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When you’ve done all you can do, what do you do?

As I start this, I’m thinking it will be kind of brief, but you and I have both been at the receiving end of my brevity, so we’ll see what happens.

As I ponder the various and sundry processes that make up an effective program for managing the physical environment, I cast my mind back to some instances in which self-identified corrective actions were not completed before our friends from the regulatory world parachuted out of their black helicopters to conduct accreditation surveys (I will freely admit that sometimes those black helicopters look exactly like commercial airliners—I’m not sure how the technology works, but it looks to be pretty seamless…) and the questions are inevitably raised as to (more or less) “How come it’s taking so long?”

There’s also the possibility (it may even be a likelihood, but I shy away from pronouncements based on a small data sample) that when there are findings relating to the physical environment, the general concept of the organization’s responsibility vs. just the Environment of Care (EC) folks sometimes flies out the window. Only you folks know what kind of culture you have in your organization and how much acknowledgement of shared responsibility is going to occur post-survey. But, in response to that “knowledge,” I would ask you to think carefully about how the EC program escalates issues that are difficult, if not impossible, to resolve within the EC program. Sometimes I get the sense that folks are less inclined to “air their dirty laundry” in the direction of organizational leadership, but (in my mind) one of the most important capabilities of any management process is knowing when to ask for help. Clearly, you don’t to “cry wolf” too often, but sometimes you just have to raise your paw…

By way of providing context, as this is generally the time of the annual evaluation (as opposed to the time of the season, though they may coexist), I would encourage you, in your “look back” over the year, to consider whether there were issues identified for which resolution has not been forthcoming. Part of this (OK, perhaps quite a lot of this) may have to do with all things COVID—if the effectiveness of our “product” is based on the juggling of (at times competing) priorities. Much as September 11, 2001 shifted the safety/preparedness world in an unanticipated direction, likewise COVID has pushed things around rather a lot. I suspect that everyone is going to have a COVID list of things that either didn’t get done or didn’t get done as well as one would like. Now is a good time (as we start to close on the birthday of the declared emergency) to quantify the impact of those “things.” I don’t know that it needs to be the sole focus of the annual evaluation process, but if you were to do so, I think you (and your organization) might be well-served for it.

As we rocket through January, I hope this finds you well and staying safe—we will get through this!

We know it will never be easy, but will it ever get easier?

It’s always interesting (and perhaps a bit thrilling) when an announcement comes flying over the transom from our friends in Chicago unveiling “modifications” to the Environment of Care (EC) survey process for healthcare occupancies (e.g., ASCs, hospitals, critical access hospitals), but this ended up being a little less breaking news and a little more of a good news/less-good news situation.

For quite some time now, I have mulled over the general thought that the EC interview session portion of the accreditation survey process really doesn’t yield a lot of findings. My sense of the session is that it’s more of an evaluation of group participation than anything else and it appears that others in a position to do something about it are in agreement, at least as a function of identifying survey vulnerabilities.

At any rate, The Joint Commission recently announced that the EC interview session is going away (good news) to provide more time for surveying in the field, including even more focus on EC stuff for the clinical surveyors during tracers (less-good news). I am certainly not worried about folks getting into “big” trouble during this extra hour of time, but it is another hour of wandering around that is likely to generate at least a few more “dings” in the physical environment.

As the Chicagoans continue to battle the forces of CMS in their pursuit of deemed status and reported shortfalls in the surveying of the physical environment, there is a certain inevitability at play here, so I guess we’ll have to wait and see. My immediate prediction is that there will be an increase in EC/Life Safety findings over the next little while (and perhaps a little while after that…).

Now, if they would only remove the requirements to maintain the safety, security, HazMat, fire, medical equipment, and utility systems management plans—I don’t think they generate very many findings and they really don’t serve any real operational purpose for healthcare organizations. Fire response plans and emergency response plans make sense to me, but the rest of it should be captured through the annual evaluation process. Is it really that big a “step” to go from evaluating effectiveness of the EC plans to evaluating the effectiveness of the EC programs in whole? Somehow I don’t think so…

Hope you are all well and staying safe!

The Fountains of Youth and Water Management Programs

As a follow to last week’s item about water management programs, I know a lot of folks are not using their drinking fountains (or as we know them in the Boston areas, bubblers—pronounced “bubblahs”—I was hoping to find an audio link, but if you doubt the veracity of that pronunciation, this sort of backs it up). How are you managing those as a function of your water management program?  I’ve seen a lot of these devices sitting idle (and not just in healthcare) and looks like they may be sitting that way for a while. Are you periodically having someone go around to operate them or have you modified other practices to keep an eye on these? Not quite sure why it took me so long to think about this—perhaps it’s the ever-growing drinking fountains covered in plastic. The other question I had in this regard is whether any of you are using this as an opportunity to remove them completely? Depending on the design of your building, these are sometimes placed in a way that reduces the clear width of an egress pathway or two. This might be the best opportunity evah to get rid of them.

Of course, the other dynamic that comes into play (though perhaps less in healthcare than in other industries) is the whole notion of how to manage facilities that are experiencing reduced utilization. Perhaps you have a business office or the equivalent, and you have folks working remotely or some other variation on the theme of forced vacancy. If that’s the case (or could become the case if COVID persists), then you might find the following information worth checking. Fortunately, resources continue to provide guidance in this regard and I don’t think there’s anyone among us that would wish to endure a breakout of waterborne pathogens in the midst of the current climate.

Check out the following resources:

Hope all is well and you folks are staying safe. See you next time!

Madman Across the Water Management Program

This week brings us something of an unexpected development in the management of the physical environment as our friends in Chicago are seeking comments on a proposed standards revision that more clearly indicates the required elements for water management programs. I don’t know that I was expecting this change, though I suppose it falls under the “one outbreak is one too many” category, nor was I expecting the solicitation of commentary from the field (I look forward to seeing the results of the comment period). It would seem that the proposed performance element is based very closely on the CDC recommendations, which clearly take into consideration the guidance from ASHRAE 188 Legionellosis: Risk Management for Building Water Systems and ASHRAE 12 Managing the Risk of Legionellosis Associated with Building Water Systems, so it doesn’t appear that we’re breaking new ground here.

Additionally, we know from past discussions that CMS has been pretty focused on the risks associated with building water systems (most recently, here, but there are others), so this may be a case of ensuring that everyone is paying attention to the areas of (presumably) greatest risk. And, as near as I can tell, none of the existing COVID-related blanket waivers exempts folks from managing the risks associated with building water systems, so hopefully you’ve been staying with your identified frequencies for testing, etc. And if you haven’t, you probably should be identifying a game plan for ensuring that those risks are being appropriately managed.

Clearly, there’s a little time before these “changes” go into effect (the comment period ends November 16, 2020), but since this is pretty much what CMS has been looking for since 2017 or so, you want to have a solid foundation of compliance moving forward. I recognize with everything else going on at the moment, this might not be a priority, but this is one of those concerns in which proactivity will keep you out of compliance jail.

Until next time, hope you are all well and staying safe!

Is it really transparency if they have to catch you first?

A few months ago, I was working with a facility that, as it turns out, was experiencing challenges with managing temperature and humidity in some of their procedural areas. When I got to the space in question during the building tour, I took particular note of some portable dehumidifiers in a couple of the rooms (one of which hadn’t been emptied in enough time that water was pooling on the floor). In both rooms, the humidity level indicated on the monitoring devices in the rooms was in the 70+ range—a value most surveyors would consider a tad “moist” for a procedural area (my first thought was how high would the humidity be if they weren’t running additional dehumidifiers). At any rate, I asked to see the logs and found enough irregularities to ask to see the perioperative department director. I should mention that this was day four of a four-day consulting gig.

In meeting with the director, I was told that they were embracing full transparency in informing me that they had been experiencing environmental issues in this space for quite some time. My immediate response (which, I will admit, was a bit catty) was: “Is it really transparency if you only tell me after I’ve identified the issue?” I know that sometimes folks like to leave things to see if I can find them (or see if I remember something from the last time I was there) and I think I have a pretty good track record of identifying the various and sundry gaps that can make a good survey go bad in a hurry. But this one really caught me sideways (and continues to) relative to the transparency thing. As I’ve maintained is the case for managing garden variety deficiencies; if folks have to go look for things to fix that have already been identified, it doesn’t strike me as particularly efficient, but that may just be me…

In other news, our friends from Chicago recently published a piece penned by Herman McKenzie, the director of the engineering group at The Joint Commission (TJC); in the piece, Mr. McKenzie provides some insight into what FAQs have been updated, as well as some common concerns in the physical environment. I don’t know if we’ll be seeing Mr. McKenzie as a featured contributor to Perspectives, but hopefully this represents the re-commencement of regular information regarding TJC’s expectations in the physical environment. Generally, September/October is round about the time we hear about the most frequently cited standards during the first half of the year, but I guess that schedule (like pretty much everything else) has been knocked on its keister. At any rate, this link will take you to what’s current (I hesitate to say “new”, just because) in the management of the environment.

Until next time, please be well and stay safe!

Why does it happen? Because it happens…

As to that thought/question (or question/thought), for those of you working through your utility systems risk assessments to ensure compliance with NFPA 99 Chapter 4: How are you accounting for components/equipment that aren’t necessarily being managed through your work order system? I’m think of systems like pharmacy hoods, nurse call systems, IT equipment, etc. Strictly speaking, those would fall under the categories found in NFPA 99, so are you reaching out for the info or are those stakeholders doing their own risk assessments? To be honest, I’m not sure how much of a compliance vulnerability this might be. I know it’s important to identify and appropriately manage your high-risk utility systems components and that’s certainly a potential area of scrutiny during a survey (particularly if they start moving towards a more extensive, virtual document review process). It can be a chore trying to account for everything that would be considered a utility system component, especially if you don’t have it in “your” inventory.

I know there have been instances in the past relative to the management of medical equipment in which primary stakeholders like imaging or lab services manage their own equipment inspection, testing, and maintenance without ever really bringing performance data, etc., up through the EOC committee function. Anything that is considered medical equipment, as would be the case with utility systems equipment, is part of the hospitalwide program and needs to be represented as such. There is no specific frequency for these “branches” of your programmatic “tree” to be reported at EOC, but you need to be able to trace the associated processes as a function of your EOC program.

Have a great week and stay safe. Perhaps autumn will bring a change in fortunes!

Identifying issues and finding solutions…

…versus identifying issues and pointing fingers.

I think we can all agree that (at least for the moment) our friends in the regulatory survey services world have misplaced the location of their customers and, as a result, have become significantly more punitive in administering the survey process. Of course, the accreditation survey team always tells organizations that, despite the umpty-ump number of findings, they are a quality organization and really, this was a good survey. I have yet to hear of any instances in which the survey team “supported” anything other than a positive vibe, but it seems that, in growing numbers, that vibe is not really translating past the point of the exit conference.

Now, I know that it is not the role of the accreditation organizations to do anything more than identify deficiencies (I have hopes that a more consultative approach will re-emerge before too long, but I am not holding my breath), but what I keep bumping into are instances in which the folks (internal and external to an organization) charged with preparing organizations for survey are almost as punitive in their administration of the survey prep process. The purpose of environmental rounding/touring, etc., is to help folks become as prepared as possible and to identify strategies for sustaining compliance. It is not about the “gotcha,” with follow-up paperwork. My personal philosophy (as a safety professional in general, but certainly as a consultant) is that my obligation to the process is to help get things going in the right direction, even to the point of cleaning up a spill or picking something up off the floor while touring. Certainly, I can (and do) identify lots of things that need attention, because there are always lots of things to find that need attention (this goes back to my “no perfect buildings” philosophy; probably too much philosophy for so early in the year, but so be it). But I go into this having suffered at the hands of consultants (and others) who are not as interested in helping work through an issue to achieve some sort of sustainable solution.

As an example, I recently heard about an instance in which the environment of care rounding team had identified a resolution to a pesky issue (in this case, ensuring that specimen containers were appropriately labeled) but did not share that resolution with the entire organization. So last time, a “sticky” label was affixed to the container, but the label didn’t stick so well; this “failure mode” was communicated to the folks in infection control, but there was no immediate follow-up. So, next rounding activity, a specimen container to which a “sticky” label had been affixed was, in the local parlance (not really), nekkid in terms of labeling. Well, after the labeling issue had been cited, it was “revealed” that, after some consideration (may have been careful consideration, but less careful in the communication), it was determined that the containers would be stenciled in more permanent fashion. Interesting thing, the “finding” still required response, etc. even though the “finding” was the result in a communications misfire.

At any rate, as I think I’ve noted here before, there’s no regulatory statute that requires us to shoot ourselves in the foot, or, indeed, to engage in friendly fire. To my way of thinking, internally punitive surveying is not helpful and since we know the “real thing” isn’t particularly helpful (to healthcare organizations, at any rate), doesn’t it make more sense to work together towards sustainable compliance?

Quick closing question: While I was having some lab work done today, I noticed that the emergency eyewash station in the sink area was covered with a clear plastic bag. Has anyone out there in blogland encountered this or are practicing it? I’m thinking that this adds a step to activation of the eyewash station, but perhaps there’s a risk assessment that supports it. Just asking for a friend…

Don’t get soaked by your water management program!

I don’t know about you, but lately I’ve been finding the most interesting stuff being published in Perspectives are the articles entitled “Consistent Interpretation” because I am fascinated by the data they are collecting that drives taking particular note of the standard or performance element being featured. For example, the January 2020 issue covers the intricacies of managing the risks associated with waterborne pathogens, a topic that I’ve been keeping an eye on if only because of the attentions paid to that topic by our friends at CMS (if you’ve lost track of where they are in the fray, feel free to make the jump—but don’t forget to come back!). I figure there are just enough peculiarities involved for this to wreak some havoc during accreditation surveys, and while there are ways for survey findings to be generated, it would appear (based on the just under 4% citation rate during the first half of 2019) that you folks out there in the field are making pretty good headway.

So, where things can go awry include: Not having a water management plan to deal with waterborne pathogen risks (not sure how someone would have missed that, but perhaps it was a question of a slower than normal implementation track); failing to include a new piece of equipment (for instance, a brand new cooling tower) in the program (I should think the time for risk assessment and inclusion is during the commissioning of new equipment); failing to maintain the water in the system in accordance with the levels called for in the water management plan; failing to document scheduled testing and monitoring; and failing to establish acceptable ranges and/or control measures to be taken when levels are out of range.

It would seem that decorative water features, ice machines, and water dispensers were in the mix as well, including issues with equipment not being maintained in accordance with the manufacturers’ instructions for use, but in looking at all the different ways water management concerns could be cited, I suspect a lot of the cited conditions (you can find more specifics in the January Perspectives) were not widely observed.

That said, since a lot of the nuts and bolts implementation of water management programs may be accomplished by “others,” I think that going forward, the surveyors will be especially attentive to reviewing your water management plan and any deliverables from testing and monitoring activities. There are a lot of moving parts in this endeavor; best to be ahead of the curve and keep a close eye on those reports.

I heard the bells! Or did I see three ships?

Yet another mixed bag of festive goodies for you this week: I know you’ve all been good (our profession doesn’t really leave a lot of room for anything other than good, so Santa Mac doesn’t even need to make a list and check it once or twice).

First up, a set of HazMat-related items for your consideration:

I’m not sure how many of you folks are still managing ethylene oxide sterilization systems, but it does appear that there’s a movement afoot (or a continuation of an existing movement) to really pare back on the use of ethylene oxide. At present, the proposed rule seems to be aimed at folks using larger quantities of ethylene oxide (more than 1 ton of ethylene oxide per year), but I suspect that the next pass may well start to push down through the smaller-scale users. To that end, the information on the EPA website is probably worth looking at to determine where your current processes and equipment might fall on that continuum. I don’t know any safety professional who is keen to have the stuff in their “house”, but there remains reusable medical equipment that can only be appropriately sterilized (per manufacturer Instructions For Use) with ethylene oxide, so hopefully things will catch up and we can move past this risk.

Next up, an interesting article on increasing climate friendliness in your surgical procedure rooms. I guess anything that can reduce energy costs is worth investigating, though it may work better for those of you planning renovations or new construction of surgical procedure rooms. At any rate, I find that it’s always kind of interesting to see what’s working for folks (recognizing the importance of knowing what doesn’t work as well), so a tale from the land of the New English.

Extending the renovation/construction thought, Becker’s Hospital Review recently published an article discussing healthcare facility construction trends to watch in 2020. I suspect that Becker’s is something that might be on the reading list of the folks in the C-Suite, so it might be worth working their take on construction into your pleas for resources. It certainly can’t hurt.

Finally (I haven’t decided if I’m going to have anything for you next week—I’d rather you enjoy your families), I wanted to share a link to a blog by Peter Martin of Gosselin-Martin Associates that shares some quotes and insights gathered over the last year (and a fitting jumping off point for the (hopefully) next roaring ’20s). If you’re not familiar with Peter and Gosselin-Martin, I would encourage you to do a little checking of the additional blog entries as well as the services they provide. I’ve corresponded fairly often with Peter over the years and I’ve found him to be a consummate professional and a very thoughtful guy—an excellent resource to be sure.

On that note, I will extend my best wishes to each and every one of you for a joyous holiday and that “roaring” start to the ’20s mentioned earlier. Be safe (not that you need me to tell you that) and I’ll be back in almost no time flat!

It appears that everything isn’t meant to be OK…

You may recall a few weeks back we were discussing some recent survey findings relative to the placement of eyewash stations once one has determined that one needs an eyewash station (or stations). At the time, my dream was to clarify those findings and have them vanish into the ether (which is pretty much where they belong). But alas, that dream crashed upon the rocks of an overreach—can’t say for sure if this signals a sea change or is based on a reluctance to overturn a judgement call in the field. The ruling from the home office read thusly (but not justly): “The organization must do a risk assessment to determine if substances that may be in the sink would not splash onto the person using the eyewash station and inadvertently be contaminated.”

And so, I guess we add an additional imponderable to the equation: How do we install the eyewash station close enough to the area of greatest risk without placing the eyewash in a location that could be adjudged to be too close to the risk area? I suppose the ultimate goal would be to try to remove the hazard entirely, but with all the focus on disinfection and the likelihood that whatever disinfectant in use is going to be firmly in the high-risk zone, that seems unlikely to win favor during survey. Is it possible to “sell” engineering controls to a surveyor that is looking to find things to cite? I think we can all agree that the use of PPE and other forms of engineering controls are probably never going to be the interventions we would hope for them to be, but it is often so difficult to protect folks from themselves.

That said, I suppose it wouldn’t be the worst idea to do a little global evaluation of your eyewash station locations (much like a conjunction function) and add yet another risk assessment to the mix. If you’ve got a survey coming up in the near future, it may save you some aggravation.