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I am barely breathing: Gas Equipment is on TJC’s Radar!

The past couple of weeks, I’ve been fielding some questions relative to some new performance elements under the Medical Equipment Management standard that covers inspection, testing, and maintenance activities. Apparently, folks have been receiving some sort of notifications from profession groups (in this case, it seems to be the respiratory therapy folks that are being targeted with the notifications.

At any rate, I think we can say (pretty much for all time) that any changes to the standards/EPs is likely to result in (at the very least) consternation and a potential uptick in findings related to said standards/EPs. At least some of the questioning is focused on a certain element of reliance on vendors (and we know how that can go). So, while I do believe that for the most part folks are going to be OK with the changes, I also recognize that a little conversation couldn’t possibly hurt…

In case you’ve not yet encountered the new stuff, what we have is this. For equipment listed for use in oxygen-enriched atmospheres (more on that in a moment), the following must be “clearly and permanently” labeled on the equipment (permanently meaning the labeling withstands cleaning and disinfecting—how many labels are like that?): 1) Oxygen-metering equipment, pressure-reducing regulators, humidifiers, and nebulizers are labeled with name of manufacturer or supplier; 2) Oxygen-metering equipment and pressure reducing regulators are labeled “OXYGEN–USE NO OIL”; 3) Labels on flowmeters, pressure-reducing regulators, and oxygen-dispensing apparatuses designate the gases for which they are intended; and 4) Cylinders and containers are labeled in accordance with Compressed Gas Association (CGA) C-7.

The source material for these “new” requirements is in NFPA 99-2012 11.5.3.1; and please note that color coding is not to be utilized as the primary method of determining cylinder or container contents; I suppose when you come right down to it, cylinders are no different than any other secondary container when it comes to identifying the contents.

The follow-up question becomes one of what constitutes an “oxygen-enriched atmosphere”; in the definitions section of NFPA 99-2012, section 3.3.131 gives us this: “3.3.131 Oxygen-Enriched Atmosphere (OEA). For the purposes of this code, an atmosphere in which the concentration of oxygen exceeds 23.5 percent by volume. (HYP)” Now, you may notice the little tag at the end of this definition, which gives us some indication of where we need to be particularly mindful, with “HYP” referring to hyperbaric therapy. I know there are more hyperbaric therapy locations than there used to be, but some folks aren’t going to have to worry too much about this. But in the interest of a complete picture, I looked over the materials in the NFPA 99 Handbook and I think the information there further narrows down the field of concern:

“The normal percentage of oxygen in air is 20.9 percent, commonly expressed as 21 percent. The value of 23.5 percent reflects an error factor of ± 2.5 percent. Such a margin of error is necessary because of the imprecision of gas measurement devices and the practicality of reconstituting air from gaseous nitrogen and oxygen. Hyperbaric chambers located in areas of potential atmospheric pollution cannot be pressurized with air drawn from the ambient atmosphere. Such chambers are supplied by ‘air’ prepared by mixing one volume of oxygen with four volumes of nitrogen. It is impractical to reconstitute large volumes of air with tolerances closer than 21 percent ± 2.5 percent. The code does not intend to imply that the use of compressed air cylinders in normal atmospheric areas (i.e., outside hyperbaric chambers) would create an oxygen-enriched atmosphere. The compressed air expands as it leaves the cylinder, drops to normal atmospheric pressure, and is not oxygen-enriched. This definition varies slightly from the one appearing in NFPA 53, Recommended Practice on Materials, Equipment, and Systems Used in Oxygen-Enriched Atmospheres [12], which states that the concentration of oxygen in the atmosphere exceeds 21 percent by volume or its partial pressure exceeds 21.3 kPa (160 torr). The scope of the definition is limited to the way the term is used throughout NFPA 99. The definition is independent of the atmospheric pressure of the area and is based solely on the percentage of oxygen. In defining the term, the issue of environments, such as a hyperbaric chamber, where the atmospheric pressure can vary, was taken into consideration. Under normal atmospheric conditions, oxygen concentrations above 23.5 percent will increase the fire hazard level. Different atmospheric conditions (e.g., pressure) or the presence of gaseous diluents, however, can actually increase or decrease the fire hazard level even if, by definition, an oxygen-enriched atmosphere exists. An oxygen-enriched atmosphere, in and of itself, does not always mean an increased fire hazard exists.”

At the moment, given the definition above, I can’t think of anything other than hyperbaric environments that would be covered under the new requirements, but I’ll keep my ear to the ground and pass on any information that seems worth sharing; beyond that, I would do an analysis of equipment for hyperbaric therapy and go from there.

When we consider how we’re going to make this happen (if it isn’t already; I’m thinking/hoping that the gas equipment suppliers are paying attention to the new rules), at the end of the day, compliance with Joint Commission standards and performance elements rests solely in the hands of the organization. Again, presumably/hopefully/expectantly, the vendors from whom you obtain medical gases, equipment, etc., will be familiar with the requirements as they are based on the currently adopted/approved version of NFPA 99, as well as the requirements of the Compressed Gas Association (CGA). I would reach out to them to see what their plans are for compliance, remembering that (at least for the moment) the new requirements apply only to the gases and equipment used in oxygen-enriched atmospheres. I suspect that there will come a time when all related equipment, etc., is similarly labeled, but you may find that in the short term that you will have to keep a close eye on equipment used in surgery, hyperbaric oxygen, etc., to ensure that everything is as it should be. The general concept of not using oil on oxygen equipment is not new, so it may be that this is not going to be as big a struggle as might first appear. I’d be interested in finding out what you learn from the vendors you’re using, just to establish a baseline for advising folks.

 

Breaking good, breaking bad, breaking news: Ligature Risks Get Their Day in Court

As I pen this quick missive (sorry for the tardiness of posting—it was an unusually busy week), the final vestiges of summer appear to be receding into the distance and November makes itself felt with a bone-chilling greeting. Hopefully, that’s all the bone-chilling for the moment.

Late last month brought The Joint Commission’s publication of their recommendations for managing the behavioral health physical environment. The recommendations focus on three general areas: inpatient psychiatric units, general acute care inpatient settings, and emergency departments. The recommendations (there are a total of 13) were developed by an expert panel assembled by TJC and including participants from provider organizations, experts in suicide prevention and design of behavioral healthcare facilities, Joint Commission surveyors and staff, and (and this may very well be the most important piece of all) representatives from CMS. The panel had a couple of meetings over the summer, and then a third meeting a few weeks ago, just prior to publication of the recommendations, with the promise of further meetings and (presumably) further refinement of the recommendations. I was going to “cheat” and do a little cut and pasting of the recommendations, but there’s a fair amount if explanatory content on the TJC website vis-à-vis the recommendations, so I would encourage you to check them out in full.

Some of the critical things (at least at first blush—I suspect that we, as well as they, will be discussing this for some little while to come) include an altering of conceptual compliance from “ligature free” to “ligature resistant,” which, while not really changing how we’re going to be managing risks in the environment, at least acknowledge the practical reality that it is not always possible to provide a completely risk-free physical environment. But we can indeed appropriately manage the remaining risks by appropriate assessment, staff monitoring, etc. Another useful recommendation is one that backs off on the notion of having to install “alarms” at the tops of corridor doors to alert that someone might be trying to use the door as a ligature point. It seems that the usefulness of such devices is not supported by reported experience, so that’s a good thing, indeed.

At any rate, I will be looking at peeling these back over the next few weeks (I’ll probably “chunk” them by setting as opposed to taking the recommendations one at a time), but if anyone out there has a story or experience to share, I would be more than happy to facilitate that sharing.

As a final note for this week, a shout out to the veterans in the audience and a very warm round of thanks for your service: without your commitment and duty, we would all be the lesser for it. Salute!

 

Healthcare Leadership Culture Moving Forward: What I (probably) didn’t do during my summer vacation

As a frequent traveler, I tend to read a fair amount in transit (my preferred operating system for reading is the traditional “hard copy”, aka “books” most often from the coffers of the public library), and in doing so, I try to mix in fiction and non-fiction titles. Also, as a function of traveling, I hear about a lot of stuff on the radio (usually the local NPR station—there’s almost one of those everywhere I go), which is not quite as mesmerizing as chasing videos on YouTube, but I’ve found that there’s a whole world of stuff out there, some of which I only learn about because I’m in the right place at the right time. To that end, I have a few suggestions to share with you that (hopefully) will remove some of the happenstance of discovering something you might not otherwise have encountered. So here I present to you, if you will, a fall reading list.

To ease into things, first up is an article from the September 2017 issue of Occupational Health & Safety entitled “The Right Amount of Leadership Done Easy” by Robert Pater. The opening premise asks the question of how many folks have adopted a strategy because it was easy, even though it was ineffective. I liken this to the “all purpose” response to deficiencies in the environment that focuses on more education of staff, when the response should really by aimed towards why the current education process is not as effective as it needs to be, based on results. My philosophy on this is that (unless you have a woefully inadequate education process) staff have received as much education as they need to. You may need to tweak subject matter over time as risks and conditions change. At any rate, I found the article to raise some interesting / thought-provoking concerns and I think definitely worth checking out.

I just finished reading “Shooting Ghosts: A U.S. Marine, a Combat Photographer, and Their Journey Back from War” by Thomas J Brennan USMC (Ret) and Finbarr O’Reilly. I’ve heard both of the authors interviewed recently (yes, on NPR) and found their account of recent events in various war/strife zones compelling enough to take on the book. Now, you may well ask, what does this have to do with healthcare? And I can tell you there is a lot to do with healthcare—from Mr. Brennan’s travails with the management of behavioral health patients (Mr. Brennan suffered a traumatic brain injury during a deployment in Afghanistan and has been dealing with the consequences of that event) in the VA and civilian systems to some insight to how healthcare can more effectively manage care and treatment of folks by learning more about the “patient experience” (definitely a buzzword in healthcare). At any rate, Mr. Brennan and Mr. O’Reilly’s stories are harrowing, both from an experiential standpoint, but also on (and this is my “take”) the uncertainty of the treatment process—even when practitioners act with certainty.

Next up, we have the Managing Millenials for Dummies Cheat Sheet; a little while back, we covered some the more operational aspects of the impact of millennials in our workplaces (and believe me, they’re not going away), from their view of the world to the more tribal aspects of their attire and personal presentation. I think those of us older (I’m more than half way to my next colonoscopy, so I can no longer consider myself among the young ‘uns) folks can say with some degree of accuracy that things have changed a bit over the last 10-15 minutes (OK, maybe even years, but sometimes it’s overwhelming to look that far back into the past) and I think you’ll find the Cheat Sheet both amusing and perhaps somewhat illuminating. It would be nice if all these generational “buckets” were more easy to profile, but it might beg some questions with/for folks you have working for you. Just sayin…

These last two titles I have not yet read (they’re in my pile), but heard mention of them on the radio (unfortunately, I cannot recall exactly which program might have been the one that planted the seeds of interest). The first, “Games People Play: The Basic Handbook of Transactional Analysis” by Dr. Eric Berne (originally published in 1964—thankfully I was born at that point) rang some bells with me, particularly an example of how certain individuals collect slights against them to be used in the future when they have slighted someone else. The example that sprang to mind was a department director to whom I had to speak about a recalcitrant employee (I think it was a parking issue), with the director responding that “well, a couple of months ago, we found a member of your staff asleep in an exam room,” with the intent that my sleeping staff person was far worse than whatever parking issue was at hand. Of course, I did ask as to why I hadn’t been notified at the time, but the response was somewhat vague and not particularly helpful. I guess it’s kind of like saving things for a “rainy day,” but I am a firm believer in taking care of things now if there is an issue. At any rate, I think it’s kind of interesting to see the various scenarios laid out in a scholarly fashion. I think you’ll find more than a little of the information to represent familiar interactions with folks.

The last title for our little book club is of a little more recent vintage; “Mistakes Were Made (but not by me)” would be interesting if only for the title alone, but the subtitle “Why We Justify Foolish Beliefs, Bad Decisions, and Hurtful Acts” is probably a little more timely than at any other time in recent history. That said, as we in healthcare move ever closer to the vision of just culture (and all the accompanying acts of finger-pointing along the way), I think this is worth a read.

If any of you folks out there check any of these out, please feel free to provide feedback as to whether or not I should stay away from book recommendations.

Stay Calm and Read A Good Book!

Keep calm and stock up on emergency supplies

Hospitals are generally prepared for emergencies, but don’t be afraid to kick those tires one last time.

I don’t know that this last spate is officially the most congested high-intensity weather pattern we’ve ever encountered, but it has got to be right up there in the uppermost tier. As we continue to keep our thoughts on those who have been managing the effects of Harvey, Irma, and Jose, I suppose it’s only a matter of time before the critiques start arriving.

I do believe that hospitals in general are appropriately prepared to respond to emergencies (and I know for certain a number of hospitals that appropriately prepared). As I pen this, I am sitting at the airport in Charlotte, North Carolina, waiting to see if Irma is going to let me get to some client work this week or force me to be Boston-bound.

My philosophy about these things is that there is very little, if any, control that can be exercised as events unfold; the only true aspect of control is to be able to position yourself to make good decisions for the duration of whatever event you might be facing. From what I can gather, this was very much in effect as hospitals in the southeastern U.S. and into the Caribbean responded to recent weather events.

Not every physical plant fared as well as some, but one of the quirky things about catastrophes is they tend to be, well, catastrophic—if it had been business as usual, we probably wouldn’t be talking about it at the moment. At any rate, kudos to those folks who did what they had to do to keep things together, and our best to those for whom every preparation in the world could not have been enough.

In other news

I was going through some stuff I’ve had in the queue for a while that really didn’t fit thematically in the conversation of the week but that I think would be useful to bring to your collective attention. So, in brief (some of you will probably question my definition of brevity, but I can live with that), here they are:

  • For the foreseeable future, there will be a fair amount of scrutiny of the physical environment in your outpatient locations, and a key component of managing those environments is making sure that the folks who are keeping the place clean are on top of their game. It is not uncommon for organizations to have to use independent contract cleaning services for their outpatient locations, but clean is clean is clean—and we know some of the surveyors are not shy about getting out their white gloves and rooting around for GFM (gray fibrous material, a.k.a. dust). Patient environments need to be properly maintained–and you know who’ll suffer the consequences if that’s not happening.
  • Back in April, our friends in Chicago, The Joint Commission, published Quick Safety 32: Crash-cart preparedness; while not everything on their list is specific to the physical environment, there is a lot of fair info relative to process. There are certainly safety and security (not to mention life safety) implications if resuscitation supplies and equipment are not properly maintained—and this applies to your outpatient settings as well. Keep an eye on crash carts wherever they may be.
  • Finally, (and going way, way back to January 2017), The Joint Commission’s Quick Safety 30 covered the all-too-current topic of protecting patients during utility system outages. I think we can all agree that this summer has brought a few too many opportunities to test our mettle in this regard (and, again, great job everyone!), but, as we all know, utility systems can crap out at any time, with minimal warning. So, the watch words (or watch concepts, as it were) are “contingency” and “plans”—redundancies, staff ability to respond to disruptions, etc. are some of the keys to success. Quick Safety 30 also provides a couple of links to some contingency planning resources. The truism underneath all this stuff is that one can never be too prepared, so don’t be afraid to kick those tires one last time.

 

Any world that I’m welcome to…

Sometimes a confluence of happenings makes me really question the legitimacy of coincidence. For example, it can’t possibly be coincidence that our friends in Chicago use the backdrop of September to tell us how poorly we are faring relative to compliance in the management of the physical environment. Yet, like clockwork, September brings the “drop” of the most frequently cited standards (MFCS) during the first half of the year. (I did look back a few years to validate my pre-autumnal angst—they waited until October to publish the MFCSs in 2012.) And, for a really, really, really long time, the physical environment continues to maintain its hegemony in the hierarchy of findings.

In years past, we’ve analyzed and dissected the living heck out of the individual standards, looking at the EPs likely to be driving the numbers, etc. Anybody wishing to revisit any of those halcyon days, you can find the (not quite complete) collection here:

Anyhoooo… I really don’t see a lot of changes in what’s being found, though I will tell you that there has been a precipitous increase in the number of organizations that are “feeling the lash.” Last year’s most frequently cited standard, which deals with various and sundry conditions in the care environment (you might know it as EC.02.06.01, or perhaps not), was found in about 62% of organizations surveyed. This year, the percentage has increased to 68% of organizations surveyed, but that number was only good enough for 5th place—the most frequently cited standard (the one that deals with all that fire alarm and suppression system documentation*) was identified in a whopping 86% of the hospitals surveyed!

I think it’s important, at this point, to keep in mind that this is the first year of a “one and done” approach to surveying, with the decommissioning of “C” or rate-based performance elements. I don’t know that I have encountered too many places with absolutely perfect documentation across all the various inspection, testing, and maintenance activities relating to fire alarm and suppression system documentation. I also don’t know that I’ve been to too many places where the odd fire extinguisher in an offsite building didn’t get missed at some point over the course of a year, particularly if the landlord is responsible for the monthly inspections. Face it, unless you have the capacity to do all this stuff yourself (and I’m pretty sure I haven’t run into anyone who has unlimited resources), the folks charged with making this happen often don’t have an appreciation for what a missed fire extinguisher, missed smoke detector, etc., means to our sanity and our peace of mind.

As I’ve been saying right along, with the exceptions being management of the surgical environment and the management of behavioral health patients, what they are finding is not anything close to what I would consider big-ticket items. I refrain from calling the findings minutiae—while in many ways that is what they are, the impact on folks’ organizations is anything but minute. If the devil is indeed in the details, then someone wicked must have passed their CORI check for a survey job…

Relative to last week’s rant regarding policies; first a shout-out of thanks to Roger Hood, who tried to post on the website (and was unable to ) regarding the CMS surveyor Emergency Preparedness survey tool as a potential source for the TJC policy requirement. (It’s an Excel spreadsheet, which you can find here, in the downloads menu near the bottom of the page: Surveyor Tool – EP Tags.) While I “see” that a lot of the sections invoke “policies and procedures,” I still believe that you can set things up with the Emergency Plan (Operations / Response / Preparedness—maybe one day everyone will use the same middle for this) as your primary organizational “policy” and then manage everything else as procedures. I suppose to one degree or another, it’s something of an exercise in semantics, but I do know that managing policies can be a royal pain in the tuchus, so limiting the documents you have to manage as a “policies” seems to make more sense to me. But that may just be me being me…

*Update (9/7/17): Quick clarification (I could play the head cold card, but I should have picked up on this); the most frequently cited standard deals with fire suppression system stuff—gray fibrous material (GFM) on sprinkler heads, 18-inch storage, missing escutcheons, etc. While I suppose there is some documentation aspect to this, my characterization was a few bricks shy of a full load. Mea maxima culpa!

You are so beautiful, to me…

In the interest of a little summertime reading, I wanted to diverge a bit from the usual rant-a-minute coverage (rest assured, the ranting will continue next week—too much going on in the world) and cover a couple of “lighter” topics (though one does have to do with my favoritest topic—risk assessments).

First up, we have Soliant Healthcare’s list of the 20 most beautiful hospitals in the U.S. (as a music lover, I find that I am an absolute sucker for lists—go figure!); while I have not had the opportunity to do any work at the listed facilities (and have done some work at places I think measure up pretty well from a design perspective, etc.), I can say that the buildings represented on the list are pretty easy on the eye. I don’t know if anyone out there in the Mac’s Safety Space blogosphere works at any of the listed facilities, but congratulations to you if you do or did!

The other item for this week focuses on the pediatric environment; from my experiences, a lot of community hospitals have really scaled back their pediatric care facilities, mostly because demand is not quite what it used to be. Where there might once have been dedicated pediatric units, now there are a handful of rooms used for pediatric patients when they need in-hospital care, but not much in the way of dedicated spaces.

If you happen to be in a position in which your dedicated pedi spaces are not quite as dedicated as they once were, you might find it useful to perform a little risk assessment based on a toolkit provided by the University of California, San Francisco, and endorsed by a couple of professional groups. While the focus is more towards the home environment, I think it’s helpful to simply ask the questions and be able to rule out the concerns outlined in the toolkit. Any time you have to “run” with an environment that has to function for different patients, risk factors, etc., it never hurts to be able to pull a risk assessment out of your back pocket when a surveyor starts jumping ugly because they don’t agree with what they’re seeing or how you’re managing something.

The National Center for Missing & Exploited Children used to provide some risk assessment guidance for healthcare professionals, but in looking at their website, it appears to me that they are confining guidance to law enforcement, media, and families. (Some of the stuff for families is interesting and worth sharing in general.) Since they’re an at-risk patient population, you never know when your efforts to provide an appropriate environment for infants, children, and teens will come under survey scrutiny—and it never hurts to periodically review your efforts to ensure that your plan is current.

If brevity is the soul of wit…

Hope everyone enjoyed a festive and (most importantly) safe Independence Day—with any luck, today (July 5) does not mark the end of summer (as some do say) so much as it marks the beginning of the end of spring (up here in the Northeast, spring was loath to depart, but it does seem that pre-autumn weather has finally made a commitment to spending some time in the northern hemisphere).

I was looking recently at past blog posts for a reference to the CMS stance on law enforcement interactions with patients as a function of restraints and patient rights—always a fun topic—and I noted that the posts used to be a mite briefer than tends to be the case of late. (You can be the judge of whether my decline in brevity has left me soulless or witless.) I absolutely recognize that there’s been a lot of stuff to cover over the past 18 months with the firestorms of compliance that swept the healthcare environment, which has (no doubt) promoted some of the “volume” of bloggery. But it has caused me to wonder whether I am consuming the compliance elephant in sufficiently small bites to be of use to you folks out there in the field. As near as I can tell, the purpose of this whole thing (as much as I enjoy having a place to pontificate) is to provide information and thoughts on what is happening at the moment to you, my faithful audience of safety folk. And (as near as I can tell) it never hurts to ask one’s audience whether this works for you—please feel free to give me an e-dope slap if you think the “Space” has gone intergalactic in a less-than-useful way. At any rate, I am going to experiment with smaller bites of information in the coming weeks so you’ll have more time for other things—perhaps outdoors…

As far as news goes, things are relatively quiet as we observe the anniversary of CMS’s adoption of the 2012 Life Safety Code. Hopefully you all have done your NFPA 99 risk assessments; polished off those door inspections and are speeding towards the completion of activities relating to initial compliance with the Emergency Preparedness Final Rule. Health Facilities Management This Week discussed some prepublication EC/LS standards relating to the testing of emergency lighting systems; inspection and testing of piped medical gas and vacuum systems; and updating pertinent NFPA code numbers. The pre-pub stuff is aimed at behavioral health care, laboratory, nursing care center, and office based surgery accreditation programs. You can find the details here: https://www.jointcommission.org/prepublication_standards_%E2%80%93_standards_revisions_to_environment_of_care_and_life_safety_chapters_related_to_life_safety_code_update_/

(I guess some of those links are about as brief as I am…)

Thanks, as always, for tuning in—I really appreciate having you all out there at the other end of the interweb…see you next week!

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.