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Lazy days of autumn: CMS does emergency management (cue applause)!

I suppose you could accuse me of being a little lazy in this week’s offering, but I really want you to focus closely on what the CMS surveyors are instructed to ask for in the Emergency Management Interpretive Guidelines (more on those here; seems like forever ago), so I’ve done a bit of a regulatory reduction by pulling out the non-hospital elements (I still think they could have done a better job with sorting this out for the individual programs) and then pulling out the Survey Procedures piece—that’s really where the rubber meets the road in terms of how this is going to be surveyed, at least at the front end of the survey process.

I suspect (and we only have all of recorded history to fall back on for this) that as surveyors become more comfortable with the process, they may go a little off-topic from time to time (surprise, surprise, surprise!), but I think this is useful from a starting point. As I have maintained right along, I really believe that you folks have your arms around this, even to the point of shifting interpretations. This is the stuff that they’ve been instructed to ask for, so I think this is the stuff that you should verify is in place (and, really, I think you’ll find you’re in very good shape). There’s a fair amount of ground to cover, so I will leave you to it—until next week!

BTW, I purposely didn’t identify which of the specific pieces of the Final Rule apply to each set of Survey Procedures. If there is a hue and cry, I will be happy to do so (or you can make your own—it might be worth it to tie these across to the requirements), but I think these are the pieces to worry about, without the language of bureaucracy making a mess of things. Just sayin’…

Survey Procedures

  • Interview the facility leadership and ask him/her/them to describe the facility’s emergency preparedness program.
  • Ask to see the facility’s written policy and documentation on the emergency preparedness program.
  • For hospitals and critical access hospitals (CAH) only: Verify the hospital’s or CAH’s program was developed based on an all-hazards approach by asking their leadership to describe how the facility used an all-hazards approach when developing its program.

Survey Procedures

  • Verify the facility has an emergency preparedness plan by asking to see a copy of the plan.
  • Ask facility leadership to identify the hazards (e.g., natural, man-made, facility, geographic, etc.) that were identified in the facility’s risk assessment and how the risk assessment was conducted.
  • Review the plan to verify it contains all of the required elements.
  • Verify that the plan is reviewed and updated annually by looking for documentation of the date of the review and updates that were made to the plan based on the review.

 

Survey Procedures

  • Ask to see the written documentation of the facility’s risk assessments and associated strategies.
  • Interview the facility leadership and ask which hazards (e.g., natural, man-made, facility, geographic) were included in the facility’s risk assessment, why they were included and how the risk assessment was conducted.
  • Verify the risk assessment is based on an all-hazards approach specific to the geographic location of the facility and encompasses potential hazards.

Survey Procedures

Interview leadership and ask them to describe the following:

  • The facility’s patient populations that would be at risk during an emergency event
  • Strategies the facility (except for an ASC, hospice, PACE organization, HHA, CORF, CMHC, RHC, FQHC and end stage renal disease (ESRD) facility) has put in place to address the needs of at-risk or vulnerable patient populations
  • Services the facility would be able to provide during an emergency
  • How the facility plans to continue operations during an emergency
  • Delegations of authority and succession plans

Verify that all of the above are included in the written emergency plan.

Survey Procedures

Interview facility leadership and ask them to describe their process for ensuring cooperation and collaboration with local, tribal, regional, state, and federal emergency preparedness officials’ efforts to ensure an integrated response during a disaster or emergency situation.

  • Ask for documentation of the facility’s efforts to contact such officials and, when applicable, its participation in collaborative and cooperative planning efforts.
  • For ESRD facilities, ask to see documentation that the ESRD facility contacted the local public health and emergency management agency public official at least annually to confirm that the agency is aware of the ESRD facility’s needs in the event of an emergency and know how to contact the agencies in the event of an emergency.

Survey Procedures

Review the written policies and procedures which address the facility’s emergency plan and verify the following:

  • Policies and procedures were developed based on the facility- and community-based risk assessment and communication plan, utilizing an all-hazards approach.
  • Ask to see documentation that verifies the policies and procedures have been reviewed and updated on an annual basis.

Survey Procedures

  • Verify the emergency plan includes policies and procedures for the provision of subsistence needs including, but not limited to, food, water and pharmaceutical supplies for patients and staff by reviewing the plan.
  • Verify the emergency plan includes policies and procedures to ensure adequate alternate energy sources necessary to maintain:

o Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions;

o Emergency lighting; and,

o Fire detection, extinguishing, and alarm systems.

  • Verify the emergency plan includes policies and procedures to provide for sewage and waste disposal.

 

Survey Procedures

  • Ask staff to describe and/or demonstrate the tracking system used to document locations of patients and staff.
  • Verify that the tracking system is documented as part of the facilities’ emergency plan policies and procedures.

 

Survey Procedures

  • Review the emergency plan to verify it includes policies and procedures for safe evacuation from the facility and that it includes all of the required elements.
  • When surveying an RHC or FQHC, verify that exit signs are placed in the appropriate locations to facilitate a safe evacuation.

 

Survey Procedures

  • Verify the emergency plan includes policies and procedures for how it will provide a means to shelter in place for patients, staff and volunteers who remain in a facility.
  • Review the policies and procedures for sheltering in place and evaluate if they aligned with the facility’s emergency plan and risk assessment.

 

Survey Procedures

  • Ask to see a copy of the policies and procedures that documents the medical record documentation system the facility has developed to preserves patient (or potential and actual donor for OPOs) information, protects confidentiality of patient (or potential and actual donor for OPOs) information, and secures and maintains availability of records.

 

Survey Procedures

  • Verify the facility has included policies and procedures for the use of volunteers and other staffing strategies in its emergency plan.

 

Survey Procedures

  • Ask to see copies of the arrangements and/or any agreements the facility has with other facilities to receive patients in the event the facility is not able to care for them during an emergency.
  • Ask facility leadership to explain the arrangements in place for transportation in the event of an evacuation.

 

Survey Procedures

  • Verify the facility has included policies and procedures in its emergency plan describing the facility’s role in providing care and treatment (except for RNHCI, for care only) at alternate care sites under an 1135 waiver.

 

Survey Procedures

  • Verify that the facility has a written communication plan by asking to see the plan.
  • Ask to see evidence that the plan has been reviewed (and updated as necessary) on an annual basis.

 

Survey Procedures

  • Verify that all required contacts are included in the communication plan by asking to see a list of the contacts with their contact information.
  • Verify that all contact information has been reviewed and updated at least annually by asking to see evidence of the annual review.

 

Survey Procedures

  • Verify that all required contacts are included in the communication plan by asking to see a list of the contacts with their contact information.
  • Verify that all contact information has been reviewed and updated at least annually by asking to see evidence of the annual review.

 

Survey Procedures

  • Verify the communication plan includes primary and alternate means for communicating with facility staff, federal, state, tribal, regional and local emergency management agencies by reviewing the communication plan.
  • Ask to see the communications equipment or communication systems listed in the plan.

 

Survey Procedures

  • Verify the communication plan includes a method for sharing information and medical (or for RNHCIs only, care) documentation for patients under the facility’s care, as necessary, with other health (or care for RNHCIs) providers to maintain the continuity of care by reviewing the communication plan.

o For RNCHIs, verify that the method for sharing patient information is based on a requirement for the written election statement made by the patient or his or her legal representative.

  • Verify the facility has developed policies and procedures that address the means the facility will use to release patient information to include the general condition and location of patients, by reviewing the communication plan

 

Survey Procedures

  • Verify the communication plan includes a means of providing information about the facility’s needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee by reviewing the communication plan.
  • For hospitals, CAHs, RNHCIs, inpatient hospices, PRTFs, LTC facilities, and ICF/IIDs, also verify if the communication plan includes a means of providing information about their occupancy.

 

Survey Procedures

  • Verify that the facility has a written training and testing (and for ESRD facilities, a patient orientation) program that meets the requirements of the regulation.
  • Verify the program has been reviewed and updated on, at least, an annual basis by asking for documentation of the annual review as well as any updates made.
  • Verify that ICF/IID emergency plans also meet the requirements for evacuation drills and training at §483.470(i).

 

Survey Procedures

  • Ask for copies of the facility’s initial emergency preparedness training and annual emergency preparedness training offerings.
  • Interview various staff and ask questions regarding the facility’s initial and annual training course, to verify staff knowledge of emergency procedures.
  • Review a sample of staff training files to verify staff have received initial and annual emergency preparedness training.

 

Survey Procedures

  • Ask to see documentation of the annual tabletop and full scale exercises (which may include, but is not limited to, the exercise plan, the AAR, and any additional documentation used by the facility to support the exercise.
  • Ask to see the documentation of the facility’s efforts to identify a full-scale community based exercise if they did not participate in one (i.e., date and personnel and agencies contacted and the reasons for the inability to participate in a community based exercise).
  • Request documentation of the facility’s analysis and response and how the facility updated its emergency program based on this analysis.

 

Survey Procedures

  • Verify that the hospital, CAH, and LTC facility has the required emergency and standby power systems to meet the requirements of the facility’s emergency plan and corresponding policies and procedures
  • Review the emergency plan for “shelter in place” and evacuation plans. Based on those plans, does the facility have emergency power systems or plans in place to maintain safe operations while sheltering in place?
  • For hospitals, CAHs, and LTC facilities which are under construction or have existing buildings being renovated, verify the facility has a written plan to relocate the EPSS by the time construction is completed

For hospitals, CAHs, and LTC facilities with generators:

  • For new construction that takes place between November 15, 2016 and is completed by November 15, 2017, verify the generator is located and installed in accordance with NFPA 110 and NFPA 99 when a new structure is built or when an existing structure or building is renovated.  The applicability of both NFPA 110 and NFPA 99 addresses only new, altered, renovated or modified generator locations.
  • Verify that the hospitals, CAHs and LTC facilities with an onsite fuel source maintains it in accordance with NFPA 110 for their generator, and have a plan for how to keep the generator operational during an emergency, unless they plan to evacuate.

 

Survey Procedures

  • Verify whether or not the facility has opted to be part of its healthcare system’s unified and integrated emergency preparedness program. Verify that they are by asking to see documentation of its inclusion in the program.
  • Ask to see documentation that verifies the facility within the system was actively involved in the development of the unified emergency preparedness program.
  • Ask to see documentation that verifies the facility was actively involved in the annual reviews of the program requirements and any program updates.
  • Ask to see a copy of the entire integrated and unified emergency preparedness program and all required components (emergency plan, policies and procedures, communication plan, training and testing program).
  • Ask facility leadership to describe how the unified and integrated emergency preparedness program is updated based on changes within the healthcare system such as when facilities enter or leave the system.

 

To close out this week’s bloggy goodness, Diagnostic Imaging just published a piece on emergency preparedness for radiology departments that I think is worth checking out: http://www.diagnosticimaging.com/practice-management/emergency-preparedness-radiology . Imaging services are such a critical element of care giving (not to mention one of the largest financial investment areas of any healthcare organization) that a little extra attention on keeping things running when the world is falling (literally or figuratively) down around your ears. I think we can make the case that integration of all hospital services is likely to be a key element of preparedness evaluation in the future—this is definitely worthy of your consideration.

Survey Preparation—When do you start kicking the tires?

In the “old” days, the survey preparation cycle was a fairly well-defined undertaking—you knew (pretty much) when they were coming and about six months before their estimated arrival, prep activities began in earnest. Now, you might say, that it’s pretty freaking obvious that that particular strategy is not so great for ensuring results in the current climate (even though, at least at the moment, surveys are happening on that same 36-month recurrence—there have been a few wild card survey arrivals, but not like we’ve been led to expect), but I still find a lot of folks (particularly when it comes to bringing in an extra pair of eyes to look things over) are waiting until the “survey year” to really give the place a thorough review. Now, I am two minds on that topic—while I understand that the closer you can get to survey, the (purportedly) more accurate a picture you have of what things will look like during the actual survey, I also know (from experience) that if you find vulnerabilities (particularly when it comes to documentation), you really need to have something of a track record of compliance (12 months of pristine is a good place to be, though surveyors can certainly walk you back as far as they want—a greater risk for facilities that are smaller in terms of square footage) if you are going to “survive” with minimal findings—recognizing that it is really, really tough to pull off no physical environment findings.

In other news this week, emergency management stuff continues to take center stage as Jose takes aim at the Northeast (it’s beginning to appear that any place that could experience a hurricane is going to endure just that). On the Joint Commission website (www.jointcommission.org) there’s an announcement that TJC is temporarily suspending survey activities in Florida, Puerto Rico, and the Virgin Islands, as well as the Houston area for organizations that have been severely affected by recent weather events. The posting does indicate that if there are questions, organizations should reach out to their Joint Commission Account Executives, which I suspect will involve ascertaining a working definition of “severely affected.” I’m sure that TJC-accredited organizations went through the appropriate notification sequence if they had to curtail or otherwise modify their services, in accordance with the requirement to notify TJC within 30 days of any substantive changes in operations (I think we’re still within the 30-day window from the onset of Harvey, but if your organization has altered services, etc., and not yet made the call to TJC, I would put that on the to-do list for this week). I guess it would be good not to have to go through a survey during the recovery phase, but I don’t know that it wouldn’t be worth seeing how well you could do in the midst of everything else.

Let’s see what else do we have? Ah yes—the Centers for Disease Control and Prevention have updated the hurricane preparedness page on their website; definitely a cornucopia of information for health care providers, response and recovery workers, as well as affected communities in general. Nothing jumps out at me as being super special, but I think all of the available information is worthy of review. I won’t say that I’ve pored over every bit of information, but with all that’s happened (and all that might yet be on the horizon), it’s nice to have some learned source material. Speaking of which, the Association for Linen Management has also published some disaster recovery guidelines; for those of you with operational responsibilities for linen, there’s some good stuff here (and not just the warm feeling I get whenever I think about my halcyon days managing the linen department) and definitely worth checking out.

 

Keep calm and stock up on emergency supplies

Hospitals are generally prepared for emergencies, but don’t be afraid to kick those tires one last time.

I don’t know that this last spate is officially the most congested high-intensity weather pattern we’ve ever encountered, but it has got to be right up there in the uppermost tier. As we continue to keep our thoughts on those who have been managing the effects of Harvey, Irma, and Jose, I suppose it’s only a matter of time before the critiques start arriving.

I do believe that hospitals in general are appropriately prepared to respond to emergencies (and I know for certain a number of hospitals that appropriately prepared). As I pen this, I am sitting at the airport in Charlotte, North Carolina, waiting to see if Irma is going to let me get to some client work this week or force me to be Boston-bound.

My philosophy about these things is that there is very little, if any, control that can be exercised as events unfold; the only true aspect of control is to be able to position yourself to make good decisions for the duration of whatever event you might be facing. From what I can gather, this was very much in effect as hospitals in the southeastern U.S. and into the Caribbean responded to recent weather events.

Not every physical plant fared as well as some, but one of the quirky things about catastrophes is they tend to be, well, catastrophic—if it had been business as usual, we probably wouldn’t be talking about it at the moment. At any rate, kudos to those folks who did what they had to do to keep things together, and our best to those for whom every preparation in the world could not have been enough.

In other news

I was going through some stuff I’ve had in the queue for a while that really didn’t fit thematically in the conversation of the week but that I think would be useful to bring to your collective attention. So, in brief (some of you will probably question my definition of brevity, but I can live with that), here they are:

  • For the foreseeable future, there will be a fair amount of scrutiny of the physical environment in your outpatient locations, and a key component of managing those environments is making sure that the folks who are keeping the place clean are on top of their game. It is not uncommon for organizations to have to use independent contract cleaning services for their outpatient locations, but clean is clean is clean—and we know some of the surveyors are not shy about getting out their white gloves and rooting around for GFM (gray fibrous material, a.k.a. dust). Patient environments need to be properly maintained–and you know who’ll suffer the consequences if that’s not happening.
  • Back in April, our friends in Chicago, The Joint Commission, published Quick Safety 32: Crash-cart preparedness; while not everything on their list is specific to the physical environment, there is a lot of fair info relative to process. There are certainly safety and security (not to mention life safety) implications if resuscitation supplies and equipment are not properly maintained—and this applies to your outpatient settings as well. Keep an eye on crash carts wherever they may be.
  • Finally, (and going way, way back to January 2017), The Joint Commission’s Quick Safety 30 covered the all-too-current topic of protecting patients during utility system outages. I think we can all agree that this summer has brought a few too many opportunities to test our mettle in this regard (and, again, great job everyone!), but, as we all know, utility systems can crap out at any time, with minimal warning. So, the watch words (or watch concepts, as it were) are “contingency” and “plans”—redundancies, staff ability to respond to disruptions, etc. are some of the keys to success. Quick Safety 30 also provides a couple of links to some contingency planning resources. The truism underneath all this stuff is that one can never be too prepared, so don’t be afraid to kick those tires one last time.

 

Thoughts and prayers for Houston; plus, thoughts on required ‘policies’

First off, thoughts and prayers going out to the embattled folks in Texas; I do a fair amount of work in Texas, including the Houston area, and while I have absolute confidence in folks’ ability to respond to and recover from catastrophic events, I also know that this is going to be a very tough next little while for that part of the world. Hurricane Harvey will likely fade from the headlines, but the impact will linger past the news cycle, so don’t forget about these folks in the weeks to come. Thanks!

As I was casting about for a subject for this week’s missive, I happened upon a news item in Health Facilities Management This Week (HFMTW) that outlines some of the pending changes to the ambulatory care / office-based surgery medication management standards and the potential further impact of those changes on some of the EC performance elements in those environments. The changes are pretty much focused on emergency power as a function of being able to provide medication dispensing and refrigeration during emergencies.

Now, I have absolutely no issue with making provisions for the safe physical management of medications during power outages, etc.—it is a critical part of the delivery of safe and appropriate care to patients in any setting, and the more we can do to prepare for any outages, etc., the greater the likelihood of continuity of services if something does happen. What really caught my eye in the TJC blog entry cited in HFMTW (you can find the blog here) is something about half-way down the page titled “Emergency Back-Up Policies.”

At the outset of this discussion, I will tell you that, in most instances, I am no big fan of “policies.” In my mind, mostly what a policy represents is an opportunity to get into trouble for not following said policy. So, the question I wrestle with is whether we need to be mandated to have specific policies in order to appropriately manage our facilities, including preparing to respond to emergencies. For example, I am not entirely certain that a policy is going to make the difference in how well hospitals in the Houston area are responding to Hurricane Harvey (at the time of this writing, there are hospitals facing evacuation), though I would be happy to hear otherwise. I just have a hard time believing that having a policy is the answer to life’s problems; I am absolutely fine with requiring hospitals and other healthcare organizations to have a process in place to ensure appropriate management of medications during power outages, etc.—and I’m reasonably confident that those processes already exist in most, if not all, applicable environments.

I don’t know, maybe some folks do need to be told what to do, but I can’t help but think that those folks are fairly limited in number. And the blog even indicates that “there is no specific direction on the content of the policy”, but publishing this blog is going to force the issue during survey. I don’t know, when you look at the Conditions of Participation, etc., there are really very few policies that are required. It seems a bit odd to think that introducing new requirements for policy will somehow address some heretofore unresolved issue (or something). This one just doesn’t feel “right” to me…

If brevity is the soul of wit…

Hope everyone enjoyed a festive and (most importantly) safe Independence Day—with any luck, today (July 5) does not mark the end of summer (as some do say) so much as it marks the beginning of the end of spring (up here in the Northeast, spring was loath to depart, but it does seem that pre-autumn weather has finally made a commitment to spending some time in the northern hemisphere).

I was looking recently at past blog posts for a reference to the CMS stance on law enforcement interactions with patients as a function of restraints and patient rights—always a fun topic—and I noted that the posts used to be a mite briefer than tends to be the case of late. (You can be the judge of whether my decline in brevity has left me soulless or witless.) I absolutely recognize that there’s been a lot of stuff to cover over the past 18 months with the firestorms of compliance that swept the healthcare environment, which has (no doubt) promoted some of the “volume” of bloggery. But it has caused me to wonder whether I am consuming the compliance elephant in sufficiently small bites to be of use to you folks out there in the field. As near as I can tell, the purpose of this whole thing (as much as I enjoy having a place to pontificate) is to provide information and thoughts on what is happening at the moment to you, my faithful audience of safety folk. And (as near as I can tell) it never hurts to ask one’s audience whether this works for you—please feel free to give me an e-dope slap if you think the “Space” has gone intergalactic in a less-than-useful way. At any rate, I am going to experiment with smaller bites of information in the coming weeks so you’ll have more time for other things—perhaps outdoors…

As far as news goes, things are relatively quiet as we observe the anniversary of CMS’s adoption of the 2012 Life Safety Code. Hopefully you all have done your NFPA 99 risk assessments; polished off those door inspections and are speeding towards the completion of activities relating to initial compliance with the Emergency Preparedness Final Rule. Health Facilities Management This Week discussed some prepublication EC/LS standards relating to the testing of emergency lighting systems; inspection and testing of piped medical gas and vacuum systems; and updating pertinent NFPA code numbers. The pre-pub stuff is aimed at behavioral health care, laboratory, nursing care center, and office based surgery accreditation programs. You can find the details here: https://www.jointcommission.org/prepublication_standards_%E2%80%93_standards_revisions_to_environment_of_care_and_life_safety_chapters_related_to_life_safety_code_update_/

(I guess some of those links are about as brief as I am…)

Thanks, as always, for tuning in—I really appreciate having you all out there at the other end of the interweb…see you next week!

Plan be nimble, plan be quick

As we have discussed (pretty much ad nauseum) in this hallowed hall of electrons, there is likely to be a renewed (and I don’t mean renewed in a healthful way, this would be more like a subscription to a magazine that someone sent you as a prank) interest/scrutiny in how you and your organization are complying with all these lovely (and pesky, can’t forget pesky) new emergency management considerations. But there is one word of caution that I wanted to inject into the conversation, and while it probably doesn’t “need” to be said, I try not to leave any card unplayed when it comes to compliance activities.

Over the years (officially 16 of consulting—time flies!) I have found that sometimes (OK, maybe more frequently than sometimes), the prettiest plans, policies, procedures, etc. end up falling to the ground in demonic spasms because they did not accurately reflect the practice of the organization. The general mantra for this is “do the right thing, do what you say, say what you do,” but sometimes it’s tough to figure out exactly what constitutes “the right thing” (as opposed to “The Right Stuff,” natch). When it comes to emergency preparedness, response, recovery, etc. probably the single most important aspect of the plan (at least I think it’s an aspect—if you can think of a better descriptor, please sing out!) is that it is flexible enough to be able to react to minute-by-minute changes that are (frequently) the hallmark of catastrophic events. I think anyone who has worked in healthcare for any length of time has seen what happens to a rigid structure, be it policy, plan, expectations, buildings, flora and fauna—whatever, when things get to swirling around in intense fashion—things start to pull apart (figuratively and/or literally) and sustaining your response becomes that much more difficult.

So, as we “embrace” the challenges of the changes, I would encourage you to think about how you’ll maintain (and test during exercises) that flexibility of response that will give you enough wiggle room to weather the storms (of outrageous and other fabulous fortune). Exercise scenarios can push (or be pushed) in any number of directions (strangely, it is very much like real life)—make sure you take full advantage of those folks in the Command Center—if they’re not sweating—turn up the heat!

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.)

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 19.3.5.7. Originally, this section of the LSC referenced 19.3.5.1 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…

What a long strange trip it’s been…

And we’re still in the first month!

As I’ve been working with folks around the country since November 8, there’s been a lot of thought/concern/etc. relative to how the new administration is going to be impacting the healthcare world and the end of January may have offered us a taste of what’s to come with the issuance of an executive order to reduce regulatory influence/oversight of the healthcare industry by establishing a plan that requires federal agencies to remove two existing regulations for every one new regulation that they want to enact (for the healthcare take on this, please check out the Modern Healthcare article here. As with pretty much everything that’s been happening lately, there appear to be widely (and wildly) disparate interpretations on how this whole thing is going to manifest itself in the real world (assuming that what we are currently experiencing is, in fact, the real world), so for the moment I am adopting a wait and see attitude about the practical implications of these moves (and acquiring truckloads of antacid). I don’t know of too many healthcare organizations that are so fantastically endowed from a resource ($$$$) standpoint to be able to endure further reimbursement reductions, etc. In fact, once you start looking at the pool of available cash for capital expenditures (and for too many, it’s more of an almost-dried up puddle), it hardly seems worth the effort to plan on expenditures that are likely never to come to fruition. Quick aside: section 482.12(d) of the Conditions of Participation requires each participating organization to have an institutional plan and budget, including a capital expenditure plan for at least a three-year period, though for far too many 3 x 0 is still a big fat goose egg, but still you must plan.

I would like to think that there’s a way forward that will result in greater financial flexibility for hospitals—in spite of some late-2016 chatter about allowing failing hospitals to do just that—fail! There were some closures last year. Hope nothing that impacted you; I couldn’t find anything that specifically indicated how many hospitals might have closed in 2015, so I can’t tell if last year was an aberration or business as usual. I do know that it is very tough when safety and facilities have to compete with some of the sexier members of the technology family; particularly those that generate revenue—growl! I couldn’t tell you the last time I saw an ad saying how clean and comfortable a hospital was (I think it would be a nice change of pace). And while I absolutely recognize the importance of wait times, technology advances, etc., if the physical environment is not holding up its end of the equation, it doesn’t really make for the best patient experience and that’s kinda where things are headed. It’s the total patient experience that is the measure of a healthcare organization—you’ve got to do it all and you have to do it good.

So, I guess we’ll have to keep an eye on things and hope that some logic (in spite of recent tendencies) prevails.