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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:

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:

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.

I got those travelin’ code compliance blues…

One occupational hazard (or probably more correctly an occupational preoccupation) I find is a constant awareness of code violations wherever I go. It seems that there are an awful lot of airports, concert venues, and the like that are engaged in upgrading facilities, and often, there are plenty of opportunities to look up into the areas above the ceiling envelope. Now I absolutely understand why healthcare gets a lot of scrutiny relative to concerns of life (and general) safety—far too many folks incapable of self-preservation to put them at risk. But as I wander around looking at stuff, I’m thinking we’re dealing with a whole mess of folks (euphemistically called passengers) in almost a collective daze, mesmerized by their cell phones, etc., who would be difficult to manage in the event of an emergency (I also have no doubt that the folks in charge in these various venues have already considered this and have plans in place).

At any rate, just this morning, I was privy to a number of open junction boxes, cabling attached to sprinkler piping, the odd penetration (don’t have the life safety drawings to hand, so I can’t say), in areas just outside of the main construction zone(s)—and no, I didn’t see a posted infection control risk assessment, but it does make one wonder whether it might not be such a bad thing. Presumably things are well-isolated from an HVAC standpoint, though certainly less so from a noise standpoint, but the whole thing does periodically give one (or at least gives me) pause. It is generally acknowledged that healthcare is a heavily regulated industry, and while I think we could certainly engage in extensive debate about the prioritization of risk when it comes to some of the minor imperfections that have become so much a part of the typical survey report, I don’t know that I would alter the accreditation process (which is kind of self-serving as helping folks manage the process is how I make a living).

In the end, this probably a little ado about nothing, but sometimes one is charged with channeling one’s inner curmudgeon…

One item as we close out this week, Health Facilities Management is soliciting input on the operational challenges relating to various monthly inspection and testing items (exit signs, elevator recall) as a function of (more or less) “if you already have a reduced resource pool with which to work, how are you going to manage these.” Check out an article discussing this in general, which includes links to the surveys for each area of consideration. ASHE has been a very effective advocate over time when it comes to compliance activities, so I think it would be good to make your voice heard.

Hanging on in quiet desperation is the safety way: Thought of something more to say!

Recognizing that authorities having jurisdiction (AHJ) always reserve the right to disagree with any decision you’ve ever made or, indeed, anything they (or any other AHJ) have told you in the past, how long are existing waivers, guidance and/or equivalencies good for? Answer: It depends (with more permutations that you can shake a stick at…).

Last week, we chatted a little bit about the whole water management thing, including mention of what CMS is telling surveyors to look for, but I thought it might be useful to extract some of the specifics from that missive (if you missed it last week, it’s here). So, here we have:

Expectations for Healthcare Facilities

CMS expects Medicare and Medicare/Medicaid certified healthcare facilities to have water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems.

Facilities must have water management plans and documentation that, at a minimum, ensure each facility:

  • Conducts 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.
  • Develops and implements a water management program that considers the American Society of Heating, Refrigerating, and Air-Conditioning Engineers (ASHRAE) industry standard and the CDC toolkit.
  • Specifies testing protocols and acceptable ranges for control measures, and document the results of testing and corrective actions taken when control limits are not maintained.
  • Maintains compliance with other applicable federal, state, and local requirements.

Note: CMS does not require water cultures for Legionella or other opportunistic waterborne pathogens. Testing protocols are at the discretion of the provider.

Healthcare facilities are expected to comply with CMS requirements and Conditions of Participation to protect the health and safety of its patients. Those facilities unable to demonstrate measures to minimize the risk of LD are at risk of citation for noncompliance.

Expectations for Surveyors and Accrediting Organizations

Long-term care (LTC) surveyors will expect that a water management plan (which includes a facility risk assessment and testing protocols) is available for review but will not cite the facility based on the specific risk assessment or testing protocols in use. Further LTC surveyor guidance and process will be communicated in an upcoming survey process computer software update. Until that occurs, please use this paragraph as guiding instructions.

Just so you know, I chose to use some of the text in bold font because I think that’s probably the most important piece of this for folks moving forward (kind of makes me think that, just perhaps, there have been citations for folks not actively pursuing water cultures). But it does establish the expectation that a piece of the required risk assessment is going to include something that relates to whether you choose to culture, how often, and how you came to make that determination. I think this helps folks manage some of the ins and outs of this process, but I still feel like this could end up being a source of consternation as surveyors “kick the tires” in the field.


A quiet week in Lake Forgoneconclusion: Safety Shorts and Sandals!

But hopefully no open-toed sandals—maybe steel toed sandals…

Just a couple of quick items as we head out of the Independence Day holiday and into the heat of the summah (and so far, scorching has been the primary directive up here in the Northeast—hope it’s cooler where you are, but I also hope it didn’t snow where you are either…but I guess if you were in Labrador last week, all bets are off).

When last week’s musings on the ligature risk stuff in the July Perspectives went to press (or when I finished my scribbling), the new materials had not yet made their way to TJC’s Frequently Asked Questions page, though I thought that they might—and that’s exactly what has happened. To the tune of 17 new FAQs for hospitals, so if you haven’t yet laid eyes on the July Perspectives, head on over to the FAQ page and immerse yourself in the bounty (that’s a somewhat weird turn of phrase, but I’m going to stick with it).

While you’re there, you should definitely poke around at some of the other stuff on the FAQ page. There are lots and lots of recommendations for risk assessment types of activities, so if you’re looking for some risk minimization opportunities, you might find some useful thoughts. Of particular note in this regard is the practical application of safety practices in those organizational spaces for which your oversight is somewhat more intermittent; I’m thinking offsite physician practices or medical office buildings and similar care locations. Depending on where you are and where they are, it might not be quite so easy to keep a really close eye on what they’re doing. And while I tend to favor scheduling surveillance rounds with folks in general, I also know that if you don’t stop by from time to time, you might not catch any lurking opportunities (and they do tend to be lurksome when they know you’re coming for a visit). In a lot of the survey results I’ve seen over the last 18 months or so, there’s still a pretty good chunk of survey findings generated during the ambulatory care part of the survey process. Safety “lives” at the point of care/service, wherever that may be—definitely more ground to cover now that in the past. At any rate, I think you could use the FAQ stuff as a jumping off point to increase the safety awareness of folks throughout—and you can do that independently of anyone’s vacation schedule (including your own).

Hope you and yours had a most festive 4th!