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.

The Fountains of Youth and Water Management Programs

As a follow to last week’s item about water management programs, I know a lot of folks are not using their drinking fountains (or as we know them in the Boston areas, bubblers—pronounced “bubblahs”—I was hoping to find an audio link, but if you doubt the veracity of that pronunciation, this sort of backs it up). How are you managing those as a function of your water management program?  I’ve seen a lot of these devices sitting idle (and not just in healthcare) and looks like they may be sitting that way for a while. Are you periodically having someone go around to operate them or have you modified other practices to keep an eye on these? Not quite sure why it took me so long to think about this—perhaps it’s the ever-growing drinking fountains covered in plastic. The other question I had in this regard is whether any of you are using this as an opportunity to remove them completely? Depending on the design of your building, these are sometimes placed in a way that reduces the clear width of an egress pathway or two. This might be the best opportunity evah to get rid of them.

Of course, the other dynamic that comes into play (though perhaps less in healthcare than in other industries) is the whole notion of how to manage facilities that are experiencing reduced utilization. Perhaps you have a business office or the equivalent, and you have folks working remotely or some other variation on the theme of forced vacancy. If that’s the case (or could become the case if COVID persists), then you might find the following information worth checking. Fortunately, resources continue to provide guidance in this regard and I don’t think there’s anyone among us that would wish to endure a breakout of waterborne pathogens in the midst of the current climate.

Check out the following resources:

Hope all is well and you folks are staying safe. See you next time!

Madman Across the Water Management Program

This week brings us something of an unexpected development in the management of the physical environment as our friends in Chicago are seeking comments on a proposed standards revision that more clearly indicates the required elements for water management programs. I don’t know that I was expecting this change, though I suppose it falls under the “one outbreak is one too many” category, nor was I expecting the solicitation of commentary from the field (I look forward to seeing the results of the comment period). It would seem that the proposed performance element is based very closely on the CDC recommendations, which clearly take into consideration the guidance from ASHRAE 188 Legionellosis: Risk Management for Building Water Systems and ASHRAE 12 Managing the Risk of Legionellosis Associated with Building Water Systems, so it doesn’t appear that we’re breaking new ground here.

Additionally, we know from past discussions that CMS has been pretty focused on the risks associated with building water systems (most recently, here, but there are others), so this may be a case of ensuring that everyone is paying attention to the areas of (presumably) greatest risk. And, as near as I can tell, none of the existing COVID-related blanket waivers exempts folks from managing the risks associated with building water systems, so hopefully you’ve been staying with your identified frequencies for testing, etc. And if you haven’t, you probably should be identifying a game plan for ensuring that those risks are being appropriately managed.

Clearly, there’s a little time before these “changes” go into effect (the comment period ends November 16, 2020), but since this is pretty much what CMS has been looking for since 2017 or so, you want to have a solid foundation of compliance moving forward. I recognize with everything else going on at the moment, this might not be a priority, but this is one of those concerns in which proactivity will keep you out of compliance jail.

Until next time, hope you are all well and staying safe!

Is it really transparency if they have to catch you first?

A few months ago, I was working with a facility that, as it turns out, was experiencing challenges with managing temperature and humidity in some of their procedural areas. When I got to the space in question during the building tour, I took particular note of some portable dehumidifiers in a couple of the rooms (one of which hadn’t been emptied in enough time that water was pooling on the floor). In both rooms, the humidity level indicated on the monitoring devices in the rooms was in the 70+ range—a value most surveyors would consider a tad “moist” for a procedural area (my first thought was how high would the humidity be if they weren’t running additional dehumidifiers). At any rate, I asked to see the logs and found enough irregularities to ask to see the perioperative department director. I should mention that this was day four of a four-day consulting gig.

In meeting with the director, I was told that they were embracing full transparency in informing me that they had been experiencing environmental issues in this space for quite some time. My immediate response (which, I will admit, was a bit catty) was: “Is it really transparency if you only tell me after I’ve identified the issue?” I know that sometimes folks like to leave things to see if I can find them (or see if I remember something from the last time I was there) and I think I have a pretty good track record of identifying the various and sundry gaps that can make a good survey go bad in a hurry. But this one really caught me sideways (and continues to) relative to the transparency thing. As I’ve maintained is the case for managing garden variety deficiencies; if folks have to go look for things to fix that have already been identified, it doesn’t strike me as particularly efficient, but that may just be me…

In other news, our friends from Chicago recently published a piece penned by Herman McKenzie, the director of the engineering group at The Joint Commission (TJC); in the piece, Mr. McKenzie provides some insight into what FAQs have been updated, as well as some common concerns in the physical environment. I don’t know if we’ll be seeing Mr. McKenzie as a featured contributor to Perspectives, but hopefully this represents the re-commencement of regular information regarding TJC’s expectations in the physical environment. Generally, September/October is round about the time we hear about the most frequently cited standards during the first half of the year, but I guess that schedule (like pretty much everything else) has been knocked on its keister. At any rate, this link will take you to what’s current (I hesitate to say “new”, just because) in the management of the environment.

Until next time, please be well and stay safe!

Fall protection in all seasons

This week’s missive is something more of a “bite” than the usual multi-course jabbering, but I think you may find this of interest.

I’ve found that sometimes it’s difficult to explain to folks why we, as safety professionals, insist on certain things, like fall protection and appropriate storage of compressed gas cylinders. I think we all understand that the “right thing” to do is not always the most convenient and sometimes folks cut a corner or two. And a lot of times, we only find the (more or less) near misses in that we identify the noncompliant condition or practice after the deed has been done (so to speak) and the involved individual(s) have fled the scene, making a legitimate root cause analysis of the failure in process a very difficult thing to accomplish. The example that springs most quickly to mind is the improperly secured compressed gas cylinder—primarily the one standing in the corner of a utility room. Now, it is true that this doesn’t happen very often in hospitals (or if it is, nobody is talking about it), but I think it is helpful to “share” with those folks that seem more prone to leaving cylinders hanging around some footage of what can happen.

And, in recognition that it doesn’t take great heights (or wuthering heights, but that’s a whole ’nother kettle of fish) to provide the backdrop for some serious injury potential. When it’s time to remind folks of the dangers of working without appropriate fall protection, you might find this video useful. Much like the driver education videos of yore (and maybe still today), the results can be quite graphic. It’s not a short video, but there is a lot of good, potentially dissuasive, information about falls and the importance of protection.

That’s it for this week. I hope you all continue to be well and are staying safe!

At what point does an emergency response activation become the ‘new normal’?

As we approach the “end” of 2020 (and holding on to the hope that 2020 won’t find a way to persist into next year), I was pondering the question of how one might meet the requirement for a second emergency response activation if one did not have the extraordinary foresight to plan and conduct an exercise before the wheels fell off the world back in March. My thought was that the complexities of the current situation (and the onset of the “flu season”) might give you enough variation to parse the current response (certainly we are not in the same “place” as we were back in the spring) into two evaluations (making sure that we are accounting for an evaluation of the critical response elements: communications, resources and assets, staff roles and responsibilities, safety and security, utility systems, patient care). I suppose one could also “leverage” the update of your hazard vulnerability analysis (HVA)—if you have had a spare moment to do so. As I recall, everyone had pandemic on their HVA, with varying degrees of presumed preparedness. It will be interesting/instructive to see how well your previous analysis matched up with how your organization has fared thus far. It is certainly within the realm of improvement to evaluate current response activities in terms of lessons learned over the past few months (and extrapolating into the next few months).

One glimmer of hope for organizations that are accredited by The Joint Commission is a note attached to the drill requirements that indicates that organizations are exempt from engaging in their next full scale exercise following the onset of the emergency event. My “read” is that (and I believe that this applies for as long as the presidential declaration is in place) folks are allowed to focus their attentions on managing the emergency at hand as opposed to having to come with something else (new, different, etc.) to exercise. I hope to get some confirmation of this over the next little while, but I’d be interested to hear from anyone that has undergone recent survey—my hope is for some flexibility on this count—in full recognition that flexibility has not necessarily been the hallmark of the survey process of late.

At any rate, as this whole megillah had a beginning (and is certainly having a middle), hopefully it will have an end that results in a return to the “old normal.”

Hope you are all well and staying safe. Please stay in touch as you can!

The impossible year continues: Emergency response in 2020

Interestingly enough, I don’t believe that I have a great deal of yammering to do this week; not sure if it’s just a case of mental fatigue with all that continues to transpire (or I daresay, escalate) in terms of community emergencies of virtually every and any imaginable kind. Just between COVID-19 and a typical hurricane season, it would have been an adventure of epic proportions, but perhaps a wee bit more manageable than the various forces assailing the planet. But no, what in the past had tended to be rather transient in nature has now turned towards an aggregation of conditions that rivals…certainly nothing in recent memory and perhaps not ever (the Dark Ages, maybe).

One of the positive byproducts of such a year as this is the ongoing development and promulgation of resources – I have maintained, and will continue to do so, that hospitals are generally pretty well prepared to deal with “stuff.” As I see it, the whole point of preparedness is to be able to manage circumstances (be they singular or plural) without “breaking” (by breaking, I mean a catastrophic failure of response such that folks are actually placed in unprotected risk because of the break, as opposed to facing a situation in which hospital operations would need to be altered, moved, etc.). There are no perfect organizations when it comes to this, which is as it should be—but that doesn’t mean that folks are content to rest on past experiences, but rather to build on those experiences and make improvements. The magnitude of events this year has tested the healthcare industry in ways that would only have been predicted as a hyperbolic planning exercise (this year has been a whole lot of “and then this happens”). As has been the case any number of times in the past, hospitals and other healthcare organizations have had to manage things on their own and/or with community partners as the upper levels of the response infrastructure have been less effective than might have been desired (not pointing any fingers—this is not the first time, nor is it likely to be the last time that the most effective response happens at the local level).

At any rate, there are a few resources that I’ve noted over the past couple of weeks that I wanted to share. I somehow doubt that you’ll have a lot of spare time with which to review written materials, but I’m thinking that at least the links to these materials will be in a place you can “find” again. Lots of stuff here, a lot of it coming out of the response to wildfires in California, but as a primer for relocation, establishing alternative care sites, etc., there is much that is applicable to any untenable emergency condition:

As always, I hope this finds you safe and in reasonable sanity. I would like to think that we’ve got more of this behind us than in front of us, but the numbers are frowning at me, so I will just hold that hope…until next time!

Punching above your weight: Virtual inspections are coming!

As we continue the endurance test that is 2020, one of the general concepts that keeps cropping up relates to external folks (I hesitate to characterize them as “agencies” because of the potential for this to extend well beyond intrinsically compliance or regulatory-related processes) wanting to “visit” with you while minimizing the potential for physical “exposure” to your organization. For example, those of you who have been able to complete construction and/or renovation projects that require oversight from various folks, including your contractors, as a function of the punch list process before one can “close out” the project—in full recognition that the closing out of a project tends to represent a process under which as much of the “to-do” list is handed over to the onsite facilities folks by the contractor. And, yes, I suspect that statement reveals something in the way of a bias regarding the close-out process—but it’s a shoe that fits far more often than I would like, based on my experience.

Be that as it may, virtual inspections can be very much a double-edged sword (once again mixing far too many metaphors) in that, in some instances, the less that is found, the better (think the regulatory compliance angle), and, in other instances, the more that is found, the more “real” the assignment of responsibility for repair, etc. (i.e., the project close-out process). A little bit ago, I was chatting with a facilities director who was bemoaning the fact that his contractor had elected to conduct the punch list inspection virtually (not exactly sure how the process was administered, but it sounds like the facilities folks did not have representation in that process until after the punch list was received). An internal review of the space revealed a number of items that were not otherwise complete that (for whatever reason; you might be able to guess one or two) did not make it to the virtual punch list.

Ideally, the virtual inspection process would be an effective means of ensuring that everything in your building is “up to snuff,” but is the technology at a reliable point? Particularly if you’re the one left “holding the bag” if conditions, etc., get missed during the process and show up sometime in the future. I know some of the tech solutions are more than fascinating at first blush, but how do you folks feel is the appropriate level of trust for the results of the virtual survey? Please weigh in as you see fit. I’m really curious about folks’ experiences.

As we head towards the inevitability of autumn, I hope this finds you in good health and safe. Please keep it that way!

If you’re the AHJ, it really isn’t an “interpretation,” is it?

I’m sure we all have stories about Authorities Having Jurisdiction (AHJ) whose “sense” of what is required by code was less operationally friendly than one might have preferred. The instructor at my first educational program at NFPA headquarters indicated that there is a single response to any question than can be asked regarding compliance with (in this case, but it applies fairly universally) the Life Safety Code®: “It depends.” There may be some that think that that was a rather flippant thing to say, but in my experience it holds way more truth than hyperbole, pretty much to the point of embracing it as a central concept for pursuing compliance. The corollary that extends from that is one of the other compliance “truths”: Any AHJ can disagree with any decision you’ve made, or, indeed, anything that they or another (competing) AHJ might have told you in the past. A good example of this is when you run into a state surveyor who is not particularly inclined to “honor” an existing waiver or equivalency. If I’ve learned anything over the past X number of years, it’s that results of previous encounters have little bearing on future encounters.

At any rate, I recently received a question regarding the audibility of occupant notification appliances as a function of NFPA 72 and the interpretation of an AHJ that there is no such thing as an “average ambient sound level.” It would seem that this particular interpretation is based on the “sense” that “average ambient sound level” (and it’s cousin “ambient sound level”) are unrelated to any measurements taken by a contractor or through the AHJ’s office. As we know (being the stewards responsible for ensuring that care environment is as functionally quiet as possible), NFPA 72 does indeed invoke (for audible public mode appliances) that the sound level of those appliances must have a sound level of at least 15 dB above the average ambient sound level or 5 dB above the maximum sound level having a duration of at least 60 seconds, whichever is greater, etc. NFPA 72 also stipulates a process for making that determination, calling for sound pressure level being measure over the period of time any person is present, or a 24-hour period, whichever time period is lesser. And to be honest, I don’t know that I’ve ever seen (perhaps because I never asked for it, but I may start) any documentary evidence of that measurement when determining the sound levels for a fire alarm system.

So, the thought occurs to me that it is entirely possible that, based on his observations and experience, his statement regarding the measurement of ambient noise levels is accurate to the extent of that experience, etc. He may know the contractor that installs fire alarm systems in his jurisdiction and received feedback that the process stipulated under NFPA 72 is not routinely included in acceptance testing of a system. Or it may be that, in his determination, the standard industry practice in his jurisdiction is not sufficiently consistent to allow for the use of the ambient noise levels as a determining factor and has identified an acceptable range for his jurisdiction (75 to 110 dB). He also knows that his office is not performing this measurement, so his statement, while perhaps a bit hyperbolic, is accurate from his standpoint. But I know there are areas in which even 75 dB can make quite a racket (I’m thinking recovery rooms, ICUs, etc.), which leads me to a closing anecdote.

Back when I was responsible for day-to-day operations, I had (on a number of occasions) tried to convince my local AHJ that we could reduce the volume of the notification appliances in the PACU (which, of course, begs the question of why anyone would spec audible devices in the PACU, but sometimes…) and still achieve the same level of safety in the event of fire, etc. (primarily based on staffing levels), but I couldn’t sell that scheme. This went on over the course of several years until one day I happened to find out this individual was coming in for surgery and darn if there wasn’t a fire alarm activation when he was in the PACU. Long story, short: His next visit resulted in him signing off on reducing the volumes on the appliances (I couldn’t get my boss to sign off on replacing them—lean budget times, but sometimes you have to take what you can get).

Hope you’re staying away from any exceptionally pesky AHJs, but if you’re dealing with an unbending presence, I hope you get the opportunity to cast some illumination on your “interpretation.”

Take care and stay safe!

Why does it happen? Because it happens…

As to that thought/question (or question/thought), for those of you working through your utility systems risk assessments to ensure compliance with NFPA 99 Chapter 4: How are you accounting for components/equipment that aren’t necessarily being managed through your work order system? I’m think of systems like pharmacy hoods, nurse call systems, IT equipment, etc. Strictly speaking, those would fall under the categories found in NFPA 99, so are you reaching out for the info or are those stakeholders doing their own risk assessments? To be honest, I’m not sure how much of a compliance vulnerability this might be. I know it’s important to identify and appropriately manage your high-risk utility systems components and that’s certainly a potential area of scrutiny during a survey (particularly if they start moving towards a more extensive, virtual document review process). It can be a chore trying to account for everything that would be considered a utility system component, especially if you don’t have it in “your” inventory.

I know there have been instances in the past relative to the management of medical equipment in which primary stakeholders like imaging or lab services manage their own equipment inspection, testing, and maintenance without ever really bringing performance data, etc., up through the EOC committee function. Anything that is considered medical equipment, as would be the case with utility systems equipment, is part of the hospitalwide program and needs to be represented as such. There is no specific frequency for these “branches” of your programmatic “tree” to be reported at EOC, but you need to be able to trace the associated processes as a function of your EOC program.

Have a great week and stay safe. Perhaps autumn will bring a change in fortunes!

Why are we here? Because we’re here!

One item came up on the radar this past week or so and it appears (I poked around in the archival blogosphere and could find no mention) that I’ve not discussed this before—mea maxima culpa! This has the potential for generating some findings, perhaps at a higher risk level than would seem reasonable in the moment, but I guess that will sort itself out one way or the other.

I can’t quite remember how it all came to be, but at some point in the misty past, I was “schooled” that decontamination showers (like the ones that you typically find in areas near emergency room ambulance entrances) are not required to undergo weekly testing as they are not, as defined, “emergency eyewash or shower equipment” and, thus, not subject to the requirements of ANSI Z358.1 Standard for Emergency Eyewash and Shower Equipment. I was skeptical at the time, but I can say that the latter part of that concept is, indeed, correct in that decontamination shower equipment is not subject to ANSI Z358.1. But it is not correct relative to the weekly testing sequence because there is an ANSI standard—ANSI 113 Standard for Fixed and Portable Decontamination Shower Units—that covers decontamination showers and, lo and behold, it covers exactly what is required for those pesky fixed and portable decon shower units. So we have:

7.2 Fixed shower units shall be activated weekly for a period long enough to verify operation and ensure that flushing fluid is available.

That should sound familiar as a general concept, so you may need to add the decon shower(s) to the weekly to-do list, but things get even more interesting for the portables:

7.3 Portable shower units shall be deployed every 3 months to ensure proper operation.

I’m going to guess that we have some room for improvement on the weekly testing side of things, but I’m going to guess that we may even more of an opportunity on the portable side of things (those of you who possess portable decon showers). I daresay it’s almost enough to make someone not want to have anything elaborate or portable when it comes to decon shower equipment. I’ll let you gnaw on that for a bit…