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It’s been a long time: Revisiting an EOC perennial

Setting the wayback machine for the dark ages of safety (well, 2011 or so), we come to the last time we covered the monitoring of temperature and/or humidity in surgical spaces, etc. (if you want to revisit those halcyon days, you can head here). The funny thing about this most ancient of history is that, since then, while there have been changes in applicable codes and references, the “new” stuff comes up a little short when it comes to providing guidance relating to monitoring temperature and humidity, particularly as a function of frequency (I suppose we could call it the frequency function if we were being excessively alliterative). The baseline response (catty though it may be) is that you should be monitoring conditions on as frequent a basis as is required to ensure appropriate conditions, given due consideration of the systems you have in place, any manufacturers’ recommendations (which are also not particularly helpful in determining monitoring frequencies), and regulatory guidance (ASHRAE 170; state mechanical code) as applicable.

Ultimately, this all comes down (back?) to the requirements as outlined in the Conditions of Participation, which gives us:

  • 482.41(c)(4) – There must be proper ventilation, light, and temperature controls in pharmaceutical, food preparation, and other appropriate areas.

So, you might well ask, what are those “other appropriate areas”? For that information, we need to head over to the State Operations Manual/Interpretive Guidelines, which is where the skeleton of the Conditions of Participation is fleshed out into the survey process.  And what do we find there? Take a look:

Interpretive Guidelines §482.41(c)(4) – There must be proper ventilation in at least the following areas:

  • Areas using ethylene oxide, nitrous oxide, glutaraldehydes, xylene, pentamidine, or other potentially hazardous substances;
  • Locations where oxygen is transferred from one container to another;
  • Isolation rooms and reverse isolation rooms (both must be in compliance with Federal and State laws, regulations, and guidelines such as OSHA, CDC, NIH, etc.);
  • Pharmaceutical preparation areas (hoods, cabinets, etc.);
  • Laboratory locations; and
  • Anesthetizing locations. According to NFPA 99, anesthetizing locations are “any area of a facility that has been designated to be used for the administration of nonflammable inhalation anesthetic agents in the course of examination or treatment, including the use of such agents for relative analgesia.” NFPA 99 defines relative analgesia as “A state of sedation and partial block of pain perception produced in a patient by the inhalation of concentrations of nitrous oxide insufficient to produce loss of consciousness (conscious sedation).” (Note that this definition is applicable only for Life Safety Code® purposes and does not supersede other guidance we have issued for other purposes concerning anesthesia and analgesia.)

Interesting to note that the list here does not quite match up with the totality of issues for which The Joint Commission is citing folks (clean and soiled utility rooms being first and foremost, though I know that it is merely an extrapolation of the ASHRAE 170 requirements). Also interesting to note that, sterile supply and processing is not specifically mentioned, but (again), I think we can see where the importance of maintaining those spaces drives out of ASHRAE 170.

But what’s the endgame when it comes down to the survey process? The general unhelpfulness of the answer will not surprise you:

  • Review monitoring records for temperature to ensure that appropriate levels are maintained
  • Review humidity maintenance records for anesthetizing locations to ensure, if monitoring determined humidity levels were not within acceptable parameters, that corrective actions were performed in a timely manner to achieve acceptable levels

So (still!) if you follow the temperature and humidity rabbit all the way back to the Interpretive Guidelines, we see that the surveyors are instructed to ask to see “records,” so it all comes down to what you can produce in terms of a deliverable that reflects that temperature and humidity levels are appropriate/acceptable and levels that were not within acceptable parameters (which they do not define, so you better have a sufficiently flexible definition) were dealt with in a “timely manner” (again, not defined, so it’s up to you, based on your risk assessment).

As a closing thought on this (for now), apparently there are some folks that have determined that they don’t have to monitor both elements (temperature and/or humidity) and if there is nothing else that you derive from this week’s missive, it is this: You gotta do both! You can determine the frequency (though I would recommend at least daily—if you recall, the question that started this conversation in 2011 was whether quarterly monitoring was sufficient), but you clearly want to be able to use performance data to make that determination (and from whence comes that data—regular monitoring). You can determine what is acceptable/appropriate (based on utilization, types of procedures, preference of surgical staff, etc.); you can determine what is a timely timeframe for corrective action (Timely Timeframe—that sounds like a name Stan Lee would’ve loved). But you gotta do the monitoring; to do otherwise risks too much if the CMSers darken your door (which is becoming a much more common occurrence).

One last quick note for this week: There seems to be a bit of a groundswell of survey findings relating to hand sanitizer dispensers not having drip trays. It would seem that there must have been some recent mention of this in surveyor education as there are some surveyors indicating that this is a new requirement, but the overarching requirement has been in place for rather a while. To whit (and, again, the State Operations Manual becomes then go-to resource):

  • 482.41(b)(9) (ii) The dispensers are installed in a manner that minimizes leaks and spills that could lead to falls; with the associated Survey Procedure being: “Determine whether the hospital maintains the ABHR dispensers in accordance with the manufacturer’s guidelines, or, if there are no manufacturer’s guidelines, that the hospital has adopted policies and procedures to ensure that the dispensers neither leak nor the contents spill.”

Now, nowhere in the regulatory canon does it discuss drip trays (though, when you come right down to it, how else are you going to manage the threat of leaks/drips, especially over hard-surface flooring?). But apparently drip trays have become the “gold standard” for leak/drip control, so you might want to keep an eye on this for the future. These things do tend to spread and who wants to be chasing this during a (or post) survey? Not me.

Eat, drink, and be safe: Some guidance on the care and feeding of staff

One of the more universal conditions I find is the whole issue of where staff can grab something to eat or drink in the midst of busy periods, particularly when staffing levels don’t necessarily dovetail with leaving the work space to go to the cafeteria, etc. And there’s always the specter of someone, somewhere having invoked the “You can’t eat there, it’s against TJC regulations” or “You can’t drink there, it’s against regulations” and so forth and so on. And what better strategy than to use a regulatory presence from outside the organization to be the heavy.

Many’s the time I’ve tried to convince folks that, from a regulatory perspective (with some fairly well-defined exceptions, like laboratories), there is nothing that approaches a general prohibition when it comes to the how, when, and where of eating and drinking in the workplace (and yes, I absolutely understand that prohibition is the easiest thing to “police,” but I think prohibitions also tend to “drive” more creative workarounds). And in the March 2019 edition of Perspectives, our friends in Chicago provide a couple of clarifications for folks, and if you think that there’s a risk assessment involved, then you would be correct.

So, the clarifications are two in number:

  • There are no TJC standards that specifically address where staff can have food or drink in the work areas.
  • You can identify safe spaces for food and drink as long as those locations  comply with the evaluation (read: risk assessment) of the space and your exposure control plan as far as risks of contamination from chemicals, blood, or body fluids, etc.

The guiding light in all of this, if you will, are the regulations provided by the Occupational Safety & Health Administration, and while they have a lot to say about such things (Bloodborne Pathogens and Sanitation), a careful analysis should yield a means of designating some spaces. I have seen a lot of designated “hydration stations,” particularly in clinical areas, to help keep folks hydrated over the course of the working day, so clearly some folks are working towards providing some flexibility based on a risk assessment. This is a good thing both in terms of staff support, but also in not drawing a line in the sand that they don’t have to. Prohibitions can bring about some of your toughest compliance challenges, so if you can work with folks to build in some flexibility, it could mean fewer headaches during rounding activities.

Making a checklist, making it right: Reducing compliance errors

As you may have noticed, I am something of a fan of public radio (most of my listening in vehicles involves NPR and its analogues) and every once in a while, I hear something that I think would be useful to you folks out in the field. One show that I don’t hear too often (one of the things about terrestrial radio is that it’s all in the timing) is called “Hidden Brain”, the common subject thread being “A conversation about life’s unseen patterns.” I find the programs to be very thought-provoking, well-produced, and generally worth checking out.

This past weekend, they repeated a show from 2017 that described Dr. Atul Gawande’s (among others) use of checklists during surgical (and other) procedures to try to anticipate what unexpected things could occur based on the procedure, where they were operating, etc. One of the remarks that came up during the course of the program dealt with how extensive a checklist one might need, with the overarching thought being that a more limited checklist tends to work better because it’s more brain-friendly (I’m paraphrasing quite a bit here) than a checklist that goes on for pages and pages. I get a lot of questions/requests for tools/checklists for doing surveillance rounds, etc. (to be honest, it has been a very long time since I’ve actually “used” a physical checklist; my methodology, such as it is, tends to involve looking at the environment to see what “falls out”). Folks always seem a little disappointed when the checklist I cough up (so to speak) has about 15-20 items, particularly when I encourage them not to use all the items. When it comes to actual checklists that you’re going to use (particularly if you’re going to try and enlist the assistance of department-level folks) for survey prep, I think starting with five to seven items and working to hardwire those items into how folks “see” the environment is the best way to start. I recall a couple of years ago when first visiting a hospital—every day each manager was charged with completing a five-page environmental surveillance checklist—and I still was able to find imperfections in the environment (both items that they were actually checking on and a couple of other items that weren’t featured in the five-pager and later turned out to be somewhat important). At the point of my arrival, this particular organization was (more or less) under siege from various regulatory forces and were really in a state of shock (sometimes a little regulatory trouble is like exsanguination in shark-infested waters) and had latched on to a process that, at the end of the day, was not particularly effective and became almost like a sleepwalk to ensure compliance (hey, that could be a new show about zombie safety officers, “The Walking Safe”).

At any rate, I think one of the defining tasks/charges of the safety professional is to facilitate the participation of point-of-care/point-of-service folks by helping them learn how to “see” the stuff that jumps out at us when we do our rounds. When you look at the stuff that tends to get cited during surveys (at least when it comes to the physical environment), there’s not a lot of crazy, dangerous stuff; it is the myriad imperfections that come from introducing people into the environment. Buildings are never more perfect than the moment before occupancy—after that, the struggle is real! And checklists might be a good way to get folks on the same page: just remember to start small and focus on the things that are most likely to cause trouble and are most “invisible” to folks.

Waste not, want not: The rest of the CMS Emergency Preparedness picture

Moving on to the rest of the guidance document (it still lives here), I did want to note one last item relative to emergency power: There is an expectation that “as part of the cooperation and collaboration with emergency preparedness officials,” organizations should confer with health department and emergency management officials, as well as healthcare coalitions to “determine the types and duration of energy sources that could be available to assist them in providing care to their patient population. As part of the risk assessment planning, facilities should determine the feasibility of relying on these sources and plan accordingly.

“NOTE: Hospitals, CAHs and LTC facilities are required to base their emergency power and stand-by systems on their emergency plans and risk assessments and including the policies and procedures for hospitals. The determination of the appropriate alternate energy source should be made through the development of the facility’s risk assessment and emergency plan. If these facilities determine that a permanent generator is not required to meet the emergency power and stand-by systems requirements for this emergency preparedness regulation, then §§482.15(e)(1) and (2), §483.73(e)(1) and (2),

  • 485.625(e)(1) and (2), would not apply. However, these facility types must continue to meet the existing emergency power provisions and requirements for their provider/supplier types under physical environment CoPs or any existing LSC guidance.”

“If a Hospital, CAH or LTC facility determines that the use of a portable and mobile generator would be the best way to accommodate for additional electrical loads necessary to meet subsistence needs required by emergency preparedness plans, policies and procedures, then NFPA requirements on emergency and standby power systems such as generator installation, location, inspection and testing, and fuel would not be applicable to the portable generator and associated distribution system, except for NFPA 70 – National Electrical Code.”

I think it is very clear that hospitals, et al., are going to be able to plot their own course relative to providing power during emergency conditions, but what’s not so clear is to what depth surveyors will be looking for you to “take” the risk assessment. I suspect that most folks would run with their permanently installed emergency generators and call it a day, but as healthcare organizations become healthcare networks become healthcare systems, the degree of complexity is going to drive some level of flexibility that can’t always be attained using fixed generator equipment. If anyone has any stories to share on this front (either recent or future), I hope you’re inclined to share (and you can reach out directly to me and I will anonymize your story, if you like).

Wrapping up the rest of the changes/additions, you’ll be pleased to hear that you are not required to provide on-site treatment of sewage or waste, but you need to have provisions for maintaining “necessary services.” Of course, the memo indicates that they are not specifying what “necessary services for sewage or waste management” might be, so a little self-definition would appear to be in order.

If your organization has a home health agency, then you need to make sure that the communication plan includes all the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. I think that one’s pretty self-evident but may be worth a little verification.

Next up are some thoughts about providing education to folks working as contracted staff who provide services in multiple surrounding areas; the guidance indicates that it may not be feasible for these folks to receive formal training for each of the facilities emergency response plan/program. The expectation is that each individual (and this applies equally to everyone else in the mix) knows the emergency response program and their role during emergencies, but each organization can determine how that happens, including what constitutes appropriate evidence that the training was completed. Additionally, if a surveyor asks one of these folks what their role is during a disaster, then the expectation would be for them to be able to describe the plan and their role(s). No big surprise there (I suspect that validating the competency of point-of-care/service staff is going to be playing a greater role in the survey process—how many folks would they have to ask before somebody “fumbles”?)

The last item relates to the use of real emergency response events in place of the required exercises; I would have thought that this was (relatively) self-evident, but I guess there were enough questions from the field for them to specify that you can indeed use a real event in place of an exercise. Just make sure you have the documentation in order (I know I didn’t “have” to say that, but I figure if it’s important enough for CMS to say it, then who am I…). The timing would be one year from the actual response activation, so make sure you keep a close eye on those calendars (unless, of course, you have numerous real-life opportunities…).

I do think the overarching sense of this is positive, at least in terms of limiting the prescriptive elements. As is sometimes the case, the “responsibility” falls to each organization to be prepared to educate the surveyors as to what preparedness looks like—it has many similar components, but how things integrate can have great variability. Don’t be afraid to do a little hand-holding if the surveyors are looking for something to be done a certain or to look a certain way. You know what works best in your “house,” better than any surveyor!

Walking in the shadow of the big man: CMS isn’t done with emergency preparedness

Imagine that!

The turn of February brought with it the latest epistle from our friends at CMS as they continue to noodle on the preparedness of the nation’s hospitals. I don’t know that this represents a ton of hardship for folks and I do know, for at least some folks, the latest directive is fairly straightforward as a function of their emergency preparedness programs, activities, etc. As we’ve discussed once or twice over the years (decades?!?), emergency preparedness is a journey, it is not a destination. And while we do have the opportunity to plot our own course on this, it seems that the regulatory oversight piece will never be very far away.

So, the first piece of this (you can find the whole missive here) is the pronouncement that planning for using an all-hazards approach to emergency management (and who isn’t?!?) should also include consideration of emerging infectious disease (EID: Influenza, Ebola, Zika, etc.) threats. The guidance goes on to indicate that planning for EIDs “may require modifications to facility protocols to protect the health and safety of patients, such as isolation and personal protective measures.” I think my immediate inclination would be to include EID threats as a separate line item for your HVA (my fear being if you integrate things too well into your existing, then you’ll be that much harder-pressed to “pull out” the EID portion of your organizational analysis). And/or if you combine all the IC stuff into one, then you might make changes to your plan to address the higher-risk stuff and create some operational challenges for your “normal” stuff. It’s early in the game on this one, so we’ll see how the process matures.

Next up we have some discussion relative to the use of portable/mobile generators as part of our emergency preparedness activities. It would seem that a lot of folks reached out to CMS to see if they were going to have to replace portable/mobile generators with the typical generator equipment found in hospitals, and (hooray!) the answer to that question is no, you don’t have to: unless your risk assessment indicates that you should. Apparently, there were other questions relating to the care and feeding of portable/mobile generators and the ruling on the field is that you would have to maintain them in accordance with NFPA 70 (and, presumably, the manufacturers’ IFUs), which includes:

  • Have all wiring to each unit installed in accordance with the requirements of any of the wiring methods in Chapter 3.
  • Be designed and located to minimize the hazards that might cause complete failure due to flooding, fires, icing, and vandalism.
  • Be located so that adequate ventilation is provided.
  • Be located or protected so that sparks cannot reach adjacent combustible material.
  • Be operated, tested and maintained in accordance with manufacturer, local and/or state requirements.

It also mentions that extension cords and other temporary wiring devices may not be used with the portable generators, so make sure that you have those ducks in a row.

There are a few more things to cover, but I think those can wait until next week. See you then!

Don’t bleed before you are wounded, and if you can avoid being wounded…

…so much the better!

Part of me is wondering what took them so long to get to this point in the conversation.

In their latest Quick Safety utterance, our friends in Chicago are advocating de-escalation as a “first-line response to potential violence and aggression in health care settings.”  I believe the last time we touched upon this general topic was back in the spring of 2017 and I was very much in agreement with the importance of “arming” frontline staff (point of care/point of service—it matters not) with a quiver of de-escalation techniques. As noted at the time, there are a lot of instances in which our customers are rather grumpier than not and being able to manage the grumpies early on in the “grumprocess” (see what I did there?!?) makes so much operational sense that it seems somewhat odd that we are still having this conversation. To that end, I think I’m going to have to start gathering data as I wander the highways and byways of these United States and see how much emphasis is being placed on de-escalation skills as a function of everyday customer service. From orientation to periodic refreshers, this one is too important to keep ignoring, but maybe we’re not—you tell me!

At any rate, the latest Quick Safety offers up a whole slate of techniques and methods for preparing staff to deal with aggressive behaviors; there is mention of Sentinel Event Alert 57 regarding violence and health workers, so I think there is every reason to think that (much as ligature risks have taken center stage in the survey process) how well we prepare folks to proactively deal with aggressive behaviors could bubble up over the next little while. It is a certainty that the incidence rate in healthcare has caught the eyes and ears of OSHA (and they merit a mention in the Quick Safety as well as CDC and CMS), and I think that, in the industry overall, there are improvements to be made (recognizing that some of this is the result of others abdicating responsibility for behavioral health and other marginalized populations, but, as parents seem to indicate frequently, nobody ever said it would be fair…or equitable…or reasonable…). I personally think (and have for a very long time, pretty much since I had operational responsibilities for security) that de-escalation skills are vital in any service environment, but who has the time to make it happen?

Please weigh in if you have experiences (positive or negative are fine by me) that you’d feel like sharing—and you can absolutely request anonymity, just reach out to the Gmail account (stevemacsafetyspace@gmail.com) and I will remove any identifying marks…

Power Up: When your generator doesn’t carry a 30% load

Particularly for smaller facilities (or, I suppose, big places with multiple generators), consistently meeting the requirement for a 30% load during monthly generator testing activities can be a bit of a chore. And it can result in having to consider performing an annual load test at increasing loads, which usually means that you have to contract out that extra load test (and they ain’t cheap, all things being equal).

But if you look at NFPA 110-2010, it does provide another means of complying with the monthly requirements. Section 8.4.2 indicates that “(d)iesel generator sets in service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:

  1. Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
  2. Under operating temperature conditions and at not less than 30 percent of the EPS standby nameplate KW rating

Note: The 2019 edition of NFPA 110 removes the word “diesel” for the text, which opens things up a bit for folks who don’t have diesel generators.

So, the trick becomes how best to capture the exhaust gas temperatures, so you are assured of a compliant test and not being at risk for wet-stacking during the generator test. Fortunately, when it comes to emergency power system information, there is no better source than the good folks at Motor & Generator Institute (MGI). Dan Chisholm and the folks at MGI have just the thing to get you started and even if you’re an experienced generator owner/operator, I would encourage you to check out the information here.

It might just give you a leg up on the survey process!

E to the E to the E to the E: Next step(s) towards a reporting culture

Thinking that this may have gotten lost in the year-end shuffle, I wanted to take a moment to cover a little ground relative to Sentinel Event Alert (SEA) #60: Developing a reporting culture: Learning from close calls and hazardous conditions. I believe (I was going to say “know,” but that’s probably a little more hyperbolic than I can reasonably venture, but I’m basing it on your “presence” here—you folks are all about getting better and on the off chance that I provide something useful to that end, I’m pleased to have you along for the ride) that you folks are committed to ongoing evaluation of performance, occurrences, funky happenstance, etc. and so little of this will come as anything resembling revelation. That said, I think we do need to prepare ourselves for the wild and wacky world of surveyor overreach and draconian interpretation. Part of my “concern” (OK, perhaps most of it) revolves around the innate simplicity of the thrust of SEA #60. It’s straightforward, cogent, and all the things you would want through which to develop a compliance framework:

  • Establish trust
  • Encourage reporting
  • Eliminate fear of punishment
  • Examine errors, close calls and hazardous conditions

But, how do you know when you’ve actually complied with this stuff? Is this more of an activity-driven requirement: We’re going to do A, B, and C to “establish” trust, then we’ll do D, E, F, G, and H to encourage reporting? (Aren’t we already encouraging reporting?) And the whole “eliminate fear” thing (I’ve had one or two bosses that would have a hard time not administering some sort of retributory action if you messed up)…how do you pull that off? Likely, the examination of errors and close calls is a normal part of doing business, but the examination of hazardous conditions seems less of a fit in this hierarchy. My own tendency when I find a hazardous condition is to try and resolve it (I do love a good session of problem-solving), but maybe it’s more of an examination once someone reports the condition as hazardous. Not quite sure about that.

At any rate, there’s lots of information available on the subject, including an infographic on the 4E methodology, as well as the usual caches of information, etc. which you can find here and here and here.

I am a big fan of encouraging the reporting of stuff by the folks at the point of care/point of service, so to the extent that this moves healthcare in that direction, I’m all for it. So, my question to you is: Does  this represent a shift for the way in which you practice safety in your organization or perhaps gives you a little bit more leverage to get folks to “say something if they see something”? Does this help or is it just so much “blah, blah, blah”?

In security we trust, insecurity we fear: Are you up for a challenge?

Last week we started noodling on where things might go from a regulatory/accreditation perspective as the dust “settles” relative to the management of behavioral health patients, ligature risks, etc., as well as the continuing march on infection control targets, items that are certainly on the radar. But there’s one other item that I keep coming back to (in my mind’s eye): Getting our arms around issues relating to workplace violence. While I have no data to support it beyond a general impression based on conversations with various folks, I would venture to say that, if you look at it purely in terms of “room for improvement,” concerns relating to the management of workplace violence has got to be sitting pretty near the top of the “to do” list (I suspect it’s at the top of that list, but if you should happen to either have this one completely under control or there’s something that concerns you more, I’d love to hear about it).

I don’t think (and I’m certainly not in a position to dispute) the numbers are indicative of anything but a pervasive, tough-to-solve issue, particularly in the current healthcare environment. I hear stories about difficulties getting funding for technology solutions, additional staffing to maximize those technology solutions, etc. sometimes forcing us to be reactive as opposed to being able to develop a proactive response. But in looking at the OSHA website as a warmup to penning this particular entry into the Safety Space canon, I noticed that some updated materials have been posted on the OSHA website, including an executive summary for hospital leaders, some examples of best practices, and some information on how you might integrate workplace violence prevention into your organization’s “regular” compliance activities. The addition of these materials, perhaps as a subset of being helpful, tells me that there’s still a fair amount of consideration being given to the subject and we, as an industry, might be well-served to give these materials a look-see. Share that executive summary with your organization’s leaders if you have not already done so; start talking with your organizational risk management and occupational health folks to start working towards elevating this to an organizational priority before the events of the day force you to do so (or to explain to your boss why you didn’t). I’ve worked in healthcare long enough to remember those halcyon days when hospitals were not the hotbed of safety and security risks they are today—until somebody invents a working time machine, we’re not going back there, so we have to focus on future improvement.

And, interestingly enough, I’m not the only one thinking about this stuff; I would encourage you to check out Tim Richards’ blog post. He provides some good food for discussion and perhaps even some early budget planning. There’s a lot of technology out there, some of it (I daresay) could be very useful in protecting folks in a more effective way. This one’s not going away any time soon, and to be honest, I can see this becoming something of a survey focus in the not-too-distant future.

Manage the environment, manage infection control risks

In looking back at 2018 (heck, even in looking back to the beginning of 2019—it already seems like forever ago and we’re only a week in!), I try to use the available data (recognizing that we will have additional data sometime towards the end of March/beginning of April when The Joint Commission (TJC) reveals its top 10 most frequently cited standards list) to hazard a guess on where things are heading as we embark upon the 2019 survey year.

First up, I do believe that the management of ligature risks is going to continue to be a “player.” We’re just about two years into TJC’s survey focus on this particular area of concern; and typically, the focus doesn’t shift until all accredited organizations have been surveyed, so I figure we’ve got just over a year to go. If you feel like revisiting those halcyon days before all the survey ugliness started, you could probably consider this the shot heard ’round the accreditation world or at least the opening salvo.

As to what other concerns lie in wait on the accreditation horizon, I am absolutely convinced that the physical environment focus is going to expand into every nook and cranny in which the environment and the management of infection control risks coexist. I am basing that prediction primarily on the incidence of healthcare-associated infections (HAI) and related stuff (and, as was the case with ligature risk, I suspect that having a good HAI track record is not going to keep you from being cited for breakdowns, gaps, etc.). We’ve certainly seen the “warning shots” relating to water management programs, the inspection, testing, and maintenance of infection control utility systems, management of temperature, humidity, air pressure relationships, general cleanliness, non-intact surfaces, construction projects, etc. Purely from a risk (and survey) management perspective, it makes all the sense in the world for the survey teams to cast an unblinking eye on the programmatic/environmental aspects of any—and every—healthcare organization. Past survey practice has certainly resulted in Condition-level deficiencies, particularly relative to air pressure relationships in critical areas, so the only question that I would have is whether they will be content with focusing on the volume of findings (which I suspect will continue to occur in greater numbers than in the past) or will they be looking to “push” follow-up survey visits. Time will tell, my friends, time will tell.

But it’s not necessarily just the environment as a function of patient care that will be under the spotlight; just recently there was a news story regarding the effects of mold on staff at a hospital in New York. TJC (as well as other accreditors including CMS) keeps an eye on healthcare-related news stories. And you can never be certain that it couldn’t happen in your “house” (it probably won’t—I know you folks do an awesome job, but that didn’t necessarily help a whole lot when it came to, for example, the management of ligature risks). Everything filters into how future surveys are administered, so any gap in process, etc., would have to be considered a survey vulnerability.

To (more or less) close the loop on this particular chain of thought (or chain of thoughtless…), the Centers for Disease Control and Prevention are offering a number of tools to help with the management of infection control risks in various healthcare settings, including ambulatory/outpatient settings. I think there is a good chance that surveys will start poking around the question of each organization’s capacity to deal with community vulnerabilities and these might just be a good way of starting to work through the analysis of those vulnerabilities and how your good planning has resulted in an appropriately robust response program.