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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!

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!

That’s the FAQ, Jack!

It may be that I am covering one topic of conversation more than necessary (it’s getting to the point where this might eclipse the discussion of eyewash stations—yow!), but I cannot help but be very concerned about the amount of play that the management of the environment in which we place behavioral health patients is receiving in the annals of The Joint Commission. April 24 saw an electronic update announcing the “birth” of a new standards FAQ regarding ligature risks that appears to be aimed at dovetailing with Sentinel Event Alert #56 and includes mention of a “Suicide Risk Booster” (who comes up with these names?!?). As we have discussed before, FAQs, Sentinel Event Alerts, and stuff that finds its way into Perspectives all take on the weight of standards when applied in the field, so clearly organizations need to have all their ducks in a row. (And this is starting to look like a whole mess o’ ducks to be “rowed”, which brings new meaning to that Willie Nelson classic “On The Rowed Again,” but I digress—and who wouldn’t?) The question I keep coming back to is whether there’s been an uptick in actual events in which patients have come to harm as the result of poorly or inappropriately managed ligature risks. Or is this the result of surveyors in the field citing organizations for having ligature risks and not being able to produce a risk assessment of the existing conditions and the identification (and communication to staff—key point, that one) of mitigation strategies to manage the identified risks?

Part of the challenge with this particular issue (and this is true of a great many things in the physical environment) is that it is virtually impossible to provide an environment that is entirely, absolutely (please insert your favorite qualifier here) impossible to provide a completely risk-free environment—at least on this planet (perhaps there are safer planets in the Federation, but I couldn’t say for sure), so there’s always going to be something with which patients intent on hurting themselves might use to that end. Now I know that not every healthcare setting is set up to deal with behavioral health patients (and somehow, I do think that for any hospital that has not come face-to-face with the management of BH patients in areas not designed for that purpose, it is just a matter of time) and I also know that the BH patient volumes can be very mercurial. Even if you have one “safe” room, there are no guarantees that, at any given moment, that will be enough to handle however many patients you have in the queue—and you really can’t leave these folks out in the waiting room. Again, I’m not convinced that the issue here is that there is data to support that folks are not managing things appropriately, but rather more along the lines of not being able to consistently communicate the process for assessing and identifying risks, educating staff to be able to speak to the mitigation strategies being used to manage the identified risks, etc. I would (as I have been for a while now) encourage you to really take this topic and do a deep dive into the particulars of your organization. I firmly believe that this is not going to be one of those “one and done” instances of risk assessment and that you will be well-served by periodically revisiting the initial assessment (if it has been completed) to ensure that the conditions upon which you based your initial assessment have not changed (and that includes the volume and acuity of the patients). There is every indication that TJC is going to be hammering on this for some time to come (remembering that EC.02.06.01 was the most frequently cited standard in 2016; the ligature risk findings tend to show up there when cited) and, much as issues with the surgical environment and interim life safety measures, process gaps can get you in a heap of trouble. A little extra work on this (and those others) can only increase your chances for a successful survey (or at least a not spectacularly ugly survey).

As a closing note, after a dinner discussion with my wife (who happens to be a nurse), I’ve been contemplating how the role of the safety professional has changed over the last 10-15 years, including my surprise when I encounter evidence of “old school” approaches to safety. To my mind (such as it is), where safety compliance was once the result of (more or less) coercion, sustained compliance can truly only come as the result of collaboration with the folks who have to manage the environment on a day to day basis—pretty much everyone at point of care/point of service. It is not enough for a safety professional to periodically stroll through an area and point out deficiencies, there has to be a conversation and there has to be problem-solving. I think the old coercive style was based on something approaching a lack of faith in the folks out in the environment to be able (or willing) to “do the right thing.” But in this era of “just” culture and empowerment, etc., safety has to happen all the time and that, my friends, can only come with an atmosphere of collaboration. If people hide stuff or behave more appropriately when they hear you are coming, then it makes the surveillance process less useful. And if you don’t work with folks to figure out how to resolve the issues that you “keep finding,” the likelihood of it fixing itself on its own is pretty remote. I freely admit that problem-solving is my favorite part of my safety consulting work (meeting folks is also a fave); there is nothing better than talking through a problem and achieving some sort of consensus on how to proceed. It’s not always easy, but it is worth every moment you put into it!

Or the light that never warms

Continuing in our somewhat CMS-centric trajectory, I did want to touch upon one last topic (for the moment) as it portends some angst in the field. A couple of weeks ago (April 14, 2017, to be exact), the friendly folks at CMS issued notice of a proposed regulation change focusing on how Accrediting Organizations (AO) communicate survey results to the general public (you can find the details of the notice here).

At present, the various AOs do not make survey results and subsequent corrective action plans available to the general public, but apparently the intent is for that to change. So, using the Joint Commission data from 2016 as test data, it seems that a lot of folks are going to be highlighted in a manner that is not going to paint the prettiest picture. As we covered last week, hospitals and other healthcare organizations are not CMS’ customers, so their interest is pretty much solely in making sure that their customers are able to obtain information that may be helpful in making healthcare decisions. Returning to the Joint Commission data from last year, pretty much at least 50% of the hospitals surveyed will be “portrayed” as having issues in the environment (I’m standing by my prediction that those numbers are going to increase before they decrease—a prediction about which I will be more than happy to be incorrect). Now, the stated goal of this whole magillah is to improve the quality and safety of services provided to patients (can’t argue with that as a general concept), but I’m not entirely certain how memorializing a missed fire extinguisher check at an outpatient clinic or a missed weekly eyewash station check is going to help patients figure out where they want to obtain healthcare. So, I guess the question becomes one of how the folks we hire to assist with accreditation services (the folks for whom we are the customers) are going to share this information in the name of transparency? (Though I suppose if you were really diligent, it might be a little easier to discern trends in survey findings if you’re of a mind to dig through all the survey results.) It will be interesting to see how this plays out; I can’t imagine that they’d be able to publish survey results particularly quickly (I would think they would have to wait until the corrective action plan/evidence of standards compliance process worked itself through).

As with so many things related to the survey process, I understand what they are trying to do (begging the question: Is transparency always helpful?), but I’m not quite catching how this is going to help the process. I absolutely believe that the CMS and the AOs (could be a band name!) have a duty and an obligation to step in when patients are being placed at risk, as the result of care, environment, abuse, whatever. But does that extend to the “potential” of a process gap that “could” result in something bad happening—even in the presence of evidence that the risk is being appropriately managed? There always have been, and always will be, imperfections in any organization—and interpretations of what those imperfections may or may not represent. Does this process make us better or more fearful?

Remembering it wasn’t fair outside…

First off, a mea culpa. It turns out that there was an educational presentation by CMS to (nominally) discuss the final Emergency Preparedness rule, with a focus on the training and testing requirements (you can find the slide deck here; the presentation will be uploaded sometime in the next couple of weeks or so) and I neglected to make sure that I had shared that information with you in time for you to check it out. My bad!

That said, I don’t know that it was the most compelling hour I’ve ever spent on the phone, but there were one or two (maybe as many as three) aspects of the conversation that were of interest, bordering on instructive. First off, when the final rule speaks to the topic of educating all staff on an annual basis, the pudding proof is going to be during survey when staff are asked specific questions about their roles in your plan (presumably based on what you come up with through the hazard vulnerability assessment—HVA—process). Do they know what to do if there is a condition that requires evacuation? Do they know how to summon additional resources during an emergency? Do they know what works and what doesn’t work as the result of various scenarios, etc.? This is certainly in line with what I’ve seen popping up (particularly during, but not limited to, CMS/state surveys)—there is an expectation (and I personally can’t argue against this as a general concept) that point-of-care/point-of-service staff are competent and knowledgeable when it comes to emergency management (and, not to mention, management of the care environment). As I’ve noted to I can’t tell you how many folks, the management of the physical environment, inclusive of emergency preparedness/management does not live on a committee and it is not “administered” during surveillance rounds or during fire drills. Folks who are taking care of the patients’ needs to know what their role is in the environment, particularly as a function of what to do when things are not perfect (I’ll stop for a moment and let you chew on that one for a moment).

Another expectation that was discussed (and this dovetails a wee bit with the last paragraph) is that your annual review of your emergency preparedness/management process/program must include a review of all (and I do mean all) of the associate/applicable policies and procedures that are needed for appropriate response. So far (at least on the TJC front—I’m less clear on what some of the other accrediting organizations (AO)—might be doing, though I suspect not too very far from this. More on the AO front in a moment), the survey review of documentation has focused on the emergency plan (or emergency operations plan or emergency response plan—if only a rose were a rose were a rose…), the exercise/drill documentation, HVA, and annual evaluation process. But now that the gauntlet has been expanded to include all those pesky policies and procedures. I will freely admit that I’m still trying to figure out how I would be inclined to proceed if I still had daily operational responsibility for emergency management stuff. My gut tells me that the key to this is going to be to start with the HVA and then try to reduce the number of policies and procedures to the smallest number of essential elements. I know there are going to be individual response plans—fire, hazmat, utility systems failures, etc.—is it worth “appendicizing” them to your basic response plan document (if you’ve already done so, I’d be interested to hear how it’s worked out, particularly when it comes to providing staff education)? I’m going to guess that pretty much everybody addresses the basic functions (communications, resources and assets, safety and security, utility systems, staff roles and responsibilities, patient care activities) with the structure of the E-plan, which I guess limits the amount of reviewable materials. There was a question from the listening audience about the difficulty in managing review of all these various and sundry documents and the potential for missing something in the review process (I am, of course, paraphrasing) and the response was not very forgiving—the whole of it has to be reviewed/revised/etc. So, I guess the job is to minimize/compact your response plans to their most essential (the final rule mentions the development of policies and procedures, but doesn’t stipulate what those might be) elements and guard them diligently.

The final takeaways for me are two in number. Number 1: Eventually, there will be Interpretive Guidelines published for the Emergency Preparedness final rule, but there is no firm pub date, so please don’t wait for that august publication before working towards the November implementation deadline. Number 2: While there is an expectation that the AOs will be reviewing their requirements and bringing them into accordance with the CMS requirements, there is no deadline for that to occur. Something makes me think that perhaps they are waiting on the Interpretive Guidelines to “make their move”—remembering it’s not going to be fair any time soon. I think the important dynamic to keep in mind when it comes to our friends at CMS (in all their permutations) is that they are paying hospitals to take care of their patients: the patients are CMS’ customers, not us. Which kind of goes a ways towards explaining why they are not so nice sometimes…

A bientot!

Point the finger (doesn’t matter which)

Or extend your hand?

First up, as a general rule of thumb (which could be one of the pointed fingers represented above, unless you don’t think a thumb is a finger), when CMS identifies an implementation date that is in the future, I think that we can safely work towards being in full compliance with whatever the Cs are implementing—on that implementation date. Apparently there’s been enough confusion (not really sure who may or may not have been confused, but sometimes it’s like that) for CMS to issue something of a clarification as to what is expected to be in place by November 15, 2017, which means education and exercises (and any other pesky items in your EM program that didn’t quite synch up with the final rule on emergency preparedness for healthcare organizations). Since this is very much brave new world territory when it comes to how (though perhaps the correct term would be “how painfully”) CMS is going to administer the final rule as a function of the survey process. I think it initially, unless we hear something very specific otherwise, means that we need to be prepared to meet the full intent of the language (making sure that you have trained/educated “all” staff; making sure that you participated in a community-wide exercise of some level of complexity) until these things start to sort out. My gut tells me that if they were going to engage in any more exculpatory/explanatory/clarifying communications, it would have been included in the above-noted transmission. And while I have little doubt that there will be some variability (states do not necessarily coordinate response) as to how this all pans out in the field, the education of “all” staff and participation in the communitywide exercise deal seem to be pretty inviolable. Certainly there have been instances in the past in which healthcare organizations have struggled to coordinate exercises with the local community(s), but my fear is that if you fall short on this, you will need to have a very compelling case of why you weren’t able to pull off a coordinated exercise. Community finances and fiscal years and local emergency response hegemony are all contributing factors, to be sure, but where you could “sell” that as a reason for not dancing with the locals to some of the accreditation organizations, I’m thinking that (as is usually the case) reasonableness and understanding might not be the highlights of any discussion with the feds and those that survey on their behalf. From what I’ve seen in the field, when it comes to CMS and the survey process, you are either in compliance or you are not in compliance and there is very little gray in between. Community drill done—compliant! Community drill not done—not compliant! Wouldn’t it be nice if life were always that simple?

At any rate, just to use this a reminder that the first anniversary of the 2012 Life Safety Code® is coming up—make sure you get all that annual testing and such out of the way—and don’t forget to make sure that all your fire alarm and suppression system documentation includes the correct version of the applicable NFPA code used for testing. I am dearly hoping to retire EC.02.03.05 from the most frequently cited standards ranks and while I fear the worst with this change. (To my mind, getting tagged for having the wrong NFPA year on the documentation would pretty much suck—please excuse my coarse language—but sucking is exactly what that type of finding would do.)

I understand all destructive urges

It seems so perfect…

A couple of somewhat disparate, but important, items for your consideration this week. I’m still somewhat fixated on how the survey process is going to manifest itself (regardless of which accrediting organization is doing the checking—including the feds). There are one or two clues to be had at the moment and I am most hopeful that the reason there is so little information coming out of the survey trenches is because there have been minimal change of a drastic nature/impact.

So, on to the discussion. As noted above, while the topics of conversation are indeed somewhat disparate, they do share a common theme—perhaps the most common theme of recent years (not to mention the most common theme of this space): the hegemony of the risk assessment. The topics: management of the behavioral health physical environment, and the risk assessment of systems and equipment indicated by NFPA 99-2012 Health Care Facilities Code. Fortunately, there are resources available to assist you in these endeavors—more on those in a moment.

For the management of the behavioral health physical environment, it does appear that our good friends in Chicago are making the most use of their bully pulpit in this regard. Health Facilities Management had an interesting article outlining the focus that would be well worth your time to check out if you have not already done so. I can tell you with absolute certainty that you need to have all your ducks in a row relative to this issue: risks identified, mitigation strategies implemented, staff educated, maybe some data analysis. As near as I can tell, not having had an “event” in this regard is probably not going to be enough to dissuade a surveyor if they think that they’ve found a risk you either missed or they feel is not being properly managed. If I have said this once, I couldn’t tell you how many times I’ve said it (if I had a dollar for every time…): It is, for all intents and purposes, impossible to provide a completely risk-free environment, so there will always be risks to be managed. It is the nature of the places in which we care for patients that there is a never-ending supply of risky things for which we need to have appropriate management strategies. And I guess one risk we need to add to the mix are those pesky surveyors that somehow have gotten it in to their heads that there is such a thing as a risk-free environment. Appropriate care is a proactive/interactive undertaking. We don’t wait for things to happen; we manage things as we go, which is (really) all we can do.

As to the risk assessment of systems and equipment, as we near the first anniversary of the adoption of the 2012 edition of the Life Safety Code® (LSC) (inclusive of the 2012 edition of NFPA 99), the question is starting to be raised during CMS surveys relative to the risk assessment process (and work product) indicated in Chapter 4 Fundamentals (4.2 is the reference point) and speaks of “a defined risk assessment procedure.” I would imagine that there’s going to be some self-determination going on as to how often one would have to revisit the assessment, but it does appear that folks would be well-served by completing the initial go-through before we get too much closer to July. But good news if you’ve been dawdling or otherwise unsure of how best to proceed: our friends at the American Society for Healthcare Engineering have developed a tool to assist in managing the risk assessment process and you can find it here. I think you will find that the initial run-through (as is frequently the case with new stuff) may take a little bit of time to get through. (In your heart of hearts, you know how complex your building is, so think of this as an opportunity to help educate your organization as to how all those moving parts work together to result in a cohesive whole.)


These things have a habit of spreading very quickly in the survey world, so I would encourage you to keep at it if you’ve already started or get going if you haven’t. Even if you don’t have an immediately pending survey, a lot of this stuff is going to be traceable back to your previous survey and with that first anniversary of the LSC adoption rapidly approaching, better to have this done than not.

Roll over Beethoven!

As we mark the passing of yet another (couple of) pop culture icon(s), I’m feeling somewhat reflective as I place fingers to keyboard (but only somewhat). As I reflect on the potential import of Sentinel Event Alert #57 and the essential role of leadership, one of the common themes that I can conjure up in this regard has a lot to do with the willingness/freedom of the “generic” Environment of Care/Safety program to air the organization’s safety-related (for lack of a better term—if you have a better one that’s not really PC, send it on) dirty laundry (kick ’em when they’re up, kick ’em when they’re down). I’ve seen a spate of folks getting into difficulties with CMS because they were not able to demonstrate/document the management of safety shortfalls as a function of reporting those shortfalls up to the top of their organization in a truly meaningful way. As safety professionals, you really can’t shy away from those difficult conversations with leadership—leaky roofs that are literally putting patients and staff at risk (unless you are doing incredibly vigorous inspections above the ceiling—or even under those pesky sinks); HVAC systems that are being tasked with providing environmental conditions for which the equipment was never designed; charging folks with conducting risk assessments in their areas…perhaps the impact of reduced humidity on surgical equipment. There’s a lot of possibilities—and a lot of possibility for you to feel the jackboots of an unhappy surveyor. One of the responsibilities of leaders, particularly mid-level leaders—and ain’t that all of us—is to work things through to the extent possible and then to fearlessly (not recklessly) escalate whatever the issue might be, to the top of the organization.

I was recently having a conversation with my sister about an unrelated topic when we started discussing the subtle (OK, maybe not so subtle) differences between two of my favorite “C” words: commitment and convenience. My rule of thumb is that convenience can never enter the safety equation at the expense of commitment (I suppose compliance works as well for this) and all too often I see (and I suspect you do, too) instances in which somebody did something they shouldn’t have because to do the right thing was less convenient than doing the wrong (or incorrect) thing. Just last week, I was in an MRI suite in which there were three (count ’em: 1, 2, 3) unsecured oxygen cylinders standing (and I do mean standing) in the MRI control right across the (open) door from the MRI. There was nobody around at the moment and I thought if there was a tremor of any magnitude (and I will say that I was in a place that is no stranger to the gyrations of the earth’s crust) and those puppies hit the deck, well, let’s just say that there would have a pretty expensive equipment replacement process in the not-too-distant future. The question I keep coming back to is this: who thinks that that is a good idea? I know that recent times have been a struggle relative to segregation of full and not full cylinders, but I thought we had really turned a corner on properly securing cylinders. These are the times that try a person’s soul: tell Tchaikovsky the news! Compliance ≠ Convenience…most of the time.

Do you know the way to TIA?

Last week we touched upon the official adoption of a handful of the Tentative Interim Agreements (TIA) issued through NFPA as a function of the ongoing evolution of the 2012 edition of the Life Safety Code® (LSC). At this point, it is really difficult to figure out what is going to be important relative to compliance survey activities and what is not, so I think a brief description of each makes (almost too much) sense. So, in no particular order (other than numerical…):

  • TIA #1 basically updates the table that provides the specifications for the Minimum Fire Protection Ratings for Opening Protectives in Fire Resistance-Rated Assemblies and Fire-Rated Glazing Markings (you can find the TIA here). I think it’s worth studying up on the specific elements—and perhaps worth sharing with the folks “managing” your life safety drawings if you’ve contracted with somebody external to the organization. I can tell you from personal experience that architects are sometimes not as familiar with the intricacies of the LSC—particularly the stuff that can cause heartburn during surveys. I think we can reasonably anticipate a little more attention being paid to the opening protectives and the like (what, you thought it couldn’t get any worse?), and I suspect that this is going to be valuable information to have in your pocket.
  • TIA #2 mostly covers cooking facilities that are open to the corridor; there are a lot of interesting elements and I think a lot of you will have every reason to be thankful that this doesn’t apply to staff break rooms and lounges, though it could potentially be a source of angst around the holidays, depending on where folks are preparing food. If you get a literalist surveyor, those pesky slow cookers, portable grills, and other buffet equipment could become a point of contention unless they are in a space off the corridor. You can find the whole chapter and verse here.
  • Finally, TIA #4 (there are other TIAs for the 2012 LSC, but these are the three specific to healthcare) appears to provide a little bit of flexibility relative to special locking arrangements based on protective safety measures for patients as a function of protection throughout the building by an approved, supervised automatic sprinkler system in accordance with Originally, this section of the LSC referenced which doesn’t provide much in the way of consideration for those instances (in Type I and Type II construction) where an AHJ has prohibited sprinklers. In that case, approved alternative protection measures shall be permitted to be substituted for sprinkler protection in specified areas without causing a building to be classified as non-sprinklered. You can find the details of the TIA here.


I suppose before I move on, I should note that you’re probably going to want to dig out your copy of the 2012 LSC when looking these over.

As a quick wrap-up, last week The Joint Commission issued Sentinel Event Alert #57 regarding the essential role of leadership in developing a safety culture (some initial info can be found here). While I would be the last person to accuse anyone of belaboring the obvious (being a virtual Rhodes Scholar in that type of endeavor myself), I cannot help but think that this might not be quite as earth-shattering an issuance as might be supposed by the folks in Chicago. At the very least, I guess this represents at least one more opportunity to drag organizational leadership into the safety fray. So, my question for you today (and I suspect I will have more to say on this subject over the next little while—especially as we start to see this issue monitored/validated during survey) is what steps has your organization taken to reduce intimidation and punitive aspects of the culture. I’m reasonably certain that everyone is working on this to one degree or another, but I am curious as to what type of stuff is being experienced in the field. Again, more to come, I’m sure…