April 19, 2021 | | Comments 0
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Water is wet: How about your ORs?

Howdy folks, as our friends from Chicago return to the field, a couple of items have come to my attention that I felt were worth sharing. There’s also an updated resource that we’ve mentioned in the past (though it seems that there are always many things that we’ve mentioned in the past—go figure).

First up, as we know from our diligent perusal of the intricacies of NFPA 99, Section 6.3.2.2.8.4 indicates that “(o)perating rooms shall be considered to be a wet procedure location, unless a risk assessment conducted by the health care governing body determines otherwise.” Consequently, the Life Safety surveyors are asking to see the risk assessment that determined otherwise or validation that your ORs are appropriately protected in accordance with the requirements for wet locations (isolated power, etc.). In previous discussions, I did note that “health care governing body” would seem to indicate that the assessment needs to include, at least to some degree—it doesn’t specify—hospital leadership. My general thought is that if your ORs aren’t considered wet locations and weren’t designed that way, you should be able to use the initial design/build aspect of the ORs to represent an assessment of those risks and, nominally, as construction activity, would have involved hospital leadership. I guess that then begs the question of how often you would need to revisit the assessment. It might be a(nother) good use of the annual evaluation process; I’m a big fan of using that process to “plant” things where you know they are likely to be viewed during survey. Much as the comments section of the eSOC is a good place to memorialize waivers, equivalencies, and the like, the annual evaluation is a good place to revisit important historical decisions. At any rate, it appears that wet locations are high on the “ask list,” so be prepared.

Another consideration that appears to be on the table is a risk assessment regarding what type(s) of fire extinguishers are in your ORs (could surgical fire management be a theme?). Our friends from the Windy City have something to say about this, and it appears that there was a recent update (though what got updated is not immediately apparent) to the FAQ, so probably worth a visit. I don’t doubt that these elements came into play when extinguishers were first chosen, but (again!) it never hurts to review…

Lastly this week, while this hasn’t necessarily been a survey hot topic, somehow it feels like water management programs are going to start to become more heavily surveyed. I think we can agree that this is a significant risk to be managed and while there is minimal evidence that these risks are not being appropriately managed in U.S. hospitals, any time something “new” comes along, it tends to represent a shift in survey focus. In the past, I’ve recommended checking out Matt Freije’s work at HC Info for really useful information on water management concerns. He does a great job of keeping an eye on water management across the globe, but also keeps an eye on our friends. If you’ve not settled into a water management program yet (and you really do need to get on it), it is definitely worth checking out the HC Info website.

On that note, I will bid you adieu for now; hope you all are doing well and staying safe. See you next week!

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Filed Under: The 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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