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I’m happy, hope you’re happy too…

A couple of weeks ago, HCPro’s Accreditation Insider featured an article that addressed a study published by the American Journal of Infection Control on compliance by nurses with the many and varied requirements of the Bloodborne Pathogens standard.

I guess I’m of two minds about the study; it is a somewhat smallish sample size (116 nurses were studied), though presumably statistically valid (not being wicked up on the whole statistical analysis thang, I wouldn’t even presume to presume, but I’m thinking that it would hardly have been worth publishing if it were not of some note). I think in my heart of hearts that (at this point) I would have hoped for better compliance numbers but again I’m not certain that I was particularly surprised that gloves aren’t worn all the time, hands are not washed as often as is necessary (e.g., after taking care of patients, after taking off gloves), and face shields are not worn as often as would be advisable given the risks (no big surprise on the face shields—it is a struggle, struggle, struggle—not just for the potential of an exposure to blood or other potentially infectious materials (OPIM to those among you that are acronymically inclined), but also for potential chemical exposures. (Everybody wants a freaking eyewash station “in case”, but nobody wants to use appropriate PPE to ensure that “case” doesn’t occur—jeepers!)

I haven’t had a chance to actually read the study (yes, I know—shame!), but the article in Accreditation Insider doesn’t really get into what the compliance barriers might have been (I honestly don’t know if the study gets into some of the causative factors), which I think would have been instructive. Apparently, the study concludes with a recommendation for stricter enforcement of compliance policies and to address problem areas with better monitoring and staff education. Now, those are fine things indeed, but kind of begs the question as to what constitutes better monitoring and staff education. I will go on the record here (I don’t think I have previously, but if I have, mea maxima culpa) as no particular fan of computer-based learning. I “get” that it is more convenient for folks to do and thus, generally results in better “compliance” when it comes down to numbers of folks completing the required “modules,” etc. And I also “get” that it is compliant from a regulatory standpoint (BTW, just because I “get” something doesn’t necessarily mean that I am convinced that such claims are valid). What I don’t find as I travel the highways and byways of healthcare facilities is evidence that this process results in an enhancement of staff competence and knowledge. I don’t necessarily think of myself as a Luddite (in fact, I’m pretty okay with a lot of technology), but I don’t know that convenience is the yardstick by which we should be measuring the effectiveness of education. Rant over…

Before I hop along, I do have one favor to ask (and it sort of relates to the above). I understand that, from a sterile processing perspective, it is important to do some sort of enzymatic pre-treatment of soiled instruments so the OPIM doesn’t get all caked and hardened on the surface of said instruments. The favor (or question) is this: Has anyone identified a product that will appropriately pre-treat instruments but not require emergency eyewash equipment? If you have a risk assessment of that determination, that would be very cool. I’m running into another uptick in the proliferation of eyewash stations—I’m a great believer in having them when they are appropriate, but I’m no fan of eyewash stations “in case” (that sounds somewhat familiar…where have I seen that before?). Any feedback would be most appreciated.

Happy Mardi Gras for those of you disposed towards that kind of celebratory activity…

More portal chortlings—under the god(s) of compliance

I guess one could say that it took them a wee bit to get around to the topic of the requirements (and survey vulnerabilities) relating to the built healthcare environment, but they’re really going full bore on EC.02.06.01, particularly as a function of making sure that the responsibility of organizational leadership is recognized as a (if not the) critical component of compliance. I know we’ve already covered the latest fireside chats from Messrs. Mills and Woodin, but if you have not already done so, I would encourage you to do two things (and part of me is a little anxious as this smacks a bit of endorsement, but I think this is important):

 

  • Include a viewing of the fireside chats at your EOC Committee meetings; I don’t know that I would do all of them at once, but they are certainly brief enough to do one a month. I think it’s crazy important for everyone on the Committee to review the contents of the videos and while I know that you could just furnish the links to the Committee members and have them view on their own, I suspect that there might be some very valuable discussions to be had if you watch it as a group (heck, you could even make some popcorn—multigrain, no butter, perhaps a light dusting of sea salt), with maybe 10 minutes of discussions. While there is not much in the way of epiphanies in the content of the videos (I think everyone kind of recognizes what needs to happen), again, I think you could have a pretty good discussion regarding some of the concepts covered and the practical application of those concepts in your organization. You might even invite folks from procedural environments that are not typically members of the Committee. This is a huge focus of the survey process at the moment and the closer we can get to an intimate understanding of the dynamics, the better off we’ll all be.
  • Share the video with your boss (and if you can do it, your boss’s boss); the fact of the matter is that findings in this area could very well (it’s almost a likelihood) result in a finding under the Leadership standards, which ostensibly ties this up (and back) to the governing board of your organization. I don’t think that you’ll have a very easy time of managing the built healthcare environment without the knowledge and support of your organization’s leaders. We can no longer act as though this stuff is the responsibility of a few folks in the “trenches”; the management of the physical environment extends from point of care/point of service all the way to the top of the organization. It’s all about stewardship and everyone’s role in that pursuit.

Now I’m sure some folks are getting tired of me harping on this dynamic, but until we start managing the physical environment in a proactive, risk-aware manner, the Top 10 is going to continue to be EC Corner—and I don’t think any of us want that.

To assist in providing information to leaders, the latest update to this part of the portal is a downloadable file of the contents of the videos and the posted materials (not quite a transcript). Hopefully you have a leadership team that’s on board with this stuff, but if not, you’ve got to keep hammering on it. Visit this link to get a refresher on the materials.

 

 

If anyone has some success stories in this regard, I (for one) would love to hear about them. We are a community of safety professionals; the success of one can be the success of all, so let’s make it happen!

 

Does closing rooms due to environmental conditions always make the best sense?

Every once in a while, someone asks me a question about why (or as is more the case here, “how”) a certain approach or response “becomes” the standard of practice, etc. For instance, a lot of times, I will find Interim Life Safety Measures policies that always seem to drive implementation, almost in direct opposition to the level of risk engendered by the deficiency (one caveat: I think you really have to tend towards over-implementing for construction and renovation activities, if only because you can have so little actual control over contractor behaviors. You need think only of the number of truly successful above the ceiling work permit processes—almost makes Powerball sound like a sure thing, but I digress). Anyways, to bring this back to today’s topic, I am reasonably certain (I was going to say “know,” but since I haven’t been everywhere) that many, many folks (very close to all) have intermittent struggles with the management of environmental conditions in surgical procedure areas. If we can use the number and type of Joint Commission findings as any indicator, the struggles continue.

I think we can operate under the assumption that there are very few surgical procedure areas that are perfectly configured every moment of every day (I don’t think that’s a stretch, but please let me know if you have found perfection in this regard). But what I see all the time are policies for which the response to out-of-range values (once you’re done with the call tree) is to make the decision to continue with cases or to close the rooms until the conditions can be resolved. Now I know there are instances in which you need to be a little more careful; I can see the risks of continuing with an invasive surgical procedure if your air pressure relationships are bit squirrelly. But what about the actual risks associated with out-of-range temperature and/or humidity? I mean, if you have an upper humidity limit of 60% (which I think is fairly common), a condition of 60.1% RH is an out-of-range value, but I don’t see where it would necessitate closing the room, delaying cases, etc.

I did a little poking around to figure out the genesis of the “closing the room” dynamic and I have been unable to make anything close to a real determination of where this started. Anecdotally, I got some indication that CMS was the perpetrator, but I’ve heard the same thing about CMS and the general prohibition of cardboard, so I think this may very well reside in that vast wasteland of healthcare compliance mythology (and no Mythbusters to tackle these pressing issues—bugger!). At any rate, I’m wondering if anyone out there has really analyzed the increasing/decreasing risk factors relative to out-of-range (low and/or high) humidity or temperature conditions. I can’t help but thinking that we can do better in this regard, so if someone has something to share (perhaps this would be a very good improvement project for 2016). There’s got to be a point where the risk of the environmental condition(s) actually outweighs the risk of delaying treatment/procedures, etc. Maybe it’s time to figure out exactly where those tipping points live…

We can be heroes

Very much a quick peek this week at more of the latest offerings from our friends in Chicago as they turn to some updated emergency management references. For those of you that have not yet book marked it, first and foremost, you can find the Joint Commission Emergency Management portal here.  The portal homepage includes links to information already published, including a Q&A blog from John Maurer’s 2013 presentation at the JCR Annual Ambulatory Care Conference; while the questions primarily relate to ambulatory settings, some of the general concepts certainly carry over. As I look over the materials, I hope that Mr. Maurer finds more opportunities to write (maybe he could fill in for Mr. Mills once in a while); I don’t know about you, but I like to read different “voices” from time to time and I’ve always found Mr. Maurer very informative and useful in helping folks understand what compliance can look like. At any rate, three’s lots of links to lots of stuff—definitely worth checking out (though I will say that perhaps it’s time to remove the 2013 date from the Joint Commission requirements section at the bottom of the home page; I know that 2013 was the last time that the standards were revised, but it makes things look a little dated).

So, on to the new stuff. First up is an update of general references; this includes links to the CDC Hospital Disaster Preparedness Budget Model, which is an Excel-based tool to assist in estimating resource needs across key departments and to help calculate funding reserves that would be needed for response and recovery (I think a lot of folks are good on financing response, but I’m not so sure about recovery—what say you?). Also, there’s a link to ASPR TRACIE (Technical Resources Assistance Center and Information Exchange—which came first, the acronym or the title?), which aims to provide “timely and innovative disaster information, tools and practice guidance for hospitals and community-based providers”; as well as a link to a Religious Literacy Primer for Crises, Disasters, and Public Health Emergencies. Finally for this page, there’s a link to the 5th edition of the Hospital Incident Command System Guidebook, so, basically, the latest and greatest IC stuff. I still think that the toughest thing about IC is getting consistent buy-in from leadership (sometimes it’s hot, sometimes it’s not), but perhaps edition #5 has the key to their hearts.

Lastly, but certainly not leastly, we have some information regarding the management of vulnerable populations, which can be found here.

There is a wide-ranging batch of information here (I would have liked to see a little more for adult behavioral health; they do touch on the pediatric behavioral health population, but maybe that will be in future missives), much of which I think you’ll find pretty helpful, if only to prompt discussion of the various populations served by your organization.

As with any materials published/shared by TJC, there is always the potential that surveyors will start to equate compliance with each organization’s efforts in dealing with this wealth of information. As always, not everything published is going to be as effective everywhere, so it certainly comes down (back?) to the individual organization’s to determine what preparedness looks like for their organization (and it never looks the same across organizations—even organizations that are in the same system). Emergency preparedness is very much a customizable undertaking—one size fits all does not apply very effectively across organizations (in fact, it would be much closer to one size fits none). You know what works best in your house (and, of course, you used the risk assessment process to make that determination, you clever boys and girls!), so don’t be afraid to set something aside because it is not a good “fit” for your organization. You are the best judge of what you need to do, have in place, educate for, etc. Be confident (but not cocky—that never plays well during a survey…).

Jan. 20 webcast highlights how to deal with high-risk patients

Patients with high-risk behaviors pose a danger to healthcare staff and other patients and are difficult for healthcare employees to manage. In this live webcast, expert speakers Tony W. York, MS, MBA, CHPA, CPP, and Jeff Puttkammer, M.Ed., will discuss the patient factors that often lead to violent events in the workplace, provide a clear understanding of environmental influences and triggers that contribute to violence, and supply tools and resources to help you reduce the risk of a violent event in your facility. The program is scheduled for Wednesday, January 20 from 1 to 2:30 p.m. ET.

Employees have the power to influence their own safety, but they often lack the proper training. Give your staff the knowledge they need to deal with high-risk patients and keep themselves and their facility safe!

At the conclusion of this program, participants will be able to:

  • Define high-risk patient behavior (more than just mental health patients)
  • Explain how a balanced approach to patient-focused care and personal safety impacts patient satisfaction and work-related injuries
  • Identify how workspace design and medical equipment placement can promote or reduce the safety of staff, patients, and visitors
  • Define policies, procedures, and practices aimed at reducing safety risks associated with at-risk patients
  • Understand the critical role staff education and training plays in helping provide the culture, tools, and competencies required to successfully reduce and manage patient-generated violence

Visit here for more information and to register.

Don’t be a Haz-been (or perhaps Haz-not would be more appropriate…)

I would like to take this opportunity to draw your attention to the two most recent issues of Perspectives, for a couple of reasons. First, as the articles (part 1 and part 2) deal with EC.02.02.01, which is on the top 10 list for most-cited standards during 2015, and Joint Commission interpretation relative to the wonderful world of hazardous materials (and it is, indeed, a wonderful world). Second, these articles introduce a new “voice” into the mix, Kathy Tolomeo, CHEM, CHSP, who is one of the engineers at The Joint Commission’s Standards Interpretation Group and is one of the folks in Chicago who reviews clarifications, ESC submittals, perhaps (presumably) PFIs, etc. In that context, I think it’s important to have a sense of how individual reviewers “see” the regulatory compliance landscape, and these articles provide some sense (I will stop short of saying insight) of compliance strategies.

As a starting point, those are good reasons to check out the articles. But I also found these articles particularly helpful in that compliance strategies are discussed in some detail (I mean the articles are only a couple of pages long, so there are limits to how much detail), including an example (in the December Perspectives) of a hazardous materials inventory form, which I think paints a very nice (and perhaps most importantly, clear) picture of what you need to have in place (I’ve encountered a lot of folks struggling with what is expected for the HazMat inventory). There are discussions of eyewash stations and lead PPE, ventilation, and risk assessments (imagine that!) in the December Perspectives; the January issue covers hazardous gases and vapors, permits, licenses, manifests, and other documentation, labeling, monitoring for radiation exposure, proper routine storage, and prompt disposal of trash.

I guess you could say it’s a bit of hodgepodge in terms of ground covered, but that is the wonderful world of hazardous materials and waste. Check out these articles and maybe, just maybe, you can keep yourself off this year’s (or next year’s, depending on when you’re going to be surveyed) Top 10 list.

Fear is not sustainable

A Welshman of some repute once noted that “fear is a man’s best friend” and while that may have been the case in a Darwinian sense, I don’t know that the safety community can rely as much on it as a means of sustainable improvement. I’ve worked in healthcare for a long time and I have definitely encountered organizational leaders that traded in the threat of reprisal, etc., if imperfections were encountered in the workplace (and trust me when I say that “back in the day” something as simple as a match behind a door—left by a prickly VP to see how long it stayed there—could result in all sorts of holy heck), it typically resulted in various recriminations, fingerpointing, etc., none of which ended up meaning much in the way of sustained improvement. What happened was (to quote another popular bard—one from this side of the pond), folks tended to “end up like a dog that’s been beat too much,” so when the wicked witch goes away, the fear goes too, and with it the driving force to stay one step ahead of the sheriff (mixing a ton of metaphors here—hopefully I haven’t tipped the obfuscation scales).

At any rate, this all ties back to the manner in which the accreditation surveys are being performed, which is based on a couple of “truisms”:

 

  1. There is no such thing as a perfect building/environment/process, etc.
  2. Buildings are never more perfect than the moment before you put people in them.
  3. You know that.
  4. The regulators know that.
  5. The regulators can no longer visit your facility and return a verdict of no findings, because there are always things to find.
  6. See #1.

Again, looking at the survey process, the clinical surveyors may look at, I don’t know, maybe a couple of dozen patients at the most, during a survey. But when it comes to the physical environment, there are hundreds of thousands of square feet (and if you want to talk cubic feet, the numbers get quite large, quite quickly) that are surveyed—and not just the Life Safety (LS) surveyor. Every member of the survey team is looking at the physical environment (with varying degrees of competency—that’s an editorial aside), so scrutiny of the physical environment has basically evolved (mutated?) since 2007 from a couple hours of poking around by an administrative surveyor to upwards of 30 hours (based on a three-day survey; the LS surveyor accounts for 16 hours, and then you will have the other team members doing tracers that accounts for at least another 16 hours or so) of looking around your building. So the question really becomes how long and how hard will they have to look to find something that doesn’t “smell” right to them. And I think we all know the answer to that…

It all comes back (at least in my mind’s eye) to how effectively we can manage the imperfections that we know are out there. People bump stuff, people break stuff, people do all kinds of things that result in “wear and tear” and while I do recognize that the infamous “non-intact surface” makes is more difficult to clean and/or maintain, is there a hospital anywhere that has absolutely pristine horizontal and vertical surfaces, etc.? I tend to think not, but the follow-up question is: to what extent do these imperfections contribute to a physical environment that does not safely support patient care? This is certainly a question for which we need to have some sense of where we stand—I’m guessing there’s nobody out there with a 0% rate for healthcare-acquired infections, so to what degree can we say that all these little dings and scrapes do not put patients at risk to the extent that we cannot manage that level of risk? My gut says that the environment (or at least the environmental conditions that I’m seeing cited during surveys) is not the culprit, but I don’t know. As you all know by now (if you’ve been keeping tabs on me for any length of time), I am a big proponent of the risk assessment process, but has it come to the point where we have to conduct a risk assessment for, say, a damaged head wall in a patient room? Yes, I know we want to try and fix these types of conditions, but there are certain things that you can’t do while a patient is in the room and I really don’t think that it enhances patient care to be moving patients hither and yon to get in and fix surfaces, etc. But if we don’t do that, we run the risk of getting socked during a survey.

The appropriate management of the physical environment is a critical component of the safe delivery of healthcare and the key dynamic in that effort is a robust process for reporting imperfections as soon as possible (the “if you see something, say something” mantra—maybe we could push on “if you do something, say something”) so resources can be allocated for corrective actions. And somehow, I don’t think fear is going to get us to that point. We have to establish a truly collaborative, non-knee-jerk punitive relationship with the folks at the point of care, point of service. We have to find out when and where there are imperfections to be perfected as soon as humanly possible, otherwise, the prevalence of EC/LS survey findings will continue in perpetuity (or something really close to that). And while there may be some employment security pour moi in that perpetual scrutiny, I would much rather have a survey process that focuses on how well we manage the environment and not so much on the slings and arrows of day-to-day wear and tear. What say you?

IFU? No, you IFU!

As this little screed represents the closing of the 2015 blogging season (I figure there’s gotta be a lumberjack tie-in—blogging and logging are just too close for words), I’m going to try and keep it relatively brief. If brevity is indeed the soul of wit, then I tend to be rather more witless than not…

Another recent trend in survey findings relates to the management of some of your more “peripheral” patient care equipment, particularly the stuff that gets used by the good folks in the rehabilitation/physical therapy world: hydrocollators, paraffin baths, etc. While I do believe that we have things well in hand from a medical equipment standpoint (most of the equipment being cited falls very clearly into the low-risk/no-risk category), where this is skidding a bit sideways is when the devices in question are not being maintained by the end users in accordance with the manufacturer Instructions For Use (IFU). Now, I will freely indicate that some of the equipment we’re talking about is almost Biblically ancient and the IFUs might not be easily obtainable, but in the absence of a risk assessment to indicate that maintaining this stuff in a manner that is not in strict accordance with the IFUs results in an acceptable level of operational performance/reliability/cleanliness, etc. then you’re at risk for yet another of the (seems like) gazillion little imperfections that are gracing survey reports across the continuum. Interestingly enough, these findings do seem to be “clumping” under the Infection Control standards (pretty much IC.02.02.01, EP 4, which deals with the storage of supplies and equipment), so this may not be on everyone’s radar at the moment. That said, it might be a good idea to poke around a little bit—including any offsite rehab/PT locations—to see if you have any survey risk exposure. Once again, I’m not convinced that this represents a significant risk to patients, but my being convinced (or not) doesn’t necessarily keep you out of trouble during survey. We need to be very sure about where we “stand” in relation to what manufacturers are recommending and what practices and conditions provide appropriate levels of safety, cleanliness, etc. The Joint Commission doesn’t tell us how to do these things, but we need to be able to respond definitively when the questions are (and there is a certain inevitability here) raised during survey.

And on that note, I wish each and every one of you a most prosperous, safe, and successful 2016. See you next year!

Portal chortling: Who wants to be surveyed at Christmas?

I know that this is typically characterized as a season of giving, but I have somewhat of a huge favor to ask of you folks out there in the depths of the blogosphere, so I hope you will bear with me.

With an almost astonishing regularity, the first of each month continues to bring with it a new module being posted in the Environment of Care portal. For the month of December 2015, the featured topic is the Built Environment, inclusive of elements covered under EC.02.06.01, which (as you may recall) was the #1 most frequently cited standard during the first six months (Freudian typo: When I first typed this passage, I came up with “first sux months”—make of that what you will…).

Since I know a lot of folks have been tapped on this one (both as a function of the published data and my own experiences), I was keen to look over the new material—including the latest fireside chat from our partners in compliance George Mills, director of engineering at TJC and Dale Woodin, executive director at ASHE, which covers EP 1 and EP 13 (in separate episodes). One of the interesting things I noticed was, in describing the many and varied findings that are generated under EP 1, a direct comparison was made to OSHA’s General Duty Clause as a function of how this particular EP is being used. Now, the GDC concept as a part of TJC’s survey efforts is certainly not unknown to us (in the “old” days, EC.02.01.01 used to be the catch-all for general safety findings) and basically it comes down to pretty much anything that isn’t quite as it should be (what I have taken to euphemistically describing as imperfections). Could be stained ceiling tiles, could be non-intact flooring, wall, or horizontal surfaces. Could be nurse call cords that are not properly configured (too long, too short, too wrapped around restroom grab bars), could be improperly segregated compressed gas cylinders. The list of possibilities is pretty much infinite.

The second video episode talks about maintaining temperature, humidity, and air-pressure relationships in the “other” locations (pretty much everywhere that isn’t an invasive procedure area or an area that supports invasive procedure areas). I know that there’s been some consternation from findings relating to issues such as pressure relationships in clean utility and soiled utility rooms (clean rooms have to blow and soiled rooms have to suck, so to speak), pressure relationships in pharmacies (positive), laboratories (negative) and so on. There’s some discussion about how these types of conditions might manifest themselves in the environment and the importance of staying on top of these things, particularly during surveys (personal note: my consultative advice is to have an action plan for checking all these various areas that have pressure relationship requirements the moment you learn that “Elvis,” my code name for TJC, is in the building). It is very, very clear that the Life Safety surveyor is going to be checking pressure relationships early on in the survey process—you want to have a very, very good idea of where you stand in the applicable areas.

At any rate, the favor I have to ask (and I’m sure I’ve gone on long enough that the favor is blissfully in the past) is for those of you who’ve viewed the contents of the portal (according to TJC figures, there were 48,000 views of the first two modules; I know I account for a couple of those, but clearly others have checked things out, though it might be interesting to see how many of that number are TJC surveyors…), particularly those of you who have been surveyed in the last few months: Has the material actually been helpful? Part of me feels that the materials are presented in such a general fashion that it makes them less useful from a practical standpoint (perhaps the better part of me), but since I don’t have to worry so much about day-to-day stuff anymore, I will freely admit that I’m too far away from it to be able to say. That said, I am really keen to hear if you think they’ve done a good job, not-so-good job, or somewhere in between. Pretty much any sense of whether the material has been helpful (of course, I could ask the same question about this space, as well, so feel free to weigh in—I always like feedback).

As a final note for this week’s epistle, you may be curious to read about what TJC’s leadership thinks about the portal. You may recall a bit of hand-wringing at the beginning of the year, by Mark Pelletier, the COO of accreditation and certification operations at TJC, regarding the recent “spike” in EC/LS findings (you can find my comments, including a link to Mr. Pelletier’s comments from January, here). As we all know very well, the torture in the EC/LS world has continued (presumably until morale is restored), but the EC Portal is being looked upon as “a light at the end” (at the end of what, I’m not sure, as it isn’t specifically indicated). The thing I keep coming back to in my mind’s eye, is that the typical list of findings is what (again, my “imperfections”) are the types of conditions and practices that, while not perfect (yes, we are imperfect) are not conditions that significantly increase the risks to patients, staff, visitors, etc. If these imperfections are not managed correctly, they could indeed become something unmanageable, but I’m just not convinced that the environment is the big boogie man when it comes to healthcare-acquired infections, which is pretty much the raison d’etre for this whole focus. I keep telling myself that it’s job security, but it frustrates the bejeezus out of me…

Mr. Pelletier’s latest can be found here.

And on that note, I wish you a most joyous holiday season and a safe and inspiring New Year! I may find the urge to put fingers to keys twixt now and the end of the year, but if I do not, please know that it’s taking every ounce of my self-control not to pontificate about something. Consider the silence my gift to you!

Be well and stay in touch as you can!

Only a few shopping days left before the next phase of TJC’s clinical alarm management wishes…

Just in time for the holidays, our good friends at the Association for the Advancement of Medical Instrumentation (more acronymically known as AAMI) have released an Alarm Compendium (isn’t that a fancy title!) to assist healthcare organizations meet the challenges of (our other friends—isn’t it good to have so many friends!) The Joint Commission’s National Patient Safety Goal on Clinical Alarms for which Phase 2 (is it really Phase 2? I’ve kind of lost track since this the second iteration of the Patient Safety Goal, so why don’t we call this v.2.2?) kicks in next month. I haven’t had the chance to look through the whole thing, but I have a sneaking suspicion that we might be observing some of the practices and activities outlined in the Compendium as a benchmark for performance during the 2016 survey year (those of you who have been following this topic closely will recognize some of the 10 Ideas for Safe Alarm Management).

At any rate, the Compendium offers a lot of information about current available knowledge, a list of alarm management challenges, some ideas (10, if you’re counting) for safe alarm management, some sample default parameter settings (for both adult and pediatric patients) and some (what I suspect you’ll find to be) useful appendices. Strictly speaking, the whole thing boils to the simple concept of using alarms safely (simple, but not so easy to pull off). Basically, what we’re looking at (particularly as a function of the next phase of operations) is a classic process improvement activity. I suppose if you (and your organization) have been fortunate enough never to have experienced a failure relative to clinical alarm management you might even be able to use this as a Failure Mode and Effects Analysis (FMEA) to meet TJC’s requirements for a proactive risk reduction activity. That said, I think we can anticipate some interest on the part of the Joint Commission surveyors as they hit the accreditation beaches in 2016 (and, no doubt, beyond). Minimally, it would be more than advisable to dissect the information contained in the Compendium and determine how it may (or may not) relate to clinical operations in your facility. One of the things I like about the Compendium is that it stays away from a “one size fits all” trap (frequently this results in a one-size-fits-none scenario) by providing a fairly broad framework for moving forward. Of course, there is always the possibility (I won’t go so far as to call it a likelihood, but if you’re feeling it, I say “go or it!”) that surveyors will form their own sense of what compliance looks like. I think the best defense is to be prepared to demonstrate, within the framework of the Compendium, to demonstrate what compliance means within your four walls. My mantra when it comes to this stuff is this—you know what “works” in your house better than any surveyor dropping by for a quick visit can—at the end of the day, the responsibility is to ensure an appropriately safe environment for patients, staff, and visitors. Your efforts in this regard should fit quite neatly into your risk management strategy(s): make sure you have all the appropriate folks sign off on the strategy(s) and you should be able to successfully navigate the survey process (this is true of pretty much everything, now that I think about it…)

While the more cynical part of me thinks that perhaps they could have provided a little more lead time for hospitals to absorb the materials, I guess that might be a little too much like looking a gift (insert animal name here) in the mouth. The Compendium is available online. I think this is one gift I’d unwrap now and start playing with—January 1, 2016 will be here before you know it!