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.

That’s a Wrap! EPA’s Final Rule: Early present or gag gift?

Just a couple of brief items to close things out (I’m going to give you folks a break from my blathering next week—unless something of interest breaks—more on that in a bit), the first being the release of EPA’s Final Rule Management Standards for Hazardous Waste Pharmaceuticals and Amendment to the P075 Listing for Nicotine. From where I’m sitting, although the promise is relatively good in terms of making things simpler to manage, particularly when it comes to the disposal of over-the-counter nicotine products, I’m still not certain how this will play out in the long run. I am (as always) hopeful that the Final Rule will blaze a trail towards a process in which doing the right thing is also relatively easy (that, my friends, should be the goal of all compliance activities—the more difficult the process to use, the greater the likelihood of noncompliant workarounds).

The notification I received from EPA characterized things thusly:

“The final rule provides tailored and streamlined standards for managing hazardous waste pharmaceuticals that reduce the cost and compliance burden for the healthcare sector, while ensuring the safe management of hazardous waste pharmaceuticals. Additionally, EPA is taking a common-sense regulatory approach to the disposal of FDA-approved over-the-counter nicotine replacement therapies (NRTs – i.e., gums, patches, lozenges), which will no longer be considered hazardous waste when discarded.

EPA has scheduled two webinars to discuss the contents of the final rule. The webinars, which are free and open to the public, are scheduled for 1 pm Eastern on the following dates:

  • Wednesday, January 9th
  • Wednesday, January 23rd

Both webinars will be the same, with a one-hour general presentation about the final rule, followed by a 30-minute question and answer session. See our website to register to attend one of the webinars: https://clu-in.org/conf/tio/HazWastePharmaceuticals/

Finally, if you would like to receive future updates from EPA’s Office of Resource Conservation and Recovery about solid and hazardous waste, sign up for our listserv by sending a blank email to: solid-and-hazardous-waste-subscribe@lists.epa.gov

I freely admit that that sounds like a pretty good deal, but I think I would advise you folks with some responsibility in this area to make some time in January to listen in to one (or both: the e-mail says the programs are the same, but you and I both know that last 30 minutes is much less likely to be the same, so maybe tune in for the Q & A). From a regulatory compliance perspective, there’s nothing like a “final rule” to get the accreditation organizations into a whirling maelstrom of interpretation, but I guess we’ll have to wait and see if this becomes a hot topic in 2019.

And so to the close of 2018: I’m not exactly sure what it is (though I suspect it’s mostly internal), I tend to find this time of year rather more reflective than not and this year seems to call for introspection more than some in the past. That said, I have no overarching words of wisdom, etc., beyond my hopes that you folks will have some time to power down from the onslaught of life as we know it and spend some time with family, friends, self—whoever makes you feel complete and happy. One of the big changes for me personally over the past year is embracing at least 10 minutes of quiet time every day (some would call it meditation, and I’m OK with that as a descriptor); I have found that it really makes a difference in being able to manage the many stressors of existence. I don’t know (and, in fact, I can’t know) if it would work the same for everyone, but I would encourage you to give it a try. And to that end, I’m going to provide you can opportunity to do just that—next week, please use the time you’d usually use to peruse this space—and I pledge to you that I will do the same.

A most joyous holiday and New Year to all of you and your families! Be safe, take good care, and I will see you in 2019!

Last Call for 2018: National Patient Safety Goal on suicide prevention

While I will freely admit that this based on nothing but my memory (and the seeming constant stream of reasons to reiterate), I believe that the management of behavioral health patients as a function of ligature risks, suicide prevention, etc., was the most frequently occurring topic in this space. That said, I feel (reasonably, but not totally) certain that this is the last time we’ll have to bring this up in 2018. But we’ve got a whole 52 weeks of 2019 to look forward to, so I suspect we’ll continue to return to this from time to time (to time, to time, to time—cue eerie sound effects and echo).

If you’ve had a chance to check out the December 2018 edition of Perspectives, you may have noticed that The Joint Commission is updating some of the particulars of National Patient Safety Goal (NPSG) #15, which will be effective July 1, 2019, though something tells me that strategies for compliance are likely to be bandied about during surveys before that. From a strategic perspective, I suspect that most folks are already taking things in the required direction(s), so hopefully the recent times of intense scrutiny (and resulting survey pain for organizations) will begin to shift to other subjects.

At any rate, for the purposes of today’s discussion, there is (and always will be) a component relating to the management of physical environment, both in (and on) psychiatric/behavioral health hospitals and psychiatric/behavioral health units in general hospitals (my mother-in-law loves General Hospital, but I never hear her talking about risk assessments…). So, the official “environmental risk assessment” must occur in/on behavioral health facilities/units, with a following program for minimizing the risks to ensure the environment is appropriately ligature-resistant. No big changes to that as an overarching theme.

But where I had hoped for a little more clarity is for those pesky areas in the general patient population in which we do/might manage patients at risk to harm themselves. We still don’t have to make those areas ligature resistant, with the recommendation aimed at mitigating the risk for patients at high risk (the rest of the NPSG covers a lot of ground relative to the clinical management of patients, including identification of the self-harm risks). But there is a note that recommends (the use of “should” in the note is the key here, though I know of more than a handful of surveyors that can turn that “should” into a “must” in the blink of an eye) assessment of clinical areas to identify stuff that could be used for self-harm (and there’s a whole heck of a lot of stuff that could be used for self-harm) and should be routinely removed when possible from the area around a patient who has been identified as high risk. Further, there is an expectation that that information would be used to train staff who monitor these high-risk patients, for example (and this is their example, but it’s a good ‘un), developing a checklist to help staff remember which equipment, etc., should be removed when possible.

It would seem we have a little time to get this completed, but I would encourage folks to start their risk identification process soon if you have not already done so. I personally think the best way to start this is to make a list of everything in the area being assessed and identify the stuff that can be removed (if it is not clinically necessary to care for the patient), the stuff that can’t be removed (that forms the basis of the education of staff—they need to be mindful of the stuff that can’t be removed after we’ve removed all that there is to be removed) and work from there. As I have maintained right along, in general, we do a good (not perfect) job with managing these patients and I don’t think the actual numbers support the degree to which this tail has been wagging the regulatory dog (everything is a risk, don’t you know). Hopefully, this is a sign that the regulatory eyeball will be moving on to other things.

The coexistence of safety leadership and empathy

Two items this week; one survey-related musing and a suggestion for your holiday season reading list.

Monthly GFCI testing: How are you making that happen? While I believe this came up during a mock survey (albeit by an “official” accreditation organization that starts with the letter “C,” ends with a “Q” and greets you if you look in the mirror…), these things sometimes feed on themselves, so to speak. And, since this is one for which I suspect folks might have some challenges, I figured I’d open this Pandora’s Box just in time for the holiday season.

In this particular mock survey, the facilities folks were asked to produce documentation of the monthly testing of the ground fault circuit interrupter (GFCI) receptacles, which is required as a function of the manufacturer’s instructions for use. In this particular instance, the response was generally minimal, with some questioning back as to the validity of the question. Of course, a quick web search for the GFCI receptacles in question (manufactured by Hubbell) revealed that, why yes indeedy, the monthly testing is right there in the details (I think this may be a good take on who lives in the details, but I digress). In this particular instance, the hospital wasn’t doing it, hadn’t done a risk assessment—either as a singularity or as a function of including the receptacles in an Alternative Equipment Management (AEM) program. So, I put the question to the studio audience: How many of you folks out there are doing the monthly testing of the GFCI (or are you not)? Have you gone the AEM route for this one? Seems like it would be a good candidate with which to get your feet “wet” relative to the risk assessment process. Somehow, I think this might be the dawn of the latest “gotcha” finding, so maybe a little fair warning is in order.

Moving on to the bookshelf (I still read books—I don’t mind using a tablet for some stuff, but for real “reading,” I still like the tactile sensation of a book), I’m in the middle (well, a little past middle, say ¾) of a book entitled “Forged in Crisis—The Power of Courageous Leadership in Turbulent Times” by Nancy Koehn. The book contains five stories of historical figures (Ernest Shackleton, Abraham Lincoln, Frederick Douglass, one less well-known to me—Dietrich Bonhoeffer—and Rachel Carson). So far, and probably because his story was the least familiar to me, the Dietrich Bonhoeffer portion of the book was most interesting. He was a minister in Germany during the period leading up to, and through, World War II. I won’t spoil any of the details but one key element of Herr Bonhoeffer’s leadership that’s identified (among others) is empathy, with the point being “the more volatile the larger environment, the more crucial it is for…others with significant authority to appreciate the experiences of those with less power and fewer options.” For a number of reasons (some personal, some professional) that struck me as a very useful quality to possess when one is trying to manage a large and complex environment, particularly consideration of that less power/fewer options dynamic. At any rate, I’m all in favor of lionizing positive role models, so if you have some reading time over the holidays, you might find this a most compelling read.

You might have succeeded in changing: Using the annual evaluation to document progress!

I know some folks use the fiscal year (or as one boss a long time ago used to say, the physical year) for managing their annual evaluation process, but I think most lean towards the calendar year. At any rate, I want to urge you (and urge you most sincerely) to think about how you can use the annual evaluation process to demonstrate to leadership that you truly have an effective program: a program that goes beyond the plethora of little missteps of the interaction of humans and their environment. As we continue to paw through the data from various regulatory sources, it continues to be true more often than not that there will be findings in the physical environment during your organization’s next survey. In many ways, there is almost nothing you can do to hold the line at zero findings, so you need to help organizational leadership to understand the value of the process/program as a function of the management of a most imperfect environment.

I think I mentioned this not too long ago: I was probably cursing the notion of a dashboard that is so green that you can’t determine if folks are paying attention to real-life considerations or if they’re just good at cherry-picking measures/metrics that always look good. But as a safety scientist, I don’t want to know what’s going OK, I want to know about what’s not going OK and what steps are being taken to increase the OK-ness of the less than OK (ok?!?). There are no perfect buildings, just as there are no perfect organizations (exalted, maybe, but by no means perfect) and I don’t believe that I have ever encountered a safety officer that was not abundantly aware of the pitfalls/shortcomings/etc. within their organizations, but oh so often, there’s no evidence of that in the evaluation process (or, indeed, in committee minutes). It is the responsibility of organizational leadership to know what’s going on and to be able to allocate resources, etc., in the pursuit of excellence/perfection; if you don’t communicate effectively with leadership, then your program is potentially not as high-powered as it could be.

So, as the year draws to a close, I would encourage you to really start pushing down on your performance measures—look at your thresholds—have you set them at a point for which performance will always be within range. Use the process to drive improvement down to the “street” level of your organization—you’ve got to keep reaching out to the folks at point of care/point of service—in a lot of ways they have the most power to make your job easier (yeah, I know there’s something a little counterintuitive there, but I promise you it can work to your benefit).

At any rate, at the end of the process, you need to be able to speak about what you’ve improved and (perhaps most importantly) what needs to be improved. It’s always nice to be able to pat yourself on the back for good stuff, but you really need to be really clear on where you need to take things moving forward.

Walls and Bridges: Managing construction projects large and small

As you might guess, part of my approach when I’m doing onsite client work is to review the process for managing construction projects, inclusive of the risk assessment process (infection control, life safety). To my mind, there is no more risky business in the physical environment (the management of ligature risks notwithstanding) than undertaking construction or renovation projects, particularly when those projects are in spaces adjacent to occupied patient care (or indeed, any occupied) areas. And with the adoption of the 2012 Life Safety Code® (LSC) and the growing invocation of Chapter 43 Building Rehabilitation, it would seem that the tip of the regulatory spear is getting sharper by the moment.

One of the things that I encounter with some regularity is a fundamental flaw in how the risk assessment actually captures/identifies the risks to be managed as a function of what strategies are to be implemented to eliminate/mitigate the impact of those risks. For example, I can’t tell you how many times I’ve seen assessments of a project that is going to include construction barrier walls in a corridor for which the assessment indicates no impact on egress. Now, you can certainly indicate that, based on the implementation of X, Y, and Z, you have mitigated the impact on egress, but to indicate in the assessment that there was no impact on egress from a barrier wall that has encroached on the corridor, is inaccurate at best—and possibly could draw the ire of a literalist surveyor. As I like to tell folks when I encounter this: You don’t get credit for doing the math in your head; the assessment should indicate that there was an impact, but the impact was mitigated by the implementation of ILSM(s).

Similarly, if you remove the suspended ceiling in a project area, you have impaired the smoke detection/sprinkler protection in the area. Now it may be that the impairment is sufficiently minor in nature to not require implementation of ILSMs, based on your policy, but you still have to indicate that such is the case. You can’t say there was no impact or impairment, because the condition you have represents an impairment and so, there’s got to be some level of impact.

I think perhaps the way to look at this is much in the vain of our emergency management Hazard Vulnerability Analysis (HVA) process. There is no harm/no foul in identifying risks for which you would need to be prepared (you could make the case that there are few things as disruptive to an organization as a construction project) as long as you have a strategy for managing those risks. So, if you carry over the philosophy to construction/renovation, it makes it “easier” to frame the assessment as a proactive management of risks rather than trying to figure out how to do as little as possible (and I do see pre-construction risk assessments that seem to be aimed at a de minimis implementation strategy). But using the HVA algorithm (likelihood, impact, preparedness, response) you might find that your “packaging” is a little tidier than it was previously.

As a final note on this subject, I really think you need to get in the habit (if the habit has not already formed) of posting infection control permits, ILSM permits, etc., outside of construction/renovation areas so it is clear what the expected conditions and/or practices might be. You can’t be looking over the shoulder of the contractors every minute, so it helps to have some eyes in the field (with a reasonable knowledge base) keeping watch. There is definitely an expectation of regulatory surveyors that these will be posted in conspicuous locations (yeah, I know there’s no rule that says you have to, so chalk this up to a best practice invocation), so better to have visible postings.

Please let me close things out with best wishes for a joyous and restful (Can you combine those two? I think you can!) Thanksgiving to you and your families. 2018 whipped along at a pretty good clip and I suspect that the holidays will launch us into 2019 before too long, so take a few deep breaths and enjoy the day.

And the wind blew the echoes of long faded voices: Some Emergency Management thoughts…

While the year seemed to start out relatively quietly on the emergency front (relative being a completely relative and arbitrary term—and perhaps never more so than at the moment), it appears that the various and sundry forces of nature (and un-nature) are conspiring to send 2018 out with a bang. From wildfires out West to curiously damp weather patterns in the East to some funky temperature swings in the middle, it seems preparedness levels are as critical an undertaking as ever (and frequently coming nowhere close to being over-resourced, but I guess there’s no reason that the “do more with less” mantra wouldn’t extend to the EM world), with a likely follow-up of focus by the accreditation preparedness panjandrums (more this than this, but I’m fine with either). And one area of vulnerability that I see if the regulatory noggins should swivel in this direction relates to improvements in educating folks on an ongoing basis (the Final Rule says annual, so that determines a baseline for frequency), including some sort of evidence that what you’re doing is effective. (I see lots and lots of annual evaluations that track activities/widgets without getting down to a means of determining effectiveness—another improvement opportunity!) The other “shoe” that I fear might drop is the inclusion of all those care sites you have out in the community. There are very (very, very) few healthcare organizations that are comprised of a single standalone facility; over time, acquisitions of physician practices and other community-based healthcare delivery settings have increased the complexity of physical environment compliance, including emergency management stuff. I don’t know that I’ve run into anyone who couldn’t somehow, to one degree or another, point to participation of the offsite care locations. But it typically comes as, if not quite an afterthought, then a scenario that kind of “grafts” the offsites into the exercise. And, much as I wish community exercises would include testing of response activities in which the hospital acts in a diminished or non-capacity (there’s always this sense that we’ll just keep bringing folks to the local ED), some of the events of this year have really impacted ready access to hospital services for communities. At any rate, if you have thoughts on how you are (or could be) doing a good/better job at testing preparedness across your whole healthcare network, I am all ears and I suspect that there might be some other attentive ears as well.

In closing for this week (a little late, but this truly shouldn’t be tied to just one day or week), my thanks to all that have served in the armed forces: past, present, and future. Your sacrifices continue to mean so much to our lives and I cannot thank you enough (but with the annual Day of Thanks coming up next week, I will surely try)!

It’s been a quiet week in Lake Hazard-be-gone: Water and Legionella

Not a ton of “hair on fire” stuff in the news this week, so (yet again), a quick perusal of something from the “things to consider” queue.

It seems likely that Legionella and the management of water systems is going to continue to have the potential for becoming a real hot-button issue. I suppose any time that CMS issues any sort of declarative guidance, it moves things in a (potentially) direction of vulnerability for healthcare organizations. That said, it might be worth picking up the updated legionellosis standard from ASHRAE to keep up with the current strategies, etc. I don’t know that there’s any likelihood of eradication of Legionella in the general community (by the way—and I’m sure this is the case, but it never hurts to reiterate—those of you with responsibilities for long-term care facilities are definitely in a bracket of higher vulnerability). But there remains a fair amount of risk in the community, as evidenced by the most recent slate of outbreaks. Water is definitely the common denominator, but beyond that, this can happen anywhere at any time, so vigilance is always the end game when it comes to preventive measures.

As a final thought for the week, I wanted to share a blog item (not mine) that I found very interesting as food for thought (the concept is very powerful, though you may have a tough time convincing your boss to embrace it, as I think you’ll see): treating failure like a scientist. You can find the whole post here, but the short take is that you may have a positive or a negative result of whatever strategy you might employ—each of which should be considered data points upon which you can make further adjustments. Not everything works the way you thought it would, but rather discarding something outright if it doesn’t succeed, try to figure out the lesson behind the failure to make a better choice/strategy/etc. moving forward. The blog covers things more elegantly than I did here, but I guess my closing thought would be to have the courage (maybe “luxury” is the better term) to really learn from your mistakes—if we were perfect, there would never be a need for improvement.

Time to bust a cap in your…eyewash station?!?

Howdy folks! A couple of quick items to warm the cockles of your heart as winter starts to make its arrival a little more obvious/foreboding (at least up here in the land of the New English) as we celebrate that most autumnal of days, All Hallows Eve (I’m writing this on All Hallows Eve Eve)…

The first item relates to some general safety considerations, mostly as a function of ensuring that the folks who rely on emergency equipment to work when there is an emergency are sufficiently prepared to ensure that happens. It seems that lately (though this is probably no more true than it usually is, but perhaps more noticeable of late) I’ve been running into a lot of emergency eyewash stations for which the protective caps are not in place. Now I know this is partially the result of too many eyewash stations in too many locations that don’t really need to have them (the reasoning behind the desire for eyewash stations seems to lean towards blood and body fluid splashes, for which we all know there is no specific requirement). At any rate, my concern is that, without the protective caps, the eyewash stations are capable of making the situation worse if someone flushes some sort of contaminant into their eyes because stuff got spilled/splashed/etc. on the “nekkid” eyewash stations. The same thing applies to making sure the caps are in place for the nozzles of the kitchen fire suppression system (nekkid nozzles—could be a band name!—can very quickly get gunked up with grease). We only need these things in the event of an emergency, but we need them to work correctly right away, not after someone wipes them off, etc. So, please remind the folks at point of care/point of service/point of culinary marvels to make sure those caps are in place at all times.

The other item relates to the recent changes in the fire safety management performance element that deals with your fire response plan. Please take a moment to review the response plan education process to ensure that you are capturing cooperation with firefighting authorities when (periodically) instructing staff and licensed independent practitioners. One of the ages-old survey techniques is to focus not so much on the time-honored compliance elements, but rather to poke around at what is new to the party, like cooperation with firefighting authorities (or 1135 waiver processes or continuity of operations plans or, I daresay, ligature risk assessments). It would seem that one of the primary directives of the survey process is to generate findings, so what better way to do that than to “pick” on the latest and (maybe not so) greatest.

Have a safe reorientation of the clocks!

I may not be perfect, but I’m perfect for you: CMS rates the accreditation organizations!

Another mixed bag of stuff for you this week, leading off with a quick spin through CMS’ report card to Congress.

While the numbers have shifted around a little, infection control is making a move on the outside, but the physical environment is still the big point of focus, though you can see where the two are starting to cross over at a greater frequency. I think issues relating to ligature risks are going to be a very sharp focus, particularly with CMS surveys. Although it is interesting to note that (at least at the moment) when ligature risks come up in the CMS survey process, those risks have been cited under the Patient Rights Condition of Participation (each patient has a right to receive care in a safe setting), so we may see Patient Rights at the top of the heap next year. One way you can avoid that little dance of ignominy is to make sure that you have completed a comprehensive ligature risk assessment in those areas in which you are managing behavioral health patients, including mitigation strategies for items that cannot be immediately corrected and solid anticipated completion dates. They are taking ligature risks very seriously because of the potential for harm to patients and you don’t want to have a whole lot of open-ended plans of correction. It almost comes down to a sense that everything that exists is a potential risk to be managed and while I am hopeful that cooler heads will prevail, right now this is a very, very hot topic.

One other thing to note with the report card is a section that deals with an analysis of survey disparity relating to Life Safety Code® compliance and health and safety considerations. I’ve looked at the contents of this section, including their conclusions and recommendations, and I have a hard time thinking that this is ever going to go away as a survey focus. While I tend not to rely on absolutes when it comes to periods of time, I can say quite confidently that there will always be stuff to find during a survey. You can look today and find stuff, you can look tomorrow and find different stuff, you can look the day after and—you guessed it! Stuff happens; people do stuff we don’t want them to, including unauthorized field modifications. The list is literally and figuratively endless. I know they have to find something, but as a collective, I think most hospitals are very well maintained and managed as a function of the physical environment. But if the big “C” knocks on the door (and I guess we have to include the minions as well), there’s going to be a list of stuff. Our job is to keep that list to a minimum. Good luck with that!

A hospital in trouble is a temporary thing: Post-survey blues!

As you might well imagine, based on the number of findings floating around, as well as CMS’ continuing scrutiny of the various and sundry accreditation organizations (the latest report card is out and it doesn’t look too lovely—more on that next week after I’ve had a chance to digest some of the details), there are a fair number of organizations facing survey jeopardy for perhaps the first time in their history. And a lot of that jeopardy is based on findings in the physical environment (ligature risks and procedural environment management being the primary drivers), which has resulted in no little chagrin on the part of safety and facility professionals (I don’t think anyone really thinks that it would or could in their facility, but that’s not the type of philosophy that will keep the survey wolves at bay). The fact of the matter is (I know I’ve said this before, though it’s possible that I’ve not yet bent your collective ears on this point) that there are no perfect buildings, particularly in the healthcare world. They are never more perfect than the moment before you put people in them—after that, it is a constant battle.

Unlike any other time in recorded history, the current survey epoch is all about generating findings and the imperfect nature of humans and their interactions with their environment create a “perfect storm” of opportunities to grow those numbers. And when you think about it, there is always something to find, so those days of minimal to no findings were really more aberrant than it probably seemed at the time.

The other piece of this is the dreaded adverse accreditation decision: preliminary denial of this, termination of that and on, and on. The important thing to remember when those things happen is that you will be given (well, hopefully it’s you and not your organization sailing off into the sunset without you) an opportunity to identify corrective action plans for all those pesky little findings. I can’t tell you it doesn’t suck to be in the thick of an adverse accreditation decision because it truly, truly does suck, but just keep in mind that it is a process with an end point. There may be some choppy seas in the harbor, but you have the craft (both figuratively and literally) to successfully make landfall, so don’t give up the ship.