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Keeping an eye on things: Managing behavioral health patients

What, again?!?

Recently, our friends in Chicago added a new FAQ to the canon, this time reflecting on the use of video monitoring/electronic sitters for patients at high risk for suicide (you can find the details here). For those of you paying attention over the years—and I think that’s everybody within the sound of my “voice”—the situational requirements are based on a clear invocation of the “it depends” metric. I think it is pretty clear (and pretty much the standard “problem” relative to the management of behavioral health patients at serious risk for suicide) that providing sufficient flexibility of staffing to be able to provide 1:1 observation of these patients is where folks are looking for that flexibility in technological monitoring and the FAQ pretty much puts a big stop on that front. I think the quote that comes into focus for this aspect is, “The use of video monitoring or ‘electronic-sitters’ would not be acceptable in this situation because staff would not be immediately available to intervene.” So, as a general practice, a 1:1 observation means that somebody (a human somebody) is “immediately available to intervene,” which means all the time, at any time.

At this point in the discussion, I think the important piece of this is (and is likely to remain so) the clinical assessment of the patient, inclusive of the identification of the risk level for suicide. I don’t think that the “reality” of having to deal with way more of these patients than we would prefer is going to change any time soon, and with it, the complete unpredictability of that patient volume as a function of staffing (full moons notwithstanding).

The FAQ goes on to discuss the use of video monitoring in those instances in which it is not safe for staff to be physically located in the patient’s room, but the use of video monitoring has to result in the same level of observation, immediacy of response, etc. It also indicates that video monitoring for patients that are not at high risk for suicide is at the discretion of the organization, indicating that there are no “leading practices” in this regard. I guess that means that you’re really going to have to make your own way if you chose the video monitoring route, which should include (as also noted in the FAQ) provisions for reassessment of the patient(s). Interesting times, my friends, interesting times…

As a final (and almost completely unrelated) note, I wanted to bring to your attention some discussion over at the Motor & Generator Institute (MGI) relating to recent CMS guidance regarding expected temperatures in the care environment during normal power outages and how, if you have a long-term care facility in your mix, a risk assessment might not be enough. You can find the details here and the folks at MGI are encouraging feedback, so I think it might be worth checking out and weighing in.

 

It’s been a long time: Revisiting an EOC perennial

Setting the wayback machine for the dark ages of safety (well, 2011 or so), we come to the last time we covered the monitoring of temperature and/or humidity in surgical spaces, etc. (if you want to revisit those halcyon days, you can head here). The funny thing about this most ancient of history is that, since then, while there have been changes in applicable codes and references, the “new” stuff comes up a little short when it comes to providing guidance relating to monitoring temperature and humidity, particularly as a function of frequency (I suppose we could call it the frequency function if we were being excessively alliterative). The baseline response (catty though it may be) is that you should be monitoring conditions on as frequent a basis as is required to ensure appropriate conditions, given due consideration of the systems you have in place, any manufacturers’ recommendations (which are also not particularly helpful in determining monitoring frequencies), and regulatory guidance (ASHRAE 170; state mechanical code) as applicable.

Ultimately, this all comes down (back?) to the requirements as outlined in the Conditions of Participation, which gives us:

  • 482.41(c)(4) – There must be proper ventilation, light, and temperature controls in pharmaceutical, food preparation, and other appropriate areas.

So, you might well ask, what are those “other appropriate areas”? For that information, we need to head over to the State Operations Manual/Interpretive Guidelines, which is where the skeleton of the Conditions of Participation is fleshed out into the survey process.  And what do we find there? Take a look:

Interpretive Guidelines §482.41(c)(4) – There must be proper ventilation in at least the following areas:

  • Areas using ethylene oxide, nitrous oxide, glutaraldehydes, xylene, pentamidine, or other potentially hazardous substances;
  • Locations where oxygen is transferred from one container to another;
  • Isolation rooms and reverse isolation rooms (both must be in compliance with Federal and State laws, regulations, and guidelines such as OSHA, CDC, NIH, etc.);
  • Pharmaceutical preparation areas (hoods, cabinets, etc.);
  • Laboratory locations; and
  • Anesthetizing locations. According to NFPA 99, anesthetizing locations are “any area of a facility that has been designated to be used for the administration of nonflammable inhalation anesthetic agents in the course of examination or treatment, including the use of such agents for relative analgesia.” NFPA 99 defines relative analgesia as “A state of sedation and partial block of pain perception produced in a patient by the inhalation of concentrations of nitrous oxide insufficient to produce loss of consciousness (conscious sedation).” (Note that this definition is applicable only for Life Safety Code® purposes and does not supersede other guidance we have issued for other purposes concerning anesthesia and analgesia.)

Interesting to note that the list here does not quite match up with the totality of issues for which The Joint Commission is citing folks (clean and soiled utility rooms being first and foremost, though I know that it is merely an extrapolation of the ASHRAE 170 requirements). Also interesting to note that, sterile supply and processing is not specifically mentioned, but (again), I think we can see where the importance of maintaining those spaces drives out of ASHRAE 170.

But what’s the endgame when it comes down to the survey process? The general unhelpfulness of the answer will not surprise you:

  • Review monitoring records for temperature to ensure that appropriate levels are maintained
  • Review humidity maintenance records for anesthetizing locations to ensure, if monitoring determined humidity levels were not within acceptable parameters, that corrective actions were performed in a timely manner to achieve acceptable levels

So (still!) if you follow the temperature and humidity rabbit all the way back to the Interpretive Guidelines, we see that the surveyors are instructed to ask to see “records,” so it all comes down to what you can produce in terms of a deliverable that reflects that temperature and humidity levels are appropriate/acceptable and levels that were not within acceptable parameters (which they do not define, so you better have a sufficiently flexible definition) were dealt with in a “timely manner” (again, not defined, so it’s up to you, based on your risk assessment).

As a closing thought on this (for now), apparently there are some folks that have determined that they don’t have to monitor both elements (temperature and/or humidity) and if there is nothing else that you derive from this week’s missive, it is this: You gotta do both! You can determine the frequency (though I would recommend at least daily—if you recall, the question that started this conversation in 2011 was whether quarterly monitoring was sufficient), but you clearly want to be able to use performance data to make that determination (and from whence comes that data—regular monitoring). You can determine what is acceptable/appropriate (based on utilization, types of procedures, preference of surgical staff, etc.); you can determine what is a timely timeframe for corrective action (Timely Timeframe—that sounds like a name Stan Lee would’ve loved). But you gotta do the monitoring; to do otherwise risks too much if the CMSers darken your door (which is becoming a much more common occurrence).

One last quick note for this week: There seems to be a bit of a groundswell of survey findings relating to hand sanitizer dispensers not having drip trays. It would seem that there must have been some recent mention of this in surveyor education as there are some surveyors indicating that this is a new requirement, but the overarching requirement has been in place for rather a while. To whit (and, again, the State Operations Manual becomes then go-to resource):

  • 482.41(b)(9) (ii) The dispensers are installed in a manner that minimizes leaks and spills that could lead to falls; with the associated Survey Procedure being: “Determine whether the hospital maintains the ABHR dispensers in accordance with the manufacturer’s guidelines, or, if there are no manufacturer’s guidelines, that the hospital has adopted policies and procedures to ensure that the dispensers neither leak nor the contents spill.”

Now, nowhere in the regulatory canon does it discuss drip trays (though, when you come right down to it, how else are you going to manage the threat of leaks/drips, especially over hard-surface flooring?). But apparently drip trays have become the “gold standard” for leak/drip control, so you might want to keep an eye on this for the future. These things do tend to spread and who wants to be chasing this during a (or post) survey? Not me.

Eat, drink, and be safe: Some guidance on the care and feeding of staff

One of the more universal conditions I find is the whole issue of where staff can grab something to eat or drink in the midst of busy periods, particularly when staffing levels don’t necessarily dovetail with leaving the work space to go to the cafeteria, etc. And there’s always the specter of someone, somewhere having invoked the “You can’t eat there, it’s against TJC regulations” or “You can’t drink there, it’s against regulations” and so forth and so on. And what better strategy than to use a regulatory presence from outside the organization to be the heavy.

Many’s the time I’ve tried to convince folks that, from a regulatory perspective (with some fairly well-defined exceptions, like laboratories), there is nothing that approaches a general prohibition when it comes to the how, when, and where of eating and drinking in the workplace (and yes, I absolutely understand that prohibition is the easiest thing to “police,” but I think prohibitions also tend to “drive” more creative workarounds). And in the March 2019 edition of Perspectives, our friends in Chicago provide a couple of clarifications for folks, and if you think that there’s a risk assessment involved, then you would be correct.

So, the clarifications are two in number:

  • There are no TJC standards that specifically address where staff can have food or drink in the work areas.
  • You can identify safe spaces for food and drink as long as those locations  comply with the evaluation (read: risk assessment) of the space and your exposure control plan as far as risks of contamination from chemicals, blood, or body fluids, etc.

The guiding light in all of this, if you will, are the regulations provided by the Occupational Safety & Health Administration, and while they have a lot to say about such things (Bloodborne Pathogens and Sanitation), a careful analysis should yield a means of designating some spaces. I have seen a lot of designated “hydration stations,” particularly in clinical areas, to help keep folks hydrated over the course of the working day, so clearly some folks are working towards providing some flexibility based on a risk assessment. This is a good thing both in terms of staff support, but also in not drawing a line in the sand that they don’t have to. Prohibitions can bring about some of your toughest compliance challenges, so if you can work with folks to build in some flexibility, it could mean fewer headaches during rounding activities.

Manage the environment, manage infection control risks

In looking back at 2018 (heck, even in looking back to the beginning of 2019—it already seems like forever ago and we’re only a week in!), I try to use the available data (recognizing that we will have additional data sometime towards the end of March/beginning of April when The Joint Commission (TJC) reveals its top 10 most frequently cited standards list) to hazard a guess on where things are heading as we embark upon the 2019 survey year.

First up, I do believe that the management of ligature risks is going to continue to be a “player.” We’re just about two years into TJC’s survey focus on this particular area of concern; and typically, the focus doesn’t shift until all accredited organizations have been surveyed, so I figure we’ve got just over a year to go. If you feel like revisiting those halcyon days before all the survey ugliness started, you could probably consider this the shot heard ’round the accreditation world or at least the opening salvo.

As to what other concerns lie in wait on the accreditation horizon, I am absolutely convinced that the physical environment focus is going to expand into every nook and cranny in which the environment and the management of infection control risks coexist. I am basing that prediction primarily on the incidence of healthcare-associated infections (HAI) and related stuff (and, as was the case with ligature risk, I suspect that having a good HAI track record is not going to keep you from being cited for breakdowns, gaps, etc.). We’ve certainly seen the “warning shots” relating to water management programs, the inspection, testing, and maintenance of infection control utility systems, management of temperature, humidity, air pressure relationships, general cleanliness, non-intact surfaces, construction projects, etc. Purely from a risk (and survey) management perspective, it makes all the sense in the world for the survey teams to cast an unblinking eye on the programmatic/environmental aspects of any—and every—healthcare organization. Past survey practice has certainly resulted in Condition-level deficiencies, particularly relative to air pressure relationships in critical areas, so the only question that I would have is whether they will be content with focusing on the volume of findings (which I suspect will continue to occur in greater numbers than in the past) or will they be looking to “push” follow-up survey visits. Time will tell, my friends, time will tell.

But it’s not necessarily just the environment as a function of patient care that will be under the spotlight; just recently there was a news story regarding the effects of mold on staff at a hospital in New York. TJC (as well as other accreditors including CMS) keeps an eye on healthcare-related news stories. And you can never be certain that it couldn’t happen in your “house” (it probably won’t—I know you folks do an awesome job, but that didn’t necessarily help a whole lot when it came to, for example, the management of ligature risks). Everything filters into how future surveys are administered, so any gap in process, etc., would have to be considered a survey vulnerability.

To (more or less) close the loop on this particular chain of thought (or chain of thoughtless…), the Centers for Disease Control and Prevention are offering a number of tools to help with the management of infection control risks in various healthcare settings, including ambulatory/outpatient settings. I think there is a good chance that surveys will start poking around the question of each organization’s capacity to deal with community vulnerabilities and these might just be a good way of starting to work through the analysis of those vulnerabilities and how your good planning has resulted in an appropriately robust response program.

That’s a Wrap! EPA’s Final Rule: Early present or gag gift?

Just a couple of brief items to close things out (I’m going to give you folks a break from my blathering next week—unless something of interest breaks—more on that in a bit), the first being the release of EPA’s Final Rule Management Standards for Hazardous Waste Pharmaceuticals and Amendment to the P075 Listing for Nicotine. From where I’m sitting, although the promise is relatively good in terms of making things simpler to manage, particularly when it comes to the disposal of over-the-counter nicotine products, I’m still not certain how this will play out in the long run. I am (as always) hopeful that the Final Rule will blaze a trail towards a process in which doing the right thing is also relatively easy (that, my friends, should be the goal of all compliance activities—the more difficult the process to use, the greater the likelihood of noncompliant workarounds).

The notification I received from EPA characterized things thusly:

“The final rule provides tailored and streamlined standards for managing hazardous waste pharmaceuticals that reduce the cost and compliance burden for the healthcare sector, while ensuring the safe management of hazardous waste pharmaceuticals. Additionally, EPA is taking a common-sense regulatory approach to the disposal of FDA-approved over-the-counter nicotine replacement therapies (NRTs – i.e., gums, patches, lozenges), which will no longer be considered hazardous waste when discarded.

EPA has scheduled two webinars to discuss the contents of the final rule. The webinars, which are free and open to the public, are scheduled for 1 pm Eastern on the following dates:

  • Wednesday, January 9th
  • Wednesday, January 23rd

Both webinars will be the same, with a one-hour general presentation about the final rule, followed by a 30-minute question and answer session. See our website to register to attend one of the webinars: https://clu-in.org/conf/tio/HazWastePharmaceuticals/

Finally, if you would like to receive future updates from EPA’s Office of Resource Conservation and Recovery about solid and hazardous waste, sign up for our listserv by sending a blank email to: solid-and-hazardous-waste-subscribe@lists.epa.gov

I freely admit that that sounds like a pretty good deal, but I think I would advise you folks with some responsibility in this area to make some time in January to listen in to one (or both: the e-mail says the programs are the same, but you and I both know that last 30 minutes is much less likely to be the same, so maybe tune in for the Q & A). From a regulatory compliance perspective, there’s nothing like a “final rule” to get the accreditation organizations into a whirling maelstrom of interpretation, but I guess we’ll have to wait and see if this becomes a hot topic in 2019.

And so to the close of 2018: I’m not exactly sure what it is (though I suspect it’s mostly internal), I tend to find this time of year rather more reflective than not and this year seems to call for introspection more than some in the past. That said, I have no overarching words of wisdom, etc., beyond my hopes that you folks will have some time to power down from the onslaught of life as we know it and spend some time with family, friends, self—whoever makes you feel complete and happy. One of the big changes for me personally over the past year is embracing at least 10 minutes of quiet time every day (some would call it meditation, and I’m OK with that as a descriptor); I have found that it really makes a difference in being able to manage the many stressors of existence. I don’t know (and, in fact, I can’t know) if it would work the same for everyone, but I would encourage you to give it a try. And to that end, I’m going to provide you can opportunity to do just that—next week, please use the time you’d usually use to peruse this space—and I pledge to you that I will do the same.

A most joyous holiday and New Year to all of you and your families! Be safe, take good care, and I will see you in 2019!

Walls and Bridges: Managing construction projects large and small

As you might guess, part of my approach when I’m doing onsite client work is to review the process for managing construction projects, inclusive of the risk assessment process (infection control, life safety). To my mind, there is no more risky business in the physical environment (the management of ligature risks notwithstanding) than undertaking construction or renovation projects, particularly when those projects are in spaces adjacent to occupied patient care (or indeed, any occupied) areas. And with the adoption of the 2012 Life Safety Code® (LSC) and the growing invocation of Chapter 43 Building Rehabilitation, it would seem that the tip of the regulatory spear is getting sharper by the moment.

One of the things that I encounter with some regularity is a fundamental flaw in how the risk assessment actually captures/identifies the risks to be managed as a function of what strategies are to be implemented to eliminate/mitigate the impact of those risks. For example, I can’t tell you how many times I’ve seen assessments of a project that is going to include construction barrier walls in a corridor for which the assessment indicates no impact on egress. Now, you can certainly indicate that, based on the implementation of X, Y, and Z, you have mitigated the impact on egress, but to indicate in the assessment that there was no impact on egress from a barrier wall that has encroached on the corridor, is inaccurate at best—and possibly could draw the ire of a literalist surveyor. As I like to tell folks when I encounter this: You don’t get credit for doing the math in your head; the assessment should indicate that there was an impact, but the impact was mitigated by the implementation of ILSM(s).

Similarly, if you remove the suspended ceiling in a project area, you have impaired the smoke detection/sprinkler protection in the area. Now it may be that the impairment is sufficiently minor in nature to not require implementation of ILSMs, based on your policy, but you still have to indicate that such is the case. You can’t say there was no impact or impairment, because the condition you have represents an impairment and so, there’s got to be some level of impact.

I think perhaps the way to look at this is much in the vain of our emergency management Hazard Vulnerability Analysis (HVA) process. There is no harm/no foul in identifying risks for which you would need to be prepared (you could make the case that there are few things as disruptive to an organization as a construction project) as long as you have a strategy for managing those risks. So, if you carry over the philosophy to construction/renovation, it makes it “easier” to frame the assessment as a proactive management of risks rather than trying to figure out how to do as little as possible (and I do see pre-construction risk assessments that seem to be aimed at a de minimis implementation strategy). But using the HVA algorithm (likelihood, impact, preparedness, response) you might find that your “packaging” is a little tidier than it was previously.

As a final note on this subject, I really think you need to get in the habit (if the habit has not already formed) of posting infection control permits, ILSM permits, etc., outside of construction/renovation areas so it is clear what the expected conditions and/or practices might be. You can’t be looking over the shoulder of the contractors every minute, so it helps to have some eyes in the field (with a reasonable knowledge base) keeping watch. There is definitely an expectation of regulatory surveyors that these will be posted in conspicuous locations (yeah, I know there’s no rule that says you have to, so chalk this up to a best practice invocation), so better to have visible postings.

Please let me close things out with best wishes for a joyous and restful (Can you combine those two? I think you can!) Thanksgiving to you and your families. 2018 whipped along at a pretty good clip and I suspect that the holidays will launch us into 2019 before too long, so take a few deep breaths and enjoy the day.

It’s been a quiet week in Lake Hazard-be-gone: Water and Legionella

Not a ton of “hair on fire” stuff in the news this week, so (yet again), a quick perusal of something from the “things to consider” queue.

It seems likely that Legionella and the management of water systems is going to continue to have the potential for becoming a real hot-button issue. I suppose any time that CMS issues any sort of declarative guidance, it moves things in a (potentially) direction of vulnerability for healthcare organizations. That said, it might be worth picking up the updated legionellosis standard from ASHRAE to keep up with the current strategies, etc. I don’t know that there’s any likelihood of eradication of Legionella in the general community (by the way—and I’m sure this is the case, but it never hurts to reiterate—those of you with responsibilities for long-term care facilities are definitely in a bracket of higher vulnerability). But there remains a fair amount of risk in the community, as evidenced by the most recent slate of outbreaks. Water is definitely the common denominator, but beyond that, this can happen anywhere at any time, so vigilance is always the end game when it comes to preventive measures.

As a final thought for the week, I wanted to share a blog item (not mine) that I found very interesting as food for thought (the concept is very powerful, though you may have a tough time convincing your boss to embrace it, as I think you’ll see): treating failure like a scientist. You can find the whole post here, but the short take is that you may have a positive or a negative result of whatever strategy you might employ—each of which should be considered data points upon which you can make further adjustments. Not everything works the way you thought it would, but rather discarding something outright if it doesn’t succeed, try to figure out the lesson behind the failure to make a better choice/strategy/etc. moving forward. The blog covers things more elegantly than I did here, but I guess my closing thought would be to have the courage (maybe “luxury” is the better term) to really learn from your mistakes—if we were perfect, there would never be a need for improvement.

Shine on you crazy fire response plan!

On the things I’ve been doing over the past couple of weeks has been reading through the EC/LS/EM standards and performance elements to see what little pesky items may have shown up since the last time I did a really thorough review. My primary intent is to see if I can find any “Easter eggs” that might provide fodder for findings because of a combination of specificity and curiosity. At any rate, while looking through the fire safety portion of the manual, I noticed a performance element that speaks to the availability of a written copy of your fire response plan. That makes sense to me; you can never completely rely on electronic access (it is very reliable, but a hard-copy backup seems reasonable). The odd component of the performance element is the specificity of the location for the fire response plan to be available—“readily available with the telephone operator or security.”

Now, I know that most folks can pull off that combo as an either/or, but there are smaller, rural facilities that may not have that capacity (I think my personal backup would be the nursing supervisor), so it makes me wonder what the survey risks are for those folks who don’t have 24/7 switchboard or security coverage. At the end of the day, I would think that you could do a risk assessment (what, another one!?!?!?) and pass it through your EC Committee (that kind of makes the Committee sound like some sort of sieve or colander) and then if the topic comes up during survey, you can push back if you happen to encounter a literalist surveyor (insert comment about the likelihood of that occurring). As there is no specific requirement to have 24/7 telephone operator or security presence (is it useful from an operational standpoint to do so, absolutely—but nowhere is it specifically required), I think that this should be an effective means of ensuring you stay out of the hot waters of survey. For me, “readily available” is the important piece of this, not so much how you make it happen.

At any rate, this may be much ado about nothing (a concept of which I am no stranger), but it was just one of those curious requirements that struck me enough to blather on for a bit.

As a closing note, a quick shout-out to the folks in the areas hit by various and sundry weather-related emergencies the past little while. I hope that things are moving quickly back to normal and kudos for keeping things going during very trying times. Over the years, I’ve worked with a number of folks down in that area and I have always been impressed with the level of preparedness. I would wish that you didn’t have to be tested so dramatically, but I am confident that you all (or all y’all, as the case may be) were able to weather the weather in appropriate fashion.

Never say never: The ligature risk conversation continues…

I truly was thinking that perhaps I could go a couple more weeks without coming back to the ligature risk topic, but continued percolation in this area dictates otherwise. So here’s one news item and one (all too consultative) recommendation.

If you took a gander at the September issue of Briefings on Accreditation and Quality, you will have noted that the Healthcare Facilities Accreditation Program (HFAP) isn’t revising their existing standards in the wake of the recent CMS memorandum indicating that The Joint Commission’s (TJC) focus work on the subject of managing physical environment risks and behavioral health patients is an acceptable starting point (and I am very serious about that descriptor—I don’t see this ending real soon, but more on that in a moment). I’m not sure if HFAP makes as much use of Frequently Asked Questions forums as TJC does (and with that use, the “weight” of standards), so it may be that they will start to pinpoint things (strategies, etc.) outside of revising their standards (which prompts the question—at least to me—as to whether TJC will eventually carve out the FAQs into specific elements of performance…only time will tell). At any rate, HFAP had done some updating prior (already approved by CMS) to the recent CMS memorandum, but, in using existing CMS guidance (which tends not to be too specific in terms of how you do things), should be in reasonable shape. You can see a little more detail as to where the applicable HFAP standards “live” by checking out this and this. I would imagine that the other accreditation organizations are looking at/planning on how to go after this stuff in the field and I suspect that everyone is going to get a taste of over-interpretation and all that fun stuff.

In the “dropping of the other shoe” department, recent survey results are pointing towards a more concerted look at the “back end” of this whole process—clear identification of mitigation strategies, education of applicable staff to the risks and mitigation strategies, and building this whole process into ongoing competency evaluation. You really have to look at the proactive risk assessment (and please, please, please make sure that you identify everything in the environment as a risk to be managed; I know it’s a pain in the butt to think so, but there continues to be survey findings relating to items the survey team feels are risks that were not specifically identified in the assessment) as the starting point and build a whole system/program around that assessment, inclusive of initial and ongoing education, ongoing competency evaluation, etc. Once again, I would seem that we are not going to be given credit for doing the math in our (collective) head; you have to be prepared to “show” all your work, because if you don’t, you’ll find yourself with a collection of survey findings in the orange/red sections of the ol’ SAFER matrix—and that is not a good thing at all. We are (likely) not perfect in the management of behavioral health patients and that is clearly the goal/end game of this, but right now anything short of that has to be considered a vulnerability. If you self-identify a risk that you have not yet resolved and you do not specifically indicate the mitigation strategy (in very nearly all circumstances, that’s going to be one-to-one observation), then you are at survey risk. I cannot stress enough that (at least for the now) less is not more, so plan accordingly!

How green is your dashboard? Using the annual evaluation process to make improvements

I was recently fielding a question about the required frequencies for hazard surveillance rounds (hint: there are no longer required frequencies—it is expected that each organization will determine how frequency of rounding and effective management of program complement each other) and it prompted me to look at what was left of the back end of the EC chapter (and there really isn’t a lot compared to what was once almost biblical in implication). I think we can agree that there has been a concerted effort over time to enhance/encourage the management of the physical environment as a performance improvement activity (it’s oft been said that the safety committee is among the most important non-medical staff committees in any organization—and even more so if you have physician participation) and there’s been a lot of work on dashboards and scorecards aimed at keeping the physical environment in the PI mix.

But in thinking back to some of the EC scorekeeping documents I’ve reviewed over the years (and this includes annual evaluations of the program), the overarching impression I have is one of a lot of green with a smattering of yellow, with a rather infrequent punctuation of red. Now I “get” that nobody wants to air their dirty laundry, or at least want to control how and where that type of information is disseminated, but I keep coming back to the list of most frequently cited standards and wonder how folks are actually managing the dichotomy of trying to manage an effective program and having a survey (aimed at those imperfections that make us crazy) that flies in the face of a mostly (if not entirely) green report card.

While it’s always a good thing to know where you stand relative to your daily compliance stuff, when it comes down to communication of PI data, it’s not so much about what you’re doing well, but where you need to make improvements. I venture to predict that the time will come when the survey process starts to focus on how improvement opportunities are communicated to leadership and how effective those communications are in actually facilitating improvement. It’s not so much about “blaming” barriers, but rather the facilitation of barrier removal. There will always be barriers to compliance in one form or another; our task is to move our organizations past those barriers. With the amount of data that needs to be managed by organizational leadership, you have to make the most of those opportunities when direct communications are possible/encouraged. And if there are considerations for which the assistance of organizational leadership is indicated, you have a pipeline in place to get that done with the annual evaluation process.