RSSAuthor Archive for Steve MacArthur

Steve MacArthur

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.

Would you believe there’s nothing up my sleeve?: Protective measures

Caution: This is not a product endorsement, but rather an observation of a product that might, at times, sound a little endorse-y. I can be persuaded…

While working at a hospital somewhere in the United States, I was apprised of a product being installed that will (hopefully) facilitate securing doors that might not otherwise be secured, in the event of an active shooter or other threat that would require the establishment of a safe barricade. Effectively, the product is a metal wedge-shaped sleeve (hence the product name: Fighting Chance) that slides over the arm of a door closer and prevents the door from being opened.

At first encounter, I thought it was a pretty nifty idea (and still do), but I was curious about how one would be able to consistently operationalize the device from a practical standpoint: How do you make sure that you’ve got someone tall enough to be able to reach up and slide the sleeve over the arm? I’ve seen a lot of doors and door arms in my time and I can tell you (I’m about 5’ 6”) that there are some door arrangements for which I would have a very difficult time being able to reach the arm.

So, the question I have (and I will be happy to share the information) is if you are using this product (or even considering using this product), are you including provisions/consideration to assist the more diminutive members of your organization (maybe some sort of step stool stored in close proximity, perhaps something else—I know you folks are creative as all get out)? Have you drilled the used of these devices and found any other opportunities for improvement? I am a great admirer or simple technology and I do like the simplicity of the design—I’m just curious as to how it will play in the field.

I hope it’s a winner!

Don’t forget to leave room for amazement: The perils of occupational fatigue

If you’ll bear with me, friends, this week deals not so much with the harsh realities of our vocation, but with the hope that those harsh realities can be effectively managed.

One of the true blessings of my work as a consultant is the opportunity to change things up on a regular basis—meeting new people and seeing new places while still renewing acquaintances encountered on the journeys of the past 18 years. And, as I think about it, I do hope (at least some of the time) this blog provides you with some level of diversion, but occupational fatigue (aka work burnout) is more common than serves anyone’s benefit.

I am in the habit of collecting things that interest me, and sometimes I’ll encounter something of sufficient interest that I want to share it with you folks. In wandering around the internet in the wake of the anniversary of the first moon landing, I came across a blog post (written by Brad Stulberg) describing some ways of dealing with work burnout that I felt was worth sharing.

As with so many things that “occur” to me, it’s not so much the revelatory aspect of the piece (though there is that to some degree), but rather the “tone” of the article that really caught my attentions to the extent that I wanted to share this with you. It doesn’t necessarily relate to safety in a global sense (though I could make the case that it does relate to personal safety to a fair degree), but I think anything that can shift the direction of conversation, even for the briefest of moments, is time well spent.

So, a short one this week, but that should give you some time to seek out a little amazement—you can never have too much magic in your life!

Maybe there’s a hole in there somewhere: Keeping your critical equipment running!

An interesting line of questioning is emerging in some recent survey activity (mostly during state visits, but the accreditation organizations are moving in this direction, particularly those with a focus on ISO processes) relates to the management of “high mortality” utility systems components, particularly emergency power supply system parts. If you look at this as a function of high reliability, ensuring that you have close to immediate access to a means of repairing those things that are most likely to break (and I suspect that everyone out there in the reading audience know which of your utility systems are most likely to give you fits—from experience, elevators always seem to figure in on that count).

I think in most instances it would require some level of working with your service providers to identify the things that are most likely to go wrong and then to set up a process for ensuring ready access to parts and service. Let’s face it, there are few more angst-filled moments than when you have to tell your boss that a critical piece of equipment is going to be down because parts need to be ordered, etc. And I don’t know of too many service vendors that are maintaining a broad-range of replacement parts, etc. on their shelves (I’m sure there are some and that’s great for you if they “live” in your neighborhood); inventory can be an expensive undertaking. But maybe there’s a way to build that into your next service contract—something to think about—your incumbent is probably going to have the most specific failure data relative to your equipment, but I would think there are sufficient commonalities of systems and equipment to allow for competitive proposals if you choose to go that route.

Some other contractual considerations (and this is more on the compliance front than anything, but still)—a “hard” touch whenever folks are onsite servicing equipment—at the very least, they can let you know if they see anything that might prove troublesome, so you don’t have to hunt for it when the paperwork arrives (hopefully sooner rather than later—that’s another contractual consideration—turnaround time for service reports/records). I don’t know that we’ll ever have enough granularity of data from the regulatory folks, but I am absolutely convinced (based on what I’ve seen) that the reason that findings in and around fire safety (and other) systems documentation relates to stuff being buried in vendor reports: the “classic” smoke detector that didn’t get tested or the heat detector in an elevator shaft that someone terms “inaccessible.” We (as a collective) are on the hook for ensuring that 100% of your devices and equipment are inspected, tested, and maintained in accordance with code and regulation. Our vendors really don’t have any “skin” in the game.

I’m sure this is all rather self-evident to you folks, but where I’m sitting at the moment, there’s not a lot of “new” stuff floating around and it was a miserable rainy day, so this is what the connection of head and fingers conjured up.

Like water for opportunistic organisms: Protecting patients through utility systems

As a wise individual once noted, “water always wins” (at risk of betraying my nerd status, you can find the entire quote here), and it seems like water in its numerous forms is giving facilities professionals a run for their money this year. From mold in an OR in the Northwest to the constant battle (or so it seems) with Legionella prevention, this is as challenging a time as I can recall for facilities. And that doesn’t even take into account the ongoing impact of minor intrusions—leaks, condensation, overflowing toilets—it is an almost endless list of troubles.

My intent was to provide the above as information, with my usual encouragement to leverage point-of-care/point-of-service staff in the early identification of trouble spots, but I’m also thinking that perhaps someone out there in the field has been able to develop an effective plan for the proactive management of water woes. Certainly, I know of folks with fairly predictable “rainy seasons” and then there are those locations in which rain is a constant threat, not to mention the intrusion of humidity by various (and sometimes nefarious) means. So, what do you do that works (recognizing that this is not a one size fits all proposition)? Do you have any useful/effective strategies you can share with the blogosphere? I generally only hear about stuff that doesn’t work, so it would be a treat indeed to tout someone’s intuitive brilliance.

As a final note for this week, those of your laboring under the yoke of TJC accreditation might do well to give the August issue of Perspectives a look (it’s become less of a regularly useful read for me, but every once in a while). In the Consistent Interpretation column/article, there’s a lot of discussion (under the guise of the Infection Control standards) of PPE use/availability/education, etc. Again, the findings are falling under the IC standards from a past survey result standpoint, but I don’t think it’s a stretch for some (or almost any) of these to be applied as Hazardous Materials & Wastes Management findings. Again, not everything applies, but I think if we’ve learned nothing else over the years, it’s the funky application of survey concepts from one are of scrutiny to another. Stranger things have happened…

Try to keep things cool over the second half of the summer!

People get ready: There’s a (survey) train a-coming!

When it comes right down to it, I think it is nigh on impossible to have access to too many resources or, indeed, to have access to too many perspectives on the various and sundry processes that make up our little EOC world (OK, maybe not so little), so I’m always on the lookout for stuff that I think might be worth sharing with you folks. (It’s one way I’ve managed to not run out of things to say over the past 600+ weeks since I started this journey.)

Our good friends over at ASHE’s Health Facilities Management magazine recently published an article describing some of the ways facilities and safety professionals can effectively manage the accreditation process, primarily as a function of survey preparedness/readiness. I don’t know that there was anything of great surprise contained therein (with the important note that surveying hospitals is pretty much my life’s work, at least at the moment), but I think the authors did a nice job of providing an overview of the survey process with some key information points that may give you a “leg up” on your next survey.

The one thing we “know” is that we really don’t know when they’re coming next, so the general concept of continuous survey readiness is one that really needs to be taken to heart. But one of the key components of which you need to be mindful is that CMS is definitely ratcheting up on the “looking over the shoulder” aspect of the validation survey process. Where previously, CMS would conduct a validation of survey of the various accreditation organizations within 60 days of the accreditation survey activity, now CMS resources are observing the accreditation organization process as it happens. At the moment, any organization encountering the “enhanced” (my characterization) survey process are notified ahead of time, so you can do a little planning (not sure how much notice is given—if anyone out there can shed some light, based on experience, I’d love to hear from you). But there will come a time when it will be a (more or less) complete surprise!

At any rate, if you want to read about the opening salvo in this little endeavor, you can find it here, and the latest news on this front can be found here, which includes a link to the proposed rule change that deals with changes of ownership, etc. of accreditation organizations. Not very exciting stuff…yet! But I think the pendulum is going to continue swinging in the direction of more oversight (and probably, intervention) for the next little while…

In the realm of possibility: More listening, less posturing!

An interesting anomaly that I encounter periodically is the time-honored “first opinion,” particularly when it exists outside of a second opinion. All too often I hear clients tell me that  “X told us we have to do something a particular way,” often with a wake of disruption because whatever strategy, etc., that was identified didn’t take into full consideration elements of organizational culture, resources, practice, etc. But what I don’t understand is when I look at Environment of Care committee minutes, etc., I don’t see any discussion about whether the recommendation(s) were useful, germane, etc., to appropriately manage whatever the condition might be. I think it is very important to use any survey activity (regulatory, consultative) as an opportunity to identify best practices and ensure that policy and practice are in alignment. That way, you’ll have some experience in being able to sort out what is truly required from a regulatory perspective and what is solely in the land of surveyor interpretation.

In all the years I’ve been involved in healthcare safety, the one defining truth I’ve found is that compliance is rarely a black and white endeavor. And while I absolutely understand that managing anything as a “black and white” is a whole lot easier to police, from an operational standpoint, absolutes (either positive or negative) are not always easily, or practically, implemented.

The other dynamic is (and this is very much the case with response to regulatory surveys) that often we “over-promise,” particularly in terms of frequency of monitoring. Don’t set yourself up for failure, for example, by indicating in a corrective action plan that there will be weekly inspections of electrical panels for inappropriately configured circuit breakers. Unless you know that folks are mucking around in the panels on a frequent basis, is there really a compelling reason to embrace an inspection frequency that is not a regulatory requirement? I would tend to think: Not so much.

As we have established beyond any reasonable doubt, there will always (always, always, always) be imperfections in the environment, but don’t go crazy trying to chase all these things yourself (or have your staff do the chasing). As I’ve said any number of times (before any number of audiences), all this stuff “lives” at the point of care/point of service and if you can’t get the folks that “live” in those areas to help feed the gaping maw of work order system, you are managing a process that is not as efficient as it might otherwise be. With the ongoing impact of the “do more with less” mantra, it’s not so much about working smarter (though there is certainly an element of that), but about working collaboratively. Everyone is caregiver—everyone is a steward of the environment—and by judicious application of only what is actually required by code and/or regulation, you can start to break down the barriers between mutually assured noncompliance and an environment that appropriately supports care. Compliance is the byproduct of consistently doing the right thing.

Update: Defunct Links to/in the FAQ-niverse!

Greetings, fellow travelers!

With special thanks to Claire Rebouche for bringing this to my attention, it appears that the links to the new ligature risk FAQs that appeared in this week’s blog post no longer direct you to the content of the latest information (I swear to you that the links were working Monday), but rather direct you to the FAQ homepage. Now, that wouldn’t be such an awful thing if the latest FAQ (for the record, TJC describes it thusly: “Ligature Risks – Assessing and Mitigating Risk For Suicide and Self-Harm”) were readily discernible, but alas (at least for the moment), this particular FAQ is among the missing.

Rest assured, top people are working on trying to find out what’s going on, and hopefully this is but a temporary circumstance (I figure if we can’t find the information, the surveyors might be having a tough time as well—helps to level the playing field). One other thing to note is that where previously the ligature-related FAQs could be found in the EC section of the FAQ homepage, they’ve all been moved to the NPSG section (and, interestingly enough, increased the number of FAQs dealing with ligatures to just over 20), so you may want to keep an eye on any changes in that section (from a practical standpoint, I understand the shift, but I don’t know that they couldn’t have shown up in both sections as a transition, though perhaps they did—I don’t spend a lot of time monitoring the NPSG section of the FAQ page).

At any rate, what I suspect may be happening is that, in their efforts to “clean up” the FAQ page, it would seem that some of the internal links are no longer working, so I’m hoping that we’re just working through a funky transition period and everything will be up and running soon.

That said, there are a couple of other new items relative to the management of this at-risk patient population that I want to share (while they are still available): this one and this other one, which deal with how the process for managing at-risk patients can result in catastrophic gaps in care. I think they’re pretty straightforward in terms of information, but with everything else going on this week, I would encourage you to check ’em out sooner rather than later.

Déjà vu all over again: A new ligature resistant FAQ!

Using the Hospital FAQ page as the baseline, I reckon we’ve got about a dozen FAQs dealing with ligature resistance with this latest offering. For some reason, the “visual” I get from all of this FAQing is the difference between looking at something from a distance (for example, a celestial body) and seeing that same thing up close and personal. What started out as a sphere of incomprehensibility has become (slowly, ever so slowly, over time) a much more nuanced endeavor—an endeavor that continues to represent survey vulnerabilities for accredited organizations.

One of the interesting things to me is how the narrative has evolved over the last couple of years relative to how hospitals are to deal with all the intricacies of managing ligature risks as a survey vulnerability (which is different than managing the risks to patients, but more on that in a moment). This FAQ reveals some specifics as to what you are required to include in the mitigation strategy for those risks that are not yet removed/resolved/corrected/adjudicated, etc. Now, I don’t know that this is truly ground-breaking stuff, but I think this is cray-cray important because this is what the surveyors are going to be looking for, both in terms of structure, but also as a function of an ongoing process. I’m not going to quote verbatim from the FAQ. I know youse guys are excellent readers and such, so a quick summary:

  • Leaders and staff have to know what risks are currently in the mix and somebody has to be responsible for telling them (and documenting that they were told…)
  • Identification of patients at risk for suicide/self-harm, with appropriate risk-based interventions
  • A process for ongoing assessments and reassessments of organization-defined at-risk behavior
  • Staff education re: management of patient risk and implementation of appropriate interventions
  • Ensuring this whole program/process is integrated into the organization’s quality assurance/performance improvement (QAPI) program (sounds like it might be a good time to include this as a standing agenda item at your QAPI committee meetings)
  • Making sure that any equipment that poses a risk, but is necessary for safe treatment of behavioral health patients (the example given is medical beds with siderails on a geriatric unit), is considered, as a risk, in the patients’ overall suicide/self-harm risk assessments, with appropriate interventions to minimize the identified risks

As I reflect over the seemingly endless amount of survey angst that this topic has wrought over the past couple of years, I keep coming back to the reality that while we can always do better (would we have done as much as quickly without enduring survey bludgeoning?), there is minimal data to support that, while not perfect, hospitals were not doing a good job in managing these at-risk patients. Purely from a risk management perspective, this would be a subject of great interest and concern to any healthcare organization as the burden of managing these patients has shifted over time. I suppose it ultimately gets filed under the “abdication of responsibility” that comes with the disenfranchising of difficult patient demographics and the subsequent “arrival” of those patients in the acute care settings, but it seems to me that (and yes, I recognize that this is part of doing business in healthcare) a little more collaboration during this process (as opposed to pointing fingers and assigning “blame”) might have yielded a better end-product. Hopefully, at some point, we will be given credit for the good work that has been done (and quantified), but I don’t think we are quite there yet.

Don’t Call It A Comeback: The Statement of Conditions breathes again!

Not a whole lot going on in the July 2019 issue of Perspectives, but it appears that a little more consideration will need to be paid to the Statement of Conditions (SOC) and Basic Building Information (BBI) sections of The Joint Commission’s web portal for hospitals and other healthcare organizations. The article in Perspectives indicates that we can expect some changes to the questions asked in the BBI section, though the only specific indication thus far is that the questions relating to square footage of your buildings will be aimed at obtaining greater specificity of information, ostensibly to aid in the planning of survey visits. The impression I always had when it came to the square footage ranges was that they tended to “look” at the upper end of the range information, sometimes “encouraging” additional survey days when they might not necessarily have been warranted. My consultative recommendation to folks was to use the comment section to indicate the precise (or would “exact” be the more appropriate descriptor?) square footage so there would be minimal potential for extra survey days. Should be interesting to see how this all shakes out over the next few months as more “reveals” make themselves known.

In other news, the next edition (2022—can you imagine!?!) of the FGI Guidelines for the Design of Healthcare Facilities is in the development pipeline and the good folks at FGI are looking for comments/suggestions to aid in that development, but the window for doing so is quickly closing. You can check out the skinny here, but please know that the comment, etc., period ends on June 30. So if you have some burning thoughts/suggestions for how we will be managing our future facilities (including renovation activities), now is the time for all good safety professionals to come to the aid of their craft (or something like that…).

To close out this week’s chatter, I would encourage you to (yet again!) check out Tim Richards’ blog regarding medical gas certifications and qualifications. As you’ve no doubt noticed, the ongoing codification of everything has really “leaned” into staff competencies and qualifications, sometimes to the point of really muddying the waters as to what really is required. When it comes to medical gas stuff, I don’t know that you’ll be surprised, but it might be useful information to share with your boss (or your boss’s boss). Check it out here.

Wishing each of you a most festive and safe Independence Day!

One size fits all…or one size fits none

In a world in which the economies of scale don’t always economize, I keep running into situations and/or conditions that result from trying to make something do too much. The classic example (other than those one-size-fits-all bunny suits in ORs across this great land of ours—I always end up looking like late-model Elvis, Vegas edition) is the temperature log that is used for food refrigerators, medication refrigerators, etc. As a general rule of thumb, unless the temperature range for each of the refrigerators being monitored is the same (and never mind trying to mix Fahrenheit and Celsius), then you are just asking for trouble. “Pushing” staff to have to discern between competing “out of range” temperature values requires an almost infinite amount of attention, and while there is, in certain instances, some overlap (food is usually 33-40 degrees F and medication 36-46 degrees F, so 36-40 works for both), it just makes so much more sense to limit confusion to the extent possible. And, to my mind, that means individualized temperature logs. One quick note regarding temperature logs for freezers, if your log doesn’t have a temperature “safe” range clearly indicated, I’ve been seeing a lot of mix-ups regarding those pesky negative numbers. For instance, if you establish a target of -15 degrees or colder, -10 degrees would be considered an -out-of-range value, but in talking with the folks doing the monitoring, they “think” of “10” being less that “15,” kind of missing the whole negative number dynamic. I won’t say that this is happening everywhere, but I have run into it in a couple of instances, so that’s something to keep an eye on.

Turning to the Oddities page, I was cruising through The Joint Commission’s FAQ page (admittedly, looking for blog fodder) and came across something of a puzzle; in the text of the FAQ dealing with the “old” requirement of the building assessment as a function of the Statement of Conditions (the old Part 3, which is no longer available) and has not been since 2007. But if you look at the text of LS.01.01.01, the second performance element indicates that a building assessment is required (at time frames to be determined by each organization) to determine compliance with the Life Safety chapter of the Joint Commission manual. I guess the thing that struck me about this happenstance is that the FAQ would have a good opportunity to indicate that the building assessment has evolved (or mutated—your pick) into its present day purpose  as an exercise in assessing your building for compliance with the LS chapter. Maybe they just haven’t gotten around to updating this FAQ (it is a ways down the FAQ page), and I suppose it is no more than a curiosity.