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You’ve got to get in to get out: New safety adventures in ambulatory care

Hoping that this is more treat than trick, I had cause (albeit minimal) to reflect on what I see as a reasonably significant increase in EC findings being generated in the ambulatory care world. If we accept (and I certainly do) that one of the primary drivers to the survey process is the generation of findings, then it makes all the sense in the world to start “pushing” the survey process in those environments over which we have less control/influence/oversight. I talked a little bit about tools for the ambulatory setting back in January of this year (continuing our program of a self-referential October), and the good folks at ECRI are offering what they are terming a “deep dive” into safe ambulatory care (if you scroll about 1/3 of the way down the ECRI homepage, you’ll find the link to download the report for the low purchase price of some contact information).

The report breaks things down into four key areas: Diagnostic testing, medication safety, falls, and, safety & security. While I recognize the latter two may be of primary interest to this audience, I would encourage you to check out the information relating to diagnostic testing and medication safety. Everything in healthcare (and pretty much any and everywhere else) “exists” in the physical environment (thinking of concentric circles with the patient at the center and the physical environment being the outermost circle), so the interactions between “disciplines” can generate a lot of opportunities when it comes to the practical application of safety and the environment. Taking that with the (at times infuriating) “grayness” of what is required from a regulatory standpoint, it really prompts a level of vigilance that is unlikely to subside any time soon.

To close things out for this week/month, another resource that you might find of interest is a podcast dealing with all things water treatment; you’ve heard (metaphorically speaking) me speak of Matt Freije and the good work he’s spearheading at hcInfo.com and he appears on an episode of the ScalingUp podcast. I found it pretty interesting, but that may just be me. That said, I think the focus and attentions paid to water management plans during survey activities is going to continue to rise and I can see a future in which funky water values will drive Condition-level survey results. Now is the time to start educating ourselves to what it all means and I think this podcast is a good start for folks. Check it out!

And a happy and safe All Hallows Eve to you all…

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…

Ground Control to Major Compliance: EOC, baby!

As September brings around the unwinding of summah, it also brings around The Joint Commission’s annual state of compliance sessions in locations across the country, better known as Executive Briefings. And, one of the cornerstone communications resulting from the Briefings is the current state of compliance as a function of which standards have proved to be most problematic from an individual findings standpoint.

Yet again (with one exception, more on that in a moment), EOC/Life Safety standards stand astride the Top 10 list like some mythical colossus (the Colossus of Chicago?), spreading fear in the hearts of all that behold its countenance (OK, maybe not so much fear as a nasty case of reflux…).

You can find the Top 5 most frequently cited standards across the various accreditation programs; you’ll have to check out the September issue of Perspectives for the bigger compliance picture, which I would encourage you to do.

At any rate, what this tells us is that (for the most part) the singular compliance items that are most likely to occur (for example, we’ve already discussed the loaded sprinkler head hiding somewhere in your facility—way back in April) are still the ones they are most likely to find. According to the data, of the 688 hospitals surveyed in the first six months of 2019, 91% of the hospitals surveyed (626 hospitals) were cited for issues with sprinkler/extinguishment equipment—and that, my friends, is a lot of sprinkler loading. I won’t bore you with the details (I think everyone recognizes where the likely imperfections “live” in any organization), but (at least to me) it still looks like the survey process works best as a means of generating findings, no matter how inconsequential they might be in relation to the general safety of any organization. I have no doubt that somewhere in the mix of the Top 10 list, there are safety issues of significance (that goes back to the “no perfect buildings” concept), particularly in older facilities in which mechanical systems, etc. are reaching the end of their service life—I always admired Disney for establishing a replacement schedule that resulted in implementation before they had to. It’s like buying a new car and having the old one still on the road: Are you going to replace the engine, knowing that the floor is going to rust through (and yes, I know that some of you would, but I mean in general)? But if the car dies on the way to the dealer to pick up the new one, you’re not going to do anything but tow it to the junkyard. But we can’t do that with hospitals and it’s usually such a battle to get funding/approval for funding/etc. that you can get “stuck” piecing something together in order to keep caring for your patients. It sure as heck is not an ideal situation, but it can (and does) happen. Maintaining the care environment is a thankless, unforgiving, and relentless pursuit—therein is a lot of satisfaction, but also lots of antacid…

One interesting shift (and I think we’ve been wondering when it would happen) is the appearance of a second infection control (IC) standard, which deals with implementation of an organization’s IC plan. I personally have always counted the IC findings relating to the storage, disinfection, etc. of equipment as being an EOC standard in all but name, but I think we may (finally) be seeing the shift to how appropriately organizations are managing infection risks. According to Perspectives, 64% of the hospitals surveyed in the first six months of 2019 were cited for issues relating to implementation, but not sure how the details are skewing. Certainly, to at least some degree, implementation is “walking the talk,” so it may relate to the effectiveness of rounding, etc. Or, it may relate to practice observed at point-of-care/point-of-service. I think we can agree that nosocomial infections are something to avoid and perhaps this is where that focus begins—but it all happens (or doesn’t) in the environment, so don’t think for an instant that findings in the environment/Life Safety will go gentle into that good night. I think we’re here for the long haul…

In the realm of possibility: More listening, less posturing!

An interesting anomaly that I encounter periodically is the time-honored “first opinion,” particularly when it exists outside of a second opinion. All too often I hear clients tell me that  “X told us we have to do something a particular way,” often with a wake of disruption because whatever strategy, etc., that was identified didn’t take into full consideration elements of organizational culture, resources, practice, etc. But what I don’t understand is when I look at Environment of Care committee minutes, etc., I don’t see any discussion about whether the recommendation(s) were useful, germane, etc., to appropriately manage whatever the condition might be. I think it is very important to use any survey activity (regulatory, consultative) as an opportunity to identify best practices and ensure that policy and practice are in alignment. That way, you’ll have some experience in being able to sort out what is truly required from a regulatory perspective and what is solely in the land of surveyor interpretation.

In all the years I’ve been involved in healthcare safety, the one defining truth I’ve found is that compliance is rarely a black and white endeavor. And while I absolutely understand that managing anything as a “black and white” is a whole lot easier to police, from an operational standpoint, absolutes (either positive or negative) are not always easily, or practically, implemented.

The other dynamic is (and this is very much the case with response to regulatory surveys) that often we “over-promise,” particularly in terms of frequency of monitoring. Don’t set yourself up for failure, for example, by indicating in a corrective action plan that there will be weekly inspections of electrical panels for inappropriately configured circuit breakers. Unless you know that folks are mucking around in the panels on a frequent basis, is there really a compelling reason to embrace an inspection frequency that is not a regulatory requirement? I would tend to think: Not so much.

As we have established beyond any reasonable doubt, there will always (always, always, always) be imperfections in the environment, but don’t go crazy trying to chase all these things yourself (or have your staff do the chasing). As I’ve said any number of times (before any number of audiences), all this stuff “lives” at the point of care/point of service and if you can’t get the folks that “live” in those areas to help feed the gaping maw of work order system, you are managing a process that is not as efficient as it might otherwise be. With the ongoing impact of the “do more with less” mantra, it’s not so much about working smarter (though there is certainly an element of that), but about working collaboratively. Everyone is caregiver—everyone is a steward of the environment—and by judicious application of only what is actually required by code and/or regulation, you can start to break down the barriers between mutually assured noncompliance and an environment that appropriately supports care. Compliance is the byproduct of consistently doing the right thing.

He held his head in his hands: Outpatient/Offsite Vulnerabilities

Being something of a quiet week on the compliance front (as we embrace the “dog days” of summer—and spring’s got 10 or so days to go), I wanted to use a recent Joint Commission announcement relative to Environment of Care standards relating to fluoroscopy as they apply to outpatient/office-based surgery practices (which seems rather more logical than not, particularly when one reflects on the Conditions of Participation requirements relating to the management of imaging equipment). You can find the particulars here, but I don’t think that there’s anything that’s going to come as a surprise. To my mind, why would the expectations be any different based on where the equipment “lives”? Just as there must be continuity of care, there must also be continuity of compliance.

Now one could certainly disagree as to how much of a sea change this represents relative to the survey process, but (and I’m going out on a limb here, but it’s a very, very stout one) I think the next significant survey “beachhead” (mixing all sort of metaphors today) is going to be all those pesky little physician practices and clinics and such that dot the landscape and are covered by the “umbrella” of hospital operations (you know, offsite locations that have become “departments of the hospital”). If we accept the premise that the primary goal of the survey process is to generate as many findings as possible (and I accept that premise—the evidence doesn’t really point to much else), then the likelihood of the regulatory folks looking for areas with greater levels of vulnerability seems, again, rather more logical than not.

At any rate, my best advice to those of you with these types of sites is to really kick the tires when you’re rounding. As you are no doubt aware, there can be a lot of resistance when compliance comes to the hinterlands (think about how much angst fire drills can generate!), but the stakes for non-compliance have never been greater and, for the record, one can never be too safe…or too compliant!

Dry your eyes: Keeping ahead of the water(s)

One of the more ubiquitous findings in my travels are those relating to water infiltration/intrusion: peeling paint, stained ceiling tiles, pesky growths, etc.

And, not everybody gets to put on a new roof as often as they would like, so it ends up becoming a function of maintaining and managing your building in such a way as to minimize where water can impact your organization’s operations—from routine hassles to indoor air quality concerns. Michael Crandall, CIH, penned an article that I think might be of interest/use—you can check it out here.

Remember: In the confrontation between water and the rock, water always wins. Not through strength, but through persistence.

As a final note for this week, it might be worth your while to check out the June issue of Perspectives, which includes a missive (barely a missive, perhaps mini-missive) relating to the use of power strips (aka relocatable power taps—or the Notorious RTPs). Just over 20% of hospitals surveyed in 2018 were cited for issues with power strips, primarily: not having the appropriate devices in patient care areas; and power strips attached to walls in OR procedure rooms. As you may recall, CMS issued a categorical waiver, way back when, describing the requirements and, strangely enough, the attachment of power strips to walls in ORs is not considered a compliant approach. The thing that concerns me about that is a question of who did the install of the strips in the OR. I “get” that sometimes these things will migrate from wherever, by the hands of those who always remain nameless. But wall-mounted installations “smells” like the work of someone who should know better.

Let’s begin again, begin the begin: CMS ligature risks codified!

While I have little doubt that we will yet again revisit the management of ligature risks and behavioral health patients, it would seem that chapter and verse are getting towards stone tablet form—but you have a chance to influence the future state. I suspect we will also be looking back to determine how much influence the field has on the final, final or whether the party line from Chicago holds sway (kind of looks like that at the moment, but there is still time):

  • Back on April 19 (and I do apologize for not picking up on this sooner—I need to get a better strategy for monitoring all these goings-on), CMS issued a draft clarification of the interpretive guidelines relating to ligature risk (you can find the skinny here). All things being equal, I suppose the “newest” thing is the formal introduction of the Ligature Risk Extension Request (LRER—just what we needed, another acronym), which outlines a process for correction of ligature risks that will take longer than the official 60-day turnaround time for the correction of deficiencies. One thing is very clear (well, maybe a couple of things): State agencies and/or accreditation organizations are not allowed to grant LRERs. They can, and in most instances, will act as intermediary between the organization seeking the extension and CMS, and will (basically) advocate for approval based on their analysis of the issues. This is not a Life Safety Code® waiver as ligature risks are not a compliance deficiency relative to life safety requirements. From the process outlined, it does appear that this is to be a reasonable process, (potentially) making allowances for obtaining approval of the governing body, engaging in competitive bidding, applying for funding, obtaining permits for physical changes, and lack of or delays in obtaining products and supplies needed for corrective actions. Needless to say, with the invocation of the LRER, there will be
    • Mitigation strategies to implement
    • Progress reporting to be done
    • A re-survey to verify that the deficiencies have indeed been corrected by the state agency or accreditation organization
  • As has been the case pretty much from the get-go, there are two assessment processes that need to dovetail (or perhaps they are concentric circles): An assessment of the environment and the assessment of patients to determine the level of risk for suicidal behaviors. I do believe that eventually we will be left with the latter upon which to focus, but I suppose there will need to be an ongoing due diligence relative to monitoring the environment. Ultimately, it seems to come down to striking the balance between seeing every aspect of the environment as a big hairy monster as opposed to an element in the environment that can be managed by appropriate means. At the very least, I am hoping that the survey focus returns to general patient care and infection control, with perhaps a side of medication management—I think that’s where the meaningful improvements are hiding (in plain sight).

As a final note, we do have until June 6, 2019 to weigh in on the proposed changes, so I would suggest you gather together a little working group, and if the spirit moves you, weigh right in. The data supports this being a whole bunch of ado about very little (approaching a whole bunch of doodoo), so the sooner we can refocus on the “real” challenges, the better.

 

Like the dust that settles all around me: I got those low-down TJC FAQ blues

I don’t know if there’s anything to be inferred by the fact that the latest updates on the ligature resistance front are “buried” on p. 8 of the May 2019 Perspectives (after an onslaught of what I characterize as Joint Commission advertisements), but it would be nice to think that perhaps folks are going to be allowed to move on at their own “pace” as a function of risk assessments, abatement and mitigation strategies and monitoring for gaps in safety, but I guess we shall see what we shall see.

At any rate, the May Perspectives (on p. 8—imagine that!) provides two topics, one of which, video monitoring we discussed a few weeks back (I guess they like to repurpose content as much as anyone…) and a clarification on the (admittedly somewhat awkwardly worded) requirement that self-closing and self-locking (both, not one or the other) doors are required for the separation of areas required to be ligature resistant and those that are not, with the intent being to eliminate reliance on staff to close and lock those doors to prevent patient harm. The FAQ also prohibits the use of hold-open devices of any kind on these doors, so do keep that in mind. This applies to “staff controlled” areas on a behavioral health unit, like med rooms, utility rooms, consult rooms, etc. This is all based on Recommendation #1 published in the November 2017 Perspectives and the guidance that patient rooms, patient bathrooms, corridors, and common patient areas are to be ligature resistant. If this is news to you (I don’t know that we’ve discussed this particular piece of the puzzle), I can’t say that I am surprised as it really didn’t stand out at the time and really required too much in the way of cogitation to figure out what they were getting at, particularly the descriptor (“Nursing stations with an unobstructed view (so that a patient attempt at self-harm at the nursing station would be easily seen and interrupted) and areas behind self-closing/self-locking doors do not need to be ligature-resistant and will not be cited for ligature risks.”) as it was probably a little too all-inclusive. I think I would have separated them into two bullet points:

  • Nursing stations with an unobstructed view
  • Areas behind self-closing/self-locking doors

But hey, as long as we get there in the end, right? Yeah, sure, fine…

In other news, ASHRAE is in the public comment process relative to proposed changes to ASHRAE 170 Standard for Ventilation of Health Care Facilities (you can see the proposed draft here). Given that NFPA 99 defers to ASHRAE on the ventilation front, I can’t help but think that this is going to continue to be a cornerstone compliance document during survey activities. I don’t know that I noted anything particularly egregious, etc., in the proposed update, but I always try to encourage the folks in the field to review and weigh in when these things are open for comment. Before we got to ligature-resistant considerations, the management of procedural environments as it relates to temperature, humidity, air pressure relationships, etc. was the hot-button topic, so any changes might have a similar impact on the industry. Unfortunately, I just got wind of this last week and the comment period ends May 6, so act fast!

Ticking away the moments that make up a dull day: EOC orientation and ongoing education

Going to touch on a couple of things this week. First up? Ed-yoo-ma-cation!

A week or so back, I received an email encouraging me to list what educational competencies are most important relative to preparing for the survey process. Off the top of my head, the list (in no particular order) goes a little something like this (and I will stipulate that competency is the key focal point for these):

  • Fire response, including (and perhaps most importantly) department-level protocols
  • Emergency response, including how to summon assistance in an emergency
  • How to report an Environment of Care (EOC) problem or condition (I like to include “How to recognize an EOC problem or condition” as a subset of this one)
  • How to manage their own care environment (this is a bit of a stretch as it is not specifically mandated by code or regulation, but I will characterize this as something of a distillation of the general duty clause, kind of…)

After that, things get kind of gray, but if you look really closely at that last one, it comes down to everyone being able to demonstrate competency relative to what skills and knowledge are required for them to do their job appropriately (safely, timely, etc.). From knowing how long disinfectant has to keep a surface wet to appropriately disinfect whatever surface you’re disinfecting (say that 10 times fast!) to making sure that folks who are charged with providing on-to-one safety observation of at-risk patients are conversant with what to look for, how to summon assistance, when it is appropriate to intervene, etc. There does appear to be a growing focus on the processes involved in ensuring that folks are competent to administer their job responsibilities. While the list above gives you a sense of the “umbrella” under which organizationwide orientation provides a framework, the devil (as they say ) is in the details—and those details “live” at the department level.

To that end, it may be useful (if you are not already a participant in the department-level safety orientation) to “audit” some of the department programs to see if what folks are receiving matches up with what your expectations are of the entire orientation process. Most of the folks I’ve chatted with over time have found their “time” at orientation to be shrinking almost as quickly as those new pants in a hot water wash—it may be time to leverage some other opportunities to get the safety word out.

The other item for discussion relates to survey findings and the question of how much folks “expand” their surveillance in response to a survey finding. Minimally, you’re on the hook for resolving whatever the specific finding might be and now, with the submission of the corrective action plans to The Joint Commission (or whomever), there’s that whole concept of how you’re going to sustain the processes necessary to maintain compliance. Most of the action plans I’ve seen have a good framework for long-term monitoring, etc., but what about between right now and, say, next week? Or, even, next month? There seems to be a lot of follow-up surveying going on in the healthcare world and how far do you go to prepare for that potential “sooner than later” next visit. As with pretty much all of this stuff, there is very little in the way of guidance, but I was wondering if we could dig up some “best practices” in the name of (perhaps) introducing some non-EOC stuff into next year’s top 10 lists…just sayin’.

Have a most delightful week!

I’d like to know, can you tell me, please don’t tell me: Behavioral health and egress

In response to last week’s modified Top 10 list (there’s been a request for another list regarding point-of-care/point-of-service staff knowledge of EC stuff—coming soon to a blog near you…), I received a question from the Lone Star state that I wanted to chat about with the group at large (I’m never quite sure if folks go back and revisit past questions and I thought this one might generate some comments from folks in general).

The question comes from the folks at a large hospital in east Texas who are in the process of designating a behavioral health “safe room” adjacent to their ER, where they’ll be holding patients for evaluation and eventual transportation to a local behavioral health hospital. The room in question is approximately 900 square feet (30 x 30) and the question raised relates to installing a second door in the space for use in the event of an emergency. The problem (or at least the stated problem, a little more pondering in a moment) is that this second egress door would lead into a major egress corridor. The question resulting from this “problem” is whether, due to the nature of what’s going on in the behavioral health room, having the door swing out into the egress route would be permitted, based on a risk assessment, etc.

First off (and you could certainly look at this as a bit of shameless self-promotion), it would be much more effective to be walking/talking this through in the present physical space, etc., but since I’m not scheduled to visit east Texas any time soon, I’m going to have to work this from afar. To that end, I have one question for the general audience: Do any of you have a behavioral health safe room with more than one “portal”? Since I saw this question, I’ve been racking my brain to recall an instance in which there was a room (as opposed to a designated space within an ER, or indeed, a behavioral health ER) that had a second egress door (and if I’ve visited your “house” and you have a two-door arrangement and I have somehow forgotten, please let me know). Even before I get to the door swinging into the egress corridor (and I think there are ways of being able to do this, but more on that in a moment—though it will require some homework), I start thinking about how you would secure that second door in such a way as to appropriately limit escape by the patient occupant and still provide sufficient access to staff removing themselves from a dangerous situation. Talk about a tightrope. But then I’m thinking, is there a way to configure the space that reduces the potential for a staff person to become “trapped” even with only one way out? I’m intuiting that the request for the second door is based on an actual occurrence in which an entrapment occurred, but I keep coming up against the “reality” that I can’t think of a behavioral health room with multiple ways out and that staff education of appropriate techniques for dealing with patients in a “confined” space would be the way to go.

As to the second egress door itself, while there are instances in which doors do swing out into an egress corridor, I think probably the best way forward, once you have completed the risk assessment, is to seek out the opinion of the authority having jurisdiction (AHJ), which in this instance would be the Texas Department of Health. Having had some experience with CMS surveys conducted by the state in that part of the world (and, truthfully, in most parts of the world) is to embark upon a field modification without providing the AHJ with an opportunity to review the proposed change(s). I think the primary reason that I would encourage this route is that this appears to be a somewhat unusual (if not quite rare, though it may be) arrangement; I understand the safety implications of the second door, but I also understand the implications such an arrangement can have on egress for adjacent occupants and I am not convinced that you’ll get carte blanche from the regulatory folks solely on the basis of a risk assessment in hand.

That said, I suppose you could also investigate a modification to the space that creates enough of an alcove on the egress side of the space to provide room for door swing, though that would certainly reduce the number of folks you could safely manage in the space. It may be that you folks are on the cutting edge of healthcare design, but sometimes the cutting edge “cuts” in the wrong direction. Given the attention being paid to the physical environment at the moment, it is unlikely that such a modification would escape notice (particularly with CMS).

The pendulum may swing back at some point, but I don’t see it happening any time soon—there are so many potential findings that they’d be hard-pressed to turn away. It’s very much like finding buried treasure and then leaving some for somebody else to find—it is not in line with human nature to walk away while there are still riches to be had.