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The trouble with normal?

It always gets worse!

While I can’t say with absolute certainty, it seems likely that I’ll be employing relatively brief missives over the next couple of weeks as we do seem to be shifting gears a bit as far as the “return to normal.” As I write this, it’s been a couple of weeks since my last air travel and (based solely on my own observations) I have every reason to think that the COVID surge being reported is going to be a disruptive factor—I am hoping that this is the last wave before we reach safe harbor, but I’m not just seeing noses in enclosed public spaces, I’m seeing lots of full faces. I received my second dose of the vaccine about 10 days ago, but I’m going to keep masking up for the foreseeable future when I’m traveling. I will be happy to be proven that it was more than I needed to do, but I’m still waiting on the data…

So, just a couple of resource items for moving into the next phase of normalcy. First up, I was always (OK, since last June) surprised by the variability of screening practices and that surprise continues today. But if you want to get a sense of what I’m seeing in the field, this would be a good starting point. I don’t know that there’s a whole lot of data regarding how effectively screening helped stem the tide of COVID or even how often cases were identified through that process, but maybe someday there will be some sense.

Another element for consideration is visiting folks in nursing homes and other care facilities. I don’t think there’s anyone who would argue that there has been a significant emotional toll since the onset of COVID, which, I suppose has given the powers that be a fair amount of time to come up with how to transition safely on the visitation front. In September 2020, CMS issued some guidance in that regard and, a few weeks ago, updated that guidance in light of vaccinations, etc. Again, if we get another spike, this might be the best we get for a while, but at least it’s something…

And that, as they say, is that—at least for this week. Who knows what might come flying out of nowhere to create havoc, so stay tuned.

Be well and stay safe. Every day brings us a little closer to the end of this thing!

Forever in debt to your priceless advice…

Continuing on with our discussions of the unusually revelatory April issue of Perspectives, we shall now turn to the life safety-related items, starting with the sweetness of suites (though this may result in some tart-y findings).

One of the most anticipated elements related to the adoption of the 2012 edition of NFPA 101 Life Safety Code® was the full-on acknowledgement of suites. One of things I still find curious/amusing about the whole suite designation thing is there have classically been any number of patient (and other) spaces in healthcare that were clearly designed within the suite concept—even going back to design elements present in the ’70s (yes, I am that old—the ED in the first hospital in which I worked was an area of open patient “positions” with, I think, a trauma room that had a door). The postanesthesia care units (PACU) is the example that springs most quickly to mind—I don’t know that there was ever a time when PACUs were subdivided into individual rooms. From an operational standpoint, the design of a suite makes perfect sense for such care locations. Another area that was frequently “suite-ified” was the critical care unit, though those often had doors, but not necessarily doors that positively latched.

At any rate, one of the primary clear benefits of the suite design is the subtle shifting of “corridors” into “communicating spaces” (and now, as indicated in the April Perspectives, “aisles”), allowing for a fair amount of operational flexibility when it comes to the management of equipment, supplies, etc.  I guess there is something of a quandary when it comes to how much of this information is shared with staff at point of care/point of service—mostly based on the “if you give them an inch…” logical fallacy (more info on that sequence can be found with a web search; I wouldn’t advise it, though, as it is rather a rabbit hole). At any rate, the latest issue of Perspectives is (more or less) throwing down the survey gauntlet when it comes to clear width of spaces within a suite, invoking NFPA 101-2012 7.3.4.1(2), which sets a minimum width of egress at 36 inches in all facilities or portions of facilities classified as a healthcare occupancy. Soooooo, any spaces in which there are fewer than 36 inches of clear width are probably going to be cited; my gut instinct tells me that this will be most relevant to emergency department spaces, where the activities of the day tend to lean towards more blurry lines when it comes to egress paths. The other thought that popped into my head, based on the “portions of facilities classified as a health care occupancy,” is that there may be some patient rooms that might not make the 36 inches between the foot of the bed and the adjacent wall. That may not be an issue, but in my mind’s eye, I can see some tight squeezes…

The other life safety-related item in the April Perspectives deals with the (perhaps final) curtain call for the Building Maintenance Program (BMP) strategy for maintaining certain life safety components. While I can’t necessarily refer to the BMP as an anachronism, it’s been more than a decade since there was an particular survey benefit, though I believe—at least it was the last time I was able to look—the electronic Basic Building Information does include a question asking if the organization is using a BMP. Is anybody willing to hop on their TJC portal to see if the question is still there? That said, I don’t think CMS ever really accepted the concept of the BMP as an alternative means for managing life safety deficiencies (much as the PFI process was eventually kicked to the curb). I just checked the JCR portal for the standards manuals, and the BMP entry is still there, so I guess it’s taking a couple of bows before the curtain comes down for good.

As always, I trust that you all are well and staying safe. I just received my second dose of the vaccine the other day, so hopefully this will make traveling a simpler proposition. I guess every day brings us another day closer, so let’s keep the party going!

You gotta keep one eye looking over your shoulder…

And so with the onset of Spring, our friends in Chicago are laying out some more fun stuff to deal with over the next 12-18 months. In looking at the April edition of Perspectives, I don’t know that there’s anything I would call a surprise, though I suppose one of the announcements (pronouncements?) might prove to be problematic over the long haul (the “free pass” one sometimes receives for questionable practices in areas designated as suites might be harder to come by, but I think we’ll chat about that next week). But then again, if you have an effective survey management strategy, perhaps not; at worst, probably something to practice…

First up, effective January 2022, we have something of a shift in the requirements for water management programs—a shift to the extent that they done birthed a new standard just for water management. We’ve chatted about this topic in the past will take you to everything from last October back to the very beginning of time (or so it seems), so anyone who has been paying attention, particularly to the CMS stand on such matters, should be in reasonable shape. Here’s what you need:

  • A program/plan for managing waterborne pathogens, including Legionella
  • The identity of the individual or team charged with the responsibility for the program/plan
  • A basic diagram of your water system, including all water supply sources, treatment systems, processing steps, control measures, and end-use points (that will be a lengthy list for most folks—hope you’ve started that)
  • Documentation of testing/monitoring activities; corrective actions and procedures when your testing/monitoring results are outside of acceptable limits; documentation of corrective actions when control limits are not maintained
  • Review of the program at least annually, including any time there’s a modification to the water system than could add risk, including new equipment or systems

To my eye (and mind), I don’t see anything here that has not already been in the mix and, to be honest, if you haven’t been working through this process, you may be running the risk of bad survey mojo, particularly if the survey is the result of a waterborne pathogen outbreak at your facility. Again, this one isn’t giving me any fits as I look at the details, but we can probably intuit that they’ll be kicking the water management tires a little more frequently (and perhaps with greater vigor).

As we close out this week’s epistle, I wanted to share with you a resource aimed at assisting folks in hospitals with creating programs for sustainable energy use. As we edge ever closer to whatever the “new normal” is going to represent, I have no reason to think that managing energy costs/expenses will fall by the wayside. If you’re starting to look at energy sustainability, this might be right up your alley.

Next week, we’ll talk about communicating spaces in suites and bid adieu (yet again) to the Building Maintenance Program, so until next time, I hope you continue to be well and stay safe!

It’s these little things, they can pull you under…

I guess this week’s entry (as it appears that Spring is actually going to spring) falls into the “a little bit of this, a little bit of that” category; nothing monumentally earth-shattering, but (hopefully) useful.

First up, a recent post from the American Society of Health Care Engineering’s (ASHE) YouTube channel (somehow, it escaped me that such a thing existed—shame on me!) popped up on some feed somewhere (it may have been LinkedIn, but I can’t say for sure) and I found it a very interesting topic of conversation: “The Cost of No.” Given the givens, I suspect there are not too many in the audience who haven’t been at the receiving end of a “no” response (as opposed to no response, which is equally frustrating), and this video may give you some food for thought in how best to manage that impregnable wall. It’s not often that we get what we want, when we want, but I think the video offers some insight into how to plead a better case—to the point that it might increase the chances for a positive response “next time.” The video is pretty short (you can spare 158 seconds, can’t you?) and there are a number of other short videos that are worth checking out, so don’t forget to subscribe. You can start with “No” right here, but please check out the other stuff as well.

Moving on, in a designation that doesn’t seem to have been influenced by Hallmark, March is National Ladder Safety Month (I would have sent a card, but couldn’t even find a birthday card with a ladder that could have been repurposed) and I think we can all agree that ladders are an important part of the compliance picture. I’ll let you find your own “ladder unsafety” images—there are more than I can count, but I think we can also agree that the safe use of ladders could be more thoroughly hardwired into a lot of folks’ practice, including inspecting the ladders before use.

At any rate, I encourage you to set up a ladder safety session for your folks, particularly if you haven’t done so in a while – and what better month to do so. Here are some resources to help ensure folks embrace the heights of safety:

Until next week, hope you are well and staying safe. We’ve made it this far and I am confident we can make it through this together!

Folks back home surely have called off the search…

We knew it was going to happen eventually, but our friends in Chicago have made it official (just in time for the implementation of Daylight Savings Time—for those of you participating), the return of the (more or less) completely unannounced surveys by The Joint Commission (see the first article in the March 10 edition of Joint Commission Online). To be honest (and I try never to be anything but), I really can’t say how far behind they are on the survey front. I can’t imagine that there’s not going to be some serious catching up to do, and, since the public health emergency is still in play, I’m not sure how much time they’ll be given by the feds to reach some sort of survey plateau.

Presumably, they will continue to rely on the CMS COVID data (we talked about that a little while back; if you’ve somehow managed to misplace that link, you can find it here) to determine where the trouble spots might be (if you look at the latest data, the results are promising; hopefully we won’t be remembering the beginning of March as the—yet another—calm before the storm), so if you’re in a “red” county, that may be enough to avoid being in the first wave. I suppose the other dynamic is how survey teams will they be able to field—it sounds like this is going to be a busy week for folks, so if they show up on your front door step, please know that this community is standing by with best wishes for success.

As an adjunct to the return of the survey, TJC unveiled the 2021 Survey Activity Guide, which, among other things, formally speaks to the elimination of the Environment of Care interview session, indicating that topics previously covered in the session will find their way into the EC/LS tracer activities. Thus, effectively giving the LS surveyors another hour or so to wander the halls, with the implication being that they may go to/get to places in your house where they’ve not previously been. I’m not entirely certain, though I suppose if you have a fair amount of square footage there may be one or two spots that might not have been ransacked before, but I’m guessing you have a pretty decent idea of where they’ve not been, so it might be worth kicking those tires, so to speak. We know for a pretty fair certainty that they will be visiting the kitchen (after all, there’s a checklist and far be it for a checklist to go unchecked…).

They’ve also updated/revised the list of documents, including the return (don’t call it a comeback!) of the Statement of Conditions and Basic Building Information, something of a focus on water management programs (make sure you have your ASHRAE and CDC ducks in a row) and the management of line isolation monitors (if you have them). And, of course, the perennial attentions to the Management Plans (I’m not going to say anything more about those for a bit…) and annual evaluation process. Oddly enough, it appears that the document list also includes things that are not required to be documented, but rather are in place to remind you and the surveyors of some specific expectations like, oh, how ’bout, managing safety risks. I almost forgot about that…

So, hopefully the survey process will be less lion and more lamb as we get things rolling again. I think most organizations are experiencing some variation of PTSD and I don’t think that kicking folks in the head is going to be very helpful. The fact that healthcare has managed to keep things going over the past 12 months is a testament to the effectiveness of our processes, etc. I’m not expecting pats on the back (as deserved as they may be), but I do expect some reason in the administration of the survey process—or at least, that’s my hope—especially for everyone that’s in the barrel for this coming few weeks.

Please be well and stay safe—and keep doing what you’re doing. You folks are amazing, and don’t forget it!

From the sky, the highway’s straight as it could be!

But other things, maybe not so much…

In the continuing odyssey of “what goes around, comes around,” I had to cast some tea leaves to recall the last time we chatted about eyewash stations (for those of you keeping track, it was October 2019) as I reviewed the current (March 2021) edition of Joint Commission Perspectives, particularly what I view to be the most interesting aspect (and if you want to interpret that as the only interesting aspect, I would not argue the point) of the publication, the Consistent Interpretation column (I think it’s fair to call it a column, though perhaps not always a load-bearing one). The March Interpretation article deals generally with the minimizing the risks associated with managing hazardous chemicals (for which about 50% of the hospitals surveyed in the last year of the 20-teens were cited). I would encourage you to check out the details. It may save you some future heartache, especially if you have dental clinics in the mix—dental amalgam would seem to be the “pet rock” of some surveyors.

One very useful interpretation is that “simple storage” of corrosive chemicals is (more or less—we’ll see how the play on the field reflects this) off the table in terms of having to have an eyewash station (fortunately for all of us, containers of corrosive chemicals tend not to explode on their own…). Where you do need to provide access (or at least consider) are locations where corrosive chemicals are used/mixed/ dispensed. And this is where it is of critical importance to do your due diligence when it comes to the risk assessment; corrosive (and caustic) chemicals that are injurious to the eye (and other parts) are where you cross the line into eyewash stations. And given the recent funkiness regarding disinfectant cleaners and a return to bleach as a frequently used disinfectant agent, I suspect that there’s going to be a lot of attention to where bleach is being, well, used, mixed and/or dispensed. This is going to present more than its share of challenges in the field, I suspect…

Interesting point in the explanatory section of the piece; there’s a link to an OSHA interpretation that is instructive, but could be confusing as it deals specifically with electric battery storage charging and maintenance areas. Clearly, the focus is (and should be) on managing those most hazardous chemicals, etc. that we might use in the workplace, so it will be interesting to see how this unfolds over the next survey cycle.

As a closing thought (and this it definitely out of left field), I’m not sure how many EVS folks are out there in the audience, but one condition I’ve been encountering with a fair amount of frequency (and not just in hospitals—I look at this stuff wherever I go) are baby changing tables for which the safety belts have either gone missing or been damaged, etc. I know it’s not a big thing (unless you’re a parent with a squirmy infant), but (if you look at it wearing your ugly surveyor hat) you could make the case that if it’s something provided by the manufacturer, then the expectation is for the equipment, etc., to be maintained in accordance with the manufacturer’s Instructions For Use. It’s not something you have to do all the time (unless somebody is swiping them), but it might be worth scheduling a “sweep” of your changing tables from time to time.

Until next time: Be well and stay safe!

Breaking the law: Not something you want to be doing…

A very quick item this week, mostly because I want you to have the opportunity to take advantage of a resource that I think is well worth your time and you only need your ears…if you’re thinking podcast, you’re thinking in the right direction. For those you that might not be familiar with Gosselin/Martin Associates, they are a highly respected (at least by me—and I know I’m not alone) organization (and I’m paraphrasing a bit here) devoted to the systemic improvement to healthcare facilities management. From recruitment, education, mentoring, etc., Gosselin/Martin Associates are a most reliable resource on so many levels, but for this week, I would encourage you to check out their High Reliability—The Healthcare FM Podcast to check out the current climate as it relates to the legal ramifications of healthcare facilities management. As a going concern, amidst our current state of being, being familiar with the legal implications of what we do has arguably never been more important and the likelihood that that importance will increase is virtually a sure thing. As with all things everywhere, there is only so much black and white interpretation, etc., to go around, but I think you’ll find this discussion to be quite illuminating, if only to validate what you might already be thinking/experiencing, etc. The blog post for the podcast can be found here and I very much encourage you to subscribe. I find it very stimulating to listen while I am walking in the morning (bedtime probably won’t work—this won’t put you to sleep!), but I suspect you’ll find your own “best time.” I hope you take a few moments to check out High Reliability.

As always, hope you are well and staying safe!

Doing the waive: Categorical waivers are still in the mix…

In preparation for last week’s missive on the transmission of fire alarm signals during fire drills (more on that in a moment), I ran across a CMS categorical waiver that was posted early last fall (September 25, to be exact) that provided some relief for folks wishing to use corrugated medical tubing in certain circumstances, rather than the rigid copper tubing required under NFPA 99-2012, due what CMS might consider an unreasonable hardship as corrugated medical tubing can be installed more efficiently and economically than rigid copper. The basis of the waiver is due to a more recent version of NFPA 99 (the 2018 edition) in which there are provisions that provide for installation of the corrugated. At this point, we all know the drill: You have to read the whole thing very carefully to ensure you don’t step on any regulatory toes, but if you’ve got some tricky installations coming up, this might be something of a relief. You can find all the details here.

Now, the reason I bring up the transmission of fire alarm signals deal is that the most recent edition of NFPA 101 (2021) includes some clarification in this regard (a shout out to Grant Finch out in Oregon for his detective skills on this). As noted last week, the current language indicates transmission of a fire alarm signal (with no additional information to be found as defining what that means, leaving things in the hands of the interpretive dance masters). The 2021 edition, in section 19.7.1.4, requires fire drills to include the simulation of emergency for fire conditions (much as it does now), but it goes on to say “include activation of the fire alarm system notification appliances.” Section 19.7.1.7 still provides for the coded announcement between 2100 and 0600 hours, so that piece of it remains the same.

At any rate, I am hopeful that, with this current version clarification, even if there is no categorical waiver forthcoming, the accreditation organizations will stop fussing about the fire alarm signal transmission and move on to other things. After all, the truly applicable code for testing fire alarm signals is NFPA 72, so why would need to include signals in our fire drills—which reminds me, you still need to document the elapsed time of the fire alarm signals generation to its receipt at the central monitoring service, etc. I’ve been running into a spate of vendors that are not including that in their documentation, so you probably want to give your latest testing documentation a look. And while we’re on the subject, I personally think it’s bogus for your testing vendor to just give you a printout of the month’s alarm activity in which the test occurred; they should either highlight it on the sheet or pull the dates/times/results off the printout. I suspect that they are being more than adequately compensated for their services, which (to my mind) includes a summary of the results, particularly any deficiencies. I don’t think you should have to hunt for the deficiencies and now with the rollout of the virtual survey process (something on that next week), surveyors will have more time than ever to comb through your reports for those funky little missed devices, etc. Your fire alarm (and sprinkler system) ITM vendor should be highlighting the “to do” list so you can get it “to done.”

Hope you’re having a safe and productive week. See you on the flip side!

Are you transmitting? Late night fire drills and alarm signals…

I think we can safely say that sometimes it is tough to pinpoint specifics when it comes down to what performance elements are cited during regulatory surveys, be they virtual or actual. In this regard, I really couldn’t say to what extent this particular item is being cited, but I know that it happens and often that happening results in some level of consternation of the “How am I supposed to do that?” variety.

The Life Safety Code® (LSC) NFPA 101-2012 19.7.1.4 requires that: “(f)ire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions.” Section 19.7 (section 19.7.1.7, to be precise) goes on to indicate that “(w)hen drills are conducted between 9:00 p.m. and 6:00 a.m. (2100 hours and 0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.” I suspect that, over time, a lot of folks have ended up equating the transmission of a fire alarm signal and the use of a coded announcement as being equivalent, but that really isn’t the case. 19.7.1.7 allows you to conduct a fire drill without disturbing patients, etc., but, as it turns out, you still have to include the transmission of the fire alarm signal (that’s the signal that actually “leaves” the building and goes to the central monitoring service, 911 call center, etc.). If you need further indication, I submit to you the “opinion” (or you could call it an interpretation) of one of our favorite AHJs. I think this gives you a good sense of the separation of what happen inside your facility versus making sure that pesky alarm signal finds its way outside.

But the question then becomes, how does one accomplish this if one has a fire alarm system that doesn’t provide an easy way of turning off the internal signals and still allowing for the transmission of the signal? This question bounced my way recently and I decided to do some poking around to see if there were any scholarly works, etc., and I came across some guidance published back in 2016 (the document is dated June 2016, so it would precede the official adoption of the 2012 LSC by CMS), that outlines some of the particulars of fire drills to be conducted in Minnesota.

One of the interesting elements is a note that deals with today’s discussion: “Note: When a coded announcement is used instead of audible alarms on the night shift, the fire alarm should be sounded first thing in the morning the following day to meet the requirement that each drill include ‘transmission of a fire alarm signal.’” Now I recognize that AHJ interpretations are many and varied (to an almost frightening degree), but I was wondering if anyone had been able to negotiate this type of process with their AHJ. It certainly makes sense to me that you could “extend” completion of the fire drill a few hours to ensure proper operation of the fire alarm system, but I also suspect that you’d probably be reticent to go that route without getting some sort of permission and you’d probably need to write it in to your policy or management plan as a standard practice or procedure, but it seems a rather elegant solution to me ( as a non-AHJ). What say you all?

Hoping this finds you well and staying safe; I figure every week brings us closer to whatever’s coming next, so let’s get there together!

Stay Centered and Carry On: PHE likely to persist through 2021!

As any of the Peanuts gang might opine: AAUGH!

In a letter to the governors, Norris Cochran, the acting secretary of HHS, indicated that it had been determined that the Public Health Emergency (PHE) will likely remain in place for the entirety of 2021, but there would also be a 60-day notification prior to the termination or expiration of the PHE.

Ostensibly, this removes at least some of the uncertainty of the quarterly updates of the PHE status and appears to provide a 60-day window for organizations to attain compliance with any regulatory requirements covered under the 1135 waiver process, including the blanket waivers currently in effect. I suspect this also means that support at the federal level will remain in place relative to response activities—the letter also indicates that this should be considered evidence of the government’s commitment to ongoing response to the pandemic.

Presumably, there is a cross-section of folks in the field who either didn’t adopt any of the waivers or have been able to move things back to “business as usual” in terms of inspection, testing and maintenance activities, so this may not mean that much from a practical standpoint. That said, if there are any of you out there who have been able to make good use of, you probably need to start thinking about a turnaround within 60 days. Maybe you start to reach out to your vendors—there’s probably going to be a queue for services once this whole thing breaks loose—and the indication is that the accreditation organizations are not going to be flexible once the PHE expires/terminates. I’m trying to think of what processes would take longer than 60 days to get back on track and nothing is springing to mind. Again, I suspect that scheduling the work is going to be the “sticky wicket” if there’s going to be any issue, so if there’s anything you can do to pre-load that process, it’s probably time well-spent.

Until next time, hope you are well and staying safe!