October 27, 2015 | | Comments 0
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I’m getting too old for this shift…

Because of the nature of the survey process as currently administered by our good friends in Chicago, I periodically have the opportunity to work with clients after they have been surveyed, sometimes developing cogent and not-too-ambitious corrective action plans, and sometimes working with them to try and clarify findings that were based on the surveyor(s) identifying the one or two imperfections in what was otherwise a pretty solid process. Generally speaking, these are “C” elements of performance, based in the concept that to demonstrate substantial compliance with the standard/EP in question, you would provide data to support an historical compliance rate of 90% or better. The classic example of a finding that one would always try to clarify is if the surveyor turns up a fire extinguisher (or two) with some missing monthly inspections (depending on how you inspect your fire extinguishers, there is always the possibility for something to get overlooked, etc.—again, an imperfection in the process). Classically, since each fire extinguisher has 12 monthly inspections per year, you could “miss” one of those 12 inspections and still have a compliance rate greater than 90%–in this instance, 91.66666666666667%, which I’m as positive as I can be is a numerical value in excess of the desired 90% level. So, unless you had a completely broken process for doing the monthly fire extinguisher inspections, even if they found a couple of missing months during survey, the overall picture would be workable through clarification. To take the example just a bit further, say you had 100 fire extinguishers in your inventory, which represents 1,200 potential data points over the course of a year, and the finding was that a fire extinguisher in each of two mechanical spaces was missing the two most recent inspections because the person who usually inspected them was out on leave. That would be four findings of non-compliance identified during survey, but if you compare those four instances of non-compliance to the 1,196 findings of compliance, you would have a compliance rate of about 99.6%, another numerical value that exceeds the 90% mark.

I think that’s pretty straightforward as a going concern, or at least it was until recently. (By the way, I have successfully used the above-noted strategy for clarifying fire extinguisher findings any number of times in the past. Really, this would be as close to a sure thing as anything I can think of.) In working with a client on a fire extinguisher clarification, the correspondence coming back from Chicago indicated that the clarification was not accepted because “100% of life safety devices are required to be inspected at the defined monthly frequency.” Without mentioning any names, I can say that this adjudication was issued by someone in the Engineering office with whom I am not familiar, so it may be that what we have here is an isolated strict, strict, strict interpretation (my choice is to remain hopeful until proven otherwise), but if this type of interpretation is to be applied to “C” Elements of Performance, then what indeed is the rationale for having the “C” Elements of Performance? I hear a lot of information regarding regulators trying to “work with” hospitals, but if the benchmark for maintaining everything under EC.02.03.05 is going to be perfection (and, presumably that requirement could be extended to elements in clinical engineering and utility systems management, both of which nominally fall under the aegis of NFPA 99, compliance with which is required by the Life Safety Code®), how are these most frequently cited standards going to subside in frequency? I understand that everyone involved (regulator and regulated) has a responsibility to ensure that patients, staff, and visitors are provided as safe and comfortable environment as possible, but if every swing of the bat has to be a home run, every pass downfield a touchdown (I could go on, but I will desist), the odds are very squarely stacked against the folks in the field who have to make this happen. And I, personally, do not think that that is a very good thing at all.

I suspect that I’ll have more to say about this through the coming weeks. Again, I will remain hopeful, but if this is the future, we’re in for a very bumpy ride!

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Filed Under: Environment of careLife Safety CodeThe Joint Commission

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Steve MacArthur About the Author: Steve MacArthur is a safety consultant with The Greeley Company in Danvers, Mass. He brings more than 30 years of healthcare management and consulting experience to his work with hospitals, physician offices, and ambulatory care facilities across the country. He is the author of HCPro's Hospital Safety Director's Handbook and is contributing editor for Briefings on Hospital Safety. Contact Steve at stevemacsafetyspace@gmail.com.

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