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Don’t let weighing in weigh you down…

In what I would term an interesting move (I don’t know that I would go so far as to call it unprecedented, but it might well could be), our friends in Chicago are rearranging the deck chairs in the Emergency Management chapter. It does seem like it’s more of  a consolidation than a wholesale rewrite, but the strategy of setting up new standard and performance element numbers makes this potentially a big deal (as we know, surveyors tend to focus on the stuff that has changed since the last survey visit, so if you’re using the existing numerical indicators, you’ll likely need to change—or get rid of them entirely). I suspect this may have more to do with trying to align the existing EM standards et al. with the CMS requirements (It will be interesting to see if they end up developing a crosswalk—probably when it’s adopted).

While I can’t say that I’ve digested the whole thing, it does seem like they removed a lot of the specifics relating to the management of LIP volunteers (including an allowance for organizations to forego the use of volunteers, a strategy they had never really “approved”; I know a couple of instances in which organizations were cited for declining to use volunteers), but it makes me wonder what degree of specificity is going to come into play when they start surveying to this.

That said, I don’t see anything that’s giving me heartburn; since CMS based Appendix Z on much of the TJC standards from 2007-ish, what was once old (and abandoned) is now fresh and new and cutting edge. I have the same hopes for myself over time…

At any rate, the critical processes are still represented. I think it will show over time that some of the specificity of the current standards pushed folks to do things that didn’t necessarily make sense from an organizational standpoint, but I guess we’ll have to wait until the final version is out and about and able to take care of itself. I’m guessing substantive changes are not likely to be made at this point, but they are asking for comments, so if you’ve got a mind to say something, I would encourage you to do so.

Next week we’ll chat a little bit about some recent interpretive dances from the perspective of Perspectives. Stay tuned!

If there weren’t challenges…

…it really wouldn’t be an event that requires emergency response.

Somehow over the last little while, the fundamental nature of what constitutes an emergency and, even more importantly, what an appropriate response looks like, appears to have morphed over time. Now we seem to embrace the expectation that whatever happens, hospitals are going to be right on top of things (in a way that, frankly, doesn’t seem to apply to them that would sit in judgment, but that might be something of an editorial comment). But really, can you imagine what would have happened a year ago when pretty much everybody else was working from home, suspending normal operations, etc. (in full recognition that healthcare facilities don’t have the option of opting out of such things)? Now a lot of folks (and no, I’m not going to name names—if you don’t know, then it’s probably just as well) are playing catch-up and generating a wee bit of chaos as they get back to it. Happy happy, joy joy!

At any rate, I do hope that all the surveyors out there kicking the EM tires are paying close attention to some of the information contained in the CMS updates to the emergency preparedness requirements, including:

  • It’s OK for your response process to be the same for multiple risks/hazards
  • Your HVA/program must address each type of hazard, but your policies and procedures can indeed be consolidated (can you imagine how many binders you would need?!?)
  • It is not the job of the surveyor to analyze the appropriateness of the identified risks; their job is to make sure that your program (including policies and procedures) align with your risk assessments (speaking of your risk assessments, they must be demonstrably facility-based/community-based and they must include staffing considerations; emerging infectious disease planning must be in the mix—no surprise there)
  • It is OK (and certainly much more effective) to have each organization’s EM person “show” the requested elements as opposed to surveyor “browsing” of the plan, etc. (the CMS guidance encourages the use of crosswalks to more quickly/readily identify where the component pieces “live”)
  • It is also OK to have your documentation in whatever format makes sense: hard copy, electronic, etc.

I think these are fairly representative of a common-sense approach to surveying compliance with the EM standards; I guess we’ll see how things unfold in the field…

Just a few odds and ends to wrap things up:

  • They encourage the use of the ASPR-TRACIE checklists; lots of good stuff there and well worth poking around and discovering.
  • Emergency power—you have to have what is required by the Life Safety Code® (LSC)/COP for your facility; but please remember that any additional emergency power considerations must be maintained in accordance with the LSC (and, by extension, NFPA 110 et al). I think some folks have this sense that anything not required by the LSC/110 combo can be maintained in whatever fashion they like. This seems to be drawing a line in the sand that they’re not buying it (again, I guess we’ll see what happens in the field—maybe anything that is not LSC-related isn’t offered up for scrutiny); also, they do not allow extension cords to directly connected to generators; generator must interface with facility through transfer system.
  • Functional exercises, mock disaster drills and workshops can be used to count towards the activation requirements (by the way, long-term care facilities are on the hook for annual education; everyone else can go with biannual).
  • Inpatient facilities need to have two years of documentation present; outpatient facilities have to have four years available.
  • Emergency plans are expected to evolve (mutate?) over the course of a long-term event (and I think we know a little something about that…), your plan should include provisions for monitoring guidance from public health.
  • Your plan must include provisions for tracking staff when electronic payroll systems, etc., not available—for example, power outages, etc. consider check-in procedures for on-duty and off-duty staff.
  • Your plan must include a process for communicating with the various AHJS (and, boy howdy, aren’t there an awful lot of those kicking around); as well as provisions for surge planning. As for staffing, while the use of volunteers is optional, there is an expectation that you will have a process for managing them. Over the years, I’ve run into any number of folks that were not at all inclined to deal with volunteer practitioners, but I think the days when that was a reasonable decision point are rapidly fading into the distance.
  • Your plan must also include a process for evacuating patients that refuse to do so; I figure there must be some empirical information that drove the inclusion of this in the guidance. I’m presuming that you have a process already for dealing with recalcitrant individuals, including patients, so I don’t know that this breaks any ground.

Now that I’ve finished typing this, I really don’t see a lot that I would considering troubling or, indeed, troublesome. I would imagine that a lot of this stuff has become rather more hard-wired than not over the past 15 months or so, if it were not already. I think there were a lot of common lessons learned, though the “equation” for “solving” the challenges is probably unique to every organization (unless you’re part of a system in which the facilities are virtually identical). From a compliance standpoint, I think you folks should be OK, but please reach out if you feel otherwise.

So, with June bearing down on us, I trust that you all continue to be well and are staying safe. See you next week!

Take me to your leaders…

I believe that we’ll be able to wrap up the emergency management stuff next week—though I have one or two ideas percolating that I might move to the front of the queue, but certainly before May gives way to June (unless something really interesting pops up out of nowhere…).

With our friends from Chicago returning to the playing field, there was some discussion of a modification to the session with organizational leadership, primarily involving moving the session to the opening of the survey and to have that session focus on leadership’s involvement with response to the pandemic over the last little while. The exact rationale for this strategy (which has since, more or less, gone away) kind of escapes me because I really don’t think the last 12-15 months could have been successfully navigated without some level of interest/action/participation, etc., on the part of hospital leadership teams pretty much everywhere on the globe. That said, I do suspect that the level of interest in all things emergency preparedness have probably not been as widely appreciated as they are right now (soon we will chat about making the most of this moment—but that’s for another day).

At any rate, with the unveiling of the new guidance (I don’t know that there’s necessarily anything “new” that’s going to come out of any of this, but I guess we’ll have to see, but this seems more like a recapitulation or codification than it does a significant change), there continues to be a concerted aim towards clarifying the necessity of organizational leadership participating in the emergency preparedness activities as a baseline expectation (an expectation I think we’ve all shared, yes?). Again, from a practical standpoint, your hospital, in all likelihood, would not have endured the last little while without the active participation/interest/whatever you care to call it from your leadership group. If someone managed to do so (and that doesn’t mean in spite of their participation), I’m keen to hear that story. But in the infinite wisdom of the regulatory monarchy, the following topics of conversation could be raised during any survey event in which leaders are queried about their EM roles:

  • How did the organization encourage collaborations with the available coalitions (local/regional/state: remembering that community partners are defined by each organization)?
  • How did the organization prepare for and manage staffing?
  • How did the organization prepare for and manage evacuation (including planning for the evacuation of patients that do not wish to be evacuated)?
  • How did the organization ensure that communications are collaborative and align with the methods/structures, etc., of the AHJs in the mix?
  • How did the organization promote participation in exercises and engage in the after action report process?
  • How did the organization ensure ongoing preparedness in the face of changes/shifts in community or other partners?
  • How did the organization identify what services would be provided under what circumstances?
  • How did the organization align continuity of operations and business continuity (we’ve had plenty of opportunity to look at this, I would think)?
  • How did the organization effectively manage the delegation of authority, including succession planning considerations?

In almost any other point in modern history, it might have proven to be somewhat burdensome to bring leaders up to speed in advance of a survey, but I can’t imagine that there are too many leadership groups out there that wouldn’t have more than enough practical experience (even if they never completed IS-100 and IS-200). Going forward, I think it’s going to be really helpful to keep the last year in everyone’s heads as a function of how we manage preparedness. It’s not just about regulatory compliance—it’s ensuring that providing care in a safe setting continues to be the number one priority of emergency response.

Hope you all are healthy and staying safe. Somehow I get the sense that we’re not quite done with this (though I would be more than happy to be proven incorrect in that sense), but we will prevail! See you next week!

You better? You bet!

It would seem that while the rest of the world has been busy responding to a pandemic, the folks behind the scenes have been working on identifying the lessons learned and memorializing them in an update to Appendix Z. At first glance, it seemed that this was more a codification of past updates, but as a I looked through the thing in its entirety, it does seem like the changes are more significant/substantive than I thought. That said, I do think that much of the updated material is aimed at helping surveyors to understand what is (and what is not) actually required and that, as with everything in our world, customization of approaches, etc., is not only desirable, but is really the only way to “roll” when it comes to appropriately preparing to respond to an(y) emergency. I suppose one could make the case that, after all of this hoo-hah of the past year-plus, if we’ve not managed to improve our preparedness, then what exactly have we been doing?

Part of the dynamic I keep coming back to with all this is if it were “business as usual,” then it wouldn’t be an emergency. And one of the defining aspects of an emergency is that it tends to push the normal limits of an organization. I remember the hue and cry that went out immediately following Superstorm Sandy’s trek up the East Coast regarding the level of hospital preparedness—because people struggled at the outset. But when the final report from CMS was issued, it turned out that hospitals generally did what they had to do to keep patients and staff safe.

As we look back at the past 18 months or so, I suspect that each organization within the sound of my voice is better prepared than previously for managing the impact of a long-term pandemic event. I also suspect that there have been any number of improvement opportunities identified and I am hopeful that, among other things, your organizational leadership has gained a greater appreciation for emergency preparedness as a proactive undertaking (recognizing that response is typically characterized by reactivity). The truth of the matter is this: while emergency preparedness does not, in and of itself, generate revenue. Effective emergency preparedness allows an organization to continue generating revenue while the feces is striking the rapidly rotating blades—and that makes all the difference in the world.

I suspect that this is going to take a couple of sessions to work through some of the subtleties of the updates, so I would encourage you to start chipping away at this as wander through the very merry month of May. There is a lot of material to digest and while I don’t see anything that’s making me crazy from a survey prep standpoint, I’ll let you be the judge of how that shakes out—at least for the moment.

Before I close out this week’s chat, I did want to tip you to one resource that I think will be really helpful. One of the more painful aspects of the Emergency Preparedness Final Rule has been that the official document that is Appendix Z is designed to include the requirements for all provider types, which makes an already complex set of rules that much more confusing. But someone (bless them, whoever they are) worked to peel out the requirements for each provider type, so if you’re not a “regular” hospital or you have operational responsibilities for more than one provider type, you can find the specifics for each here. There are other resources as well, but just having the requirements by provider type is (at least to me) crazy wonderful—and I hope you think so too.

Next week, we’ll chat about some of the ways in which organizational leaders are going to be looped into this on an ongoing basis—if that doesn’t sound like fun…

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…