June 22, 2016 | | Comments 0
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Are we there yet? Almost certainly not!

One of the fundamental purposes/charges of any high-reliability organization/program, etc., is to be able to identify improvement opportunities and to act upon those opportunities in a manner that actually results in sustained improvement. In the Boston area, we call that “making things bettah!” So, when it comes to the management of the physical environment, I think we can all agree that sustainable improvement is a good thing and, from an operational perspective, really makes a lot of sense. But it’s not necessarily good sense that drives your performance improvement efforts—it’s also a regulatory requirement.

If you look at the CMS Conditions of Participation, clearly there is an expectation of CMS for the management of the physical environment to be incorporated into the hospital’s QAPI program:

482.41 Condition of Participation: Physical Environment

The hospital must be constructed, arranged, and maintained to ensure the safety of the patient, and to provide facilities for diagnosis and treatment and for special hospital services appropriate to the needs of the community.

Interpretive Guidelines §482.41

This CoP applies to all locations of the hospital, all campuses, all satellites, all provider-based activities, and all inpatient and outpatient locations.

The hospital’s Facility Maintenance and hospital departments or services responsible for the hospital’s buildings and equipment (both facility equipment and patient care equipment) must be incorporated into the hospital’s QAPI program and be in compliance with the QAPI requirements.

Interpretive Guidelines §482.41(a)

The hospital must ensure that the condition of the physical plant and overall hospital environment is developed and maintained in a manner to ensure the safety and well being of patients. This includes ensuring that routine and preventive maintenance and testing activities are performed as necessary, in accordance with Federal and State laws, regulations, and guidelines and manufacturer’s recommendations, by establishing maintenance schedules and conducting ongoing maintenance inspections to identify areas or equipment in need of repair. The routine and preventive maintenance and testing activities should be incorporated into the hospital’s QAPI plan.

So, that sets things up fairly succinctly, but in looping back to what CMS is calling/looking for in terms of the indicated “QAPI requirements,” I think there may be opportunities to open things up a bit beyond merely tracking compliance rates (which, typically, perform up to/within regulatory/organizational expectations) and start to look at what those compliance rates mean in terms of demonstrating/verifying the effective management of the physical environment. For example, to my mind, monitoring fire drill compliance as a straight X number of drills per quarter, etc., really doesn’t make a great deal of sense, unless you are having difficulties meeting the requirement (and I should point out that if you are having difficulties conducting fire drills, that’s not going to play well with too many regulatory surveyors). Where I think the “gold” might be (continuing the fire drill example) is in working on figuring out how to demonstrate that the fire drills are effective in preparing folks to respond appropriately in the event of a fire, which leads us to the next piece of the CMS expectation:

482.21(a)(2) The hospital must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that assess processes of care, hospital service and operations.

 482.21(b)(2) The hospital must use the data collected to–(i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement and changes that will lead to improvement.

If you have indicators that are consistently performing at the 100% level, while someone is still going to be monitoring those programmatic aspects, it’s probably time to retire them from the active reporting structure to your EOC Committee. Now I know folks are usually loathe to focus too much on the negative stuff (nobody wants to get in trouble, etc.), but if I may make the suggestion—as a starting point, look at the stuff that you do pretty well, but not perfectly (and if we have learned nothing else over the past couple of years, it’s those things that are not perfect that can cause the biggest problems during a survey). For example, say you are tracking completion rates for non-urgent work order requests, and you are experiencing a pretty solid 90%-95% closeout rate. Now, I would call that a pretty good rate for the non-urgent stuff (presuming that this sterling completion rate is not getting in the way of completing urgent work order requests), but what about that 5%-10% of things that aren’t being completed? Are there any butt-biters in that grouping (things that later resurface to bite you on the backside)? In the interest of putting our best face forward, I think sometimes we focus too much on what has been done and not so much and what hasn’t been done. And I will tell you, the stuff that doesn’t get done will usually cause more trouble than the stuff that did get done.

So when it comes to performance improvement, while it is nice to reflect on the successes of the past, the key metrics “live” in the journey ahead: recognizing that compliance is a journey and not a destination. We ain’t never gonna be “done” with this little pursuit.

For those of you in the northern hemisphere, please enjoy these first days of summah! For those of you at the other end of the globe, wintah is nice, too!

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Filed Under: CMSEnvironment of care

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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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