RSSAuthor Archive for Steve MacArthur

Steve MacArthur

Steve MacArthur is a safety consultant based in Bridgewater, 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.

But I got the crystal ball, he said!

And he held it to the light…

In their (seemingly) never-ending quest to remain something (I’m not quite sure what that something might be, but I suspect it has to do with continuing bouts of hot water and CMS), our friends in Chicago are working towards modifying the process/documentation for providing post-survey Evidence of Standards Compliance (for the remainder of this piece, I will refer to the acronymically inclined ESC). The aim of the changes is to “help organizations focus on detailing the critical aspects of corrective actions take to resolve” deficiencies identified during survey. Previously, the queries included for appropriate ESC submittals revolved around the following: identifying who was ultimately responsible for the corrective action(s); what actions were completed to correct the finding(s); when the corrective actions were completed; and, how will you sustain compliance (that is, as they say, the sticky wicket, to be sure).

The future state will be (more or less) an expansion of those concerns, as well as including extra-special consideration for those findings identified as higher-risk Requirements For Improvement (RFIs) based on their “position” in the matrix thingy in your final report (findings that show up in the dark orange and red areas of the matrix). The changes are roughly characterized as delving “deeper into the specifics” of the original gang of four elements, so now we have the following: assigning accountability by indicating who is ultimately responsible for corrective action and sustained compliance (not a big change for that one); assigning accountability for leadership involvement (only for the high-risk findings—whew!) by indicating which member(s) of leadership support future compliance; corrective actions for the findings of noncompliance—this will combine the “what you did” with the “when you finished it”; for high-risk findings, you will also have to provide information on the corrective actions as a function of preventative analysis (this sounds like a big ol’ pain in the rumpus room, don’t it?); and , finally, an accounting of how you will ensure sustained compliance, which will have to include monitoring activities (including frequency), the type of data to be collected from the monitoring activities, and how, and to whom, the data will be reported.

In the past, there was always the lurking (almost ghoulish) presence of what’s going to happen if you have repeat findings from survey to survey, and this new process sounds like it might be paving the way for more obstreperous future survey outcomes. But I’d like to know a little bit more about what might be considered a repeat finding—does it have to be the same condition in the same place or is it enough to get cited for the same standard/performance element combo. If the former is the case, then I “get” them being a little more fussy about the process (in full recognition that every organization has some repeat-offender tendencies), but if it’s the latter, then (insert deity of choice) help us all, ‘cause it’s probably going to get more ugly before we see improvement. Or maybe it will just be repeats in the high-risk zone of the matrix—I think that’s also pretty reasonable, though I do think they (the Chicagoans) could do a little better in ensuring consistent approaches/interpretations, particularly when it comes to ligature risks.

All that said, I stand on my thought (and let me tell you, that’s not an easy task) that there are no perfect buildings, no perfect physical environments, etc., and that’s pretty much supported by what I’ve seen being cited during surveys—the rough edges are where the greatest number of findings can be generated. And since they only have to find one instance of any condition in order to generate an RFI, the numbers are not in favor of the folks who have to maintain the physical environment. If you’re interested in the official notice, the links below will take you the announcement article, as well as a delightful graphic presentation—oh boy!

Horrors beyond contemplation

It is impossible to capture, or even comment on, the events that transpired at the Bronx-Lebanon Hospital Center in New York at the end of last month with anything less than abject horror. There have been lots of news stories about the various events that contributed to what happened, so I will let you investigate the causative factors on your own. But having checked out the available information, I can’t help but feel almost powerless when it comes to being able to provide any sort of guidance relative to the compliance aspects of preparing for such an event.

I think I can say, without much fear of contradiction, that this is likely to create an additional focal point for TJC surveys this year (so, keeping count, we have ligature risks; management of environmental conditions including temperature, humidity, air pressure relationships; intermediate- and high-level disinfection activities; workplace violence, including active shooter). But I still keep coming back to Sentinel Event Alert #45, “Preventing violence in the health care setting,” and I keep pondering the import of that one word: preventing.

Much as we have discussed in the past with a whole bunch of topics, at what point can we say that we have reduced the risk associated with X, Y and/or Z to the full extent possible? It would be an amazing thing to be able to put in place measures and strategies that could actually prevent something (really anything) bad from happening, but I have yet to encounter many instances in which prevention is actually achieved. Do we work towards that as a goal every moment of every day? Absolutely! But I don’t know how you “prevent” what happened at Bronx-Lebanon.

Until we have sufficiently sophisticated early detection for armed persons, aberrant behavior, etc. (we can’t have metal detectors at the front door of everyone’s home, can’t do a behavioral health assessment at everyone’s front door either), the purpose of looking at this is to ensure that there is an appropriate response, be it de-escalation or run, hide, fight. From what I gather, the response at Bronx-Lebanon was in keeping with appropriate levels of preparedness. As is usually the case with human beings, I suspect that there will be valuable lessons learned in reviewing what happened, but the fact of the matter is that this could have been so, so much worse.

At any rate, we know this is likely to be a focus during survey (information from a survey just this past week indicates a very significant focus on the management of violent events), and I think one of the most important preparation activities is to share information with the healthcare safety community. To that end, I wanted to alert you to an opportunity to do just that: next week, on Thursday, July 20, 2017, HCPro will present a webinar, “Emergency Preparedness for SNFs: How to Plan for, Respond to, and Recover From an Armed Intruder/Active Shooter Event.” While the title indicates a focus on skilled nursing facilities (SNFs), the general concepts are very much applicable to all healthcare environments and, truthfully, couldn’t be more timely.

I’ve worked in healthcare long enough to recall a time when this level of violence occurred in environments other than health care, but I think we have to operate under the thought that it is only a matter of time before our organizations come face-to-face with the reality of 21st Century existence. Although I wish it were otherwise, not focusing on preparing is no longer an option.

If brevity is the soul of wit…

Hope everyone enjoyed a festive and (most importantly) safe Independence Day—with any luck, today (July 5) does not mark the end of summer (as some do say) so much as it marks the beginning of the end of spring (up here in the Northeast, spring was loath to depart, but it does seem that pre-autumn weather has finally made a commitment to spending some time in the northern hemisphere).

I was looking recently at past blog posts for a reference to the CMS stance on law enforcement interactions with patients as a function of restraints and patient rights—always a fun topic—and I noted that the posts used to be a mite briefer than tends to be the case of late. (You can be the judge of whether my decline in brevity has left me soulless or witless.) I absolutely recognize that there’s been a lot of stuff to cover over the past 18 months with the firestorms of compliance that swept the healthcare environment, which has (no doubt) promoted some of the “volume” of bloggery. But it has caused me to wonder whether I am consuming the compliance elephant in sufficiently small bites to be of use to you folks out there in the field. As near as I can tell, the purpose of this whole thing (as much as I enjoy having a place to pontificate) is to provide information and thoughts on what is happening at the moment to you, my faithful audience of safety folk. And (as near as I can tell) it never hurts to ask one’s audience whether this works for you—please feel free to give me an e-dope slap if you think the “Space” has gone intergalactic in a less-than-useful way. At any rate, I am going to experiment with smaller bites of information in the coming weeks so you’ll have more time for other things—perhaps outdoors…

As far as news goes, things are relatively quiet as we observe the anniversary of CMS’s adoption of the 2012 Life Safety Code. Hopefully you all have done your NFPA 99 risk assessments; polished off those door inspections and are speeding towards the completion of activities relating to initial compliance with the Emergency Preparedness Final Rule. Health Facilities Management This Week discussed some prepublication EC/LS standards relating to the testing of emergency lighting systems; inspection and testing of piped medical gas and vacuum systems; and updating pertinent NFPA code numbers. The pre-pub stuff is aimed at behavioral health care, laboratory, nursing care center, and office based surgery accreditation programs. You can find the details here: https://www.jointcommission.org/prepublication_standards_%E2%80%93_standards_revisions_to_environment_of_care_and_life_safety_chapters_related_to_life_safety_code_update_/

(I guess some of those links are about as brief as I am…)

Thanks, as always, for tuning in—I really appreciate having you all out there at the other end of the interweb…see you next week!

Plan be nimble, plan be quick

As we have discussed (pretty much ad nauseum) in this hallowed hall of electrons, there is likely to be a renewed (and I don’t mean renewed in a healthful way, this would be more like a subscription to a magazine that someone sent you as a prank) interest/scrutiny in how you and your organization are complying with all these lovely (and pesky, can’t forget pesky) new emergency management considerations. But there is one word of caution that I wanted to inject into the conversation, and while it probably doesn’t “need” to be said, I try not to leave any card unplayed when it comes to compliance activities.

Over the years (officially 16 of consulting—time flies!) I have found that sometimes (OK, maybe more frequently than sometimes), the prettiest plans, policies, procedures, etc. end up falling to the ground in demonic spasms because they did not accurately reflect the practice of the organization. The general mantra for this is “do the right thing, do what you say, say what you do,” but sometimes it’s tough to figure out exactly what constitutes “the right thing” (as opposed to “The Right Stuff,” natch). When it comes to emergency preparedness, response, recovery, etc. probably the single most important aspect of the plan (at least I think it’s an aspect—if you can think of a better descriptor, please sing out!) is that it is flexible enough to be able to react to minute-by-minute changes that are (frequently) the hallmark of catastrophic events. I think anyone who has worked in healthcare for any length of time has seen what happens to a rigid structure, be it policy, plan, expectations, buildings, flora and fauna—whatever, when things get to swirling around in intense fashion—things start to pull apart (figuratively and/or literally) and sustaining your response becomes that much more difficult.

So, as we “embrace” the challenges of the changes, I would encourage you to think about how you’ll maintain (and test during exercises) that flexibility of response that will give you enough wiggle room to weather the storms (of outrageous and other fabulous fortune). Exercise scenarios can push (or be pushed) in any number of directions (strangely, it is very much like real life)—make sure you take full advantage of those folks in the Command Center—if they’re not sweating—turn up the heat!

Is this the survey we really want?

Moving on to the type of pain that can only be inflicted at the federal level, a couple of things that might require an increase in your intake of acid-reducing supplements…

As it appears that CMS doesn’t love that dirty water (and yes, my friends, that is a shameless local plug, but it is also a pretty awesome tune), now their attentions are turning to the management of aerosolizing and other such water systems as a function of Legionella prevention. Now, this is certainly not a new issue with which to wrestle, which likely means that the aim of this whole thing, as indicated in the above notification—“Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water”—is something with which we are abundantly familiar. But I will admit to having been curious about the implied prevalence in healthcare facilities as that’s the type of stuff that typically is pretty newsworthy, so I did a quick web search of “Legionella outbreaks in US hospital.” I was able to piece together some information indicating that hospitals are not doing a perfect job on this front, but the numbers are really kind of small in terms of cases that can be verifiably traced back to hospitals. When you think about it, the waters could be a bit muddy as Legionella patients that are very sick are probably going to show up at your front door and there may be a delay in diagnosis as it may not be definitively evident that that’s what you’re dealing with. At any rate, sounds like a zero-tolerance stance is going to be, but the Survey & Certification letter does spell out the instructions for surveyors:

Surveyors will review policies, procedures, and reports documenting water management implementation results to verify that facilities:

 

  • Conduct a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g., Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system.
  • Implement a water management program that considers the ASHRAE industry standard and the CDC toolkit, and includes control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens.
  • Specify testing protocols and acceptable ranges for control measures, and document the results of testing and corrective actions taken when control limits are not maintained.

I have little doubt that you folks already have most, if not all, of this stuff in place, but it might not be a bad idea to go back and review what you do have to make sure that everything is in order. And if you are interested in some of the additional information (including some numbers) available, the following links should be useful:

Moving on to the world of emergency management, during the recent webinar hosted by CMS to cover the Emergency Preparedness final rule, one of the critical (at that time, more or less unanswered) questions revolved around whether we could expect some Interpretive Guidelines (basically, instructions for surveyors in how to make their assessments) for the EP Final Rule. And to what to my wondering eyes should appear, but those very same Interpretive Guidelines.  I will feely admit that the setup of the document is rather confusing as there are a lot of different types of providers for which the Final Rule applies and not all the requirements apply to all of the providers, etc., so it is a bit of a jumble, to say the least. That said, while I don’t think that I am sufficiently well-versed with the specific EM requirements of the various and sundry accreditation organizations (HFAP, DNV, CIHQ, etc.), I can say that those of you using TJC for deemed status purposes should be in pretty good shape as it does appear that one of the early iterations of the TJC EM standards was used in devising the Final Rule, so the concepts are pretty familiar.  A couple of things to keep in mind in terms of how the CMS “take” might skew a little differently are these:

 

  • You want to make sure you have a fairly detailed Continuity of Operations Plan (CoOP); this was a hot button topic back in the immediately post-9/11 days, but it’s kind of languished a bit in the hierarchy of emergency response. While the various and sundry performance elements in the TJC EM chapter pretty much add up to the CoOP, as a federal agency, it is likely that CMS will be looking for something closer to the FEMA model (information about which you can find here), so if you have a CoOP and haven’t dusted it off in a while, it would probably be useful to give it the once over before things start heating up in November…
  • As a function of the CoOP, you also want to pay close attention to the delegation of authority during an emergency, primarily, but not exclusively the plan of succession during an emergency (I found the following information useful and a little irreverent—a mix of which I am quite fond). It does no good at all for an organization to be leaderless in an emergency—a succession plan will help keep the party going.
  • Finally, another (formerly) hot button is the alternate care site (ACS), which also appears to be a focus of the final rule; the efficacy of this as a strategy has been subject to some debate over the years, but I think this one’s going to be a source of interest as they start to roll out the Interpretive Guidelines. At least at the moment, I think the key component of this whole thing is to have a really clear understanding (might be worth setting up a checklist, if you have not already) of what you need to have in place to make appropriate use if whatever space you might be choosing. I suspect that making sure that you have a solid evaluation of any possible ACS in the mix: remember, you’re going to be taking care of “their” (CMS’) patients, so you’d better make sure that you are doing so in an appropriate environment.

And then came the last days of May…

There’s been a ton of activity the past few weeks on both the Joint Commission and CMS sides of the equation (and if you are starting to feel like the ref in a heavyweight prize fight who keeps getting in the line of fire, yup, that’d be you!) with lots of information coming fast and furious. Some of it helpful (well, as helpful as things are likely to be), some perhaps less so than would be desirable (we can have all the expectations we want as to how we’d ask for things to be “shared,” but I’m not thinking that the “sharers” are contemplating the end users with much of this stuff). This week we’ll joust on TJC stuff (the June issue of Perspectives and an article published towards the end of May) and turn our attentions (just in time for the solstice—yippee!) to the CMS stuff (emergency preparedness and legionella, a match made in DC) next week.

Turning first to Perspectives, this month’s Clarifications & Expectations column deals with means of egress—still one of the more frequently cited standards, though it’s not hogging all the limelight like back in the early days of compliance. There are some anticipated changes to reflect the intricacies of the 2012 Life Safety Code® (LSC), including some renumbering of performance elements, but, for the most part, the basic tenets are still in place. People have to have a reliable means of exiting the (really, any) building in an emergency and part of that reliability revolves around managing the environment. So, we have the time-honored concept of cluttah (that’s the New English version), which has gained some flexibility over time to include crash carts, wheeled equipment, including chemotherapy carts and isolation carts that are being used for current patients, transport equipment, including wheelchairs and stretchers/gurneys (whichever is the term you know and love), and patient lift equipment. There is also an exception for fixed (securely attached to the wall or floor) furnishings in corridors as long as here is full smoke detector coverage or the furniture is in direct supervision of staff.

Also, we’ll be seeing some additional granularity when it comes to exiting in general: each floor of a building having two remote exits; every corridor providing access to at least two approved exits without passing through any intervening rooms or spaces other than corridors or lobbies, etc. Nothing particularly earth-shattering on that count. We’ll also be dealing with some additional guidance relative to suites, particularly separations of the suites from other areas and subdividing the areas within the suite—jolly good fun!

Finally, Clarifications & Expectations covers the pesky subject of illumination, particularly as a function of reliability and visibility, so head on over to the June Perspectives for some proper illuminative ruminations.

A couple of weeks back (May 24, to be exact), TJC unveiled some clarifications. I think they’re of moderate interest as a group, with one being particularly useful, one being somewhat curious and the other two falling somewhere in the middle:

ED occupancy classifications: This has been out in the world for a bit and, presumably, any angst relating to how one might classify one’s ED has dissipated, unless, of course, one had the temerity to classify the ED as a business occupancy—the residual pain from that will probably linger for a bit. Also (and I freely confess that I’m not at all sure about this one), is there a benefit of maintaining a suite designation when the ED is an ambulatory healthcare occupancy? As suites do not feature in the Ambulatory Occupancy chapters of the LSC, is it even possible to do so? Hmmmm…

Annual inspection of fire and smoke doors: No surprise here, with the possible exception of not requiring corridor doors and office doors (no combustibles) to be included. Not sure how that will fly with the CMSers…

Rated fire doors in lesser or non-rated barriers: I know this occurs with a fair degree of frequency, but the amount of attention this is receiving makes me wonder if there is a “gotcha” lurking somewhere in the language of the, particularly the general concept of “existing fire protection features obvious to the public.” I’m not really sure how far that can go and, given the general level of obliviousness (obliviosity?) of the general public, this one just makes me shake my head…

Fire drill times: I think this one has some value because the “spread” of fire drill times has resulted in a fair number of findings, though the clarification language doesn’t necessarily get you all the way there (I think I would have provided an example just to be on the safe side). What the clarification says is that a fire drill conducted no closer than one hour apart would be acceptable…there should not be a pattern of drills being conducted one hour apart. Where this crops up during survey is, for example, say all your third shift drills in 2016 were conducted in the range of 5 a.m. to 6 a.m. (Q1 – 0520; Q2 – 0559; Q3 – 0530; Q4 – 0540), that would be a finding, based on the need for the drills to be conducted under varying circumstances. Now, I think that anyone who’s worked in healthcare and been responsible for scheduling fire drills would tell you (at least I certainly would) that nobody remembers from quarter to quarter what time the last fire drill was conducted (and if they think about it at all, they’re quite sure that you “just” did a fire drill, like last week and don’t you understand how disruptive this is, etc.) If you can’t tell, third shift fire drills were never my favorite thing to do, though it beats being responsible for snow removal…

So that’s the Joint Commission side of the equation (if you can truly call it an equation). Next time: CMS!

Welcome to a new kind of tension…

In the “old” days, The Joint Commission’s FAQ page would indicate the date on which the individual FAQs had been updated, but now that feature seems to be missing from the site (it may be that deluge of changes to the FAQs (past, present, and, presumably, future) makes that a more challenging task than previously (I will freely admit that there wasn’t a ton of activity with the FAQs until recently). That said, there does appear to be some indication when there is new material. For example, when you click on the link (or clink on the lick), a little short of halfway down the page you will see that there’s something new relative to the storage of needles and syringes (they have it listed under the “Medical Equipment” function—more on that in a moment), so I think that’s OK.

But in last week’s (dated May 31, 2017) Joint Commission e-Alert, they indicate that there is a just posted FAQ item relating to ligature risks, but the FAQ does not appear to be highlighted in the same manner as the needle and syringe storage FAQ (at least as of June 1, when I am penning this item). Now I don’t disagree that the appropriate storage (recognizing that appropriate is in the eye of the beholder) of needles and syringes is an important topic of consideration, I’m thinking that anything that TJC issues relative to the appropriate management of ligature risks (and yes, it appears that I am far from done covering this particular topic) is of pretty close to utmost importance, particularly for those of you likely to experience a TJC survey in the next little while. I would encourage you to take a few moments to take a peek at the details here.

So, parsing these updates a bit: I don’t know that I’ve ever considered needles and syringes “medical equipment,” but I suppose they are really not medications, so I guess medical equipment is the appropriate descriptor—it will be interesting to see where issues related to the storage of needles and syringes are cited. As usual (at least on the TJC front) it all revolves around the (wait for it…) risk assessment. It’s kind of interesting in that this particular FAQ deals somewhat less specifically with the topic at hand (storage of needles and syringes) and more about the general concepts of the risk assessment process, including mention of the model risk assessment that can be found in the introductory section of the Leadership chapter (Leadership, to my mind, is a very good place to highlight the risk assessment process). So no particularly new or brilliant illumination here, but perhaps an indicator of future survey focus.

As to the ligature risks, I think it is reasonable to believe that there will be very few instances in which every single possible ligature risk will be removed from the care environment, which means that everyone is going to have to come up with some sort of mitigation strategy to manage those risks that have not been removed. With the FAQ, TJC has provided some guidance relative to what would minimally be expected of that mitigation strategy; while I dare not indicate verbatim (you will have to do your own clicking on this one—sorry!), you might imagine that there would need to be: communication of current risks; process for assessing patient risk; implementation of appropriate interventions; ongoing assessments of at-risk behavior; training of staff relative to levels of risk and appropriate interventions; inclusion of reduction strategies in the QAPI program; and inclusion of equipment-related risks in patient assessments, with subsequent implementation of interventions.

I don’t see any of this as particularly unusual/foreign/daunting, though (as usual) the staff education piece is probably the most complicated aspect of the equation as that is the most variable output. I am not convinced that we are doing poorly in this realm, but I guess this one really has to be a zero-harm philosophy. No arguments from me, but perhaps some important work to do.

I have nothing to say and I’m saying it!

A somewhat funky news item for this week’s bloggy goodness: In the March edition of the American Journal of Infection Control (house organ of APIC), there was a news release sharing the results of a study that indicates that hospital room floors may be an overlooked source of infection . The study also got a mention in Physicians Weekly, which means that in all likelihood it’s been noticed by any of the regulatory folks—and you know what that’s likely to mean…

At any rate, once I got past the “no, duh” thought (somehow this comes as no surprise to me), I got to thinking about the complexities of cleaning, particularly as a function of the omnipresent application of dwell times for disinfectant products and the whole concept of keeping things wet long enough to kill the bugs. I think we’ve focused a lot on getting folks who use disinfectants to be able to articulate how long something has to stay wet (good thing), but not as much on watching to make sure that we are applying that knowledge along with the application of the disinfectant. For example, it’s 3 p.m. on a Monday afternoon and the ED is jammed with patients waiting for inpatient beds. The EVS staff is scrambling to get the rooms ready for occupancy and somebody, somewhere is tapping their foot (and perhaps grousing about “how long is this gonna take?”). The question I keep coming back to is this: when there’s a rush on anything, have we well and truly built enough time into the process for surfaces to be properly disinfected? The study mentions surfaces in some hospital rooms in the Cleveland area, but there’s not a lot of discussion in the press release about cleaning methodologies, so I’m not sure what might be in play. The press release also talks about high-contact objects (personal items, medical devices, nurse call buttons) coming into contact with floors and subsequent transmission to other surfaces (including hands!). To me, this sounds like occupied rooms and I suspect that the likelihood of the floor in an occupied room staying wet long enough to properly disinfect is fairly remote. Wet floors are slippery floors and slippery falls increase the potential for falls. I mean think about it: how many times have you seen somebody waving a wet floor sign over a wet floor to get it to dry more quickly? In my experience, the last piece of any process is frequently the one that gets jammed the most time-wise. Think about construction projects that ended up having issues with improperly installed flooring. When you think about it (or when I think about it), it makes perfect sense: the flooring install is usually the last thing to happen and those folks are almost always under the gun to get things finished (so the project is on time, so the project is not quite so late, so the project gets done early) and floor prep (particularly preparation of the surface upon which the flooring is installed) becomes the sprint to the finish line at the end of the marathon. I am absolutely convinced that we are not going to “solve” this problem until everyone agrees to a reasonable amount of time for these tasks to be completed. Is it physically (and that includes making sure that surfaces are wet enough, long enough) possible to properly do a terminal disinfection of the room of a discharged patient in 20 minutes? 30 minutes? 45 minutes? And that’s not even considering the cleaning of the room of a discharged isolation patient. Maybe there are (or will be) quicker ways to disinfect surfaces; UV disinfection technology is growing, but it’s still pretty expensive technology and I think the jury is still out on how absolutely effective it is on all surfaces.

There’s little question that there are improvements to be made in the area of cleaning and, most times, the EVS folks seem to end up with the fingers pointed in their direction. But in the absence of some clearly established parameters that allow for proper administration of the disinfection process (parameters that are resistant to the tap-tap-tapping of feet…are you done yet?), I don’t know that it’s going to happen any time soon.

Come on, I Lean: Do you Lean?

As you are no doubt aware by now, there’s been a wee bit of a shift in this forum away from all things Joint Commission, as the CMSers seem more inclined to assert themselves in the accreditation market place. I personally have had a lot of work this year in follow-up activities relating to CMS visits and one of the structural/organizational vulnerabilities/opportunities that seem to be cropping with some regularity are those relating to the integration of the physical environment program into organizational Quality Assessment/Performance Improvement (hereafter referred to as QAPI, pronounced “Kwoppee”—I think you’re going to find that you’ll be hearing that term a lot in the coming years/decades) activities. This very much goes back to a topic we discussed back in January (it’s funny, when I started looking for the link to this story, I could have sworn that we had covered this within the last month) relative to making sure that organizational leadership is abundantly familiar with any issues that are (more or less) “stuck” in your safety committee. There is no “sin” in admitting that there are or may be improvement opportunities for which traction in making those improvements is a little slippery—you have to have a means of escalating things to point where reasonable traction is possible. So, from a regulatory standpoint, this all falls under §482.21 Condition of Participation: Quality Assessment and Performance Improvement, which includes the rejoinder: “The hospital must develop, implement, and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors.”

Now, I can tell you that this is a very big deal, particularly when it comes to the reporting up of data, occurrence reporting, etc.—even from the likes of our little world of physical environment safety and related topics. And sometimes you have to be willing to throw some light on those process areas that are not performing as you would want them to; improvement doesn’t typically happen in a vacuum and that absence of vacuum tends to require a fair amount of conversation/collaboration (with some resultant caterwauling) in order to make things happen/get things done.

One QAPI topic you will probably be hearing about (if you have not already) is Lean methodology, which pretty much embraces the general concept of reducing “waste” while still delivering positive service outcomes by focusing on what the customer wants (you can find some useful highlights here; the books are worth a look—perhaps your local library can hook you up). One organization that appears to be endorsing the Lean methodology is that kooky bunch in Chicago and while the article focuses on behavioral health, I think there is enough practical information to be worth a look. And, since we know from past experience that TJC tends to adopt a more pervasive stance when it comes to these types of things, I think it would be very useful (at the very least for those of you using TJC for accreditation) to be conversant in Lean. It’s probably going to rock your boat at some point—life preservers mandatory!

Ticking away the moments

As we continue our (hopefully not futile) attempts to peel back the layers of the current Joint Commission survey process, I think it is of great importance to pay close attention to all the various blogs and missives emanating from the mothership in Chicago. While the information shared in this is not “enforceable” as a standard, it does seem that a lot of the general concepts manage to find their way into the practical administration of accreditation surveys. And since we know with a fair degree of certainty that the physical environment is still going to be somewhere in their default survey setting, I wanted to bring to your attention a recent (April 25) blog posting from Ann Scott Blouin, TJC’s Executive VP of Customer Relations, that focuses on the management of workplace violence.

The blog suggests focusing on a couple of key elements (none of which I would have any disagreement):

 

  • Personal risk factors
  • De-escalation education for all staff
  • Development of a workplace violence prevention plan
  • Enforcing zero tolerance for violence/bullying

I know from my own experience that de-escalation education for all staff is not nearly as widespread as I think it should be. Elements of de-escalation technique should be included in basic customer service education for pretty much anybody in a service job, regardless of the industry. I see way too many ticked-off people floating around—I’m entirely certain why folks seem to be so primed to vent/fume/fuss, etc. (I have some theories, only some of them based on the influence of certain elements of popular culture), but there has very clearly been a reduction in patience levels in far too many encounters.

At any rate, as another brick in the accreditation wall, I think you would be well-served to check out Ms. Blouin’s blog posting; ostensibly, it is aimed at organizational leadership, but hey: Are we not leaders?