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Feeling pretty psyched: Some good news to share!

In full recognition that the longer the COVID-19 condition persists, the crazier it gets to folks on the front lines, so my intent is to (try—we’ll see how this works out—you know me) limit editorializing and provide you with brief episodes of useful content.

This week, it gladdens my heart to let you know that the good folks at the American Society for Health Care Engineering (ASHE) published a template (and guidance information) to facilitate facilities and safety professionals’ requests for an 1135 Waiver relating to the potential for compliance gaps relative to inspection, testing, and maintenance of fire safety and other equipment. You can find the template and table at the ASHE website. It’s a fairly straightforward process and the template (and corresponding table) really simplifies the thought process; I would encourage each and every one of you to check out these materials and get your waiver requests in the queue. To my way of thinking, this will make things a whole lot easier as we deal with survey activities in the aftermath of COVID-19 and, in the short term, allow you to focus on the important things: Supporting patient care at your organization.

Stay safe and stay in touch as you can—you guys rock!

Rock on: Where do we go from here?

It would seem that the subtext to all we are experiencing/dealing with now is how long we can anticipate this “siege” to last, and (as is typical of these types of events) we probably won’t have a clear sense of the timing until the clouds break and the “sun” comes out. From a practical standpoint, the current situation is a very robust test of each organization’s continuity of operations plan (COOP), as well as the opportunity to witness the intricacies of the 1135 Waiver process as it unfolds. Of course, the other element that is unfolding is the number of COVID-19 cases worldwide (I’ve found the Johns Hopkins University case map of particular use in watching the spread of cases, both worldwide, but particularly in the United States; if you haven’t “found” it yet, it’s definitely worth a look).

At any rate, from a planning perspective, we’ve gotten to the point where some preparations need to be made to ensure sufficient capacity in the event regions are not successful in their attempts to “flatten the curve.” And those preparations will probably involve real-life/real-time actions to be ready to establish alternate care sites (to see what that looked like 100 years ago, you can scroll down this page to see my old stomping grounds at Brockton Hospital). To aid in that pursuit, just yesterday (March 30), CMS unveiled a number of regulatory changes to encourage thoughtful expansion of capacity, including provisions for what is described as “hospitals without walls.” I would encourage you to review these new materials as they do have some restrictions (mostly checking to make sure your planning dovetails with your state’s planning for alternate care sites).

From a practical standpoint, our friends at the American Society for Health Care Engineering have included with their COVID-19 resources some guidance (including links to other materials) on options for establishing/converting alternate care sites. Again, looking at the COVID-19 map, it is fairly easy to discern where bed capacities are likely to be in greatest demand and hopefully those most dire of conditions will not spread everywhere, but there’s no reason to delay consideration of what can be done in advance to be able to flex up capacity at your facility. I know there’s a lot going on right now and the struggle to attain some level of normalcy is all too real, but it is clear that we are in the process of redefining the magnitude of planning and preparation activities. Anything we can do to stay at least a couple of steps ahead is worth our time and energies.

Stay safe until next time!

Time I had some time alone: How negative do we need to be?

Just a quick couple of items this week. Don’t want to take you too far away from your primary focus!

First up, I’ve been working with some folks for whom there’s been something of a disconnect relative to the general concept of a room being under negative pressure versus an Airborne Infectious Isolation (AII) room. While all AII rooms are negative, all rooms under negative pressure (and there is a certain inescapable logic to this) are not AII rooms. It would seem that there are clinical folks that use the terms interchangeably (albeit in good faith) and sometimes, for example, when reporting isolation capacities to authorities, that interchangeability could put people at risk. Fortunately, the current state of affairs with COVID-19 does not require the use of AII rooms for holding patients, but it’s probably a good time to make sure that everyone is on the same page relative to your organization’s “true” isolation capabilities. It’s probably also a good time to keep a close eye on performance of these spaces—current events really highlight the need to be sure of which way the wind is blowing in your critical spaces.

For further reading, you might find the following information useful:

  • This Compliant Healthcare Technologies blog post covers some of the particulars relating to negative pressure considerations; might be familiar territory, but a refresher never hurts.
  • This Stericycle article covers some of the particulars relating to the management of waste during the current conditions; a lot of useful information from my perspective and perhaps yours, too.

As a final note, I suspect there’s been a fair amount of discussion in the background as to how the current state of emergency is going to impact the survey process once it re-emerges from the swamp. Right now, it’s not clear if any of the existing waiver processes is going to result in any flexibility relative to the various and sundry compliance activities that might be delayed, particularly those activities for which you’ve contracted with external vendors (fire alarm and sprinkler system inspection, testing and maintenance being a good example). At this point, it’s anyone’s guess, but past survey experiences in the aftermath of emergencies would seem to indicate that surveyors will feel bad about citing you for missing a timeframe (and will absolutely understand how it happened, etc.), but will still write the finding. I’ve been keeping a close eye on all the issuances from CMS, TJC, etc., and I haven’t seen anything relating specifically to all the stuff we worry about.

That said, my best advice at the moment is to document any compliance challenges manifesting themselves during this implementation of your emergency response plan and have a risk assessment for the impact on the life safety of building occupants in your back pocket, with perhaps some implementation of education initiatives, etc., to ensure nobody is put at an additional risk. Certainly, there are internal processes that could still be administered, but probably there are some that are not—might not be a bad idea to take a few moments to figure out what compliance (and any gaps) might look like if this goes to the end of April, or May, or even June. I’m hoping that you got all your quarterly stuff done early this quarter (don’t forget to check fire drills—some folks will wait until the end of the quarter—don’t want to miss anything), so it will be a question of keeping an eye on the longer-term future.

Stay safe and keep in touch as you can!

What a short, strange trip it’s been…

I think we can safely say that 2020 has manifested itself in a lot of (vaguely unpleasant) ways, but this one has the potential for really shifting the compliance landscape for the next little while.

You probably have already heard this through various sources, but our friends in Chicago are suspending all regular Joint Commission survey activity, effective this past Monday, March 16 until further notice, with no anticipated restart date. I suppose those of you for whom a survey visit was imminent, this gives you a little bit of breathing room (and given the tenor of the times, even a little bit feels pretty darn good), but it also requires you to sustain your compliance and oversight efforts just that much longer (I have always maintained that accreditation surveys look best in the rear view mirror), which could prove challenging.

That said, I have absolute confidence in you folks to keep your organizations sharp and on point (sorry for the mixed metaphor there). We can only prepare one day at a time, and so, can only sustain progress one day at a time. I think we can predict that infection control and prevention will experience focus like never before (but hey, we knew this was coming), so make sure all your infection control-related risk assessments are up-to-date and minty fresh (actually, reviewing all your risk assessments is probably a good way to spend this “grace” period).

There’s a lot going on, but if the past two months+ are any indicator, 2020 has more surprises in store (hopefully not…), you don’t want a bad survey to be one of them.

Logic doesn’t always prevail…a luxury you can’t afford!

By my observations over time, I’ve found that, all-too-often, logic finishes a distant third behind self-interest (which sometimes manifests itself as crimes of convenience) and panic. Unfortunately, if you currently work in the healthcare industry, you must cling to the bastion of logic as those “other” winds threaten to pull you under.

But sometimes even bureaucracies manage to act judiciously; the good folks at the Centers for Medicare & Medicaid Services (CMS) have elected to curtail some of their “regular” survey activities to afford healthcare organizations the opportunity to focus on COVID-19 preparedness (you might want to bookmark the CMS FAQ page—they’ll be updating frequently). While this doesn’t mean CMS is going to halt all survey activity, it outlined how it would be prioritizing survey activities over the next little while:

Effective immediately, survey activity is limited to the following (in priority order):

  • All immediate jeopardy complaints (cases that represent a situation in which entity noncompliance has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment, or death or harm) and allegations of abuse and neglect
  • Complaints alleging infection control concerns, including facilities with potential COVID-19 or other respiratory illnesses
  • Statutorily required recertification surveys (Nursing Home, Home Health, Hospice, and ICF/IID facilities)
  • Any revisits necessary to resolve current enforcement actions
  • Initial certifications
  • Surveys of facilities/hospitals that have a history of infection control deficiencies at the immediate jeopardy level in the last three years
  • Surveys of facilities/hospitals/dialysis centers that have a history of infection control deficiencies at lower levels than immediate jeopardy

While that does narrow down the field somewhat, those last two possibilities might be well-served by digging out any survey reports from the past couple of years to see if there are any IC-related issues lurking in the weeds.

According to the information provided to surveyors, the aim is to keep on-site survey time to no more than two days, with a particular focus on (you guessed it!) infection control, particularly as it relates to COVID-19 preparedness. You can see the meat and potatoes of the CMS memos to providers here:

https://www.cms.gov/files/document/qso-20-12-allpdf.pdf-1

https://www.cms.gov/files/document/qso-20-13-hospitalspdf.pdf-2

https://www.cms.gov/files/document/qso-20-14-nhpdf.pdf

As a final note for this week’s entertainment, our friends at ASHE have dedicated a webpage to provide COVID-19 information and resources; some of the materials require membership to access, but this is probably another page you’ll want to visit regularly as the next few weeks unfold.

If this isn’t a holdup, why are so many people wearing masks?

I suspect this is as much a confluence of any number of (seemingly/probably) unrelated elements, including a presidential election year in a certain North American nation, but it does seem to demonstrate, on a fairly significant scale, the power of fear to motivate folks to, and in some instances, past, the point of panic. There is no question that COVID-19 represents a significant turn of events in the epidemiological world and certainly has the potential to cause real havoc across the globe (I’ve always maintained that the bugs can evolve faster than we can). But it astonishes me the lengths to which folks will go to give in to their fears.

As I type this, I am sitting in an airport that serves a large area in the Northeast (euphemistically, the home of the New English), and I am quite taken aback by the number of folks wearing surgical masks for traveling. I will admit that I have not spent a lot of time recently (or, indeed, ever) watching the doom and gloom (or is it gloom and doom?) pronouncements of the various news organs—I tend to rely on the folks whose job/charge is to keep an eye on this type of stuff—folks like the CDC. I know that there are those for whom the CDC carries not much in the way of authority, but (being comprised primarily of human beings), perfection is the goal, but not necessarily the reality. But there are certain (to my mind) inescapably logical elements:

  • CDC does not recommend that people who are well wear a facemask to protect themselves from respiratory diseases, including COVID-19.
  • Facemasks should be used by people who show symptoms of COVID-19 to help prevent the spread of the disease to others.
  • The use of facemasks is also crucial for health workers and people who are taking care of someone in close settings (at home or in a healthcare facility).
  • Stay home except to get medical care.
  • Stay home: People who are mildly ill with COVID-19 are able to isolate at home during their illness. You should restrict activities outside your home, except for getting medical care.
  • Avoid public areas: Do not go to work, school, or public areas.
  • Avoid public transportation: Avoid using public transportation, ride-sharing, or taxis.

So, if you should only wear a mask if you are sick and if you are sick, you should stay home except to get medical care (a very reasonable chain of reasoning), then why am I seeing masks at the airport?

I do believe that everyone gets to make their own way in the world, at least to the degree that the impact of that “way” does not have a negative impact on everyone else’s “way.” But there are already reported shortages of supplies and it just seems to me that such actions are not (at least not yet) supported by the data. But there is something that can be done—and I’ve not seen enough of this CDC recommendation in action:

Wash your hands often with soap and water for at least 20 seconds, especially after going to the bathroom; before eating; and after blowing your nose, coughing, or sneezing. If soap and water are not readily available, use an alcohol-based hand sanitizer with at least 60% alcohol. Always wash hands with soap and water if hands are visibly dirty.

As I think about it, wearing a mask doesn’t absolve anyone of the responsibility to wash their hands, but hand hygiene numbers in the public sector are not nearly where they should be. Which leads me to this question: What’s the best way of shaming the hand-hygiene deficient? I’d love to hear any stories you might have.

Burning with optimism’s flame: A future state in which surveys are less frightening…

As you are all no doubt familiar at this point, one of the key management processes promulgated by (or is it through?) the 2012 edition of NFPA 99 Health Care Facilities Code is that of the risk assessment as a means of determining how to best manage risks to folks using our facilities—patients, staff, visitors—it’s a tall order no matter how you parse it.

That said, I read a very interesting article in ASHE’S Health Facilities Management publication on how the industry might be able to start moving towards a standard process/practice with the (more or less) aim of being able to develop data that can truly demonstrate that the risk factors being used to determine the level of risk are supported by the numbers. Ultimately, the go-forward on this would be to have a robustly data-driven program for the management of equipment (utility systems equipment as well as medical equipment) that establishes a framework for performance, determining effectiveness, etc. that would be bulletproof during a survey. As a description of a useful future state (as opposed to the same ol’, same ol’ survey process of calm interspersed with periods of insane demands from our “customers”), I think you’ll find a lot to think about, so I encourage you to give it a look.

Moving on to what may be a trending esoteric finding, it appears that covering any outside cylinder storage locations might be one of which to be mindful. Strictly speaking, we are on the hook for protecting stored cylinders from overheating (with a target temperature of 130 degrees F—pretty hot stuff), which one might suppose is a least to some degree,  a function of geography (I would imagine there are some locales for which 130 degrees of ambient temperature might be an occurrence of some rarity. That said, if you do have cylinder storage space exterior to your facility, it might behoove you to document a little risk assessment (perhaps in coordination with your medical gas and vacuum testing vendor) to determine whether your cylinders are too hot to handle (strictly from a code perspective).

Identifying issues and finding solutions…

…versus identifying issues and pointing fingers.

I think we can all agree that (at least for the moment) our friends in the regulatory survey services world have misplaced the location of their customers and, as a result, have become significantly more punitive in administering the survey process. Of course, the accreditation survey team always tells organizations that, despite the umpty-ump number of findings, they are a quality organization and really, this was a good survey. I have yet to hear of any instances in which the survey team “supported” anything other than a positive vibe, but it seems that, in growing numbers, that vibe is not really translating past the point of the exit conference.

Now, I know that it is not the role of the accreditation organizations to do anything more than identify deficiencies (I have hopes that a more consultative approach will re-emerge before too long, but I am not holding my breath), but what I keep bumping into are instances in which the folks (internal and external to an organization) charged with preparing organizations for survey are almost as punitive in their administration of the survey prep process. The purpose of environmental rounding/touring, etc., is to help folks become as prepared as possible and to identify strategies for sustaining compliance. It is not about the “gotcha,” with follow-up paperwork. My personal philosophy (as a safety professional in general, but certainly as a consultant) is that my obligation to the process is to help get things going in the right direction, even to the point of cleaning up a spill or picking something up off the floor while touring. Certainly, I can (and do) identify lots of things that need attention, because there are always lots of things to find that need attention (this goes back to my “no perfect buildings” philosophy; probably too much philosophy for so early in the year, but so be it). But I go into this having suffered at the hands of consultants (and others) who are not as interested in helping work through an issue to achieve some sort of sustainable solution.

As an example, I recently heard about an instance in which the environment of care rounding team had identified a resolution to a pesky issue (in this case, ensuring that specimen containers were appropriately labeled) but did not share that resolution with the entire organization. So last time, a “sticky” label was affixed to the container, but the label didn’t stick so well; this “failure mode” was communicated to the folks in infection control, but there was no immediate follow-up. So, next rounding activity, a specimen container to which a “sticky” label had been affixed was, in the local parlance (not really), nekkid in terms of labeling. Well, after the labeling issue had been cited, it was “revealed” that, after some consideration (may have been careful consideration, but less careful in the communication), it was determined that the containers would be stenciled in more permanent fashion. Interesting thing, the “finding” still required response, etc. even though the “finding” was the result in a communications misfire.

At any rate, as I think I’ve noted here before, there’s no regulatory statute that requires us to shoot ourselves in the foot, or, indeed, to engage in friendly fire. To my way of thinking, internally punitive surveying is not helpful and since we know the “real thing” isn’t particularly helpful (to healthcare organizations, at any rate), doesn’t it make more sense to work together towards sustainable compliance?

Quick closing question: While I was having some lab work done today, I noticed that the emergency eyewash station in the sink area was covered with a clear plastic bag. Has anyone out there in blogland encountered this or are practicing it? I’m thinking that this adds a step to activation of the eyewash station, but perhaps there’s a risk assessment that supports it. Just asking for a friend…

On your marks, get set, sweat!

But hopefully not a Billy Idol kind of sweat…

Our friends in Chicago are once again tweaking the survey process, with the result being less time for surveyors to wait for organizations to muster their troops at the outset and pretty much no time at all before they are out and about doing tracers. Basically, what used to be the surveyor planning session in the morning of the first survey day is now being flipped and combined with the special issue resolution session at the end of the day. For organizations to adapt their process to the changes, folks should be prepared to do the following:

  • Prompt alert of/to the leadership team of any on-site survey to facilitate their availability for a prompt opening conference (I can’t think of too many folks who are not already doing this)
  • Prepare all required documentation and deliver those documents to the survey team immediately after the team is escorted to their “base” (the list of required documents is available in the Survey Activity Guide, although it begs the question as to whether this includes the life safety documentation…)
  • Gather the scribes together so they are ready to hit the pavement as soon as the (ever-so-brief) opening conference is completed

Somehow I think this may all tie across with the folks from CMS accompanying the Joint Commission folks as part of the validation process—anyone who has dealt with a state and/or CMS survey will tell you, there’s not a lot of time (or indeed, inclination) for pleasantries. The job of being prickly requires a lot of inflexibility, which does seem to be the hallmark of the current survey process.

These changes to the survey process are effective March 2020.

I sit at my table and wage war on myself—and earn an OSHA citation!

While I have a sneaking suspicion that this Top 10 list doesn’t change a whole lot from year to year (other than position in the hierarchy), I thought it would be of interest to trot out which occupational safety considerations are manifesting themselves across industries. I can certainly see where any of these might crop up in healthcare.

And so, to the list:

10: Personal Protective and Lifesaving Equipment – Eye and Face Protection

9: Machine Guarding

8: Fall Protection – Training Requirements

7: Powered Industrial Trucks

6: Ladders

5: Respiratory Protection

4: Lockout/Tagout

3: Scaffolding

2: Hazard Communication

1: Fall Protection

Again, no big surprises, but I guess it does point out some areas for future consideration, mostly as a function of initial and ongoing safety education. These are the types of things, especially when dealing with contractors, that can result in a very uncomfortable situation if something goes sideways on your campus—even if it’s not your staff. Once the Big O gets through the door, it’s tough to contain their interest in all things safety.

Closing out this week, one of the questions that seems to be coming up with greater frequency during Joint Commission surveys relates to how your organization determines that the individual(s) tasked with doing your rated door inspections are knowledgeable/competent (we know from our intense scrutiny of NFPA 80 that these folks do not need to be certified; it is a handy way to demonstrate that an individual is knowledgeable, but you can certainly evaluate/validate competency in other ways). And pondering that equation made me a little more interested in the following news story than might normally have been the case (there isn’t a time when I wouldn’t have been interested, but this was an especially telling confluence). It seems that an individual has been accused of defrauding some VA hospitals by billing them for work that had not been performed; a little more detail can be found here. I know a lot of folks have struggled over the years with vendors who prefer to “come and go as they please,” which typically results in less control over the process, including timely notifications of discrepancies. I’m curious as to how this ends up when it makes its way through the courts, but I can see a time when those pesky surveyors might start to ask about how one knows that the service for which they have documentation actually occurred. Hopefully this case is all a big misunderstanding and there were no real gaps in oversight…