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.

From the sky we look so organized and brave

Once again (I’m thinking there’s no surprise to this), the public health emergency wrought by the impact of COVID-19 on just about anything you’d care to name has been extended. You can find the somewhat reiterative announcement here (apparently, there’s no one at the federal level that proofreads this stuff—go figure). If the past sequence of review and extension continues to hold true, we can expect the next extension to “drop” sometime in April. It would be delightful to think that distribution of the vaccine would somehow interrupt a further extension, but I suspect we probably have at least one more after that, as we move ever closer to whatever is going to constitute the “new normal” (based on the latest numbers from CMS, things do seem to be retreating/receding from red, so to speak).

As we continue our slog through the pandemic, our good friends in the CMS workshop have been busy establishing a portal for all things waiver-related. It may be that there’s too much information (there are a whole bunch of links to various sites, etc.), but on the off chance that you folks might find something useful contained therein, you can check it out here.

There are a couple of YouTube videos in the mix to help complete the online waiver request forms (if you would feel so inclined, you can go directly to the waiver request site by using this link).

Ultimately, it’s all about being able to continuously provide appropriate care to our patients; sometimes that means going from one moment to the next—which, as we’ve learned over the last little while, breeds its own special brand of exhaustion…

I encourage you to make the most of what little “down” time you have to recharge your batteries as much as you can. The vaccination process seems to be gathering some momentum, but we’re still a ways away from the finish line. I guess this is one race we’ll all be finishing at the same time…

Until next time, please stay well and be safe!

When you’ve done all you can do, what do you do?

As I start this, I’m thinking it will be kind of brief, but you and I have both been at the receiving end of my brevity, so we’ll see what happens.

As I ponder the various and sundry processes that make up an effective program for managing the physical environment, I cast my mind back to some instances in which self-identified corrective actions were not completed before our friends from the regulatory world parachuted out of their black helicopters to conduct accreditation surveys (I will freely admit that sometimes those black helicopters look exactly like commercial airliners—I’m not sure how the technology works, but it looks to be pretty seamless…) and the questions are inevitably raised as to (more or less) “How come it’s taking so long?”

There’s also the possibility (it may even be a likelihood, but I shy away from pronouncements based on a small data sample) that when there are findings relating to the physical environment, the general concept of the organization’s responsibility vs. just the Environment of Care (EC) folks sometimes flies out the window. Only you folks know what kind of culture you have in your organization and how much acknowledgement of shared responsibility is going to occur post-survey. But, in response to that “knowledge,” I would ask you to think carefully about how the EC program escalates issues that are difficult, if not impossible, to resolve within the EC program. Sometimes I get the sense that folks are less inclined to “air their dirty laundry” in the direction of organizational leadership, but (in my mind) one of the most important capabilities of any management process is knowing when to ask for help. Clearly, you don’t to “cry wolf” too often, but sometimes you just have to raise your paw…

By way of providing context, as this is generally the time of the annual evaluation (as opposed to the time of the season, though they may coexist), I would encourage you, in your “look back” over the year, to consider whether there were issues identified for which resolution has not been forthcoming. Part of this (OK, perhaps quite a lot of this) may have to do with all things COVID—if the effectiveness of our “product” is based on the juggling of (at times competing) priorities. Much as September 11, 2001 shifted the safety/preparedness world in an unanticipated direction, likewise COVID has pushed things around rather a lot. I suspect that everyone is going to have a COVID list of things that either didn’t get done or didn’t get done as well as one would like. Now is a good time (as we start to close on the birthday of the declared emergency) to quantify the impact of those “things.” I don’t know that it needs to be the sole focus of the annual evaluation process, but if you were to do so, I think you (and your organization) might be well-served for it.

As we rocket through January, I hope this finds you well and staying safe—we will get through this!

Remote control: Don’t forget to close the loop

It would seem that the likelihood of ongoing remote surveys is growing in relation to the number of organizations awaiting survey. To be honest, I’ve not seen an official accounting of where the various accreditation organizations (AO) are falling relative to survey delays. That said, I can’t imagine that there must be a fairly significant backlog of surveys to be conducted, so I suppose we’d best be prepared for at least some of that process to occur remotely—particularly document review. To that end, if you missed this news item, I think it will help provide an understanding of how the process is evolving (mutating?!?); the focus of the piece is how DNV is administering the process, but there are certainly some clues as to how the process in general is likely to “exist” over the next little while.

One thing I hadn’t encountered before (or if I had, it was lost in the slipstream of last year) is the COVID data being provided by CMS. It appears that the information is updated on a regular basis (at this writing, the most recent information was for the period ending December 23, 2020) and while it is labeled as Nursing Home Data, CMS feels that the data is applicable to survey planning for hospitals. It appears that unless you are in a “green” county (you’ll see what I mean when you download the spreadsheet), then you probably won’t be seeing a “live” survey team (will we have to face zombie survey teams?). In traveling the past few months and living in a state that requires a negative test before returning or self-quarantining, I can tell you that those green windows sometimes don’t stay open for very long. Fortunately, I have not yet been in a position where I have tested positive away from home—probably my second worst fear; the worst fear being to bring this stuff back home to share with my family.

That said, my own practice has been very much “out in the field,” with a mix of some remote document review. I really do miss the interaction of document review with the folks who are actually responsible for the critical processes. It’s very difficult to have an appreciation for the process when you can’t discuss the operational challenges, the process for making corrections, etc. One of the “common” themes I’ve noted is that the documentation provided remotely tends not to include evidence of corrective actions; certainly this is something I’m accustomed to asking for when I’m doing onsite document review, but I don’t know of too many surveyors that wouldn’t be looking to “close the loop” on any identified deficiencies as soon as they find them in the documentation and it’s tough to really hold someone’s feet to the fire relative to producing corrective action documentation when you are not “in the building” with a specific ending point for the survey. There are certainly any number of surveyors who will cite an organization for failing to provide evidence of corrective actions and I think remote document review only increases the potential for missing pieces of the puzzle.

So my consultative recommendation is this: Make sure that you attach evidence of corrective actions to any documentation you might provide remotely to a survey team. You know you’re going to be asked for it anyways, so you might as well get ahead of the “ask.”

That’s it for this week. I hope you continue to be well and stay safe—we will get through this!

As I look out the window, it’s snowing, which reminds me that we’ve got to keep turning with the world, so I will let you get back to it. Until next time, hope you are well and staying safe. For those of you who are in the process of receiving the vaccine, thank you for your service!

The roar of the ’20s continues: Optimism abounds!

I trust that you all were able to carve out some downtime over the holidays. While there was (seemingly) much less rushing around than normal, in many ways, the past month or so has been no less exhausting. At any rate, I hope this finds you well and ready for the climb up (out?).

As mentioned the last time we “gathered,” our friends in Chicago are in the process of modifying the survey of the physical environment as it extends to behavioral health organizations. As fate would have it, the changes revolve around ongoing efforts to align Joint Commission standards and performance elements with the requirements of NFPA 101-2012 Life Safety Code® (LSC) and NFPA 99-2012 Health Care Facilities Code, including clarification of fire drill requirements. A couple of items of particular note follow:

  • Behavioral healthcare facilities that use door locking to prohibit individuals from leaving the building or spaces in the building are considered healthcare occupancies. I don’t see this as an issue for inpatient units as this already the “mark,” but it may come into play in your outpatient clinic settings and perhaps any residential care settings. With all the changes in the survey process relating to care locations outside of the main hospital, I think proper identification of occupancy classifications is going to be under greater scrutiny than ever.
  • If you do have residential board and care facilities in your organization, they’ll be looking for at least six fire drills per year for each building and that means evacuation (unless otherwise permitted by the LSC; please check out NFPA 101-2012: 32/33.7.3 for details and exceptions), two of which need to be conducted at night when residents are sleeping. For some strange reason, the pre-publication standard indicates that “at least two annual drills” would be conducted during the night; I think this is probably one more word—that being “annual”—than it needs to be. I don’t know, it just seems less clear than saying, perhaps, at least two drills per year would be conducted at night or something like that. But that may just be me.
  • Depending on the capacity of the branches of your essential electrical system, you may have some flexibility relative to the number of required transfer switches; your system must still be divided into three branches (life safety, critical, equipment), but if your system is 150kVA or less, then you don’t need to have at least one automatic transfer switch for each branch. I suspect that most folks that have facilities that were constructed, had a change in occupancy type, or undergone a major electrical system upgrade since 1983 are probably all set with this, but I think we can anticipate the question being asked—better to know what you have going in, and probably a useful piece of information to include on your Statement of Conditions.

The LS chapter changes appear to be aimed at ensuring that the requirements for new and existing occupancies are appropriately noted; at this point, I don’t see anything particularly problematic, but, as they so often note in the fine print, actual results may vary. You can find the details here.

As I look out the window, it’s snowing, which reminds me that we’ve got to keep turning with the world, so I will let you get back to it. Until next time, hope you are well and staying safe. For those of you who are in the process of receiving the vaccine, thank you for your service!

Just in time for the holidays: Shoes are dropping all over the place, including business occupancies!

Just when you thought that maybe, just maybe, 2020 had run out of surprises, our friends in Chicago have taken one last (hopefully) opportunity to create a little chaos in the future by introducing us to their latest brainchild—the Life Safety chapter standards and performance elements prescribing the management of business occupancies.

I don’t know that there’s anything particularly surprising in the mix, and, ultimately, may help healthcare organizations endure the scrutiny of surveyors that insist on applying healthcare occupancy requirements to business occupancies. In some ways, it also helps to clarify certain general concepts (for example, the protection of hazardous areas—I suspect you’ll be installing some door closers before too long) that were always applicable, but not always meted out during surveys. There are approximately 30 new performance elements (I count 29, but I can never tell when my math skills will legitimately start to deteriorate…) to chew on, but the “good” news is that these are not coming online until July 1, 2021, so perhaps you will have had enough time to really kick the tires in your clinics, etc.

These changes will be in play for behavioral health and critical access hospitals as well, you can find the links for each of those here.

There are also some EC and LS changes coming to behavioral health, but I think we’ll dig into those next time.

In the face of all of this, I hope that each of you has a safe and joyous holiday season and that we all get a really spiffy New Year. I think we’re earned it!

We’re only immortal for a limited time…

Just taking a quick cruise the FAQ pages and came across one or two items of interest; commentary as applicable…

Our friends in Chicago have given the thumbs up to using the current pandemic response to meet the emergency management exercise(s) requirements. Make sure you document the evaluation in accordance with the six critical areas of response:

  • Communications—what worked well and what did not
  • Resources and assets—what resources were abundant, adequate or lacking
  • Safety and security—what issues arose and how were they resolved
  • Staff responsibilities—what issues arose and how were they resolved
  • Utilities—what issues arose and how were they resolved
  • Patient clinical and support activities—what was abundant, adequate or lacking.

There is an indication that they may be “leaning” on EM when the survey process returns in earnest (and we all know how important that is…).

Moving on to the world of equipment management, specifically diagnostic imaging equipment, there is some relief relative to the completion of performance evaluations for certain systems (CT, MRI, NM, PET, but not mammography) for the duration of the declared state of emergency. I’d be curious as to how folks have been managing this in general; I suspect that some folks had these on the schedule before things came to a screeching halt, but we’re rounding the corner on a year’s worth of pandemic delight so probably want to keep an eye on where things stand. As with many things, the clock will be ticking once the state of emergency is discontinued, at which point you’ll have 60 days to get things scheduled. I bet there will be a lot of competition for external resources at that point…

We’ll close out this week’s edition with some fodder for the HVAC-heads in the crowd. I have to admit that the question being asked and the response don’t seem to match up particularly well and I do think there probably ought to be some mention of the manufacturers’ instructions for use (nothing like a little IFU to make one’s day). The question seems more along the line of “what should we be doing now,” but the response seems to focus a little more on “here’s what you do when this is all over,” when it comes to maintaining HVAC equipment being used to support COVID units. Again, I suspect the IFUs have a big part of where we should be at the moment. Hopefully, you’ve had enough ebb and flow of patients to be able to attend to something close to a normal preventive maintenance schedule and it probably couldn’t hurt to reach out to equipment manufacturers’ if we have significantly modified the use of existing systems and equipment. That said, I would certainly recommend including the bulleted items noted in the FAQ once we’re in a position to start returning things to “normal.”

Won’t you be glad when normal doesn’t have to be in quotation marks?

Hope you all remain safe and well!

Someone’s in the kitchen, but there are no banjos involved…

In the never-ending quest for generating new and challenging survey findings, our friends in Chicago have thrown down the gauntlet (or perhaps more aptly, the oven mitt) for a new focus area: the kitchen! Certainly, the kitchen has always been part of the fabric of most regulatory survey visits. If you think about it, kitchens are among the most risk-laden environments in healthcare. You’ve got all the classic physical environment risks—slips, trips, falls, fire, sharps, heat, humidity, chemical hazards, sanitation/cleaning, a lot of entry-level positions—the list goes on and on. You could make the case that the kitchen environment is among the least risk-free environments in any healthcare organization. I will stop short of calling it dangerous, but it sure is hazardous.

To that end, this week’s Joint Commission blog posting outlines some of the major focus areas for the survey process as it relates to the kitchen; the blog also includes a link to a checklist for reducing fire and other risks in the kitchen. If you don’t have a formal process for doing rounds in your kitchen(s), might be work kicking the tires on this one.

Hope you all are well and staying safe. While I think we’re starting to make the adjustments to the “new normal,” the post-Thanksgiving spike (if there is one, and there’s no reason to think there won’t be) should be arriving shortly, so keep up the good work and we’ll get through this!

Be afraid, be very afraid…but do it anyway!

Something of a mixed bag this week: Basically a couple of brief items with some interpolative commentary.

First off, in what is probably not really a surprise, the feds have not updated the status of the Public Health Emergency (PHE) (here’s the most recent correspondence in this regard) in a little bit, but I am hopeful that our sprint towards the New Year will prompt a revisitation. I guess one of the key thoughts moving forward is at what point are regulatory surveys impacted. It would seem that we are in a bit of a spike in cases (though how one can tell definitively is something of an art form), based on the information provided to folks traveling in and out of Massachusetts (which would include yours truly). While I can’t say that I’m getting used to being swabbed, I suspect that between now and Christmas, I’ll have a few more opportunities to embrace the swab.

At any rate, I’d be curious as to how folks are “falling” within their normal accreditation survey cycle. Early? Late? Pretty much on time? At some point, something’s going to have to give (and maybe that something involves virtual building tours and the like). I guess at this point all we can do is “stay the course,” and wait for the vaccine distribution challenge (we know it’s coming sometime)…

In other news, our friends in Chicago announced a revision to one of the performance elements dealing with the life safety implications of maintaining fire suppression systems. You might recall we chatted a bit about this back at the beginning of July, at least in terms of the whole spare sprinkler thang. If you accept (as I pretty much have at this point) that any change to a physical environment standard or performance element is “designed” to provide an opportunity for generating more findings (the sterling being the impending focus on the ambulatory care environments), then I think it would be prudent to really kick the tires on your spare sprinkler maintenance program to ensure that you are meeting not just the requirements of the revised performance element, but also the other related requirements. (The blog post above should serve as a good starting point, if you are so inclined.)

As always, please be well and stay safe. I appreciate everything you are and everything you do!

A cautionary tale for travelers: The only nose you’ll want to see this week…

I’m not sure how many folks will be traveling this week (the CDC is advising folks to refrain from travel). But having spent a goodly portion of the past few months traversing airports and the like, I can tell you, from personal experience, that compliance with the wearing of masks is better than it was, but there are still quite a few schnozzes on display. So, if you are traveling by public means, please be vigilant within your own practice and don’t be one of those folks that can nurse a 6-ounce bottle of water for a four-hour flight. Interestingly enough, United Airlines has started to call out folks for using consumption of food/beverage as a basis for leaving their masks off. I noticed it a lot this summer and it still seems to be a more common practice than I would prefer to see.

That said, please accept my sincerest wishes to you and yours for a most joyous Thanksgiving holiday and safe, definitely want you all to stay safe!

And as to the nose you want to see

Happy Thanksgiving!

We know it will never be easy, but will it ever get easier?

It’s always interesting (and perhaps a bit thrilling) when an announcement comes flying over the transom from our friends in Chicago unveiling “modifications” to the Environment of Care (EC) survey process for healthcare occupancies (e.g., ASCs, hospitals, critical access hospitals), but this ended up being a little less breaking news and a little more of a good news/less-good news situation.

For quite some time now, I have mulled over the general thought that the EC interview session portion of the accreditation survey process really doesn’t yield a lot of findings. My sense of the session is that it’s more of an evaluation of group participation than anything else and it appears that others in a position to do something about it are in agreement, at least as a function of identifying survey vulnerabilities.

At any rate, The Joint Commission recently announced that the EC interview session is going away (good news) to provide more time for surveying in the field, including even more focus on EC stuff for the clinical surveyors during tracers (less-good news). I am certainly not worried about folks getting into “big” trouble during this extra hour of time, but it is another hour of wandering around that is likely to generate at least a few more “dings” in the physical environment.

As the Chicagoans continue to battle the forces of CMS in their pursuit of deemed status and reported shortfalls in the surveying of the physical environment, there is a certain inevitability at play here, so I guess we’ll have to wait and see. My immediate prediction is that there will be an increase in EC/Life Safety findings over the next little while (and perhaps a little while after that…).

Now, if they would only remove the requirements to maintain the safety, security, HazMat, fire, medical equipment, and utility systems management plans—I don’t think they generate very many findings and they really don’t serve any real operational purpose for healthcare organizations. Fire response plans and emergency response plans make sense to me, but the rest of it should be captured through the annual evaluation process. Is it really that big a “step” to go from evaluating effectiveness of the EC plans to evaluating the effectiveness of the EC programs in whole? Somehow I don’t think so…

Hope you are all well and staying safe!