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.

Don’t let weighing in weigh you down…

In what I would term an interesting move (I don’t know that I would go so far as to call it unprecedented, but it might well could be), our friends in Chicago are rearranging the deck chairs in the Emergency Management chapter. It does seem like it’s more of  a consolidation than a wholesale rewrite, but the strategy of setting up new standard and performance element numbers makes this potentially a big deal (as we know, surveyors tend to focus on the stuff that has changed since the last survey visit, so if you’re using the existing numerical indicators, you’ll likely need to change—or get rid of them entirely). I suspect this may have more to do with trying to align the existing EM standards et al. with the CMS requirements (It will be interesting to see if they end up developing a crosswalk—probably when it’s adopted).

While I can’t say that I’ve digested the whole thing, it does seem like they removed a lot of the specifics relating to the management of LIP volunteers (including an allowance for organizations to forego the use of volunteers, a strategy they had never really “approved”; I know a couple of instances in which organizations were cited for declining to use volunteers), but it makes me wonder what degree of specificity is going to come into play when they start surveying to this.

That said, I don’t see anything that’s giving me heartburn; since CMS based Appendix Z on much of the TJC standards from 2007-ish, what was once old (and abandoned) is now fresh and new and cutting edge. I have the same hopes for myself over time…

At any rate, the critical processes are still represented. I think it will show over time that some of the specificity of the current standards pushed folks to do things that didn’t necessarily make sense from an organizational standpoint, but I guess we’ll have to wait until the final version is out and about and able to take care of itself. I’m guessing substantive changes are not likely to be made at this point, but they are asking for comments, so if you’ve got a mind to say something, I would encourage you to do so.

Next week we’ll chat a little bit about some recent interpretive dances from the perspective of Perspectives. Stay tuned!

If this is really accurate, how big of a deal is this to you?

First off, I will indeed stipulate that any instance of workplace violence, whatever causative factors might be in play, is at least one too many instances of workplace violence. We deal with what appears to be an increasing potential for angry (and I’m using that as a catch-all—there are so many shades in the spectrum of rage) feelings to be acted upon, sometimes at the most minute of stimulations (I was going to use provocation, but I have certainly witnessed instances of acting out in response to so little, it boggles my mind). In response, it appears that our friends in Chicago are pushing towards a more demonstrative focus on issues related to workplace violence through the establishment of some new standards in the EC chapter.

From a practical standpoint, I don’t know that there’s anything so “new” here that folks are going to have to reconfigure their programs. In all likelihood, the elements being promulgated are among the things that you’ve been looking at for more than a little while (I did remember a time when workplace violence wasn’t quite so prevalent in healthcare and there were some places for whom this was not a topic of great consideration). So, the things that will clearly be a focus in the coming survey cycle include: an annual analysis of workplace violence prevention considerations, which would in turn result in mitigation of risk elements that cannot be resolved; monitoring of workplace violence occurrences, including reporting and investigation of said occurrences; providing education and training appropriate to the risks of workplace violence in the organization; and the participation of organizational leadership in these efforts, through establishment, and ongoing implementation, of a workplace violence prevention program. I am paraphrasing a wee bit here (you can find the verbiage here) but I guess the question I keep coming back to is: who isn’t doing this? I cannot imagine that there is a healthcare organization in the United States that is not struggling with this to some degree; the effective management of the risks associated with workplace violence.

The other interesting note from the above-referenced materials is the characterization of workplace violence occurrences being underreported, which may very well be the case, but it begs the question of what that actually means? There are certainly many points in the occurrence “chain” in which something might go unreported—and I suspect we have room for improvement there, if only in getting folks to the point where they’ll speak up. But underreporting beyond someone choosing not to speak up seems fraught with peril; the occurrences that come to the attention(s) of committees, services, etc. are not easily dismissed, etc., particularly as a function of regulatory reporting. I suppose this is one way to “leverage” an existing program by playing the compliance card (XYZ agency requires us to do this, etc.), but given the difficulties associated with the retention of staff, etc., how is it not in everyone’s best interests to have an effective process? I do not believe that we are in the habit of knowingly placing folks at risk without some level of preparation, but I also know that, for a fair number of safety professionals, the competing priorities that tend to reduce the opportunities for providing direct education to frontline workers are more bountiful than ever. I think we need to try and use the numbers to advance the cause of education and preparation for staff to deal with these ever-more-likely-to-happen events.

And now a brief word from…

The source of any number of potential nightmares…

Sorry for the extraordinarily late notice on this, but our friends at the Occupational Safety & Health Administration (OSHA) are hosting a healthcare symposium on August 31, but hopefully there are spots left. It’s a day-long event, so perhaps you can jump in and out depending on the presenters, etc. I suspect it would be nice to be able to take in the whole of it, but competing priorities might dictate otherwise. I am curious as to what they may have to say about suicide prevention (one of the planned topics), but alas I will be competing with my own priorities.

Recognizing that the “elephant in the room” at the moment remains responding to the pandemic (unless you are on the Gulf Coast and are dealing with Hurricane Ida and the storm’s aftermath—thoughts and prayers going out in that direction), I suspect that it will be topic that is covered rather extensively during the program.

A couple of items of note; the initial OSHA enforcement response plan has been archived in anticipation of OSHA completing a review of guidance from the Centers for Disease Control and Prevention (CDC) relative to precautions for fully-vaccinated folks, so we’ll have to keep an eye out to see what might be in the works on that count, which can be found (as well as the latest and the greatest) here.

And for those keen on partaking of some legalese as the summer begins its (all too rapid) wind-down, you can view the sum and substance of the Emergency Temporary Standard as it was initially published. Certainly, there are going to be some differences between the original and whatever comes out of the current (and perhaps future) review sessions, it’s tough to think that the whole thing is going to get tossed, so there may be one or two pointers lurking in the verbiage.

Again, my apologies for the late notice on the seminar/webinar/symposium; not quite sure how it slipped past me, but there is a lot of material out there. Hopefully you can “attend.”

Best wishes for a productive week and (with all luck) a restful Labor Day holiday. I suspect we’re looking at a busy autumn into winter stretch. Rest those weary bones for what I think we all hope will be the (finally!) home stretch of this event.

Time has come today: There’s late and there’s LATE

Depending on where you are, you may be bumping up against process elements that are causing certain activities to be “late,” even beyond the grace periods you’ve woven into your management plans, etc. And with the Delta variant becoming more and more of a factor, there is a fair likelihood that the challenges of scheduling activities, particularly those provided by resources external to your organization. I wish that I had a “magic bullet” for this, beyond invocation of the ongoing Public Health Emergency and making use of the 1135 Waiver process (remember when it was really unclear as to what that all meant?). But I think those items should be enough, with a little judicious planning and discussion, to get you over the compliance hump. If you need a primer on that process, be sure to visit the CMS website dealing with such things.

As a somewhat related aside, it does appear more than likely that our friends from Chicago (and, likely, others of the regulatory persuasion) will be moving towards a full embrace of the remote review of documentation. And while that may end up reducing a surveyor day or two from future surveys (they do have a lot of documents to review, so that time would shift from the onsite schedule), it also increased the importance of making sure that your committee minutes, annual evaluations, and other foundation documents provide as much compliance information as possible. Clearly document what waivers have been adopted and for how long; clearly document any risk assessments/mitigation strategies for compliance gaps or shortfalls. While I won’t ask you to “air out your dirty laundry,” you absolutely want to be forthcoming on the impact COVID response has had on normal operations. And if something is late, document the issue resulting in the tardiness of the activity and, again, use the risk assessment process to clearly document that you’re not putting folks at risk while things are sorting themselves out.

As a final note, the Chicagoans are working very diligently to try and get things back on track from a survey perspective, so if you’re expecting them any time soon (or they haven’t shown up yet), I think you need to plan on seeing them before the end of the first quarter of next year. That’s not to say there might not be outliers, but they’re definitely going to be knocking on your door before you know it.

Thanks for all you’ve done and continue to do. It’s made all the difference!

Looking back, looking ahead: Where did all the heroes go?

For those of you who have been watching this space for a while, it is probably a pretty good likelihood that you know that I (at times) have a tendency to reflect on the journeys of the past and this week’s conversation is no exception. To start things off, I would like to ask you to think about your response to the following multiple choice question.

In looking back over the past 12-15 months, I feel that I am:

a. Less appreciated than last year

b. Appreciated about the same as last year

c. More appreciated than last year

My hope is that your response is c. (for a whole host of reasons, more on that in a moment) and I also hope that that is the response for everyone in your organization. But somehow I suspect that my hope is not as widespread as perhaps it could/would/should be. Flip back to last year and the “rise” of the healthcare providers as modern-day superheroes (I would submit to you that heroism and healthcare have been joined at the hip since Hippocrates uttered his oaths); everyone had to come up with new and inventive ways to thank these awesome folks as social distancing became the order of the day. Signs, posters, videos, anonymous gifts—there was a whole lot going on last year.

In answer to the question posited in this week’s headline, the heroes are still here. They’re 12-15 months more exhausted than they were when they were everyone’s darlings, and, make no mistake, the siege that is COVID shows no signs of giving up or giving in to the ministrations of the folks on the front line.

But now, much as the weeks that follow the demise of a loved one and the crowds dwindle, not so much attention is being paid to the ongoing acts of heroism involved in getting by day after day. I know that part of the issue is that expectations have altered over time and now I fear that heroism has become taken for granted, which may be the worst “side effect” to this whole pandemic. The response of this nation’s healthcare workers was—and continues to be—nothing less than extraordinary, but the small kindnesses that were so freely shared last year just don’t seem to be in the mix these days, and they’re probably more important now than they’ve ever been. What you folks and your folks have done over the past 12-15 months is simply amazing, but in the day-to-day slog, somehow that perception of amazement has been lost to the news cycle or whatever attention grabbers have managed to wiggle their way into the social consciousness.

So, I want to thank each and every one of you in the studio audience for every big and little thing you do to keep your places in operation. You are all heroes and will continue to be for the duration and I take no small measure of comfort in knowing that you are out there doing the do, day in and day out. Just as we have “learned” to thank folks in the military for their service, as a nation, we should embrace that same philosophy for our healthcare workers. It’s the least we can do!

Processing processes: Keeping everything in front of you…

I’m thinking that there’s probably a fairly limited number of you folks for whom durable medical equipment (DME) is part of your “span of control,” though, as I think about it, there may be some confluences with the DME world for those of you who provide home care services to your patients. As a going concern, this doesn’t necessarily come up on my radar a lot, but sometimes the real world provides some examples of process gaps (I won’t go so far as to call them failures—I don’t have enough data to make that assertion just yet) that might be instructive.

There’s a member of my household who uses a device to provide breathing assistance while sleeping and has for quite some time. It would seem that the device in use is the subject of a recall notice from the Food & Drug Administration (FDA), which we learned about from a family friend. After doing some research on the web (because there had been no official notification received in this regard), as one is wont to do under such circumstances, it turned out that the device in question, which is indeed involved in the recall, had never been registered with the manufacturer. Once the registration of the device was completed, the recall notice showed up around a week later. We’re still digging into the particulars, but it would seem that the DME supplier did not include registering the device as part of their “service” nor was there an effective communication as to the need for the registration to be completed within the household. I use the descriptor “effective” because it is possible that the communication was provided (I suspect that that will be the “defense” rendered by the DME company), but was insufficient to ensure that the device was registered with the manufacturer. I suspect that in this instance, like in many others, the communication was designed more towards the knowledge base of the person or persons providing the content and not so much the knowledge base of the person (or persons) receiving the information.

I can “see” what probably happened with this whole thing, but I keep coming back to the thought that transferring the responsibility of registration, etc., to the end users seems to be a recipe for all sorts of problems. There are certainly times when the management of a device or process is most powerfully administered by the end users (for instance, weekly eyewash station checks), but in the absence of a true orientation and ongoing education process for those end users, some of the administration really should be in the hands of the most knowledgeable party/parties. That said, if you have folks at home using breathing assistance devices, it might be worth checking out the recall if you’ve not yet encountered it. Also, you might find it of value to bookmark the FDA’s safety communications page; it’s well-organized and has a lot of useful information. Again, this may not apply professionally to everyone, but it never hurts to consider process gaps as they may well be instructive in other areas.

Making movies on location…

One of the constants of any effective physical environment/safety program is the effort to ensure that folks at point-of-care/point-of-service are provided adequate education and training to ensure ongoing competency. I suspect that each of you make what use you can of the “regularly scheduled” activities like fire drills, surveillance rounds, tracers, etc., to be able to get face time with folks, but as healthcare organizations become increasingly more complicated, it makes me wonder to what extent it is possible to “get” to even a majority of folks in your organization.

As a subset consideration to this, with the intended focus on the outpatient settings, at what point does the safety competency of staff outside of your/our direct oversight become a significant (potential) vulnerability relative to the survey process? In a perfect world, everyone would receive the “same” basic orientation, but I think even that can be a difficult undertaking, particularly when it comes to the folks in the outpatient settings.

The question I have for group discussion is how much folks have been able to take advantage of mobile video technology to educate staff? I have never been a particularly big fan of computer-based learning as, at least in pretty much all the instances with which I am familiar, the programs tend to be a little too much “cookie cutter” for my liking. I also know that the past 15-18 months probably haven’t left a lot of time for big productions, but has anyone out there been able to harness technology in a sufficiently “personal” way to effectively provide education to the folks in your charge?

I’m curious as to whether anyone is developing their own content, etc. Please share if you’ve got something you’re working on, or anything you’ve finished. I suspect that things are going to become more complicated on the education front and some sharing of ideas and approaches might just be the key to future success!

Maybe this time we should do things a little differently…

This may be a “me” thing, but it seems to me that I’ve seen a lot of annual evaluations recently that only minimally make note of organizational response to the pandemic. I know there are no “rules” about the contents of the annual evaluation and it seems unlikely (unless you have a very high-powered crystal ball) that response to a pandemic would have been a key point in identifying goals for 2020 (though I suppose if you’re using the fiscal year as your calendar and you had a starting point in the middle of 2020). Clearly, consideration of things relating to pandemics and emerging infectious diseases is going to be front and center for the foreseeable future (for good or ill), but I still have this (perhaps unreasoning) fear that we’re going to lose a ton of “good stuff” as we come out the other side of the current emergency.

And that “good stuff” that might be lost are the missteps that periodically intruded upon the response protocols that were, to a fair degree, made up on the fly. Innovation was definitely the overarching result, and there were certainly great successes, but there had to be some stuff that didn’t work. It seems I continue to hear about setting up tents, taking tents down, setting them up again, and on and on…

So my thought is: Go back to all those hotwashes and AARs that were written in the heat of battle and see if there were any items that really didn’t make the grade—and memorialize ’em! My sincere hope is that the learned lessons won’t have a practical application any time soon, but the reports of a resurgence of hospitalizations make me think that we’re not quite done with this sucker.

Stay tuned…

Night time in the switching yard: Listen to the train(ing) whistle whine…

I suspect that, amongst all the other things that have been pounding on the metaphorical rooftops, you saw the updated guidance from OSHA relating to the Emergency Temporary Standard. I don’t know that there’s a great deal in play that would be particularly problematic, but I think the training requirements might be worth a little bit of work to ensure that the required elements are readily discernible to a regulatory surveyor. That said, I wouldn’t necessarily consider these “new” requirements, as with so many of the post-pandemic “requirements,” it’s all kind of based on what you would do if you were facing whatever event was coming down the pike. I really don’t think this is anything about which you should be concerned, but I figure it can’t hurt to get the list out and make sure that your program speaks eloquently to the individual components.

Here they are:

1910.502(n)

Training.

1910.502(n)(1)

The employer must ensure that each employee receives training, in a language and at a literacy level the employee understands, and so that the employee comprehends at least the following:

1910.502(n)(1)(i)

COVID–19, including how the disease is transmitted (including pre-symptomatic and asymptomatic transmission), the importance of hand hygiene to reduce the risk of spreading COVID–19 infections, ways to reduce the risk of spreading COVID–19 through the proper covering of the nose and mouth, the signs and symptoms of the disease, risk factors for severe illness, and when to seek medical attention;

1910.502(n)(1)(ii)

Employer-specific policies and procedures on patient screening and management;

1910.502(n)(1)(iii)

Tasks and situations in the workplace that could result in COVID–19 infection;

1910.502(n)(1)(iv)

Workplace-specific policies and procedures to prevent the spread of COVID–19 that are applicable to the employee’s duties (e.g., policies on Standard and Transmission-Based Precautions, physical distancing, physical barriers, ventilation, aerosol generating procedures);

1910.502(n)(1)(v)

Employer-specific multi-employer workplace agreements related to infection control policies and procedures, the use of common areas, and the use of shared equipment that affect employees at the workplace;

1910.502(n)(1)(vi)

Employer-specific policies and procedures for PPE worn to comply with this section, including:

1910.502(n)(1)(vi)(A)

When PPE is required for protection against COVID–19;

1910.502(n)(1)(vi)(B)

Limitations of PPE for protection against COVID–19;

1910.502(n)(1)(vi)(C)

How to properly put on, wear, and take off PPE;

1910.502(n)(1)(vi)(D)

How to properly care for, store, clean, maintain, and dispose of PPE; and

1910.502(n)(1)(vi)(E)

Any modifications to donning, doffing, cleaning, storage, maintenance, and disposal procedures needed to address COVID–19 when PPE is worn to address workplace hazards other than COVID–19;

1910.502(n)(1)(vii)

Workplace-specific policies and procedures for cleaning and disinfection;

1910.502(n)(1)(viii)

Employer-specific policies and procedures on health screening and medical management;

1910.502(n)(1)(ix)

Available sick leave policies, any COVID–19-related benefits to which the employee may be entitled under applicable federal, state, or local laws, and other supportive policies and practices (e.g., telework, flexible hours);

1910.502(n)(1)(x)

The identity of the safety coordinator(s) specified in the COVID–19 plan;

1910.502(n)(1)(xi)

The requirements of this section; and

1910.502(n)(1)(xii)

How the employee can obtain copies of this section and any employer specific policies and procedures developed under this section, including the employer’s written COVID–19 plan, if required.

Note to paragraph (n)(1). Employers may rely on training completed prior to the effective date of this section to the extent that it meets the relevant training requirements under this paragraph.

1910.502(n)(2)

The employer must ensure that each employee receives additional training whenever:

1910.502(n)(2)(i)

Changes occur that affect the employee’s risk of contracting COVID–19 at work (e.g., new job tasks);

1910.502(n)(2)(ii)

Policies or procedures are changed; or

1910.502(n)(2)(iii)

There is an indication that the employee has not retained the necessary understanding or skill.

1910.502(n)(3)

The employer must ensure that the training is overseen or conducted by a person knowledgeable in the covered subject matter as it relates to the employee’s job duties.

1910.502(n)(4)

The employer must ensure that the training provides an opportunity for interactive questions and answers with a person knowledgeable in the covered subject matter as it relates to the employee’s job duties.

Again, I feel pretty confident that these elements have been in place in most instances (PPE, risks associated with COVID, health screening, any changes to procedures, etc.) and (presumably) the effectiveness of the education process supported by data of COVID-related illnesses amongst the workforce. But it might be a good idea to “pull” these elements out as a syllabus (if that makes sense) to be able to walk a surveyor through the elements.

Protection is improvement, improvement is protection: Keeping folks safe from workplace violence

When it comes to the management of workplace violence considerations, I think we all have experienced the many, many ways in which these risks can manifest themselves in the healthcare environment. And now that the tides of COVID appear to be receding, the sense of gratefulness that existed (at least for a little while) seems to be on the decline as well. Now that ambulatory volumes are picking up and waiting rooms are becoming more congested, tempers grow ever shorter and put your frontline folks back to the more traditional risks associated with managing those interactions. It’s hard to say whether the folks not working in healthcare are sufficiently with familiar with the stresses and stressors endured by folks working in healthcare over the past 15-18 months, but it does seem that the sense of healthcare workers as “heroes” (which they most definitely—as they were before the pandemic and will be when we’ve moved on to the next thing) is not enabling good behaviors on the part of patients and their families as might have the case a year ago. In my own, very informal, data collection, there are an awful lot of sick people that are now comfortable enough to seek treatment for long-standing issues, which likely means that folks are scared (but not COVID-scared) and folks that are scared can have a tendency to lash out. This points to making sure that our workers are as well-prepared to deal with patient (and family) concerns before things escalate to the point of violence.

To that end (kind of), our friends in Chicago are implementing a number of “new” requirements to provide a framework for the survey of workplace violence concerns and how effectively hospitals are managing those risks. You can find the details of the standards (they’ll become effective on January 1, 2022) here. There’s also a resource page related to workplace violence.

In noting the use of quotation marks around the “new” requirements, I don’t know that the programmatic elements they’ll be looking for are anything beyond what is typically administered in a credible safety program. I don’t know that I’ve been to an organization in the last decade or so where workplace violence was not an issue to some degree. But much as we’ve had to work hard to protect workers during COVID and in light of the expansion of protections to whistleblowers, I think we should be approaching this as an opportunity to cover as many bases as possible in ensuring all staff (throughout every level of your organization—organizational leadership is clearly on the hook for supporting this endeavor) are effectively prepared to manage the risks associated with workplace violence, particularly de-escalation education. When you break down the requirements, it’s a fairly straightforward “ask”; beyond establishing a mandated frequency for review of the workplace violence prevention program, I don’t think that there’s anything here folks aren’t already doing to some extent. I suspect the education component may require some “ramping up,” particularly if the existing education programs were aimed at an identified group of “at risk” staffers; at this point, anyone working in healthcare, regardless of the environment in which they work have to be considered at risk and would benefit from de-escalation, etc. education. Also, if you’ve not made a concerted effort to include folks in leadership positions in your organization—they need refreshers, too.

So, what will they be looking for?

  • An annual worksite analysis of the workplace violence program, including mitigation or resolution of risks identified in the analysis, based on an analysis of the work environment, investigation of incidents, analysis of supporting policies and procedures, education programs, etc. As a somewhat related aside, keep an eye on your OSHA 300 logs to make sure any occurrences are being captured and communicated (especially to leadership—more on that in a moment);
  • An workplace violence training/education program (at time of hire, annually, when changes occur) for leadership, staff, and licensed practitioners; there is an allowance for determining the contents and to what extent workers need the education (based on their roles and responsibilities), but I don’t see where you can draw the line such that any group (or individual, for that matter) would rule out of the education. And for those of you with skilled nursing facilities, you could argue that they are working in one of your highest risk environments (second, perhaps, to the behavioral health environment), so you need to make sure that you’re including them in the education mix.
  • From a leadership perspective, there needs to be an individual designated leading the workplace violence prevention program (developed by a multidisciplinary team—can be existing) that includes policies and procedures; a process to report incidents and manage the data associated with trends, etc.; a process for follow up and support to folks affected by workplace violence (victims, witnesses); and reporting incidents to the governing body.

My best consultative advice, particularly if you are in the survey window, is to start working on pulling these elements together if you have them or to work to start looking at these considerations as a function of the requirements. Recognizing that the requirements are surveyable by some regulators beginning in January, there are other regulators who are predisposed to looking at this right now. Unfortunately, workplace violence occurrences are going to happen, but we need to consider every occurrence as an opportunity to improve the process and then act on the analysis. This is not going to be a simple fix, but if we can get everybody on the same page in terms of competencies, etc., in this regard, we should be able to demonstrate improvement over time.