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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!

Show up or shut up

Every once in a while (and I don’t think I abuse this privilege, but please feel free to disabuse me of that notion), I like to vent a little regarding those annoyances that can impact how the folks in the safety world carry out their duties. In this particular instance, I’d like to rant a bit about those members of the “safety committee” that seem only to attend meetings when there is an opportunity to stonewall/derail/obstruct, etc., the ongoing work of the committee.

Lately it seems a lot of folks are struggling to bring their active shooter response plans past the initial stages and move into the implementation phase. That struggle inevitably seems to revolve around those transient members that always seem to know when you’re committee is just about to “birth” a new policy or process and they glide into the action with reservations/objections/all manner of constipations to set things back, without having participated in the work leading up to that point.

In my heart of hearts, I know that this is not very collegial behavior, but the question I have for the community is: How are you managing these occasions? My philosophy (which can be sorely tested from time to time) is that you have to birth the policy before you can tell for sure how well it will (or won’t) work when you operationalize it. I guess the analog to that is that it is better to have a flawed policy that you can work to improve than it is to have no policy at all, particularly to manage critical functions or risks. It is very, very difficult (certainly bordering on impossible) to come up with perfection without doing some trialing in the real world (maybe it’s possible, but I can honestly say I’ve never encountered it). I suspect this has happened to many (if not most, and probably all) safety professionals. Anybody have any inventive solutions for organizational blockages? Please sing out—let the world in on your secret!

Mirror, mirror on the wall … is that me?

One of the curious things I encounter on an increasingly regular basis is the Dorian Gray-like (but in reverse) effect of the ID badges of folks who’ve worked at an organization for a rather long time. So long, in fact, that they really don’t look like their ID pictures any more. I know you’ve seen it too.

Now, I’ve always considered the hassle of having folks wear ID badges as being an important component of our security management strategies. As a general consideration, we do have an obligation to ensure that we’re not giving any interlopers a chance of breaching our security (and don’t get me started on those folks who are not nearly as careful about their ID badges as they should be. I know it makes me sound petulant, but we really ask so little of folks in this regard).

So, I ask those of you responsible for the ID process, have you established criteria for an update of photo IDs? Weight loss or gain, hair color changes, the aging process (all potentially contentious topics for discussion)? Or, like the motor vehicle registry folks, do you re-take pictures after a certain amount of time, maybe contingent on how much a person has changed in the ensuing period. Any feedback or discussion would be most appreciated.

Shock the monkey (part x + y to the 10th power) – here we go again…

OK, so now it appears that we’re going to have to rethink how we schedule preventative maintenance (PM) activities on our critical equipment, particularly if that criticality affects patient health and safety. I believe that we’ve already chatted a bit about the whole clarification of PM frequencies and where CMS stands on the issue (in case you hadn’t noticed, they’re pretty much standing on your head).

In issuing the clarification (and I will freely admit that I missed this at first – check it out at:, the Feds have decided that, in the matter of critical equipment, the frequency will reflect manufacturer recommendations, AND NOTHING ELSE! Let me repeat that: AND NOTHING ELSE!

For example, PM’ing defibrillators on an annual basis (despite what your experience might indicate) is a big freaking no-no! Isn’t that special? Yeah, I thought so, too.

Maybe this isn’t anything to you folks, but I know of at least one hospital that got cited during a recent survey, so when there’s one, there’s usually others (these things almost never happen in isolation). So, if you think you may be taking advantage of logic and common sense approaches to the management of the risks associated with the use of medical equipment, think again (hopefully this won’t shift again, but if history tells us anything.)

You’ve got a new favorite…

Generally speaking, we in Safety Land don’t get too involved with Centers for Medicare & Medicaid Services (CMS) doings until they show up on our doorstep. But sometimes, the Feds weigh in on matters that can have far-ranging implications for safety operations. I think we need go back no further than the turn of 2010 to 2011, when it looked as if CMS was going to turn the whole world into a healthcare occupancy. Fortunately, through the good graces and advocacy of ASHE, that’s a bullet dodged. Bravo.

At any rate, there is a means of tracking interpretations, utterances, and the like—and it’s web-based (your tax dollars actually at work):

Basically, this site is a repository of all sort of what we might euphemistically characterize as “CMS Survey and Certification memoranda, guidance, clarifications and instructions to State Survey Agencies and CMS Regional Offices.” (Okay, not my characterization; it’s what CMS calls this stuff.) Certainly not everything found here is germane to safety and the environment, but it is searchable. (I couldn’t offer an opinion yet on how efficient the search capacity might be; to be determined.) The information could be considered a—if not the—final word on what’s happening at the ol’ Centers for Medicare & Medicaid Services. I don’t know that you would need to check it every day (and I can’t quite find a means of signing up for e-mail notifications of new postings), but probably worthy of a drop in from time to time.

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And now for something completely…the same

Time for a quick roundup of some recent survey trends:

  • We’ve talked about the overarching issues with weekly testing of plumbed eyewash stations any number of times over the years and I am always happy to respond to direct questions. The key element here is that if your organization is not conducting an at least weekly testing regimen for your plumbed eyewash stations and has not documented a risk assessment indicating that a lesser frequency is appropriate, it will likely be cited. My consultative advice: If you’re not testing at least weekly, please do so, or do the risk assessment homework.
  • With the extra life safety surveyor time during survey, the likelihood of encounters with frontline staff is on the rise. And apparently, it is not enough for folks to know what they are doing, but there is also an expectation that they will understand why they do what they do, primarily in the context of supporting patient care (which we all do—everything that happens in a hospital can trace back to the patient). I guess it won’t be enough for folks to be able to respond appropriately when asked how they would respond to a fire. They also need to understand how their response fits into the grand scheme of things. I really believe that folks understand why their jobs are important; we just need to prepare them for the question. Probably more on this as it develops.
  • 96 bottles of beer on the wall, 96 bottles of beer—but will that be enough beer to last 96 hours (I guess it depends on how thirsty you are)? So the question becomes this: If a surveyor asks to see your 96-hour capability assessment, what would you do, and perhaps most importantly, can you account for it in your Emergency Operations Plan? My general thought in this regard is that the 96-hour benchmark would be something that one would re-visit periodically, just as you would your hazard vulnerability assessment, in response to changing conditions, both internal and external.
  • As a final thought for this installment, please make sure that you (that would be the royal “you) are conducting annual fire drills in all those lovely little off-site locations listed as business occupancies on your Statement of Conditions. And make very sure that staff is aware that you are conducting those fire drills. There’s been a wee bit of an upsurge in fire drill findings based on the on-site staff not being able to “remember” any fire drills, in some instances, for several years. The requirement is annual and I don’t think any of us wishes to get tagged for something as incidental as this one.

Your mother should know…but what if she doesn’t?

I’ve noticed a little word popping up in recent survey reports, a word that strikes fear in my heart. I don’t know how widespread this might be, so if you folks have an opportunity to weigh in on this conversation, I’d be really interested in what you all are seeing out there. And so, today’s word of the day is “should.” Now scream real loud!

I think we are all pretty familiar with those things that are legitimately (perhaps specifically is a better descriptor) required by the standards. I like to refer to those requirements as “have to’s” – we have to test certain fire alarm components at certain frequencies, we have to conduct quarterly fire drills, etc. Now I’m certainly not someone who is going to complain when a regulator (of any stripe) provides us with concrete strategies (this is where we move from the “have to’s” to the “how’s,” inching ever closer to “should”) for achieving or maintaining compliance.

But the question I keep coming back to is how are we supposed to know about these unwritten requirements (we used to call them ghost standards—boo!) if they are, as noted, unwritten. And the reason I keep coming back to this question is because I’ve been seeing a number of findings lately that revolve around what an organization “should” do. And please, I am not necessarily disagreeing with the wisdom engendered in many, if not most of these findings (we’ll mention a couple of examples in a moment), but there is a point at which the line between what is consultative advice and what is actually required blurs so completely that any tipping point, compliance-wise, is almost completely subjective.

As an example (and remember, I’m not disagreeing with the concept), a recent survey report included a finding because the “clean” side of central sterile was negative to the adjacent corridor, with the qualifier “air flow should always be positive from clean areas to less clean areas”. Concept-wise, I’m down with that (I’m not loving the use of “always” in this type of context—how long is always, or maybe it should be how frequently is always, but I digress), but where in the Joint Commission standard does it say that, apart from the all-encompassing appropriate provision of pressure relationships, etc. That “should” really undercuts the whole statement. Is this something we “must” do within the context of the standard or are we trying to leverage behaviors by acting like something is deficient when it is not necessarily the case?

Another “should” that came up recently involved the results of a vendor’s testing of the medical gas system. Now you and I both know that our vendors are not always the most efficient when it comes to providing written documentation of their activities. In this particular instance, the testing had been done in June, and the report had been delivered in August, mere moments before the survey started. Within the report, there were some issues with master alarms that required repair work—repair work that had not yet been completed. Now, as near as I can tell, each organization still gets to prioritize the expenditure of resources, etc., presumably based on some sort of risk assessment (that’s a “should” for all you folks keeping track), but the finding in question ends with a resounding statement that the facility “should” have required the vendor to provide a deficiency report at the time of the inspection. Conceptually, you’ll get no argument from me, and as consultative advice I will tell you that it is a positively stupendous idea to know what problems are out there before your testing vendors leave the premises. Remember, you “own” the fixes as soon as they are identified, and if there are delays, you’d best have a pretty gosh-darn good reason for it. In fact, I would have to consider that strategy as a best practice in managing maintenance and testing activities, but where does it say that in the standards?

Reasons (not) to be cheerful, part 3

Or perhaps it should be “hit me with your Joint Commission stick”?

What follows is a compendium of recent survey findings, some from The Joint Commission (TJC), some from me. So in no particular order:

  • Rooftop isolation exhaust fans and other “biohazard” areas should be appropriately labeled to identify the hazard. I’d expand this a little to include soiled utility rooms (particularly in outpatient settings) in which medical waste is collected and stored.
  • If you have key utility components (e.g., emergency generators and the like) outside your building, make sure that they are appropriately secured from unauthorized entry. And once you’ve determined what “appropriately secured” means for your organization, document the risk assessment, so if a surveyor just happens to disagree with how you are managing things, you have the basis for a clarification of the finding. Same goes for your solid waste compactors—make sure nobody can monkey with them (all due respect to monkeys).
  • Make sure everyone in the kitchen can locate and explain the operation of the fire suppression system. This is kind of a follow up from an earlier blog post outlining the monthly inspection of the kitchen fire suppression system. TJC recognizes that we, the primary stakeholders in the management of the care environment, have our act together. More and more, the focus has gone to the point of care/point of service staff. Safety lives in the trenches. We need to keep those folks in the loop.
  • Make sure your main supply shutoff valves, including your main oxygen valve, are appropriately labeled. And if you should choose to decide that, for reasons of security, that is not an appropriate strategy, make sure you document the risk assessment that led you to that determination.
  • Make sure you know where you need to have eyewash stations and where you don’t and why. Not every potential exposure requires an eyewash station—OSHA is very specific in that regard—potential exposure to corrosive materials is the determining factor. If you want to adopt a slightly stricter standard, the American National Standards Institute expands things to include corrosive and caustic materials. Beyond that, including blood and other potentially infectious material, you don’t “have to” have eyewash stations for exposure response. As a related aside, try to convince the folks in environmental services (and by extension, infection control) to promote the use of cleaning products that are not corrosive or caustic—that will help you identify an appropriate response capability.
  • Don’t forget those pesky compressed gas cylinders—other than penetrations and doors not latching, I think the most frequently cited specific condition is the unsecured cylinder. And please promise me you won’t say that you have to do additional education. Folks know they’re not supposed to leave the cylinders hither and thither. Find out the root cause of why they can’t do the right thing. And if you find out anything useful in that regard, please let the rest of us know.

Th-th-th-that’s all folks. For now…

Since when should we let folks consider safety as an option?

Dipping into the mailbag once again, I recall a conversation I had with a client who was, with increasing frequency running in to the “everybody is so busy that they are being careless” situation. At that point, the folks around the table would nod their heads and the discussion would come to a screeching halt. Now the characterization of this (please excuse use of the congressional vernacular) filibuster was “counterproductive,” a characterization with which I could not agree more. So in thinking about this perennial sticking point, I offer the following:

There is no doubt that everybody is really busy these days and it is just as clear that the “busyness” contributes to accidents. So it boils down to being able to move beyond the busyness excuse/defense to make a real difference in behaviors.

The fact of the matter is that everyone is really busy, and that has only increased over the last decade—we don’t have more staff, more money, more time—all we have is more to do. Clearly there is a challenge to work “smarter” but sometimes getting to that smarter level takes more time than the end results provide as benefit. So then folks tend to “hide” from anything that might be representative of a “real” change—operationally, behaviorally, etc. So the question then becomes how do we decide what can we afford to be “too busy” to do? As I noted in an earlier blog entry, just after Christmas last year, I read “What If Disney Ran Your Hospital” by Fred Lee. Now I will absolutely say that not everything in the book was of particular value in this discussion, but one point that I keep returning to is the Disney concept of a ladder representing what things are most important: an actual hierarchy, as opposed to a lot of what is common in healthcare, like pillars, which all have (more or less) equal value. The Disney ladder places safety at the top—so naturally I am a bit biased—but one of the things I’ve always noted (and not particularly liked, to be honest) about the Studer columns and Magnet pillars, etc., is that neither structure truly gives safety its due. It’s like cleanliness—if a place isn’t clean it is almost impossible to control infection, but it’s frequently something of an afterthought—and left in the capable hands of the lowest compensated folks in the mix.

So, I guess it comes back to the decision point of “this is where we are too busy to worry about: being safe, providing an appropriately clean environment, whatever issue we are dealing with in the moment. I would like to think that folks could at least agree that something is important enough to merit some attentions, so maybe the follow-up question becomes—how can we be safe, be clean, be attentive, in a way that doesn’t get in the way of other things? I’m a great believer (coming from the land of the New English) that common sense, simple approaches can bear substantial fruits, but it’s back to the forest and the trees—picking the simple path is not always so simple.

Hopefully there’s something in there that’s useful. To close on the Disney thought, at orientation, Disney employees are instructed to hold safety as the most important part of their job, regardless of their “role.” If they see something that is unsafe, the expectation is that they will act on that. If we can get everyone (or even more than half) to actually live that, I think we’ll find that a lot of the stupid stuff will resolve itself before it gets to the point of conflagration. There will always be malcontents (discontents?) in the crowd, but we need to get the rest of the folks to recognize that type of attention-seeking behavior for what it is and understand that it brings nothing to the table in terms of moving things along/ahead/forward.