots”), so if that’s your practice you might get some pushback from a literalist surveyor looking for the empty cylinders to be labeled.

Next up, we have some information relative to the management of behavioral health patients, in this case, discussions of the various methodologies for determining the risks of each patient to be managed. I do believe that the regulatory focus on environmental considerations will start to diminish somewhat as we kick into the “next” survey cycle,  but I believe that the focus on the management of at-risk patient populations will continue as a function of: now that we have a “safer” environment, how are we making sure that the patients are being appropriately cared for, which is driven by the assessment process. Assessment stuff can be found here.

As an additional piece of the puzzle (I guess time will tell whether it is more piece than puzzle or the reverse…), TJC has established an information portal to assist organizations in compliance with the July 1, 2019 changes to the National Patient Safety Goal on Suicide Prevention, including links to the issues of Perspectives in which the initial (and ongoing) guidance, etc. can be found. As a one-stop-shop, it looks like a pretty useful thing to have in your back pocket. As I’ve noted any number of times (and I think once or twice in this forum), a lot of the TJC surveyor knowledge comes to them the same way it comes to you, so I think it a positively splendid idea to take a gander at the links contained herein.

Dry your eyes: Keeping ahead of the water(s)

One of the more ubiquitous findings in my travels are those relating to water infiltration/intrusion: peeling paint, stained ceiling tiles, pesky growths, etc.

And, not everybody gets to put on a new roof as often as they would like, so it ends up becoming a function of maintaining and managing your building in such a way as to minimize where water can impact your organization’s operations—from routine hassles to indoor air quality concerns. Michael Crandall, CIH, penned an article that I think might be of interest/use—you can check it out here.

Remember: In the confrontation between water and the rock, water always wins. Not through strength, but through persistence.

As a final note for this week, it might be worth your while to check out the June issue of Perspectives, which includes a missive (barely a missive, perhaps mini-missive) relating to the use of power strips (aka relocatable power taps—or the Notorious RTPs). Just over 20% of hospitals surveyed in 2018 were cited for issues with power strips, primarily: not having the appropriate devices in patient care areas; and power strips attached to walls in OR procedure rooms. As you may recall, CMS issued a categorical waiver, way back when, describing the requirements and, strangely enough, the attachment of power strips to walls in ORs is not considered a compliant approach. The thing that concerns me about that is a question of who did the install of the strips in the OR. I “get” that sometimes these things will migrate from wherever, by the hands of those who always remain nameless. But wall-mounted installations “smells” like the work of someone who should know better.

Carbon-dating compliance: What happened when…

…and how responsible are you for the sins of the past (turns out, quite a bit).

Kind of a mixed bag of things this week, so please bear with me.

First up, in looking back over the last little while of survey activity, I keep looping back around to one (possibly unanswerable) question: How many of the survey findings being generated are the result of conditions that pre-existed the prior survey? I think we can all agree that there are noncompliant conditions lurking throughout our buildings (including that pesky loaded sprinkler head we talked about a couple of weeks ago), some of which (and perhaps quite a few) are the result of actions or inactions occurring a long time ago (in a galaxy almost too close to home). I’m going to guess there are few of us that have not encountered the angst of having a surveyor pop a ceiling tile or wriggle into some crawl space and find some condition that had previously escaped prying eyes (I suspect that the most common previously undetected finding relates to things attached to sprinkler piping and supports, which supports LS.02.01.35 being the most frequently cited Joint Commission standard). And, as onerous as it may be on the face of it (and every other aspect), we are on the hook for all of it (grandfathering of conditions can help in very limited ways, but there’s really very little in the way of grandfathering noncompliant conditions and practices).

For better or worse (likely more the latter than the former), in these increasingly resource-challenged times, it is almost impossible to ferret out every little imperfection. Particularly in the sense that noncompliance happens in three dimensions—square footage just doesn’t work for this process. So, the questions I ask of you, dear readers, are these:

  • Do you proactively attempt an exhaustive search of your facility from top to bottom (and all the nooks and crannies)?
  • Do you “roll the dice” and correct deficiencies as they appear and if there’s stuff out there, let the surveyors find them?

I’m keen to see how this is going to “split.” I know if we could we would take the higher road of proactivity, but not everyone is in that position.

One other item I’ve been hanging on to for probably longer than I should relates to the management of medical gas and vacuum systems. I would hardly think that this blog is the only resource for information, commentary, etc. (though I do like to think it’s an entertaining and perhaps randomly enlightening one), there is one dedicated to the management of medical gas systems, etc., that I think you’ll find useful (and since it doesn’t publish as often, it’s an easy one to add to your bloggy queue) is sponsored by Compliant Healthcare Technologies (CHT). Recently, Tim Richards at CHT penned a blog post on upcoming changes in NFPA 99 relative to medical gases, etc. As I’ve noted once or twice in the past, I really see NFPA 99 compliance as a likely source of heartburn for facilities and safety folks in the coming survey cycles, so any resource that can increase our operational understanding of what is actually required, etc. gives us a leg up on the survey front. I encourage you to check out the information.

As a final note, it appears that we are gearing up for another wild summer of weather and I wanted to take a moment to send best wishes to those in areas already in the throes of severe weather and those that may find themselves in the same. I do believe that, as an industry, we have done some extraordinary work in the practical preparations to deal with emergencies (I would feel better if appropriate preparedness would “drive” regulatory compliance a little more closely, but perhaps in time) and I trust that we all manage the coming season with minimal impact and disruption.