My colleague Jorge Sosa and I wanted to take a moment of your time to remind you of our upcoming live webcast Surgical Environment Compliance: Meet CMS and Joint Commission Requirements to be held on Friday May 8 at 1 p.m. EDT. What a way to start the weekend! The 90-minute program will include a presentation of approximately 60 minutes with a 30-minute Q & A session to cover any questions you might have about the program content, or indeed anything else that strikes your fancy.
I really think you’ll find this program of great interest. The Joint Commission just unveiled the most frequently cited standards during 2014 surveys and the top three are all in the mix when it comes to managing conditions in the surgical environment (and beyond…we’ll cover that as well). We’ll be covering steps you can implement to avoid survey findings, as well as strategies for managing the process if you find yourself with some survey deficiencies.
At any rate, I’d like to invite you to join Jorge and me for a discussion of what is probably the most “dangerous” topic in the Environment of Care in maybe ever (this makes the management of Interim Life Safety Measures look like a walk in the park)!
Hope to “see” you on May 8. You can register for the program here.
Every once in a while (and I don’t think I abuse this privilege, but please feel free to disabuse me of that notion), I like to vent a little regarding those annoyances that can impact how the folks in the safety world carry out their duties. In this particular instance, I’d like to rant a bit about those members of the “safety committee” that seem only to attend meetings when there is an opportunity to stonewall/derail/obstruct, etc., the ongoing work of the committee.
Lately it seems a lot of folks are struggling to bring their active shooter response plans past the initial stages and move into the implementation phase. That struggle inevitably seems to revolve around those transient members that always seem to know when you’re committee is just about to “birth” a new policy or process and they glide into the action with reservations/objections/all manner of constipations to set things back, without having participated in the work leading up to that point.
In my heart of hearts, I know that this is not very collegial behavior, but the question I have for the community is: How are you managing these occasions? My philosophy (which can be sorely tested from time to time) is that you have to birth the policy before you can tell for sure how well it will (or won’t) work when you operationalize it. I guess the analog to that is that it is better to have a flawed policy that you can work to improve than it is to have no policy at all, particularly to manage critical functions or risks. It is very, very difficult (certainly bordering on impossible) to come up with perfection without doing some trialing in the real world (maybe it’s possible, but I can honestly say I’ve never encountered it). I suspect this has happened to many (if not most, and probably all) safety professionals. Anybody have any inventive solutions for organizational blockages? Please sing out—let the world in on your secret!
Meet the new Survey Activity Guide, same as the old Survey Activity Guide (with apologies to the ‘Orrible ‘Oo)
Sorry I’m a little tardy on this one. I’ve been juggling a bunch of blog ideas and this one faded to the back of the pack a bit.
Back in January (and it seems so very long ago, perhaps due to the lovely weather we’re experiencing in the Northeast), The Joint Commission released the 2015 Survey Activity Guide, which details the ebb and flow of the survey process. Fortunately, they always identify a means of determining what is new (presumably as a function of 2014 Guides and so on), so I always look for any changes to the EC/EM/LS troika to see if anything funky has come to the fore.
Strangely enough, there are three documents that are indicated as being “new” that I’m pretty sure have been in the mix for at least a little while: your written fire response plan, your Interim Life Safety Measures Policy, and your fire drill evaluations. To fact-check myself, I went back to the 2013 SAG (I was a little lazy and skipped the 2014) and sure enough, all three were identified as “new” to the mix back then (I don’t seem to have a copy of the 2012), so no big surprises on the document front.
Likewise, the EC/EM interview sessions appear to be consistent with survey practice for the last couple of survey cycles. To be honest, I’m not entirely convinced that there’s a lot of exposure for organizations during these sessions, so long as the group is “chatty.” I think a good measure of how well you’re doing is in inverse proportion to the number of questions the surveyor has to ask to keep things moving. Strictly speaking, these sessions are designed to gain information on how organizations manage risk/respond to emergencies and how planning and preparedness activities function as a means of improving the various component programmatic elements. You should be able to discuss how the program has gotten “bettah” (I like to inject a little of the Bostonian vernacular from time to time), with an eye towards the use of data to demonstrate/support the notion that things have improved. I’ve not heard of anyone getting in trouble during these sessions, but I suppose there is always the potential for some misfortune. I think as long as there is recognition that compliance is a journey and not a destination, folks will be comfortable describing that journey (including setbacks) with winning survey results.
In the February 11, 2015 issue of Joint Commission Online, there’s an interesting piece recommending organizations review their smoking policies to ensure that the risks associated with electronic cigarettes are being properly managed. The primary risk identified in the article relates to the potential for fire events, including issues with rechargeable batteries, though it does touch on potential issues with the vapor/smoke generated by the devices (and I can tell you from a close-up encounter with the vapor cloud during a hospital visit, the smell is kind of noxious) and the importance of environmental separation (ventilation, etc.). As a final inclusion, the article reasserts (so to speak) that Joint Commission standards do not require hospitals to be smoke-free (allowing provisions for smoking in specific circumstances), so those of you who have gone that route (and may be experiencing a bit of a struggle—particularly if your community is not quite ready to embrace the smoke-free environment) may be interested in the brochure provided by The Joint Commission (you can find the brochure here). It certainly can’t hurt to check it out; and adopting it as a reference in your policy might be enough to dodge a finding during survey. I mean, come on, it’s all about best practices, n’est-ce pas?
In a February 18 Joint Commission leadership blog post, Mark Crafton, TJC’s executive director of communications and external relations, focuses on the benefits of investigating different approaches for mitigating violence in hospitals. At least that’s where the conversation starts, but it ends up in kind of an interesting (and to my eyes, unexpected) direction: the question of whether hospital security officers are a more effective deterrent/mitigation strategy when they are armed. (N.B.: In Crafton’s post, he refers to security “guards”; call me whatever you like, but I think the term “guard” just doesn’t ring well with me. I’m okay with the terms “security staff” or “security officers,” but “guards” just gives me the vapors—metaphorically speaking, of course.)
In the course of the posting, Crafton points to an article in the Chattanooga Time Free Press that will likely generate some debate among healthcare security professionals, and I tend to agree with that thought. Apparently the article was the result of a healthcare system’s decision to disarm their security staff and adopt the “soft” uniform look (e.g., blazers, etc.) to more effectively emphasize the security officer’s role as a more customer-oriented (my description) countenance. Now we’ve touched on the subject of arming security officers in the past (it’s been a really long time) and it’s probably way past the time for looking at this topic, particularly as the good folks at CMS have some rather strong thoughts on the subject:
CMS does not consider the use of weapons in the application of restraint or seclusion as a safe, appropriate health care intervention. For the purposes of this regulation, the term “weapon” includes, but is not limited to, pepper spray, mace, nightsticks, tazers, cattle prods, stun guns, and pistols. Security staff may carry weapons as allowed by hospital policy, and State and Federal law. However, the use of weapons by security staff is considered a law enforcement action, not a health care intervention. CMS does not support the use of weapons by any hospital staff as a means of subduing a patient in order to place that patient in restraint or seclusion. If a weapon is used by security or law enforcement personnel on a person in a hospital (patient, staff, or visitor) to protect people or hospital property from harm, we would expect the situation to be handled as a criminal activity and the perpetrator be placed in the custody of local law enforcement.
The use of handcuffs, manacles, shackles, other chain-type restraint devices, or other restrictive devices applied by non-hospital employed or contracted law enforcement officials for custody, detention, and public safety reasons are not governed by this rule. The use of such devices are considered law enforcement restraint devices and would not be considered safe, appropriate health care restraint interventions for use by hospital staff to restrain patients. The law enforcement officers who maintain custody and direct supervision of their prisoner (the hospital’s patient) are responsible for the use, application, and monitoring of these restrictive devices in accordance with Federal and State law. However, the hospital is still responsible for an appropriate patient assessment and the provision of safe, appropriate care to its patient (the law enforcement officer’s prisoner).
As you can well imagine, equipping security staff with weapons of almost any stripe can result in the classic slippery slope. My personal practice was to have a clear delineation between security staff and law enforcement responders. Security staff were provided ongoing crisis management education and worked closely with clinical staff to proactively manage at-risk situations. Law enforcement response was summoned when appropriate and the use of weapons was solely at the discretion of those responders. I know those lines can get pretty blurry in the heat of the moment, but specific roles are, I think, the best starting point for an effective security program.
At any rate, Crafton goes on to discuss the following: the cases for armed/not armed security staff; armed staff as authority figures vs. armed staff as a potential for raised anxiety of patients who are already distressed/stressed; and how do you make patients and staff safe, etc. There are, of course, good arguments on both sides, but ultimately (and this is one of the common threads when it comes to TJC standards and expectations), it is the responsibility of each organization to determine how best to manage, in this case, security risks. It doesn’t seem likely that peace, love, and understanding are going to be breaking out any time soon; the role of the security officer has never been more important.
Because someone else will come along and move it—and it’s always been the same…
Returning to the Adding Insult to Injury desk here at the Safety Space plaza (with apologies to the Magliozzi clan), last week we learned of a delightful new development in the ongoing saga of the management of environmental conditions in surgery. You can find the opening salvo in this little skirmish here. To recap, back in January, AHA/ASHE/AHRMM issued a Joint Quality Advisory indicating that there may be supplies and equipment that are not/were not manufactured to tolerate the lower humidity levels (down to 20% relative humidity) that could be in place based on the Categorical Waiver issued back in 2013 (details here). In the Quality Advisory, there was a recommendation for a risk assessment, etc., to ensure that any risks associated with equipment/supplies and the lower humidity levels are being appropriately managed.
But apparently, that was not enough tumult to introduce into the mix (it almost makes me long for those halcyon first days of the relocatable power tap dictum). To wit, CMS (in its way beyond infinite wisdom) has weighed in on the topic of supplies and equipment that may not tolerate the lower temperature and humidity levels allowed by the categorical waiver. The sum and substance of the CMS position echoes the risk assessment process outlined by AHA/ASHE/AHRMM, but does it one step further by indicating that until the assessment has been completed and you know all your “stuff” can appropriately tolerate the lower humidity levels, you have to go back to the pre-waiver humidity levels. By the way, that could mean either the 30% low point indicated by ASHRAE or the 35% low point indicated by NFPA 99-1999. You can find links to the memorandum issued by CMS here. By the way, this memorandum is also notable for the appearance of a kicky new term—IFU (instructions for use)—to add to the pantheon of acronymic stardom. Welcome IFU!
Now, I think we can all agree that looking at all the supplies and equipment being stored in these sensitive areas is going to be a fairly labor-intensive pursuit (Can you say pain in the gluteus maximus? I knew you could!) and it makes me wonder if there’s a way to push back at our vendors to help in at least reducing the number and type of materials we would need to evaluate. The Joint Quality Advisory makes note of some examples of materials that could be in the mix—EKG electrodes are noted—but I can’t help but hope that someone, somewhere is starting to parse this into a more manageable pursuit. I fully recognize that this is probably something of which everyone should already be aware; the CMS memo is rather pointed in mentioning just that: “The CMS expects hospitals, CAHs, and ASCs to follow the current IFUs for supplies and equipment used in their ORs. Failure to adhere to the IFUs must be cited, even if the facility has opted to use the categorical waiver of the [Life Safety Code] RH requirements.”
Sometimes doing the right thing ain’t so easy…
(P.S. If you’re interested in learning more about this topic, Jorge Sosa and I will host a webcast, “Surgical Environment Compliance: Meet Joint Commission and CMS Requirements,” on Friday, May 8 at 1 p.m. Eastern. Find out more and register online here.)
I suspect that the conversations regarding the number of EC and LS findings are likely to continue for the foreseeable future, for all the reasons we’ve discussed in the past and probably some that haven’t occurred to me yet, but surely will. At any rate, I want to encourage you to grab a copy of the February 2015 issue of Joint Commission Perspectives and turn directly to p. 10, on which begins a discussion of the use of dashboards as a means of keeping EC/LS compliance on the front burner. The article (part of George Mills’ ongoing series of Clarifications and Expectations) shows some dashboard examples, as well as providing links to some tools on the Joint Commission Resources website (including a blank form suitable for use in your very own organization). Heck, it even outlines a six-step process for setting up your own dashboard if the one from JCR doesn’t quite fit the bill. All in all (as much because it pretty much reiterates what I’ve been preaching almost since the beginning of time, but I digress), a most worthy addition to the safety canon and a resource that you would be well-advised to consult as you start to formulate your calendar year 2015/fiscal year 2016 activities.
All that said, I would encourage you, particularly as any number of you are embroiled in your annual evaluation process, to look over the information and make a (very, very) good faith effort to adopt at least the dashboard concept, if not an outright adaptation of the formats included in the article. One of the truisms of the compliance game is that anything that shows up in Perspectives is potentially surveyable/enforceable as a standards-based requirement, so there is a pretty fair likelihood that the surveyors are going to start looking for something along these lines when they next stop by your place for a visit. But please don’t look at this as one more thing to do; if you set this up and operationalize this properly, you will gain a great deal of information on where your organization stands on the compliance continuum, plus you will have data that you can use to clarify findings that may come up (okay, probably will come up) during survey. As always, it goes back to the management of imperfections in the environment—you know they’re there, I know they’re there, TJC knows they’re there. Our best “safety net” is to be able to demonstrate an ongoing process for managing those imperfections. Identify those pesky vulnerabilities and you are on your way!
One bit of caveat emptor, p. 13 includes a sample “In-Depth Data Analysis Worksheet,” which in this case is being used to collect data on the Daily Verification of Appropriate Air Pressures for In-Use Rooms. And you might well note that there is no specific requirement for the daily verification of appropriate air pressures for in-use (or indeed any other) rooms. For some strange reason, this one is giving me a bit of the willies as I can certainly see an instance in which a surveyor might interpret this to mean that there is such a requirement. It may be much ado about nothing (and I, for one, hope that is indeed the case), but probably something worth keeping an eye on.
On January 21, 2015, the American Society of Healthcare Engineering (ASHE), in coordination with the American Hospital Association (AHA) and the Association for Healthcare Resource & Materials Management (ASHRMM), issued a Joint Quality Advisory, offering new guidance on humidity levels in the OR. The short version is that the CMS waiver allowing hospitals to maintain humidity levels in operating rooms at a level down to 20% relative humidity (RH) is presenting some conflicts relative to the care and feeding of certain sterile supplies and surgical equipment that were designed to be in surgical environments with a humidity level of no less than 30% RH. Can I get an “Oh yeah!”?
One of the conversations I’ve bene having with greater frequency with clients relates to the storage of sterile supplies as a function of ASHRAE 170 Standard for Ventilation of Health Care Facilities, which has very clear design specifications for sterile storage (must have positive pressure, a minimum of two outdoor air exchanges, a minimum of four total air exchanges, a maximum of 60% RH (no identified minimum) and a temperature between 72 and 78 degrees F). The conversations generally grow out of thinking about all the areas in a hospital where sterile supplies can be found and whether all of those locations constitute “sterile storage” and thus would have to adhere to the design specifications listed in ASHRAE 170.
The upshot of those conversations is typically the need for a risk assessment of what supplies are being stored where (so to speak) and determining what locations and products need to be considered in the mix for “protection” in accordance with the ASHRAE standard. For all intents and purposes, the ASHE Joint Quality Advisory is recommending the same type of process (with the “net” being cast a little further afield to include equipment stored in these locations).
As we have learned over the past little while (and reinforced through TJC surveys pretty much everywhere), there is a concerted effort on the part of regulators to scrutinize the management of special environments with an ever-broadening list of locations to be included in those ranks. I believe that I have recommended using the table in ASHRAE 170 as a starting point for conducting a risk assessment of all the potentially applicable locations in each organization, so I’m just going to put it back out there—if you haven’t looked closely at how you are maintaining compliance with this stuff, I can only encourage you to do so. But please know that any lack of preparedness on this count can lead only to survey peril.
As I eagerly await the final numbers of the most frequently cited standards during the 2014 survey season, I can’t help but think that this may the point at which the findings relating to integrity of egress finally (blessedly?!?) take a back seat to findings relating to the management of environmental conditions in surgical/invasive procedure areas, and the associated support environments (sterile processing, sterile storage, decontamination areas) at the top of the food chain. I can’t think of very many survey reports that I’ve seen in 2014 in which the surgical/invasive procedure environment didn’t show up—and too many times that has resulted in condition-level RFIs for the organizations in question.
As you are more than familiar at this point, there are a ton of variables when it comes to this subject—design specifications for the HVAC equipment being used, “field modifications” by the end users (vents taped over, doors left open when they should be closed, etc.), the usual struggles with seasonal temperature and humidity fluctuations—the list almost seems endless. And these types of conditions have cropped up in places that have what I would consider outstanding programs for managing the care environment—attentive leadership, effective buy-in from point of care/point of service staff, reasonable access to capital funds, etc.—so it’s not necessarily symptomatic of the “have not” organizations. It can be as simple as a damper that’s closed, a belt on an air-handler that’s slipping, a filter that’s just, just getting to the point where it needs to be changed.
The key to this whole magillah is having a robust process in place that takes into account those instances in which the presence out-of-range values have been assessed to point where there is a very clear delineation between the design specifications (as outlined in ASHRAE 170), the actual performance of the systems throughout the year, and an oversight process (in close coordination with Infection Prevention) that allows some pushing of the envelope, particularly when the “desires” of occupants bump up against the design specifications. Clearly, we don’t want “rain” in any of these procedure/storage areas, but we must have a definitive sense of what conditions can be legitimately tolerated without putting patients at risk. Otherwise, you’ll find yourself dangling over the precipice of the survey process without a net. Not something I would wish on anyone!
I don’t know how many of you folks subscribe to The Joint Commission’s (TJC) e-notification products, but an interesting bit of news/info came across the airwaves that relates very clearly to some of the conversations we’ve been having (to one degree or the other) over the last, oh let’s say decade or so. Mark Pelletier, the COO of TJC, has taken on the task of “calling out” those healthcare organizations accredited by the Joint to clean up their acts as it relates to the preponderance of EC/LS findings during triennial and associated survey activities. If you’ve not yet seen it, it might be useful for you to be conversant in some of the details.
Now I think that we can absolutely pinpoint when this shift first manifested itself: way back in 2007 when the initial wave of Life Safety surveyors were introduced to the TJC survey process. Since then, there has been a steady increase in EC/LS findings, particularly as the remainder of the survey teams have also been tasked with observing conditions in the physical environment, which brings me back to the age-old dynamic of “Are they looking for it because that’s what they’re finding or are they finding it because that’s what they’re looking for?”
Having pondered this for quite some time, I believe that I fall squarely in the latter camp. One thing I’ve learned over the last 10+ years of working with hospitals is that there are no perfect buildings—and I really don’t think you need any more evidence than the number of findings generated in the survey of the physical environment to be convinced of that. Does this means that we are putting patients/staff/visitors at risk because of the poor conditions in our facilities? I don’t feel that the evidence supports such a draconian interpretation. Is there an opportunity for the management of the physical environment to better resourced, utilize technology better, etc.? I don’t think there’s anyone out there who would disagree that there have always been, and always will be, opportunities to make improvements in the physical environment.
TJC has not yet revealed the final results of most frequently cited standards during 2014 (I have no reason to think that the January to June 2014 results aren’t a good indicator of what we can expect), though I get the sense from Mr. Pelletier’s blog posting that findings relative to the integrity of egress may finally be taking a back seat to findings relating to the management of the surgical procedure environment (temperature/humidity/air pressure relationships). But that said, from the survey results that I’ve seen and the facilities with whom I’ve done on-site work, it is debatable (at least in my mind) that the findings are representative of a significant systems issue. My experiences indicate that the findings are generally related to what I would euphemistically refer to as transient conditions. Sometimes there are legitimate problems that need to be addressed; I recall one decontamination room that had never had an exhaust installed, but that is indeed an exception. But a majority of the time, we are talking about the sundry imperfections that can be encountered in any facility inspection. At this point, you should have a pretty good idea of how long you’d have to tour your building to find a condition that is not quite as it should be. Do you think if you toured for two or three days in a concerted fashion that you wouldn’t be able to find anything at all? Buildings are never more perfect than the moment before you put people in them—and apparently that perfection has somehow become the expectation. Jeez!