RSSAuthor Archive for Steve MacArthur

Steve MacArthur

Steve MacArthur is a safety consultant with The Greeley Company in Danvers, Mass. He brings more than 30 years of healthcare management and consulting experience to his work with hospitals, physician offices, and ambulatory care facilities across the country. He is the author of HCPro's Hospital Safety Director's Handbook and is contributing editor for Briefings on Hospital Safety. Contact Steve at stevemacsafetyspace@gmail.com.

From the sky, the highway’s straight as it could be!

But other things, maybe not so much…

In the continuing odyssey of “what goes around, comes around,” I had to cast some tea leaves to recall the last time we chatted about eyewash stations (for those of you keeping track, it was October 2019) as I reviewed the current (March 2021) edition of Joint Commission Perspectives, particularly what I view to be the most interesting aspect (and if you want to interpret that as the only interesting aspect, I would not argue the point) of the publication, the Consistent Interpretation column (I think it’s fair to call it a column, though perhaps not always a load-bearing one). The March Interpretation article deals generally with the minimizing the risks associated with managing hazardous chemicals (for which about 50% of the hospitals surveyed in the last year of the 20-teens were cited). I would encourage you to check out the details. It may save you some future heartache, especially if you have dental clinics in the mix—dental amalgam would seem to be the “pet rock” of some surveyors.

One very useful interpretation is that “simple storage” of corrosive chemicals is (more or less—we’ll see how the play on the field reflects this) off the table in terms of having to have an eyewash station (fortunately for all of us, containers of corrosive chemicals tend not to explode on their own…). Where you do need to provide access (or at least consider) are locations where corrosive chemicals are used/mixed/ dispensed. And this is where it is of critical importance to do your due diligence when it comes to the risk assessment; corrosive (and caustic) chemicals that are injurious to the eye (and other parts) are where you cross the line into eyewash stations. And given the recent funkiness regarding disinfectant cleaners and a return to bleach as a frequently used disinfectant agent, I suspect that there’s going to be a lot of attention to where bleach is being, well, used, mixed and/or dispensed. This is going to present more than its share of challenges in the field, I suspect…

Interesting point in the explanatory section of the piece; there’s a link to an OSHA interpretation that is instructive, but could be confusing as it deals specifically with electric battery storage charging and maintenance areas. Clearly, the focus is (and should be) on managing those most hazardous chemicals, etc. that we might use in the workplace, so it will be interesting to see how this unfolds over the next survey cycle.

As a closing thought (and this it definitely out of left field), I’m not sure how many EVS folks are out there in the audience, but one condition I’ve been encountering with a fair amount of frequency (and not just in hospitals—I look at this stuff wherever I go) are baby changing tables for which the safety belts have either gone missing or been damaged, etc. I know it’s not a big thing (unless you’re a parent with a squirmy infant), but (if you look at it wearing your ugly surveyor hat) you could make the case that if it’s something provided by the manufacturer, then the expectation is for the equipment, etc., to be maintained in accordance with the manufacturer’s Instructions For Use. It’s not something you have to do all the time (unless somebody is swiping them), but it might be worth scheduling a “sweep” of your changing tables from time to time.

Until next time: Be well and stay safe!

Breaking the law: Not something you want to be doing…

A very quick item this week, mostly because I want you to have the opportunity to take advantage of a resource that I think is well worth your time and you only need your ears…if you’re thinking podcast, you’re thinking in the right direction. For those you that might not be familiar with Gosselin/Martin Associates, they are a highly respected (at least by me—and I know I’m not alone) organization (and I’m paraphrasing a bit here) devoted to the systemic improvement to healthcare facilities management. From recruitment, education, mentoring, etc., Gosselin/Martin Associates are a most reliable resource on so many levels, but for this week, I would encourage you to check out their High Reliability—The Healthcare FM Podcast to check out the current climate as it relates to the legal ramifications of healthcare facilities management. As a going concern, amidst our current state of being, being familiar with the legal implications of what we do has arguably never been more important and the likelihood that that importance will increase is virtually a sure thing. As with all things everywhere, there is only so much black and white interpretation, etc., to go around, but I think you’ll find this discussion to be quite illuminating, if only to validate what you might already be thinking/experiencing, etc. The blog post for the podcast can be found here and I very much encourage you to subscribe. I find it very stimulating to listen while I am walking in the morning (bedtime probably won’t work—this won’t put you to sleep!), but I suspect you’ll find your own “best time.” I hope you take a few moments to check out High Reliability.

As always, hope you are well and staying safe!

Doing the waive: Categorical waivers are still in the mix…

In preparation for last week’s missive on the transmission of fire alarm signals during fire drills (more on that in a moment), I ran across a CMS categorical waiver that was posted early last fall (September 25, to be exact) that provided some relief for folks wishing to use corrugated medical tubing in certain circumstances, rather than the rigid copper tubing required under NFPA 99-2012, due what CMS might consider an unreasonable hardship as corrugated medical tubing can be installed more efficiently and economically than rigid copper. The basis of the waiver is due to a more recent version of NFPA 99 (the 2018 edition) in which there are provisions that provide for installation of the corrugated. At this point, we all know the drill: You have to read the whole thing very carefully to ensure you don’t step on any regulatory toes, but if you’ve got some tricky installations coming up, this might be something of a relief. You can find all the details here.

Now, the reason I bring up the transmission of fire alarm signals deal is that the most recent edition of NFPA 101 (2021) includes some clarification in this regard (a shout out to Grant Finch out in Oregon for his detective skills on this). As noted last week, the current language indicates transmission of a fire alarm signal (with no additional information to be found as defining what that means, leaving things in the hands of the interpretive dance masters). The 2021 edition, in section 19.7.1.4, requires fire drills to include the simulation of emergency for fire conditions (much as it does now), but it goes on to say “include activation of the fire alarm system notification appliances.” Section 19.7.1.7 still provides for the coded announcement between 2100 and 0600 hours, so that piece of it remains the same.

At any rate, I am hopeful that, with this current version clarification, even if there is no categorical waiver forthcoming, the accreditation organizations will stop fussing about the fire alarm signal transmission and move on to other things. After all, the truly applicable code for testing fire alarm signals is NFPA 72, so why would need to include signals in our fire drills—which reminds me, you still need to document the elapsed time of the fire alarm signals generation to its receipt at the central monitoring service, etc. I’ve been running into a spate of vendors that are not including that in their documentation, so you probably want to give your latest testing documentation a look. And while we’re on the subject, I personally think it’s bogus for your testing vendor to just give you a printout of the month’s alarm activity in which the test occurred; they should either highlight it on the sheet or pull the dates/times/results off the printout. I suspect that they are being more than adequately compensated for their services, which (to my mind) includes a summary of the results, particularly any deficiencies. I don’t think you should have to hunt for the deficiencies and now with the rollout of the virtual survey process (something on that next week), surveyors will have more time than ever to comb through your reports for those funky little missed devices, etc. Your fire alarm (and sprinkler system) ITM vendor should be highlighting the “to do” list so you can get it “to done.”

Hope you’re having a safe and productive week. See you on the flip side!

Are you transmitting? Late night fire drills and alarm signals…

I think we can safely say that sometimes it is tough to pinpoint specifics when it comes down to what performance elements are cited during regulatory surveys, be they virtual or actual. In this regard, I really couldn’t say to what extent this particular item is being cited, but I know that it happens and often that happening results in some level of consternation of the “How am I supposed to do that?” variety.

The Life Safety Code® (LSC) NFPA 101-2012 19.7.1.4 requires that: “(f)ire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions.” Section 19.7 (section 19.7.1.7, to be precise) goes on to indicate that “(w)hen drills are conducted between 9:00 p.m. and 6:00 a.m. (2100 hours and 0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.” I suspect that, over time, a lot of folks have ended up equating the transmission of a fire alarm signal and the use of a coded announcement as being equivalent, but that really isn’t the case. 19.7.1.7 allows you to conduct a fire drill without disturbing patients, etc., but, as it turns out, you still have to include the transmission of the fire alarm signal (that’s the signal that actually “leaves” the building and goes to the central monitoring service, 911 call center, etc.). If you need further indication, I submit to you the “opinion” (or you could call it an interpretation) of one of our favorite AHJs. I think this gives you a good sense of the separation of what happen inside your facility versus making sure that pesky alarm signal finds its way outside.

But the question then becomes, how does one accomplish this if one has a fire alarm system that doesn’t provide an easy way of turning off the internal signals and still allowing for the transmission of the signal? This question bounced my way recently and I decided to do some poking around to see if there were any scholarly works, etc., and I came across some guidance published back in 2016 (the document is dated June 2016, so it would precede the official adoption of the 2012 LSC by CMS), that outlines some of the particulars of fire drills to be conducted in Minnesota.

One of the interesting elements is a note that deals with today’s discussion: “Note: When a coded announcement is used instead of audible alarms on the night shift, the fire alarm should be sounded first thing in the morning the following day to meet the requirement that each drill include ‘transmission of a fire alarm signal.’” Now I recognize that AHJ interpretations are many and varied (to an almost frightening degree), but I was wondering if anyone had been able to negotiate this type of process with their AHJ. It certainly makes sense to me that you could “extend” completion of the fire drill a few hours to ensure proper operation of the fire alarm system, but I also suspect that you’d probably be reticent to go that route without getting some sort of permission and you’d probably need to write it in to your policy or management plan as a standard practice or procedure, but it seems a rather elegant solution to me ( as a non-AHJ). What say you all?

Hoping this finds you well and staying safe; I figure every week brings us closer to whatever’s coming next, so let’s get there together!

Stay Centered and Carry On: PHE likely to persist through 2021!

As any of the Peanuts gang might opine: AAUGH!

In a letter to the governors, Norris Cochran, the acting secretary of HHS, indicated that it had been determined that the Public Health Emergency (PHE) will likely remain in place for the entirety of 2021, but there would also be a 60-day notification prior to the termination or expiration of the PHE.

Ostensibly, this removes at least some of the uncertainty of the quarterly updates of the PHE status and appears to provide a 60-day window for organizations to attain compliance with any regulatory requirements covered under the 1135 waiver process, including the blanket waivers currently in effect. I suspect this also means that support at the federal level will remain in place relative to response activities—the letter also indicates that this should be considered evidence of the government’s commitment to ongoing response to the pandemic.

Presumably, there is a cross-section of folks in the field who either didn’t adopt any of the waivers or have been able to move things back to “business as usual” in terms of inspection, testing and maintenance activities, so this may not mean that much from a practical standpoint. That said, if there are any of you out there who have been able to make good use of, you probably need to start thinking about a turnaround within 60 days. Maybe you start to reach out to your vendors—there’s probably going to be a queue for services once this whole thing breaks loose—and the indication is that the accreditation organizations are not going to be flexible once the PHE expires/terminates. I’m trying to think of what processes would take longer than 60 days to get back on track and nothing is springing to mind. Again, I suspect that scheduling the work is going to be the “sticky wicket” if there’s going to be any issue, so if there’s anything you can do to pre-load that process, it’s probably time well-spent.

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

Gimme a break…or a spare circuit breaker

One of the more common findings (as it were) over the past few years has been the condition in which a circuit breaker is in the “on” position and it is either not labeled or labeled as a “spare.” It would seem that the codified guidance in this regard is sufficiently “gray” to push our friends in Chicago to issue an official interpretation. In olden times, this information would be shared either in Perspectives, the FAQs or the standards manual(s) and I can’t seem to find mention of it anywhere other than from ASHE. Perhaps it’s nothing (from a process standpoint, this is going to be a pain in the butt; from a practical standpoint, how many circuit breakers do you have?) but, like the ubiquitous “loaded” sprinkler head, there always seems to be one breaker that’s not going in the right direction. And I suppose if a surveyor is willing to put in the time to find it, all you can do is thank them…

At any rate, I did want to take a moment to thank each and every one of you for keeping things together (both figuratively and literally) over the past months. I know these have been among the most trying times imaginable and we’re certainly going to be “in it” for a while longer, but you folks have done what needed doing and are still doing everything you can do to keep everyone safe and your facilities operational. I am proud to be associated with such a fine bunch of folks. We’ve got this!

Until next time, be well and stay safe!

From the sky we look so organized and brave

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

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

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

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

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

Until next time, please stay well and be safe!

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

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

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

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

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

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

Remote control: Don’t forget to close the loop

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

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

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

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

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

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

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

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

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

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

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

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