RSSRecent Articles

I’ve been there, I know the way: More Executive Briefings goodness

You’ve probably seen a smattering of stuff related to the (still ongoing as I write this) rollout of this year’s edition of Joint Commission Executive Briefings. As near as I can tell, during the survey period of June 1, 2017 to May 31, 2018, there were about 27 hospitals that did not “experience” a finding in the Environment of Care (EC) chapter (98% of hospitals surveyed got an EC finding) and a slightly larger number (97% with a Life Safety chapter finding) that had no LS findings. So, bravo to those folks who managed to escape unscathed—that is no small feat given the amount of survey time (and survey eyes) looking at the physical environment. Not sure what he secret is for those folks, but if there’s anyone out there in the studio audience that would like to share their recipe for success (even anonymously: I can be reached directly at stevemacsafetyspace@gmail.com), please do, my friends, please do.

Another interesting bit of information deals with the EC/LS findings that are “pushing” into the upper right-hand sectors of the SAFER matrix (findings with moderate or high likelihood of harm with a pattern or widespread level of occurrence). Now, I will freely admit that I am not convinced that the matrix setup works as well for findings in the physical environment, particularly since the numbers are so small (and yes, I understand that it’s a very small sample size). For example, if you have three dusty sprinkler heads in three locations, that gets you a spot in the “widespread” category. I don’t know, it just makes me grind my teeth a little more fiercely. And the EP cited most frequently in the high likelihood of harm category? EC.02.02.01 EP5—handling of hazardous materials! I am reasonably confident that a lot of those findings have to do with the placement/maintenance of eyewash stations (and I’ve seen a fair number of what I would characterize as draconian “reads” on all manner of considerations relating to eyewash stations, which reminds me: if you don’t have maintenance-free batteries for your emergency generators and you don’t have ready access to emergency eyewash equipment when those batteries are being inspected/serviced, then you may be vulnerable during your next survey).

At the end of the day, I suppose there is no end to what can be (and, clearly, is) found in the physical environment, and I absolutely “get” the recent focus on pressure relationships and ligature risks (and, soon enough, probably Legionella–it was a featured topic of coverage in the EC presentation), but a lot of the rest of this “stuff” seems a little like padding to me…

If it’s September, it’s time for Executive Briefings!

I suspect that, over the next few weeks, as I learn of stuff coming out of the various and sundry Joint Commission Executive Briefings sessions, I’ll be sharing some thoughts, etc., in those regards here in the ol’ blog.

The first thing to “pop” at me was some information regarding Chapter 15 (Features of Fire Protection) in NFPA 99 Health Facilities Code (2012 edition) relating to the management of surgical fire risks. If you’ve not had a chance to check out section 13 of said chapter, I think it will be worth your while as there are a couple of things that in the past one might have described as a best practice. But, with the official adoption of NFPA 99 by CMS, this has become (more or less, but definitely more than before) the law of the land. From a practical standpoint, I can absolutely get behind the concepts contained in this section (I’m pretty comfortable with the position that any surgical fire is at least one more than we should have), but from a strict compliance standpoint, I know that it can be very challenging to get the folks up in surgery to “play ball” with the physical environment rules and regulations.

As one might expect, the whole thing breaks down into a few components: hazard assessment; establishment of fire prevention procedures; management of germicides and antiseptics; establishment of emergency procedures; orientation and training. I think the piece of this that might benefit from some focused attention relates to the management of germicides and antiseptics, particularly as a function of the required “timeout” for the germicide/antiseptic application process. And yes my friends, I did say “required”; Section 15.13.3.6 indicates (quite specifically) that a preoperative “timeout” period shall be conducted prior to the initiation of any surgical procedure using flammable liquid germicides or antiseptics to verify that:

  • Application site of flammable germicide or antiseptic is dry prior to draping and use of electrosurgery, cautery, or a laser
  • Pooling of solution has not occurred or has been corrected
  • Any solution-soaked materials have been removed from the operating room (OR) prior to draping and use of electrosurgery, cautery, or a laser

Now, I will freely and openly admit that I’ve not done a deep dive into the later chapters of NFPA 99 (though that’s on my to-do list), so I hadn’t bumped into this, but I can definitely see this being a potential vulnerability, particularly in light of the recent FDA scrutiny (and it goes to Linda B’s question in follow-up to a recent blog posting—I probably should have turtled to this at that point—mea maxima culpa). At any rate, nothing in this section of NFPA 99 is arguable unless you don’t have it in place and a surveyor “goes there,” so perhaps you should be sure that your OR folks are already “there” sooner rather than later.

Two closing items:

  • The good folks at the Facilities Guidelines Institute have provided a state-by-state resource identifying which states have adopted the FGI guidelines (completely, partially, not really). You can find that information here.
  • Also,  Triumvirate Environmental is presenting a couple of webinars over the next little while that might be of interest. The one this week (sorry for the short notice) deals with the recently established by EPA’s Hazardous Waste e-Manifest Program and then the week after next, there’s a program on Best Practices to Optimize Your Waste Documentation Program. While I can’t call these crazy risky survey vulnerabilities, EC.02.02.01 is still percolating around the top of the most frequently cited list, so it never hurts to obtain greater familiarity with this stuff.

Enjoy your week safely!

Changing (not so much) perspectives on survey trends: Infection Control and Medication Safety

By now I suspect that you’re probably seen/heard that the survey results for the first half of 2018 are only surprising to the extent that there are no surprises (well, maybe a small one, but more on that in a moment). There’s a little bit of jockeying for position, but I think that we can safely say that the focus on the physical environment (inclusive of environmental concerns relating to infection control and prevention) is continuing on apace. There’s a little bit of shifting, and the frequencies with which the various standards are being cited is a wee bit elevated, but the lion’s share of the survey results that I’ve seen are indicative of them continuing to find the stuff they will always be able to find in this era of the single deficiency gets you a survey “ding.” The continuing hegemony of LS.02.01.35 just tells me that dusty sprinklers, missing escutcheons, stacked-too-high storage, etc., can be found just about anywhere if the survey team wants to look for it.

One interesting “new” arrival to the top 10 is IC.02.01.01, which covers implementation of the organization’s infection control plan. I have seen this cited, and, interestingly enough, the findings have involved the maintenance of ice machines (at least so far) and other similar utility systems infection control equipment such as sterilizers (for which there is a specific EP under the utilities management standards). I suspect that what we have here is the beginning of a focus on how infection control and prevention oversight dovetails with the management of the physical environment. I know that this is typically a most collaborative undertaking in hospitals, but we have seen how the focus on the “low hanging fruit” can generate consternation about the overall management of programs. As I’ve noted countless times, there are no perfect environments, but if don’t/can’t get survey credit for appropriately managing those imperfections, it can be rather disheartening.

Couple other items of note in the September issue of Perspectives, mostly involving the safe preparation of medications. As you know, there are equipment, utility systems, environmental concerns, etc., that can influence the medication preparation processes. The Consistent Interpretations column focuses on that very subject and while the survey finding numbers seem to be rather modest, it does make me think that this could be an area of significant focus moving forward. I would encourage you to check out the information in Perspectives and keep a close eye on the medication preparation environment(s)—it may save you a little heartache later on.

Never say never: The ligature risk conversation continues…

I truly was thinking that perhaps I could go a couple more weeks without coming back to the ligature risk topic, but continued percolation in this area dictates otherwise. So here’s one news item and one (all too consultative) recommendation.

If you took a gander at the September issue of Briefings on Accreditation and Quality, you will have noted that the Healthcare Facilities Accreditation Program (HFAP) isn’t revising their existing standards in the wake of the recent CMS memorandum indicating that The Joint Commission’s (TJC) focus work on the subject of managing physical environment risks and behavioral health patients is an acceptable starting point (and I am very serious about that descriptor—I don’t see this ending real soon, but more on that in a moment). I’m not sure if HFAP makes as much use of Frequently Asked Questions forums as TJC does (and with that use, the “weight” of standards), so it may be that they will start to pinpoint things (strategies, etc.) outside of revising their standards (which prompts the question—at least to me—as to whether TJC will eventually carve out the FAQs into specific elements of performance…only time will tell). At any rate, HFAP had done some updating prior (already approved by CMS) to the recent CMS memorandum, but, in using existing CMS guidance (which tends not to be too specific in terms of how you do things), should be in reasonable shape. You can see a little more detail as to where the applicable HFAP standards “live” by checking out this and this. I would imagine that the other accreditation organizations are looking at/planning on how to go after this stuff in the field and I suspect that everyone is going to get a taste of over-interpretation and all that fun stuff.

In the “dropping of the other shoe” department, recent survey results are pointing towards a more concerted look at the “back end” of this whole process—clear identification of mitigation strategies, education of applicable staff to the risks and mitigation strategies, and building this whole process into ongoing competency evaluation. You really have to look at the proactive risk assessment (and please, please, please make sure that you identify everything in the environment as a risk to be managed; I know it’s a pain in the butt to think so, but there continues to be survey findings relating to items the survey team feels are risks that were not specifically identified in the assessment) as the starting point and build a whole system/program around that assessment, inclusive of initial and ongoing education, ongoing competency evaluation, etc. Once again, I would seem that we are not going to be given credit for doing the math in our (collective) head; you have to be prepared to “show” all your work, because if you don’t, you’ll find yourself with a collection of survey findings in the orange/red sections of the ol’ SAFER matrix—and that is not a good thing at all. We are (likely) not perfect in the management of behavioral health patients and that is clearly the goal/end game of this, but right now anything short of that has to be considered a vulnerability. If you self-identify a risk that you have not yet resolved and you do not specifically indicate the mitigation strategy (in very nearly all circumstances, that’s going to be one-to-one observation), then you are at survey risk. I cannot stress enough that (at least for the now) less is not more, so plan accordingly!

Conflagrations of unknown origin: Surgical fire prevention trends

Well, it appears that there remain opportunities for providing a fire-safe experience for surgical patients, at least based on the latest missive from the FDA. The safety communication (released at the end of May 2018) indicates that reports continue to be received by FDA of preventable surgical fires. I can’t think of too many circumstances—OK, none—in which a surgical fire could legitimately be considered unpreventable, though I have no doubt that you all have tales to tell of clinicians who feel that everything was done correctly and there was still a fire. I’d be interested in hearing some of those.

At any rate, the communication indicates several component strategies for appropriately managing the risk(s) associated with surgical fires—and if you guessed that a risk assessment figures into that equation, it may be that we have covered this ground before. So:

  • A fire risk assessment at the beginning of each surgical procedure
  • Encourage communication among surgical team members
  • Safe use and administration of oxidizers
  • Safe use of any devices that may serve as an ignition source
  • Safe use of surgical suite items that may serve as a fuel source
  • Plan and practice how to manage a surgical fire

I don’t think there’s anything that is particularly revelatory—these are by no means new expectations (for us or by us). It does appear that the FDA is going to be leaning on the various accreditation organizations (TJC, DNV, HFAP, CIHQ, AAAHC, etc., though TJC is the only organization specifically mentioned—aren’t they special!), so I think we may see yet another round of ratcheting things up in regards to surgical fire drills, providing education to clinicians, etc. I don’t know how much reaching out you might do relative to actual events in your surgical procedure areas (I can’t say that I always see a ton of information beyond fire drill and education documentation), but I think you’ll want to be able to speak to this as a proactive undertaking. Somebody must be monitoring these types of things and if it’s not you, you need to figure out who it is and keep yourself informed.

As something of a preemptory thought, I ran across a podcast entitled “Nurses for Health Environments” (you can find some background and links to the podcast here). I haven’t had a chance to check it out (I listen to podcasts as I work towards my 10K steps before breakfast, but I always seem to have a backlog of stuff to listen to), but I do believe that (particularly as a very large percentage of the healthcare culture) partnering with nurses and other clinicians in managing the environment makes a great deal of sense. Stewardship of the environment has to happen at every level of every organization, so I would urge you to check it out and maybe recommend it as a listening opportunity for the clinicians in your organization. I’ve always believed that marketing is an important piece of what we do as safety professionals and any (and every) insight into what folks are thinking about, etc., is worth consideration.

How green is your dashboard? Using the annual evaluation process to make improvements

I was recently fielding a question about the required frequencies for hazard surveillance rounds (hint: there are no longer required frequencies—it is expected that each organization will determine how frequency of rounding and effective management of program complement each other) and it prompted me to look at what was left of the back end of the EC chapter (and there really isn’t a lot compared to what was once almost biblical in implication). I think we can agree that there has been a concerted effort over time to enhance/encourage the management of the physical environment as a performance improvement activity (it’s oft been said that the safety committee is among the most important non-medical staff committees in any organization—and even more so if you have physician participation) and there’s been a lot of work on dashboards and scorecards aimed at keeping the physical environment in the PI mix.

But in thinking back to some of the EC scorekeeping documents I’ve reviewed over the years (and this includes annual evaluations of the program), the overarching impression I have is one of a lot of green with a smattering of yellow, with a rather infrequent punctuation of red. Now I “get” that nobody wants to air their dirty laundry, or at least want to control how and where that type of information is disseminated, but I keep coming back to the list of most frequently cited standards and wonder how folks are actually managing the dichotomy of trying to manage an effective program and having a survey (aimed at those imperfections that make us crazy) that flies in the face of a mostly (if not entirely) green report card.

While it’s always a good thing to know where you stand relative to your daily compliance stuff, when it comes down to communication of PI data, it’s not so much about what you’re doing well, but where you need to make improvements. I venture to predict that the time will come when the survey process starts to focus on how improvement opportunities are communicated to leadership and how effective those communications are in actually facilitating improvement. It’s not so much about “blaming” barriers, but rather the facilitation of barrier removal. There will always be barriers to compliance in one form or another; our task is to move our organizations past those barriers. With the amount of data that needs to be managed by organizational leadership, you have to make the most of those opportunities when direct communications are possible/encouraged. And if there are considerations for which the assistance of organizational leadership is indicated, you have a pipeline in place to get that done with the annual evaluation process.

CMS Ligature Risk Update: Not quite finished…

Cast aside the doubt that nothing good came come this way again!

On July 20, 2018, CMS issued further information regarding its expectations for ensuring that behavioral health patients are being provided a safe and appropriate environment. There had been some indication that CMS might be undertaking their own analysis of the current state of things, but it appears that CMS is going to incorporate the outcomes of The Joint Commission’s (TJC) suicide panel (in which CMS representatives participated) into a comprehensive ligature risk interpretive guidance. The memorandum does not indicate when we can expect the finalized interpretive guidance, but things do seem to be moving at a pretty good clip, so I’m thinking (maybe, just maybe), we’ll see that information before the end of the year. As a point of information (and you know I’m all about the points), the Joint Commission guidance cited in the CMS memorandum can be found here: and some clarifying FAQs issued by TJC last month (but not specifically referenced in the CMS memorandum) can be found here: (the information specific to ligature risks is about half way down the page). I know we’ve covered this over the past few months, but I can never be sure at which point in the conversation folks tune in, so I figured it doesn’t hurt to have links for what is current (at the moment…).

For those of you who have not yet tackled all of the particulars relating to the guidance issued from Joint Commission (mostly because you do not use TJC for deemed status accreditation purposes), I do think that the compliance path appears to be fairly reasonable and straightforward from an implementation standpoint. That said, until the interpretive guidance is finalized by CMS, there will likely continue to be some surveyor interpretation in the mix, particularly on the part of those accreditation and regulatory organizations other than Joint Commission (DNV, CIHQ, HFAP, state agencies, etc.). Which means it will be incumbent upon pretty much all hospitals to know where they stand relative to TJC recommendations, particularly as a function of how the strategies and facilities modifications they’ve made meet the intent of the recommendations. Some recent non-TJC survey activities indicate that the “other” accreditation organizations are starting to focus on this topic and, right now, are very much where TJC was in early 2017 when surveyors were inclined to identify anything and everything as a potential, unmanageable risk. And lots of re-surveys following in the wake of those determinations

Beyond a familiarity/assessment relative to the TJC recommendations, the “other” piece of which you need to be mindful is that whatever fixes they identify need to be completed before survey or there will likely be some back and forth relative to Immediate Threat, the need for re-survey, etc.  As we’ve discussed in the past (and this surely goes beyond ligature-resistant hardware), a lot of folks with a significant number of fixes are very much at the mercy of the supplies of needed hardware, etc. At a minimum, hospitals that haven’t completed their “laundry list” of fixes must have a risk assessment in place that outlines not only what is to be done from a facilities standpoint, but what strategies are in place to ensure that the risk to patients is being properly managed in the interim (this is very similar to the survey methodology dealing with Interim Life Safety Measures). As I’ve told folks time and again, you don’t get credit for doing the math in your head—at the end of the day, when you have a survey team “in the house,” the only “good” risk assessment is a risk assessment that is fully documented, approved by the appropriate organizational authorities, etc. If you don’t have an assessment ready to go for survey, it’s likely to be a very tough slog.

At any rate, it does appear that this one is going to be winding down in terms of survey activity, which will bring no small measure of relief to the survey preparation process, but it does beg the question of whether this is the last big environmental dope-slap or if there’s something else waiting in the wings to make us crazy. Any thoughts?

Odds and Sods: Clearing out the Safety Brain

Once again, I come face-to-face with my depository for blog postings and the like, so we have something of a mixed bag this week, with very little in the way of a common theme…

I’m sure folks saw the news story regarding the dead woman found in a stairwell of a hospital power plant and it got me to thinking about the increasing importance of ensuring that all your unmonitored perimeter points are as secure as they can be. It appears that the woman was able to gain access to the stairwell and was either too confused or otherwise compromised to make her way back out. The hospital has since hardened the perimeter of the power plant, but I think this points out that you really need to encourage folks to be on the lookout (security rounds can really only go so far) for unusual circumstances/ folks in their environments. It may be that there was nothing that could be done to prevent this tragedy, but I think it serves as a reminder that you really can’t be too secure.

As something of a parallel pursuit, HCPro recently re-aired a webinar presented my good friend and colleague Ken Rohde on the topic of occurrence reporting and its impact on operations, including the safety realm. Ken is an awesome presenter with a completely useful take on how safety operations impact, and are impacted, by how we manage occurrence reporting, particularly as a source of data for making improvements. If you have some monies in your budget for education, I really encourage you to check out the On-Demand presentation and let Ken help you improve your safety program.

In other parts of my noggin, I was looking at the crosswalk that TJC provides in the online version of their accreditation manual and was contemplating what is referenced as the applicable CMS requirement that “drives” the documentation requirements under EC.02.03.05 EP #28. In all candor, what prompted me to look was this nagging feeling that there are a lot of other required process documentation elements in other parts of the Environment of Care standards and whether there is a likelihood of those documentation requirements being carried over to things like generator testing, medical gas and vacuum system testing, etc. (for you pop culture enthusiasts, I consulted the magic 8 ball and it says “signs point to yes”; for those of you not yet familiar with the amazing technology that is the Magic 8 Ball, find more here). And when I looked at the TJC/CMS crosswalk, I noted that not only is the Life Safety Code® invoked as a referenced requirement, but also the Emergency Preparedness Condition as a function of the provision of alternate sources of energy for maintaining fire detection, extinguishing, and alarm systems. It may not be an imminent shift, but I think you would do well to consider adopting the documentation format outlined under EC.02.03.05 EP #28—it will help organize compliance and maybe, just maybe, keep you a half-step ahead of the sheriff…

On a closing note, I have (yet another) summer reading recommendation for folks: I think we can all agree that the use of effective communications is one of the most powerful tools that we can bring to our safety practices. As you all know every well (I’ve been inflicting this on you all for many, many…), I do tend towards more florid descriptors (that’s one there; I mean who uses “florid” anymore?), which can make comprehension difficult across a multi-faceted audience if you do not take into consideration the entirety of the audience. At any rate, I recently finished Alan Alda’s latest If I Understood You, Would I Have This Look on My Face?, which deals with the science of communications and provides a lot of thought-provoking suggestions on how we might improve the effectiveness of interpersonal communications at every level of life. For me, the most compelling insight was the notion that is the responsibility of the person doing the communicating to make sure that the audience is comprehending what is being communicated. That prompted me to reflect on any number of conversations I’ve had over the years, more or less revolving around the frustration with an audience that “just doesn’t get it” and the thought that perhaps the audience (in all its parameters) merits more consideration when things don’t work out in the way it was planned. At any rate, I found a lot of interesting perspectives on communications and (it’s a pretty quick read) I think you might find a nugget or two for your own use.

I got those travelin’ code compliance blues…

One occupational hazard (or probably more correctly an occupational preoccupation) I find is a constant awareness of code violations wherever I go. It seems that there are an awful lot of airports, concert venues, and the like that are engaged in upgrading facilities, and often, there are plenty of opportunities to look up into the areas above the ceiling envelope. Now I absolutely understand why healthcare gets a lot of scrutiny relative to concerns of life (and general) safety—far too many folks incapable of self-preservation to put them at risk. But as I wander around looking at stuff, I’m thinking we’re dealing with a whole mess of folks (euphemistically called passengers) in almost a collective daze, mesmerized by their cell phones, etc., who would be difficult to manage in the event of an emergency (I also have no doubt that the folks in charge in these various venues have already considered this and have plans in place).

At any rate, just this morning, I was privy to a number of open junction boxes, cabling attached to sprinkler piping, the odd penetration (don’t have the life safety drawings to hand, so I can’t say), in areas just outside of the main construction zone(s)—and no, I didn’t see a posted infection control risk assessment, but it does make one wonder whether it might not be such a bad thing. Presumably things are well-isolated from an HVAC standpoint, though certainly less so from a noise standpoint, but the whole thing does periodically give one (or at least gives me) pause. It is generally acknowledged that healthcare is a heavily regulated industry, and while I think we could certainly engage in extensive debate about the prioritization of risk when it comes to some of the minor imperfections that have become so much a part of the typical survey report, I don’t know that I would alter the accreditation process (which is kind of self-serving as helping folks manage the process is how I make a living).

In the end, this probably a little ado about nothing, but sometimes one is charged with channeling one’s inner curmudgeon…

One item as we close out this week, Health Facilities Management is soliciting input on the operational challenges relating to various monthly inspection and testing items (exit signs, elevator recall) as a function of (more or less) “if you already have a reduced resource pool with which to work, how are you going to manage these.” Check out an article discussing this in general, which includes links to the surveys for each area of consideration. ASHE has been a very effective advocate over time when it comes to compliance activities, so I think it would be good to make your voice heard.

Hanging on in quiet desperation is the safety way: Thought of something more to say!

Recognizing that authorities having jurisdiction (AHJ) always reserve the right to disagree with any decision you’ve ever made or, indeed, anything they (or any other AHJ) have told you in the past, how long are existing waivers, guidance and/or equivalencies good for? Answer: It depends (with more permutations that you can shake a stick at…).

Last week, we chatted a little bit about the whole water management thing, including mention of what CMS is telling surveyors to look for, but I thought it might be useful to extract some of the specifics from that missive (if you missed it last week, it’s here). So, here we have:

Expectations for Healthcare Facilities

CMS expects Medicare and Medicare/Medicaid certified healthcare facilities to have water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems.

Facilities must have water management plans and documentation that, at a minimum, ensure each facility:

  • Conducts a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g., Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system.
  • Develops and implements a water management program that considers the American Society of Heating, Refrigerating, and Air-Conditioning Engineers (ASHRAE) industry standard and the CDC toolkit.
  • Specifies testing protocols and acceptable ranges for control measures, and document the results of testing and corrective actions taken when control limits are not maintained.
  • Maintains compliance with other applicable federal, state, and local requirements.

Note: CMS does not require water cultures for Legionella or other opportunistic waterborne pathogens. Testing protocols are at the discretion of the provider.

Healthcare facilities are expected to comply with CMS requirements and Conditions of Participation to protect the health and safety of its patients. Those facilities unable to demonstrate measures to minimize the risk of LD are at risk of citation for noncompliance.

Expectations for Surveyors and Accrediting Organizations

Long-term care (LTC) surveyors will expect that a water management plan (which includes a facility risk assessment and testing protocols) is available for review but will not cite the facility based on the specific risk assessment or testing protocols in use. Further LTC surveyor guidance and process will be communicated in an upcoming survey process computer software update. Until that occurs, please use this paragraph as guiding instructions.

Just so you know, I chose to use some of the text in bold font because I think that’s probably the most important piece of this for folks moving forward (kind of makes me think that, just perhaps, there have been citations for folks not actively pursuing water cultures). But it does establish the expectation that a piece of the required risk assessment is going to include something that relates to whether you choose to culture, how often, and how you came to make that determination. I think this helps folks manage some of the ins and outs of this process, but I still feel like this could end up being a source of consternation as surveyors “kick the tires” in the field.