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At what point does an emergency response activation become the ‘new normal’?

As we approach the “end” of 2020 (and holding on to the hope that 2020 won’t find a way to persist into next year), I was pondering the question of how one might meet the requirement for a second emergency response activation if one did not have the extraordinary foresight to plan and conduct an exercise before the wheels fell off the world back in March. My thought was that the complexities of the current situation (and the onset of the “flu season”) might give you enough variation to parse the current response (certainly we are not in the same “place” as we were back in the spring) into two evaluations (making sure that we are accounting for an evaluation of the critical response elements: communications, resources and assets, staff roles and responsibilities, safety and security, utility systems, patient care). I suppose one could also “leverage” the update of your hazard vulnerability analysis (HVA)—if you have had a spare moment to do so. As I recall, everyone had pandemic on their HVA, with varying degrees of presumed preparedness. It will be interesting/instructive to see how well your previous analysis matched up with how your organization has fared thus far. It is certainly within the realm of improvement to evaluate current response activities in terms of lessons learned over the past few months (and extrapolating into the next few months).

One glimmer of hope for organizations that are accredited by The Joint Commission is a note attached to the drill requirements that indicates that organizations are exempt from engaging in their next full scale exercise following the onset of the emergency event. My “read” is that (and I believe that this applies for as long as the presidential declaration is in place) folks are allowed to focus their attentions on managing the emergency at hand as opposed to having to come with something else (new, different, etc.) to exercise. I hope to get some confirmation of this over the next little while, but I’d be interested to hear from anyone that has undergone recent survey—my hope is for some flexibility on this count—in full recognition that flexibility has not necessarily been the hallmark of the survey process of late.

At any rate, as this whole megillah had a beginning (and is certainly having a middle), hopefully it will have an end that results in a return to the “old normal.”

Hope you are all well and staying safe. Please stay in touch as you can!

The impossible year continues: Emergency response in 2020

Interestingly enough, I don’t believe that I have a great deal of yammering to do this week; not sure if it’s just a case of mental fatigue with all that continues to transpire (or I daresay, escalate) in terms of community emergencies of virtually every and any imaginable kind. Just between COVID-19 and a typical hurricane season, it would have been an adventure of epic proportions, but perhaps a wee bit more manageable than the various forces assailing the planet. But no, what in the past had tended to be rather transient in nature has now turned towards an aggregation of conditions that rivals…certainly nothing in recent memory and perhaps not ever (the Dark Ages, maybe).

One of the positive byproducts of such a year as this is the ongoing development and promulgation of resources – I have maintained, and will continue to do so, that hospitals are generally pretty well prepared to deal with “stuff.” As I see it, the whole point of preparedness is to be able to manage circumstances (be they singular or plural) without “breaking” (by breaking, I mean a catastrophic failure of response such that folks are actually placed in unprotected risk because of the break, as opposed to facing a situation in which hospital operations would need to be altered, moved, etc.). There are no perfect organizations when it comes to this, which is as it should be—but that doesn’t mean that folks are content to rest on past experiences, but rather to build on those experiences and make improvements. The magnitude of events this year has tested the healthcare industry in ways that would only have been predicted as a hyperbolic planning exercise (this year has been a whole lot of “and then this happens”). As has been the case any number of times in the past, hospitals and other healthcare organizations have had to manage things on their own and/or with community partners as the upper levels of the response infrastructure have been less effective than might have been desired (not pointing any fingers—this is not the first time, nor is it likely to be the last time that the most effective response happens at the local level).

At any rate, there are a few resources that I’ve noted over the past couple of weeks that I wanted to share. I somehow doubt that you’ll have a lot of spare time with which to review written materials, but I’m thinking that at least the links to these materials will be in a place you can “find” again. Lots of stuff here, a lot of it coming out of the response to wildfires in California, but as a primer for relocation, establishing alternative care sites, etc., there is much that is applicable to any untenable emergency condition:

As always, I hope this finds you safe and in reasonable sanity. I would like to think that we’ve got more of this behind us than in front of us, but the numbers are frowning at me, so I will just hold that hope…until next time!

Why are we here? Because we’re here!

One item came up on the radar this past week or so and it appears (I poked around in the archival blogosphere and could find no mention) that I’ve not discussed this before—mea maxima culpa! This has the potential for generating some findings, perhaps at a higher risk level than would seem reasonable in the moment, but I guess that will sort itself out one way or the other.

I can’t quite remember how it all came to be, but at some point in the misty past, I was “schooled” that decontamination showers (like the ones that you typically find in areas near emergency room ambulance entrances) are not required to undergo weekly testing as they are not, as defined, “emergency eyewash or shower equipment” and, thus, not subject to the requirements of ANSI Z358.1 Standard for Emergency Eyewash and Shower Equipment. I was skeptical at the time, but I can say that the latter part of that concept is, indeed, correct in that decontamination shower equipment is not subject to ANSI Z358.1. But it is not correct relative to the weekly testing sequence because there is an ANSI standard—ANSI 113 Standard for Fixed and Portable Decontamination Shower Units—that covers decontamination showers and, lo and behold, it covers exactly what is required for those pesky fixed and portable decon shower units. So we have:

7.2 Fixed shower units shall be activated weekly for a period long enough to verify operation and ensure that flushing fluid is available.

That should sound familiar as a general concept, so you may need to add the decon shower(s) to the weekly to-do list, but things get even more interesting for the portables:

7.3 Portable shower units shall be deployed every 3 months to ensure proper operation.

I’m going to guess that we have some room for improvement on the weekly testing side of things, but I’m going to guess that we may even more of an opportunity on the portable side of things (those of you who possess portable decon showers). I daresay it’s almost enough to make someone not want to have anything elaborate or portable when it comes to decon shower equipment. I’ll let you gnaw on that for a bit…

Emergency management in (you guessed it) ambulatory healthcare

I was really, really, really thinking that I’d be able to glom on to some other subject matter this week (which I suppose it partially true), but it would seem that I’m going to be mining this particular vein of compliance (recognizing that “vein” rhymes with “bane”—make of that what you will…) for at least a bit longer.

At any rate, our friends in Chicago recently indicated some changes relative to the requirements for emergency exercises, but it does seem to be that the changes are intended to reflect CMS reducing the number of required exercises, as referenced in the Emergency Preparedness final rule, to one exercise per year and you only have to conduct a “big” (for lack of a better descriptor) exercise every other year. By big, that would be either a community-based, full-scale exercise (if available) or a facility-based functional exercise.

You may, of course, conduct as many “big” exercises as you like, but in the opposite years, you can even run with a tabletop exercise (though there is a fairly specific setup for the tabletop, so make sure each of the elements is accounted for before you try to take credit). Also, if your organization experiences an actual emergency that requires activation of the emergency plan, you can count that as your activation for the year (and it’s beginning to look a lot like COVID-19 is going to populate a lot of folks’ 2020-2021 emergency management program events).

As a somewhat related aside, this reduces the number of performance elements relating to exercises from three to one, so I think we can count this as a victory for the downtrodden, etc.

I know a lot of folks sometimes struggle with how to involve the ambulatory healthcare locations in exercises, so I think this provides a simpler framework to consider when identifying potential compliance gaps/shortfalls.

I think next week we’re probably going to have a little chat regarding fire drills; the July 2020 issue of The Joint Commission Perspectives has some “clarifying” thoughts on the topic that are probably worth kicking around.

Until next time, hope all is well and you’re staying safe!

’Twas the week before Christmas and all through the…

Do you ever find yourself at the end of the year with a list of random items that you just never got to? It’s not that they weren’t (or, indeed, aren’t) important, but somehow…

At any rate, in looking at my box of blog ideas, I found a bunch of stuff relating to emergency power concerns and considerations, so figured an e-power bundle of bloggy goodness is in order. As always, when it comes to the topic of emergency power, I have to tip the safety hat to Dan Chisholm, Sr. and Danny Chisholm of the Motor & Generator Institute for doing such a great job of covering the world of emergency power. Particularly in a time where healthcare employees have been charged with manslaughter after the death of 14 patients during Hurricane Irma (story here), the degree of scrutiny accorded to emergency power inspection, testing and maintenance is likely to continue apace and the Motor & Generator Institute, at least in my mind, is a must-read.

Some of the topics you’ll find (check out MGI’s blog) if you hop over for some end of the year reading are:

  • Confusion on the part of surveyors relating to the interpretation of NFPA 110 and citations resulting from folks not properly “inspecting” their automatic transfer switches and Dan Chisholm Sr.’s proposal to the NFPA 110 technical committee to help reduce that confusion: Find more info here and here.
  • Remember all those findings relating to compliance with the whole emergency generator shutoff buttons outside of the generator space (which vanished from the Joint Commission standards as a specific, but lives on in the hearts of virtually no one)? If you don’t, there’s been some movement (including hope for a brighter future state of compliance) on that front. Check it out here.

Finally for this missive, there are few more critical times in the life of a facility than the period of recovery following natural disasters; and sometimes a checklist can be helpful.

I’ll have something for you next week, but on the off chance that your holiday includes minimal consideration of work-related stuff, please accept my best wishes to you and yours for a most joyous holiday of your choosing and a productive and prosperous 2020!

Crying my eyes out: The never-ending story of emergency eyewash equipment!

October seems to be shaping up into a “greatest hits” kind of month as we once again dig back into the closet of perennial findings—this week finds us in the realm of managing occupational exposure to chemicals.

With the information contained in the September issue of Perspectives, it looked like findings relating to hazardous materials and wastes (which were mostly related to eyewash stations) had dropped off the Top 10 list (it was the #9 most-frequently cited standard for 2018), which I saw as a good thing. Generally speaking, I’ve found that the knowledge-base of the surveyor corps relative to the management of occupational exposures to hazardous materials leaves a little bit to desire, and rather prone to over-interpretation of what does and what does not constitute an inappropriately managed risk. You could, of course, (and I certainly have) give voice to the thought that over-interpretation is something of a standard practice amongst the surveyors of the world and you’d get very little in the way of argument from me. But there are a couple of recent findings that kind of crystallized (at least for me), the intersection of over-interpretation and a limited knowledge of the practical/operational aspects of appropriate management of occupational exposure to hazardous chemicals.

So, we have the following:

  • A single container of bleach in a storage room becomes a finding of moderate risk because the pH level of bleach requires the installation of an eyewash station

Now, purely from a reasonable risk assessment standpoint (and in recognition of the very remote likelihood that the container of bleach is going to somehow vomit its contents), the mere presence/storage of a corrosive does not (in my mind) constitute a risk of occupational exposure. If someone is pouring the bleach into another container (which is not the case here—again, only storage), then the risk of occupational exposure comes into play. The image that I conjured up relative to this is the local grocery store—gallons upon gallons of bleach—and nary an eyewash in sight (and yes, while OSHA doesn’t really jump ugly relative to customer exposure, the risks to customer and in-house staff is probably about equal). I suppose the best course for a corrective action would be to remove the bleach and be done with it. That said, this seems a bit of a reach…

  • Two eyewash stations (one in a soiled utility room and one in a scope decontamination room) that were located at dirty sinks in these areas, increasing the risk of staff exposure to contamination

Now, my philosophy regarding the location of emergency eyewash equipment is that you want to install them in locations as close to the point of likely exposure as is possible/reasonable, which sometimes (maybe even often) means that you install them on the only sink in a soiled utility room, etc. And you do that because?!? You do that because, the emergency eyewash station is equipped with protective covers to ensure that the emergency eyewash does not get contaminated, so you can install them in the locations in which they would be of the greatest benefit in an emergency, which might very well be in a soiled location.

It seems that the mystery of eyewash stations will never be completely solved…

It’s a lot like you: The dangerous type of emergency risks!

I know we chatted just last week about emergency management concerns, but once again, there’s more news stuff relating to the management of utility systems (it’s not just about water features) during emergencies and it does appear that the consequences of inadequately managed risks can get you into trouble with more than just the usual regulatory suspects.

A USA Today story from a couple of weeks ago outlined the charges/arrests resulting from the deaths of a number of nursing home patients in the aftermath of hurricane Irma, back in 2017. The sticking point, as it were, was the failure of the facility to evacuate once they lost the ability to effectively cool the facility. The news story paints a bleak picture of negligence, failure to call 911, etc., but also provides some indication that 911 calls from the facility received no response. I imagine that some details will emerge during trials as to what may or may not actually have transpired, including the existence of a “fully functional hospital across the street” to which (apparently) evacuation was not an option. I still maintain the most important part of any emergency response plan (and if not the most important, one of the very, very most important) is having a very clear understanding of what the trigger points are that would result in a need to evacuate. The worst thing that can happen with evacuation is to wait so long that a safe evacuation is not possible. I guess we’ll (hopefully) see what circumstances led up to this circumstance.

On a related (somewhat) note, our friends at the CDC have collaborated with the American Water Works Association to develop an Emergency Water Supply Planning Guide to assist healthcare facilities in their efforts to prepare for, respond to, and recover from, a total or partial water supply interruption. The Guide is designed to help folks assess water usage, response capabilities, and water supply alternatives. I suspect that this might be especially useful to folks in areas that tend to experience drought conditions, so if you want to check out the CDC Guide, you can find it here, along with links to some other preparedness resources.

Closing out things for this week, I’d like to share with you folks an article that I found to be of interest; while I don’t personally have managerial oversight in my current role, I saw enough parallels to “back in the day” to prompt the thought that “I wish there was something like this available when I was starting out.” So, in case you’re starting out in the amazing field of management or are interested in what’s going on in management theory, I think this would be worth your while. There’s a quote from Warren Buffett that I think really captures the essence of the compliance wars: “What the human being is best at doing is interpreting all new information so that their prior conclusions remain intact.” I bet that everyone reading this knows at least one human being like that…

You can find the whole article here.

If you don’t signal, how will I know where you want to go? Emergency management and its discontents (Just What You Needed)!

Kind of a mixed bag this week, though it all fits under the heading of emergency management, so here goes nothing…

A few weeks ago, USA Today did a story on the preparedness levels of the United States based on an analysis of state-by-state metrics. The story was based on a study, the National Health Security Preparedness Index, prepared by the Robert Wood Johnson Foundation and covers a lot of ground relative to trends in preparedness, including governmental spending on preparedness and some other stuff. The reason I “noticed” this was the indication that my home state was “best prepared” for disasters, etc., but the overarching message was that, even in the face of some setbacks in individual regions, the nation continues to improve emergency preparedness. Of course, it being USA Today, there are color slides indicating where each state ranks among the fabulous 50, so if you thought there was no scorekeeping on this front…

OK, maybe not keeping score, but a certain accreditation agency is keeping an eye on all things relating to preparedness. In this blog post, Jim Kendig (field director for the Life Safety Code® surveyors at The Joint Commission, and a very knowledgeable fellow when it comes to this stuff) provides a really good overview of the Preparedness Index and describes it in terms of how the various pieces can (and do) fit together and provide the foundation for an effective emergency management program. I see no reason why we can’t expect something more of a deep dive in the coming survey cycle and I think you’ll find the information Jim shares to be really helpful.

As a final thought for this week, it is always the case that what constitutes a mass casualty incident varies from organization to organization, but if you want to catch a glimpse of how this gets framed within the context of one of the largest metropolitan areas on the planet, the Greater New York Hospital Association developed a Mass Casualty Incident Response Toolkit that you might find worth checking out. There’s a ton of information, tools/forms, and links to more tools/forms, etc., to review in this space, but I encourage you to give the materials a look-see. It does appear that the nature of what we can expect to show up at our collective front doors is shifting and anything that facilitates better positioning to deal with an emergency is worth our time and energies.

Would you believe there’s nothing up my sleeve?: Protective measures

Caution: This is not a product endorsement, but rather an observation of a product that might, at times, sound a little endorse-y. I can be persuaded…

While working at a hospital somewhere in the United States, I was apprised of a product being installed that will (hopefully) facilitate securing doors that might not otherwise be secured, in the event of an active shooter or other threat that would require the establishment of a safe barricade. Effectively, the product is a metal wedge-shaped sleeve (hence the product name: Fighting Chance) that slides over the arm of a door closer and prevents the door from being opened.

At first encounter, I thought it was a pretty nifty idea (and still do), but I was curious about how one would be able to consistently operationalize the device from a practical standpoint: How do you make sure that you’ve got someone tall enough to be able to reach up and slide the sleeve over the arm? I’ve seen a lot of doors and door arms in my time and I can tell you (I’m about 5’ 6”) that there are some door arrangements for which I would have a very difficult time being able to reach the arm.

So, the question I have (and I will be happy to share the information) is if you are using this product (or even considering using this product), are you including provisions/consideration to assist the more diminutive members of your organization (maybe some sort of step stool stored in close proximity, perhaps something else—I know you folks are creative as all get out)? Have you drilled the used of these devices and found any other opportunities for improvement? I am a great admirer or simple technology and I do like the simplicity of the design—I’m just curious as to how it will play in the field.

I hope it’s a winner!

Maybe there’s a hole in there somewhere: Keeping your critical equipment running!

An interesting line of questioning is emerging in some recent survey activity (mostly during state visits, but the accreditation organizations are moving in this direction, particularly those with a focus on ISO processes) relates to the management of “high mortality” utility systems components, particularly emergency power supply system parts. If you look at this as a function of high reliability, ensuring that you have close to immediate access to a means of repairing those things that are most likely to break (and I suspect that everyone out there in the reading audience know which of your utility systems are most likely to give you fits—from experience, elevators always seem to figure in on that count).

I think in most instances it would require some level of working with your service providers to identify the things that are most likely to go wrong and then to set up a process for ensuring ready access to parts and service. Let’s face it, there are few more angst-filled moments than when you have to tell your boss that a critical piece of equipment is going to be down because parts need to be ordered, etc. And I don’t know of too many service vendors that are maintaining a broad-range of replacement parts, etc. on their shelves (I’m sure there are some and that’s great for you if they “live” in your neighborhood); inventory can be an expensive undertaking. But maybe there’s a way to build that into your next service contract—something to think about—your incumbent is probably going to have the most specific failure data relative to your equipment, but I would think there are sufficient commonalities of systems and equipment to allow for competitive proposals if you choose to go that route.

Some other contractual considerations (and this is more on the compliance front than anything, but still)—a “hard” touch whenever folks are onsite servicing equipment—at the very least, they can let you know if they see anything that might prove troublesome, so you don’t have to hunt for it when the paperwork arrives (hopefully sooner rather than later—that’s another contractual consideration—turnaround time for service reports/records). I don’t know that we’ll ever have enough granularity of data from the regulatory folks, but I am absolutely convinced (based on what I’ve seen) that the reason that findings in and around fire safety (and other) systems documentation relates to stuff being buried in vendor reports: the “classic” smoke detector that didn’t get tested or the heat detector in an elevator shaft that someone terms “inaccessible.” We (as a collective) are on the hook for ensuring that 100% of your devices and equipment are inspected, tested, and maintained in accordance with code and regulation. Our vendors really don’t have any “skin” in the game.

I’m sure this is all rather self-evident to you folks, but where I’m sitting at the moment, there’s not a lot of “new” stuff floating around and it was a miserable rainy day, so this is what the connection of head and fingers conjured up.