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Is this the survey we really want?

Moving on to the type of pain that can only be inflicted at the federal level, a couple of things that might require an increase in your intake of acid-reducing supplements…

As it appears that CMS doesn’t love that dirty water (and yes, my friends, that is a shameless local plug, but it is also a pretty awesome tune), now their attentions are turning to the management of aerosolizing and other such water systems as a function of Legionella prevention. Now, this is certainly not a new issue with which to wrestle, which likely means that the aim of this whole thing, as indicated in the above notification—“Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water”—is something with which we are abundantly familiar. But I will admit to having been curious about the implied prevalence in healthcare facilities as that’s the type of stuff that typically is pretty newsworthy, so I did a quick web search of “Legionella outbreaks in US hospital.” I was able to piece together some information indicating that hospitals are not doing a perfect job on this front, but the numbers are really kind of small in terms of cases that can be verifiably traced back to hospitals. When you think about it, the waters could be a bit muddy as Legionella patients that are very sick are probably going to show up at your front door and there may be a delay in diagnosis as it may not be definitively evident that that’s what you’re dealing with. At any rate, sounds like a zero-tolerance stance is going to be, but the Survey & Certification letter does spell out the instructions for surveyors:

Surveyors will review policies, procedures, and reports documenting water management implementation results to verify that facilities:

 

  • Conduct a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g., Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system.
  • Implement a water management program that considers the ASHRAE industry standard and the CDC toolkit, and includes control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens.
  • Specify testing protocols and acceptable ranges for control measures, and document the results of testing and corrective actions taken when control limits are not maintained.

I have little doubt that you folks already have most, if not all, of this stuff in place, but it might not be a bad idea to go back and review what you do have to make sure that everything is in order. And if you are interested in some of the additional information (including some numbers) available, the following links should be useful:

Moving on to the world of emergency management, during the recent webinar hosted by CMS to cover the Emergency Preparedness final rule, one of the critical (at that time, more or less unanswered) questions revolved around whether we could expect some Interpretive Guidelines (basically, instructions for surveyors in how to make their assessments) for the EP Final Rule. And to what to my wondering eyes should appear, but those very same Interpretive Guidelines.  I will feely admit that the setup of the document is rather confusing as there are a lot of different types of providers for which the Final Rule applies and not all the requirements apply to all of the providers, etc., so it is a bit of a jumble, to say the least. That said, while I don’t think that I am sufficiently well-versed with the specific EM requirements of the various and sundry accreditation organizations (HFAP, DNV, CIHQ, etc.), I can say that those of you using TJC for deemed status purposes should be in pretty good shape as it does appear that one of the early iterations of the TJC EM standards was used in devising the Final Rule, so the concepts are pretty familiar.  A couple of things to keep in mind in terms of how the CMS “take” might skew a little differently are these:

 

  • You want to make sure you have a fairly detailed Continuity of Operations Plan (CoOP); this was a hot button topic back in the immediately post-9/11 days, but it’s kind of languished a bit in the hierarchy of emergency response. While the various and sundry performance elements in the TJC EM chapter pretty much add up to the CoOP, as a federal agency, it is likely that CMS will be looking for something closer to the FEMA model (information about which you can find here), so if you have a CoOP and haven’t dusted it off in a while, it would probably be useful to give it the once over before things start heating up in November…
  • As a function of the CoOP, you also want to pay close attention to the delegation of authority during an emergency, primarily, but not exclusively the plan of succession during an emergency (I found the following information useful and a little irreverent—a mix of which I am quite fond). It does no good at all for an organization to be leaderless in an emergency—a succession plan will help keep the party going.
  • Finally, another (formerly) hot button is the alternate care site (ACS), which also appears to be a focus of the final rule; the efficacy of this as a strategy has been subject to some debate over the years, but I think this one’s going to be a source of interest as they start to roll out the Interpretive Guidelines. At least at the moment, I think the key component of this whole thing is to have a really clear understanding (might be worth setting up a checklist, if you have not already) of what you need to have in place to make appropriate use if whatever space you might be choosing. I suspect that making sure that you have a solid evaluation of any possible ACS in the mix: remember, you’re going to be taking care of “their” (CMS’) patients, so you’d better make sure that you are doing so in an appropriate environment.

Welcome to a new kind of tension…

In the “old” days, The Joint Commission’s FAQ page would indicate the date on which the individual FAQs had been updated, but now that feature seems to be missing from the site (it may be that deluge of changes to the FAQs (past, present, and, presumably, future) makes that a more challenging task than previously (I will freely admit that there wasn’t a ton of activity with the FAQs until recently). That said, there does appear to be some indication when there is new material. For example, when you click on the link (or clink on the lick), a little short of halfway down the page you will see that there’s something new relative to the storage of needles and syringes (they have it listed under the “Medical Equipment” function—more on that in a moment), so I think that’s OK.

But in last week’s (dated May 31, 2017) Joint Commission e-Alert, they indicate that there is a just posted FAQ item relating to ligature risks, but the FAQ does not appear to be highlighted in the same manner as the needle and syringe storage FAQ (at least as of June 1, when I am penning this item). Now I don’t disagree that the appropriate storage (recognizing that appropriate is in the eye of the beholder) of needles and syringes is an important topic of consideration, I’m thinking that anything that TJC issues relative to the appropriate management of ligature risks (and yes, it appears that I am far from done covering this particular topic) is of pretty close to utmost importance, particularly for those of you likely to experience a TJC survey in the next little while. I would encourage you to take a few moments to take a peek at the details here.

So, parsing these updates a bit: I don’t know that I’ve ever considered needles and syringes “medical equipment,” but I suppose they are really not medications, so I guess medical equipment is the appropriate descriptor—it will be interesting to see where issues related to the storage of needles and syringes are cited. As usual (at least on the TJC front) it all revolves around the (wait for it…) risk assessment. It’s kind of interesting in that this particular FAQ deals somewhat less specifically with the topic at hand (storage of needles and syringes) and more about the general concepts of the risk assessment process, including mention of the model risk assessment that can be found in the introductory section of the Leadership chapter (Leadership, to my mind, is a very good place to highlight the risk assessment process). So no particularly new or brilliant illumination here, but perhaps an indicator of future survey focus.

As to the ligature risks, I think it is reasonable to believe that there will be very few instances in which every single possible ligature risk will be removed from the care environment, which means that everyone is going to have to come up with some sort of mitigation strategy to manage those risks that have not been removed. With the FAQ, TJC has provided some guidance relative to what would minimally be expected of that mitigation strategy; while I dare not indicate verbatim (you will have to do your own clicking on this one—sorry!), you might imagine that there would need to be: communication of current risks; process for assessing patient risk; implementation of appropriate interventions; ongoing assessments of at-risk behavior; training of staff relative to levels of risk and appropriate interventions; inclusion of reduction strategies in the QAPI program; and inclusion of equipment-related risks in patient assessments, with subsequent implementation of interventions.

I don’t see any of this as particularly unusual/foreign/daunting, though (as usual) the staff education piece is probably the most complicated aspect of the equation as that is the most variable output. I am not convinced that we are doing poorly in this realm, but I guess this one really has to be a zero-harm philosophy. No arguments from me, but perhaps some important work to do.

I have nothing to say and I’m saying it!

A somewhat funky news item for this week’s bloggy goodness: In the March edition of the American Journal of Infection Control (house organ of APIC), there was a news release sharing the results of a study that indicates that hospital room floors may be an overlooked source of infection . The study also got a mention in Physicians Weekly, which means that in all likelihood it’s been noticed by any of the regulatory folks—and you know what that’s likely to mean…

At any rate, once I got past the “no, duh” thought (somehow this comes as no surprise to me), I got to thinking about the complexities of cleaning, particularly as a function of the omnipresent application of dwell times for disinfectant products and the whole concept of keeping things wet long enough to kill the bugs. I think we’ve focused a lot on getting folks who use disinfectants to be able to articulate how long something has to stay wet (good thing), but not as much on watching to make sure that we are applying that knowledge along with the application of the disinfectant. For example, it’s 3 p.m. on a Monday afternoon and the ED is jammed with patients waiting for inpatient beds. The EVS staff is scrambling to get the rooms ready for occupancy and somebody, somewhere is tapping their foot (and perhaps grousing about “how long is this gonna take?”). The question I keep coming back to is this: when there’s a rush on anything, have we well and truly built enough time into the process for surfaces to be properly disinfected? The study mentions surfaces in some hospital rooms in the Cleveland area, but there’s not a lot of discussion in the press release about cleaning methodologies, so I’m not sure what might be in play. The press release also talks about high-contact objects (personal items, medical devices, nurse call buttons) coming into contact with floors and subsequent transmission to other surfaces (including hands!). To me, this sounds like occupied rooms and I suspect that the likelihood of the floor in an occupied room staying wet long enough to properly disinfect is fairly remote. Wet floors are slippery floors and slippery falls increase the potential for falls. I mean think about it: how many times have you seen somebody waving a wet floor sign over a wet floor to get it to dry more quickly? In my experience, the last piece of any process is frequently the one that gets jammed the most time-wise. Think about construction projects that ended up having issues with improperly installed flooring. When you think about it (or when I think about it), it makes perfect sense: the flooring install is usually the last thing to happen and those folks are almost always under the gun to get things finished (so the project is on time, so the project is not quite so late, so the project gets done early) and floor prep (particularly preparation of the surface upon which the flooring is installed) becomes the sprint to the finish line at the end of the marathon. I am absolutely convinced that we are not going to “solve” this problem until everyone agrees to a reasonable amount of time for these tasks to be completed. Is it physically (and that includes making sure that surfaces are wet enough, long enough) possible to properly do a terminal disinfection of the room of a discharged patient in 20 minutes? 30 minutes? 45 minutes? And that’s not even considering the cleaning of the room of a discharged isolation patient. Maybe there are (or will be) quicker ways to disinfect surfaces; UV disinfection technology is growing, but it’s still pretty expensive technology and I think the jury is still out on how absolutely effective it is on all surfaces.

There’s little question that there are improvements to be made in the area of cleaning and, most times, the EVS folks seem to end up with the fingers pointed in their direction. But in the absence of some clearly established parameters that allow for proper administration of the disinfection process (parameters that are resistant to the tap-tap-tapping of feet…are you done yet?), I don’t know that it’s going to happen any time soon.

Ticking away the moments

As we continue our (hopefully not futile) attempts to peel back the layers of the current Joint Commission survey process, I think it is of great importance to pay close attention to all the various blogs and missives emanating from the mothership in Chicago. While the information shared in this is not “enforceable” as a standard, it does seem that a lot of the general concepts manage to find their way into the practical administration of accreditation surveys. And since we know with a fair degree of certainty that the physical environment is still going to be somewhere in their default survey setting, I wanted to bring to your attention a recent (April 25) blog posting from Ann Scott Blouin, TJC’s Executive VP of Customer Relations, that focuses on the management of workplace violence.

The blog suggests focusing on a couple of key elements (none of which I would have any disagreement):

 

  • Personal risk factors
  • De-escalation education for all staff
  • Development of a workplace violence prevention plan
  • Enforcing zero tolerance for violence/bullying

I know from my own experience that de-escalation education for all staff is not nearly as widespread as I think it should be. Elements of de-escalation technique should be included in basic customer service education for pretty much anybody in a service job, regardless of the industry. I see way too many ticked-off people floating around—I’m entirely certain why folks seem to be so primed to vent/fume/fuss, etc. (I have some theories, only some of them based on the influence of certain elements of popular culture), but there has very clearly been a reduction in patience levels in far too many encounters.

At any rate, as another brick in the accreditation wall, I think you would be well-served to check out Ms. Blouin’s blog posting; ostensibly, it is aimed at organizational leadership, but hey: Are we not leaders?

That’s the FAQ, Jack!

It may be that I am covering one topic of conversation more than necessary (it’s getting to the point where this might eclipse the discussion of eyewash stations—yow!), but I cannot help but be very concerned about the amount of play that the management of the environment in which we place behavioral health patients is receiving in the annals of The Joint Commission. April 24 saw an electronic update announcing the “birth” of a new standards FAQ regarding ligature risks that appears to be aimed at dovetailing with Sentinel Event Alert #56 and includes mention of a “Suicide Risk Booster” (who comes up with these names?!?). As we have discussed before, FAQs, Sentinel Event Alerts, and stuff that finds its way into Perspectives all take on the weight of standards when applied in the field, so clearly organizations need to have all their ducks in a row. (And this is starting to look like a whole mess o’ ducks to be “rowed”, which brings new meaning to that Willie Nelson classic “On The Rowed Again,” but I digress—and who wouldn’t?) The question I keep coming back to is whether there’s been an uptick in actual events in which patients have come to harm as the result of poorly or inappropriately managed ligature risks. Or is this the result of surveyors in the field citing organizations for having ligature risks and not being able to produce a risk assessment of the existing conditions and the identification (and communication to staff—key point, that one) of mitigation strategies to manage the identified risks?

Part of the challenge with this particular issue (and this is true of a great many things in the physical environment) is that it is virtually impossible to provide an environment that is entirely, absolutely (please insert your favorite qualifier here) impossible to provide a completely risk-free environment—at least on this planet (perhaps there are safer planets in the Federation, but I couldn’t say for sure), so there’s always going to be something with which patients intent on hurting themselves might use to that end. Now I know that not every healthcare setting is set up to deal with behavioral health patients (and somehow, I do think that for any hospital that has not come face-to-face with the management of BH patients in areas not designed for that purpose, it is just a matter of time) and I also know that the BH patient volumes can be very mercurial. Even if you have one “safe” room, there are no guarantees that, at any given moment, that will be enough to handle however many patients you have in the queue—and you really can’t leave these folks out in the waiting room. Again, I’m not convinced that the issue here is that there is data to support that folks are not managing things appropriately, but rather more along the lines of not being able to consistently communicate the process for assessing and identifying risks, educating staff to be able to speak to the mitigation strategies being used to manage the identified risks, etc. I would (as I have been for a while now) encourage you to really take this topic and do a deep dive into the particulars of your organization. I firmly believe that this is not going to be one of those “one and done” instances of risk assessment and that you will be well-served by periodically revisiting the initial assessment (if it has been completed) to ensure that the conditions upon which you based your initial assessment have not changed (and that includes the volume and acuity of the patients). There is every indication that TJC is going to be hammering on this for some time to come (remembering that EC.02.06.01 was the most frequently cited standard in 2016; the ligature risk findings tend to show up there when cited) and, much as issues with the surgical environment and interim life safety measures, process gaps can get you in a heap of trouble. A little extra work on this (and those others) can only increase your chances for a successful survey (or at least a not spectacularly ugly survey).

As a closing note, after a dinner discussion with my wife (who happens to be a nurse), I’ve been contemplating how the role of the safety professional has changed over the last 10-15 years, including my surprise when I encounter evidence of “old school” approaches to safety. To my mind (such as it is), where safety compliance was once the result of (more or less) coercion, sustained compliance can truly only come as the result of collaboration with the folks who have to manage the environment on a day to day basis—pretty much everyone at point of care/point of service. It is not enough for a safety professional to periodically stroll through an area and point out deficiencies, there has to be a conversation and there has to be problem-solving. I think the old coercive style was based on something approaching a lack of faith in the folks out in the environment to be able (or willing) to “do the right thing.” But in this era of “just” culture and empowerment, etc., safety has to happen all the time and that, my friends, can only come with an atmosphere of collaboration. If people hide stuff or behave more appropriately when they hear you are coming, then it makes the surveillance process less useful. And if you don’t work with folks to figure out how to resolve the issues that you “keep finding,” the likelihood of it fixing itself on its own is pretty remote. I freely admit that problem-solving is my favorite part of my safety consulting work (meeting folks is also a fave); there is nothing better than talking through a problem and achieving some sort of consensus on how to proceed. It’s not always easy, but it is worth every moment you put into it!

Roll over Beethoven!

As we mark the passing of yet another (couple of) pop culture icon(s), I’m feeling somewhat reflective as I place fingers to keyboard (but only somewhat). As I reflect on the potential import of Sentinel Event Alert #57 and the essential role of leadership, one of the common themes that I can conjure up in this regard has a lot to do with the willingness/freedom of the “generic” Environment of Care/Safety program to air the organization’s safety-related (for lack of a better term—if you have a better one that’s not really PC, send it on) dirty laundry (kick ’em when they’re up, kick ’em when they’re down). I’ve seen a spate of folks getting into difficulties with CMS because they were not able to demonstrate/document the management of safety shortfalls as a function of reporting those shortfalls up to the top of their organization in a truly meaningful way. As safety professionals, you really can’t shy away from those difficult conversations with leadership—leaky roofs that are literally putting patients and staff at risk (unless you are doing incredibly vigorous inspections above the ceiling—or even under those pesky sinks); HVAC systems that are being tasked with providing environmental conditions for which the equipment was never designed; charging folks with conducting risk assessments in their areas…perhaps the impact of reduced humidity on surgical equipment. There’s a lot of possibilities—and a lot of possibility for you to feel the jackboots of an unhappy surveyor. One of the responsibilities of leaders, particularly mid-level leaders—and ain’t that all of us—is to work things through to the extent possible and then to fearlessly (not recklessly) escalate whatever the issue might be, to the top of the organization.

I was recently having a conversation with my sister about an unrelated topic when we started discussing the subtle (OK, maybe not so subtle) differences between two of my favorite “C” words: commitment and convenience. My rule of thumb is that convenience can never enter the safety equation at the expense of commitment (I suppose compliance works as well for this) and all too often I see (and I suspect you do, too) instances in which somebody did something they shouldn’t have because to do the right thing was less convenient than doing the wrong (or incorrect) thing. Just last week, I was in an MRI suite in which there were three (count ’em: 1, 2, 3) unsecured oxygen cylinders standing (and I do mean standing) in the MRI control right across the (open) door from the MRI. There was nobody around at the moment and I thought if there was a tremor of any magnitude (and I will say that I was in a place that is no stranger to the gyrations of the earth’s crust) and those puppies hit the deck, well, let’s just say that there would have a pretty expensive equipment replacement process in the not-too-distant future. The question I keep coming back to is this: who thinks that that is a good idea? I know that recent times have been a struggle relative to segregation of full and not full cylinders, but I thought we had really turned a corner on properly securing cylinders. These are the times that try a person’s soul: tell Tchaikovsky the news! Compliance ≠ Convenience…most of the time.

And now, batting cleanup…

Or, oh me of little faith…

Another somewhat hodgepodge-ish coverage of sundry and assorted niceties this week. For some reason, this week has resulted in a lot of ideas flying around in my noggin (I suspect you might have weeks like that too, from time to time), but I think there’s a sufficiently common theme for these to hang together. Hopefully some level of cogent thought will hold sway…

First up, a discussion about topics relating to cleaning, and by extension, cleanliness. Health Facilities Management recently published an article regarding a three-year study aimed at identifying ways of improving patient room cleaning (my philosophy on that is that we need to consider more than just the cleaning of patient rooms, but more on that in a bit). The article covers some of the process breakdowns observed during the study, and speaks to the inclusion of housekeeping staff in unit meetings, etc., to enhance the sense of the importance of their roles in the process of providing care to the patient by making sure the environment is clean. I think you folks know that my primary background is in the EVS (from the EVS world?) and I have never needed to be “sold” on the importance of the frontline housekeeping staff in supporting the care environment. I know from experience that it’s a tough job and I can tell you with absolute certainty that there is way more stuff in the typical patient room to clean than their used to be. (I only had to periodically dust off the abacus, etc.) The article provides some interesting data on the cleaning of various surfaces in the room, but I’ll let you see those for yourself. In looking at the data, it does make me ponder how much of a leap of faith it is to leave a restroom without having a paper towel (or some such) in hand to twist the ol’ door knob. I just can’t bring myself to stride right out without a thought in the world—but I see folks do that all the time and only about half of them wash their hands…

One of the things I’ve been seeing in survey country is a focus on what I will call the concept of the patient-ready room; this goes beyond the regimen of daily cleaning of surfaces, etc., and gets to the land of discharge cleaning, etc. I think one of the key conversations you can have in your organization is to figure out what a “patient-ready room” means and to start educating folks. Some things to consider:  making sure the waste containers are empty; making sure that everything in the room works (just as you would yip if you had a hotel room where stuff wasn’t working properly—or at least I hope you would yip); making sure there are no stained ceiling tiles, etc. Again, this room is going to be somebody’s home—it may only be for a day or so—but think about someone flat on their back and only having the TV and that stain on the ceiling to look at. And they’re probably not going to say anything while they’re staying with you (I suspect that most folks are just to amped up about being there to speak up much), but they may very well remember that ceiling tile if they get a satisfaction survey. And don’t get me started about schmutz on the floor or on the bed rails; I see it happen far too often and I don’t know if too many organizations that can’t do a little better with that.

As a final thought in this realm, I know a lot of folks have secured the areas under sinks to prevent storage, etc. If your organization prohibits under-sink storage, it’s probably the simplest solution to keeping them (whoever “them” might) out. But I ask you this: how often are you opening up those areas to see what’s going on? It seems like lately I’ve been running into a fair number of conditions bordering on Roquefort—or perhaps a Gorgonzola or Stilton. Just because you can’t see it, doesn’t mean there isn’t something growing under those pesky sinks—and if the water intrusion isn’t enough to leak down below, you may have no reason to look. But I’m thinking you might want to think about thinking about setting that up as a process. Just sayin’…

Doo doo doo, lookin’ out my back (fire) door…

Something old and something new(ish): old rant, new requirement.

As we move ever onwards toward the close of our first year “under” the 2012 Life Safety Code® (talk about a brave new world), there was one item of deadline that I wanted to touch upon before it got too, too much further into the year. And that, my friends, is the requirement for an annual inspection of fire and smoke door assemblies—for those of you keeping track, this activity falls under the EOC chapter under the standard with all those other pesky life safety-related inspection, testing, and maintenance activities (don’t forget to make sure that your WRITTEN documentation of the door assembly inspection includes the appropriate NFPA standards reference—in this case, you have quite a few to track: NFPA 101-2012 for the general requirements; NFPA 80-2010 for the fire door assemblies; and, NFPA 105-2010 for the smoke door assemblies). Also, please, please, please make sure that the individual(s) conducting these activities can “demonstrate knowledge and understanding of the operating components of the door being tested” (if this sounds like it might be a competency that might need to be included in a position description and performance evaluation, I think you just might be barking up the correct tree). The testing is supposed to begin with a pre-test visual inspection, with the testing to include both sides of the opening. Also, if you are thinking that this is yet another task that will be well-served by having an inventory, by location, of the door assemblies, you would indeed be correct (to the best of my knowledge). As a caveat for this one, please also keep in mind that this would include shaft access doors, linen and trash chute—while not exactly endless, the list can be pretty extensive. At the moment, from all I can gather, fire-rated access panels are optional for inclusion, though I don’t know that I wouldn’t be inclined to have a risk assessment in one’s back pocket outlining the decision to include or not to include (that is the question!?!) the access panels in the program.

I’m thinking you will probably want to capture this as a recurring activity in your work order system, as well as developing a documentation form. Make sure the following items are covered in the inspection/testing activity:

 

  • No open holes or breaks in the surfaces of either the door or the frame
  • Door clearances are in compliance (no more than ¾ inch for fire doors; no more than 1 inch for corridor doors; no more than ¾ inch for smoke barrier doors in new buildings)
  • No unapproved protective plates greater than 16 inches from the bottom of the door
  • Making sure the latching hardware works properly
  • If the door has a coordinator, making sure that the inactive door leaf closes before the active leaf
  • Making sure meeting edge protection, gasketing, and edge seals (if they are required—depends on the door) are inspected to make sure they are in place and intact

 

I think the other piece of the equation here is that you need to keep in mind that “annual” is a minimum frequency for this activity; ultimately, the purpose of this whole exercise is to develop performance data that will allow you to determine the inspection frequency that makes the most sense for compliance and overall life safety. Some doors (and I suspect that you could rattle off a pretty good list of them without even thinking about it too much) are going to need a little more attention because they “catch” more than their fair share of abuse (crash, bang boom!). Now that this isn’t an optional activity (ah, those days of the BMP…), you might as well make the most of it.

 

Putting on my rant-cap, I’d like to steal just a few moments to lament the continuing decline of decency (it used to be common; now, not so much) when it comes to interactions with strangers (and who knows, maybe it’s extending into familial and friendial interactions as well—I sure hope not!) I firmly believe that any and every kindness should be acknowledged, even if it’s something that they were supposed to do! My favorite example is stopping for pedestrians (and if you’ve been behind me, yes that was me stopping to let someone complete the walk); yes, I know that in many, if not most, places, the law requires you to stop for pedestrians in a crosswalk, but I think the law should also require acknowledgement from the pedestrians. Positive reinforcement can’t possibly hurt in these types of encounters. Allowing merging traffic to move forward (signaling is a desirable approach to this, but you should also signal the person who let you in). I’m not sure if we’re just out of practice or what, but I’d ask you to just try a little more to say “hi” or “thanks” or give somebody a wave when they aren’t jerks (and just so we’re straight, a wave includes more than just the middle digit). Maybe I’m going a little Pollyanna here, but the world is just not nice enough lately. Hopefully we can make an incremental improvement…

What a long strange trip it’s been…

And we’re still in the first month!

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

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

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

 

 

Who can turn the world on with her smile?

As we find 2017 reapplying time’s onslaught against pop culture icons, once again there’s a small “c” cornucopia of stuff to cover, some perhaps useful, some most assuredly not (that would be item #1, except for the advice part). Allons-y!

As goes the passage of time, so comes to us the latest and latest edition of the Joint Commission’s Survey Activity Guide (2017 version). There does not appear to be a great deal of shifting in the survey sands beyond updating the Life Safety Code® (LSC) reference, reordering the first three performance elements for the Interim Life Safety Measure (ILSM) standard, and updating the time frame for sprinkler system impairments before you have to consider fire watches, etc. They also recommend having an IT representative for the “Emergency Management and Environment of Care and Emergency Management” (which makes EM the function so nice they named it twice…), which means that, yes indeedy, the emergency management/environment of care “interviews” remain on the docket (and review of the management plans and annual evaluations—oh, I wish those plans would go the way of the dodo…) for the building tour as well. Interestingly enough, there is no mention of the ILSM assessment discussion for any identified LSC deficiencies (perhaps that determination was made to late in the process)—or if there is, I can’t find it. So for those of you entertaining a survey this year, there’s not a ton of assistance contained therein. My best advice is to keep an eye on Perspectives—you know the surveyors will!

And speaking of which, the big news in the February 2017 issue of Perspectives is the impending introduction of the CMS K-tags to the Joint Commission standards family. For those of you that have not had the thrill of a CMS life safety survey, K-tags are used to identify specific elements of the LSC that are specifically required by CMS. Sometimes the K-tags line up with the Joint Commission standards and performance elements and sometimes they provide slightly different detail (but not to the point of being alternative facts). As TJC moves ever so closely to the poisoned donut that is the Conditions of Participation, you will see more and more readily discernible cross-referencing between the EC/LS (and presumably EM) worlds. At any rate, if I can make one consultative recommendation from this whole pile of stuff, I would encourage you to start pulling apart Chapter 43 of the 2012 LSC – Building Rehabilitation, particularly those of you that have been engaged in the dark arts of renovation/upgrading of finishes, etc. You want to be very clear and very certain of where any current or just-completed projects fall on the continuum—new construction is nice as a concept (most new stuff is), but new construction also brings with it requirements to bring things up to date. This may all be much ado about little, but I’d just as soon not have to look back on 2017 as some catastrophic survey year, if you don’t mind…

Until next time, have a Fabulous February!