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.

Walking in the shadow of the big man: CMS isn’t done with emergency preparedness

Imagine that!

The turn of February brought with it the latest epistle from our friends at CMS as they continue to noodle on the preparedness of the nation’s hospitals. I don’t know that this represents a ton of hardship for folks and I do know, for at least some folks, the latest directive is fairly straightforward as a function of their emergency preparedness programs, activities, etc. As we’ve discussed once or twice over the years (decades?!?), emergency preparedness is a journey, it is not a destination. And while we do have the opportunity to plot our own course on this, it seems that the regulatory oversight piece will never be very far away.

So, the first piece of this (you can find the whole missive here) is the pronouncement that planning for using an all-hazards approach to emergency management (and who isn’t?!?) should also include consideration of emerging infectious disease (EID: Influenza, Ebola, Zika, etc.) threats. The guidance goes on to indicate that planning for EIDs “may require modifications to facility protocols to protect the health and safety of patients, such as isolation and personal protective measures.” I think my immediate inclination would be to include EID threats as a separate line item for your HVA (my fear being if you integrate things too well into your existing, then you’ll be that much harder-pressed to “pull out” the EID portion of your organizational analysis). And/or if you combine all the IC stuff into one, then you might make changes to your plan to address the higher-risk stuff and create some operational challenges for your “normal” stuff. It’s early in the game on this one, so we’ll see how the process matures.

Next up we have some discussion relative to the use of portable/mobile generators as part of our emergency preparedness activities. It would seem that a lot of folks reached out to CMS to see if they were going to have to replace portable/mobile generators with the typical generator equipment found in hospitals, and (hooray!) the answer to that question is no, you don’t have to: unless your risk assessment indicates that you should. Apparently, there were other questions relating to the care and feeding of portable/mobile generators and the ruling on the field is that you would have to maintain them in accordance with NFPA 70 (and, presumably, the manufacturers’ IFUs), which includes:

  • Have all wiring to each unit installed in accordance with the requirements of any of the wiring methods in Chapter 3.
  • Be designed and located to minimize the hazards that might cause complete failure due to flooding, fires, icing, and vandalism.
  • Be located so that adequate ventilation is provided.
  • Be located or protected so that sparks cannot reach adjacent combustible material.
  • Be operated, tested and maintained in accordance with manufacturer, local and/or state requirements.

It also mentions that extension cords and other temporary wiring devices may not be used with the portable generators, so make sure that you have those ducks in a row.

There are a few more things to cover, but I think those can wait until next week. See you then!

Don’t bleed before you are wounded, and if you can avoid being wounded…

…so much the better!

Part of me is wondering what took them so long to get to this point in the conversation.

In their latest Quick Safety utterance, our friends in Chicago are advocating de-escalation as a “first-line response to potential violence and aggression in health care settings.”  I believe the last time we touched upon this general topic was back in the spring of 2017 and I was very much in agreement with the importance of “arming” frontline staff (point of care/point of service—it matters not) with a quiver of de-escalation techniques. As noted at the time, there are a lot of instances in which our customers are rather grumpier than not and being able to manage the grumpies early on in the “grumprocess” (see what I did there?!?) makes so much operational sense that it seems somewhat odd that we are still having this conversation. To that end, I think I’m going to have to start gathering data as I wander the highways and byways of these United States and see how much emphasis is being placed on de-escalation skills as a function of everyday customer service. From orientation to periodic refreshers, this one is too important to keep ignoring, but maybe we’re not—you tell me!

At any rate, the latest Quick Safety offers up a whole slate of techniques and methods for preparing staff to deal with aggressive behaviors; there is mention of Sentinel Event Alert 57 regarding violence and health workers, so I think there is every reason to think that (much as ligature risks have taken center stage in the survey process) how well we prepare folks to proactively deal with aggressive behaviors could bubble up over the next little while. It is a certainty that the incidence rate in healthcare has caught the eyes and ears of OSHA (and they merit a mention in the Quick Safety as well as CDC and CMS), and I think that, in the industry overall, there are improvements to be made (recognizing that some of this is the result of others abdicating responsibility for behavioral health and other marginalized populations, but, as parents seem to indicate frequently, nobody ever said it would be fair…or equitable…or reasonable…). I personally think (and have for a very long time, pretty much since I had operational responsibilities for security) that de-escalation skills are vital in any service environment, but who has the time to make it happen?

Please weigh in if you have experiences (positive or negative are fine by me) that you’d feel like sharing—and you can absolutely request anonymity, just reach out to the Gmail account (stevemacsafetyspace@gmail.com) and I will remove any identifying marks…

Power Up: When your generator doesn’t carry a 30% load

Particularly for smaller facilities (or, I suppose, big places with multiple generators), consistently meeting the requirement for a 30% load during monthly generator testing activities can be a bit of a chore. And it can result in having to consider performing an annual load test at increasing loads, which usually means that you have to contract out that extra load test (and they ain’t cheap, all things being equal).

But if you look at NFPA 110-2010, it does provide another means of complying with the monthly requirements. Section 8.4.2 indicates that “(d)iesel generator sets in service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:

  1. Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
  2. Under operating temperature conditions and at not less than 30 percent of the EPS standby nameplate KW rating

Note: The 2019 edition of NFPA 110 removes the word “diesel” for the text, which opens things up a bit for folks who don’t have diesel generators.

So, the trick becomes how best to capture the exhaust gas temperatures, so you are assured of a compliant test and not being at risk for wet-stacking during the generator test. Fortunately, when it comes to emergency power system information, there is no better source than the good folks at Motor & Generator Institute (MGI). Dan Chisholm and the folks at MGI have just the thing to get you started and even if you’re an experienced generator owner/operator, I would encourage you to check out the information here.

It might just give you a leg up on the survey process!

E to the E to the E to the E: Next step(s) towards a reporting culture

Thinking that this may have gotten lost in the year-end shuffle, I wanted to take a moment to cover a little ground relative to Sentinel Event Alert (SEA) #60: Developing a reporting culture: Learning from close calls and hazardous conditions. I believe (I was going to say “know,” but that’s probably a little more hyperbolic than I can reasonably venture, but I’m basing it on your “presence” here—you folks are all about getting better and on the off chance that I provide something useful to that end, I’m pleased to have you along for the ride) that you folks are committed to ongoing evaluation of performance, occurrences, funky happenstance, etc. and so little of this will come as anything resembling revelation. That said, I think we do need to prepare ourselves for the wild and wacky world of surveyor overreach and draconian interpretation. Part of my “concern” (OK, perhaps most of it) revolves around the innate simplicity of the thrust of SEA #60. It’s straightforward, cogent, and all the things you would want through which to develop a compliance framework:

  • Establish trust
  • Encourage reporting
  • Eliminate fear of punishment
  • Examine errors, close calls and hazardous conditions

But, how do you know when you’ve actually complied with this stuff? Is this more of an activity-driven requirement: We’re going to do A, B, and C to “establish” trust, then we’ll do D, E, F, G, and H to encourage reporting? (Aren’t we already encouraging reporting?) And the whole “eliminate fear” thing (I’ve had one or two bosses that would have a hard time not administering some sort of retributory action if you messed up)…how do you pull that off? Likely, the examination of errors and close calls is a normal part of doing business, but the examination of hazardous conditions seems less of a fit in this hierarchy. My own tendency when I find a hazardous condition is to try and resolve it (I do love a good session of problem-solving), but maybe it’s more of an examination once someone reports the condition as hazardous. Not quite sure about that.

At any rate, there’s lots of information available on the subject, including an infographic on the 4E methodology, as well as the usual caches of information, etc. which you can find here and here and here.

I am a big fan of encouraging the reporting of stuff by the folks at the point of care/point of service, so to the extent that this moves healthcare in that direction, I’m all for it. So, my question to you is: Does  this represent a shift for the way in which you practice safety in your organization or perhaps gives you a little bit more leverage to get folks to “say something if they see something”? Does this help or is it just so much “blah, blah, blah”?

In security we trust, insecurity we fear: Are you up for a challenge?

Last week we started noodling on where things might go from a regulatory/accreditation perspective as the dust “settles” relative to the management of behavioral health patients, ligature risks, etc., as well as the continuing march on infection control targets, items that are certainly on the radar. But there’s one other item that I keep coming back to (in my mind’s eye): Getting our arms around issues relating to workplace violence. While I have no data to support it beyond a general impression based on conversations with various folks, I would venture to say that, if you look at it purely in terms of “room for improvement,” concerns relating to the management of workplace violence has got to be sitting pretty near the top of the “to do” list (I suspect it’s at the top of that list, but if you should happen to either have this one completely under control or there’s something that concerns you more, I’d love to hear about it).

I don’t think (and I’m certainly not in a position to dispute) the numbers are indicative of anything but a pervasive, tough-to-solve issue, particularly in the current healthcare environment. I hear stories about difficulties getting funding for technology solutions, additional staffing to maximize those technology solutions, etc. sometimes forcing us to be reactive as opposed to being able to develop a proactive response. But in looking at the OSHA website as a warmup to penning this particular entry into the Safety Space canon, I noticed that some updated materials have been posted on the OSHA website, including an executive summary for hospital leaders, some examples of best practices, and some information on how you might integrate workplace violence prevention into your organization’s “regular” compliance activities. The addition of these materials, perhaps as a subset of being helpful, tells me that there’s still a fair amount of consideration being given to the subject and we, as an industry, might be well-served to give these materials a look-see. Share that executive summary with your organization’s leaders if you have not already done so; start talking with your organizational risk management and occupational health folks to start working towards elevating this to an organizational priority before the events of the day force you to do so (or to explain to your boss why you didn’t). I’ve worked in healthcare long enough to remember those halcyon days when hospitals were not the hotbed of safety and security risks they are today—until somebody invents a working time machine, we’re not going back there, so we have to focus on future improvement.

And, interestingly enough, I’m not the only one thinking about this stuff; I would encourage you to check out Tim Richards’ blog post. He provides some good food for discussion and perhaps even some early budget planning. There’s a lot of technology out there, some of it (I daresay) could be very useful in protecting folks in a more effective way. This one’s not going away any time soon, and to be honest, I can see this becoming something of a survey focus in the not-too-distant future.

Manage the environment, manage infection control risks

In looking back at 2018 (heck, even in looking back to the beginning of 2019—it already seems like forever ago and we’re only a week in!), I try to use the available data (recognizing that we will have additional data sometime towards the end of March/beginning of April when The Joint Commission (TJC) reveals its top 10 most frequently cited standards list) to hazard a guess on where things are heading as we embark upon the 2019 survey year.

First up, I do believe that the management of ligature risks is going to continue to be a “player.” We’re just about two years into TJC’s survey focus on this particular area of concern; and typically, the focus doesn’t shift until all accredited organizations have been surveyed, so I figure we’ve got just over a year to go. If you feel like revisiting those halcyon days before all the survey ugliness started, you could probably consider this the shot heard ’round the accreditation world or at least the opening salvo.

As to what other concerns lie in wait on the accreditation horizon, I am absolutely convinced that the physical environment focus is going to expand into every nook and cranny in which the environment and the management of infection control risks coexist. I am basing that prediction primarily on the incidence of healthcare-associated infections (HAI) and related stuff (and, as was the case with ligature risk, I suspect that having a good HAI track record is not going to keep you from being cited for breakdowns, gaps, etc.). We’ve certainly seen the “warning shots” relating to water management programs, the inspection, testing, and maintenance of infection control utility systems, management of temperature, humidity, air pressure relationships, general cleanliness, non-intact surfaces, construction projects, etc. Purely from a risk (and survey) management perspective, it makes all the sense in the world for the survey teams to cast an unblinking eye on the programmatic/environmental aspects of any—and every—healthcare organization. Past survey practice has certainly resulted in Condition-level deficiencies, particularly relative to air pressure relationships in critical areas, so the only question that I would have is whether they will be content with focusing on the volume of findings (which I suspect will continue to occur in greater numbers than in the past) or will they be looking to “push” follow-up survey visits. Time will tell, my friends, time will tell.

But it’s not necessarily just the environment as a function of patient care that will be under the spotlight; just recently there was a news story regarding the effects of mold on staff at a hospital in New York. TJC (as well as other accreditors including CMS) keeps an eye on healthcare-related news stories. And you can never be certain that it couldn’t happen in your “house” (it probably won’t—I know you folks do an awesome job, but that didn’t necessarily help a whole lot when it came to, for example, the management of ligature risks). Everything filters into how future surveys are administered, so any gap in process, etc., would have to be considered a survey vulnerability.

To (more or less) close the loop on this particular chain of thought (or chain of thoughtless…), the Centers for Disease Control and Prevention are offering a number of tools to help with the management of infection control risks in various healthcare settings, including ambulatory/outpatient settings. I think there is a good chance that surveys will start poking around the question of each organization’s capacity to deal with community vulnerabilities and these might just be a good way of starting to work through the analysis of those vulnerabilities and how your good planning has resulted in an appropriately robust response program.

Philo-safety: Improving our practice in 2019

In case it has not become abundantly clear over the last decade or so of penning this blog, there is something about this time of year that sets me to pondering the enormity of just about anything and everything (if I’m not doing onsite work, my morning routine is to get my first 10K steps in before breakfast—plenty of time to contemplate, ruminate, and various other solipsistic activities). To enhance the “environment” of the morning walk, I listen to podcasts that tend to cover other folks’ life experiences. One of my favorites is the Nerdist podcast, which tends to lean towards tech and entertainment coverage, but lately there’s been a conversational thread relating (to various degrees) to the philosophy of stoicism (please bear with me: I’ll loop this back around in a minute).

For those of you not familiar with the roots of stoicism, it goes back to the times of the ancient Greeks and, if I may steal a passage from Epictetus (bet you never expected to find him here—and neither did I!), the foundational notion geos a little something like this: “In life our first job is this, to divide and distinguish things into two categories; externals I cannot control, but the choices I make with regard to them I do control. Where will I find good and bad? In me, in my choices.” (if you’re interested in finding out more about the particulars of Epictetus and the philosophy of stoicism, you can find a bunch of stuff here).

So in looking at that dynamic, I started to think about the importance of how we, as safety professionals, interact with our “charges.” By that, I mean: Do we react to circumstances or do we respond to them? While there is a case to be made for react and respond as synonyms, I think that there is a subtle (OK, maybe not that subtle) shift from a “reaction” to a “response.” To me, “response” tends to be the result of a more thoughtful, measured consideration of whatever issue, concern, etc., we might be facing. Framing this in this age of social media, I think we need only glance at Twitter (and sometimes the various newscasts) if you’re looking for some reactive materials, but “response” seems rather more in short supply than is good for any of us. At any rate, my personal challenge for this year is to work towards the “response” side of the equation and to reduce the level of reactivity (including while driving in Massachusetts!).

One of the things that can (and does, to one degree or another) influence our reactive versus responsive nature is the presence of what can euphemistically be referred to as “implicit social cognition,” which manifests itself as hidden or unconscious bias. One could certainly debate how much impact implicit social cognition has on our individual lives, practices, etc., but there is a group at Harvard University that is trying to collect data on just this topic with anonymous testing and other activities. I’ve always been fascinated by the various psychologies that influence the workplace environment and I think the folks at Project Implicit are looking at some really interesting stuff. I haven’t done a deep, deep dive into their materials yet, but I did take the first Implicit Association Test and I can definitely see how this process might help each of us understand some of our inner workings. I do believe that the more we can learn about ourselves and how we interact with others can only help the “quality” of those interactions. To that end, I would encourage you to check out the materials noted here and if you do (no pressure), please let me know (you can share it with the group or with me directly at stevemacsafetyspace@gmail.com).

And here’s to a safe, healthy and productive 2019!

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

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

The notification I received from EPA characterized things thusly:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The coexistence of safety leadership and empathy

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

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

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

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