All Entries in the "Environment of care" Category

Gaining some Perspectives on The Doors of Perception

I’m going to guess that you all out in the audience do not necessarily place The Joint Commission’s Perspectives periodical on your list of must-reads, but for the May and June 2012 issues (and who knows beyond that), you really owe it to yourself to grab a copy and prepare for some hard-hitting door and barrier conversation with our esteemed colleague, one Mr. George Mills, Director of the Engineering Department at The Joint Commission.

At any rate, I think we can point to an increasing level of frustration on the part of the various and sundry regulatory agencies (and us, don’t forget us) relative to the number of findings in the life safety (LS) chapter and the omnipresence of these issues in the most frequently cited standards during surveys. How do we make this go away? The answer to that question, interestingly enough, is adopting a risk-based strategy for the ongoing inspection and maintenance of whatever building component is in play – this month its doors.

Now, those of you who’ve been hanging around the pea patch for one or two cycles will immediately recognize the concept as being almost eerily similar to the Building Maintenance Program of days gone by (OK, maybe not so gone by). That said, I think that I can safely say that if you can adopt the strategies contained in this month’s Perspectives (starting on page six), you will have the power (and data-driven power at that) to ensure that your organization will not have to endure another RFI for door issues on your final survey report (but remember that you may still have to use the post-survey clarification process to rid yourself of those pesky RFIs. Still, it is so worth it).

The article has recommendations, a lovely form to use, the philosophy and concept behind the whole thing – really, it’s the complete package. One word of caution: Stuff that appears in Perspectives is traditionally held to be equivalent to anything in the standards manuals and FAQs. For all intents and purposes it’s a requirement, so you’d better get to the adoption of this strategy or having a most compelling risk assessment to indicate that you are achieving an equivalent level of safety for your facility and its occupants. Failure to do so will make things very difficult when attempting post-survey clarifications.

As noted in the article (and this has been a frequent touchstone in my consulting practice), the stuff The Joint Commission is finding is mostly minor in nature: doors not latching, missing ratings labels, excessive gaps and undercuts, etc. These is not big ticket stuff by any stretch of the imagination. And, to my way of thinking—odd though it may be at times—there is no reason we should have to be burdened with having to clean up all these little survey messes (not that I’m advocating big messes as an alternative – no no no). I think we’ve been provided a very implementable strategy for keeping things on the side of compliance, which is never a bad thing.

What do you folks think?

Taking care of business

Earlier today, I was conducting an EC/EM interview session with a very participative group and I was complimenting them on their ability to speak to improvement efforts in areas that are not necessarily in their scope of practice. Now, my experience has been that the folks most familiar/expert with the EC function being discussed tend to dominate the conversation (sometimes in a good way, sometimes not) and I thought it was cool that these folks were so familiar with what others in the group felt was important. To my compliment, the observation was made (and I thought this was absolutely the grandest definition of what a high-performance team can achieve) that they mind each other’s business. In that simple turn of phrase (not an exact quote – sometimes paraphrase is the best I can do), the whole concept of what the EC team can embrace and accomplish was crystallized: It’s not about what may or may not be “somebody else’s job” (or “not my job”); it’s actually using the team concept to make and sustain improvements. In the old days we used to call that type of organizational behavior “silos,” which is OK if you’re storing grains and such, but when the goal is organizational improvement, we want to be more like a snack mix with all sorts of nuts and fibrous bits.

And please keep in mind, it’s not necessarily about never having any issues to correct. As long as there are human beings in the mix, there will be corrections to make – be assured of that. But if you can harness the power of a group of committed individuals who accept responsibility, hold each other accountable, and care enough to “mind each other’s business,” you can accomplish so much. There’ll always be stuff to do, but think about the power of getting stuff done.

Brings a smile to my face – how ‘bout you?

Shock the monkey (part x + y to the 10th power) – here we go again…

OK, so now it appears that we’re going to have to rethink how we schedule preventative maintenance (PM) activities on our critical equipment, particularly if that criticality affects patient health and safety. I believe that we’ve already chatted a bit about the whole clarification of PM frequencies and where CMS stands on the issue (in case you hadn’t noticed, they’re pretty much standing on your head).

In issuing the clarification (and I will freely admit that I missed this at first – check it out at: https://www.cms.gov/Surveycertificationgeninfo/downloads/SCLetter12_07.pdf), the Feds have decided that, in the matter of critical equipment, the frequency will reflect manufacturer recommendations, AND NOTHING ELSE! Let me repeat that: AND NOTHING ELSE!

For example, PM’ing defibrillators on an annual basis (despite what your experience might indicate) is a big freaking no-no! Isn’t that special? Yeah, I thought so, too.

Maybe this isn’t anything to you folks, but I know of at least one hospital that got cited during a recent survey, so when there’s one, there’s usually others (these things almost never happen in isolation). So, if you think you may be taking advantage of logic and common sense approaches to the management of the risks associated with the use of medical equipment, think again (hopefully this won’t shift again, but if history tells us anything.)

And your bird can sing…

One of the topics that resurfaces every once in a little while concerns those most critical documents– your life safety drawings – and what should be contained therein. If you are still uncertain about what those suckers oughta look like, I would direct your attentions to the February 2012 edition of The Joint Commission’s EC News in the “Asked and Answered” section. The laundry list of items to be included on your life safety drawings is not particularly surprising by those among us who have been advocating for a certain contingent of information. So, if you were going to air out your “dirty” life safety drawings, some items for consideration might include:

• a legend that clearly identifies fire safety features of your building
• identification of those areas of the building that are fully sprinkled (if your building it partially sprinkled – no need for such detail if you’re fully sprinkled)
• the location of all of your hazardous storage areas (if you’re not sure what that entails, check out EP #2 under LS.02.01.30 and/or NFPA 101-2000: 18/19.3.2.1);
• the locations of all your rated barriers (yes, all of them – don’t leave any out)
• locations of all your smoke barriers
• the boundaries of any areas that have been designated as suites – and don’t forget to include the square footage of the suites – both sleeping (maximum 5,000 square feet) and non-sleeping (maximum 10,000 square feet)
• locations of your smoke compartments
• the locations of any chutes and/or shafts (as opposed to chutes and ladders – that’s kids’ stuff)
• any approved waivers or equivalencies.

A quick word about waivers and equivalencies: It’s always nice to share those ahead of time with your various “Authorities Having Jurisdiction.” A proactive approach to communications, as with most proactive approaches, will yield much goodwill. This whole thing works best as a collaborative process. No surprise on either side and you’ve got yourself a pretty good survey experience.

Things can only get better…

As we sprint rapidly toward March and beyond (it seems like it was just January!), I suspect that folks are wrapping up their annual evaluations of the objectives, scope, performance, and effectiveness of your environment of care program. One of the “open” questions I like to ask during EC interview sessions is, in looking back over the last 12 months or so, how did you manage to improve the management of risk in the physical environment, or, in the vernacular: What got better over the last year?

This question usually engenders a fair amount of discussion, depending on the group (try to avoid having too many wallflowers in your real EC interview – it’s all about group participation). But the question that I don’t always have the time to ask is: Based on the initiatives.just described, how do you know that it actually represented improvement? Do you look at some specific metrics/benchmarks/ performance measures to make that determination? Is it based on impression? If you were tasked with really having to prove the value of the EC program’s efforts, how would you do that?

The other side of that coin: What about initiatives that didn’t work? Realistically, nobody succeeds with everything that might be implemented over the course of time. Sometimes organizational culture is not ready for certain types of changes; sometimes other factors come into play. So, do you have any home runs or ugly strike outs to share?  Minimally, it will serve as a means of identifying (yet again) that the similarities in our various practices generally outweigh the disparities ; we are, after all, in this together. Looking forward to hearing how folks are doing! So, in a nutshell:

What got better – how do you know?

What didn’t get better – do you know why?

Manufacturer recommendations?!? We don’t need no stinkin’ manufacturer recommendations…

As you’re no doubt aware, there is some movement afoot relative to the inclusion (or exclusion, depending on your preference and organizational experience) of the risk assessment concept when it comes to the establishment of preventative maintenance frequencies for medical equipment. The Joint Commission has historically encouraged the use of data and past performance to provide a backdrop for the most efficient utilization of clinical engineering resources. However, CMS has been pretty adamant and absolute in their preference for manufacturer recommendations for PM frequencies to be the “be all, end all” source for determining such things.

As we take on the next in our informal series—CMS – what up with them?—we bounce once again to the web–

https://www.cms.gov/SurveyCertificationGenInfo/PMSR/itemdetail.asp?filterType=none&filterByDID=-99&sortByDID=4&sortOrder=ascending&itemID=CMS1254595&intNumPerPage=10

–and find that, lo and behold, there has been some relaxation in terms of scheduled PM frequency. The caveat, at least for the moment, is that although we can judiciously schedule preventative maintenance activities to our heart’s content, we’d best not stray from the manufacturer recommendations for what those activities will include.

Now, off the top of my head, I can’t think of too many instances in which you would modify manufacturer recommendations for such activities, but maybe you can. I’m not sure how effective this will be; my gut says it helps in the long run; the fundamental change is toward a more flexible planning (they’d have been looking for us to follow manufacturer recommendations for the PM activities anyways, so this is really nothing new as near as I can tell – please feel free to disabuse me of that notion).

What say all you clinical engineers out there?

And I’ll return to claim your hand – as the King of California

I generally don’t single out any of the myriad potential demographics of this portion of the blogosphere, but the Joint Commission’s January 2012 Perspectives, has singled out of you good folks keeping the safety faith out in California, based on some state-level legislation promulgated back in 2010.

The focus of the legislation is those folks engaged in CT scanning activities, which I’m going to guess includes just about everyone (the standard applies to ambulatory, critical access, and hospital accreditation). I don’t see this as a particular nuisance for folks. I believe that everyone with a compliant radiation control program is on top of this, but if you’re not—even if outside of California—this new element of performance (EP) might be worthy of consideration moving forward.

EP #17 (an “A” EP) under EC.02.04.03 requires at least an annual measurement of the actual radiation dose produced by each CT imaging system, and further requires that the radiation dose displayed on the system is within 20% of the actual amount of radiation dose measured. Naturally, the dates of these verifications would be documented (and, by extension, made available during survey.)

(We’ll be chatting more about what documents and documentation could be considered “reviewable” during survey—it’s a long list.

Now, a 20% margin is a pretty wide range, I would say. In fact, if there’s anyone out there in Cali who’d care to weigh in, would you mind speaking to how you’re managing this process and what your experiences have been? I’m going to guess the 20% tag is fairly attainable on a regular basis, but maybe not. It’s not really something that I’ve focused on in the past. It does seem that legislation on the coasts tends to ripple across the compliance landscape, so maybe a future concern is best dealt with now.

At any rate, if you have stories to share, by all means, please include us.

I need to know

Another challenge that’s been rearing it’s ugly little head is the requirement for staff and licensed independent practitioners (LIP) to describe or demonstrate actions to be taken in the event of an environment of care incident, as well as knowing how to report an environment of care risk. I will freely admit that this one can be most tricky to pull off).

The tricky piece, at least in my estimation, is that any data that would be gathered during survey would be the result of direct interaction with staff in the care environment. For staff, one strategy would be for them to contact their immediate supervisor to report a risk, or to be able to articulate the use of a work order system to notify facilities, biomedical, safety, and/or environmental services of conditions needing resolution. Alternatively, some hospitals have a single phone number for reporting unsafe conditions. Presumably, staff can also speak to their specific roles in emergency response activations such as fire, security, disaster, etc.

As to the LIPs, this task can be exponentially more difficult as, strictly speaking, the expectations of this group are pretty much the same as the rest of the house. I’m presuming that you have an emergency phone number to report codes and fire events. An LIP who is able to articulate familiarity with those codes and events would be useful toward a finding of compliance. They really ought to be able to articulate past the point of ignoring something and to at least be able to put in motion some sort of reasonably attainable resolution.

Again, I’ve not seen this come up a great deal with the LIPs, though certainly the rest of the cadre of front line staff would be considered targets during a survey. I think the key approach is to very clearly and very simply define what constitutes appropriate responses of staff and practitioners. When The Joint Commission doesn’t specifically define what they mean in a standard, it behooves us to define how compliance works in our organizations.

A little more conversation – and a little more action too!

By this point, you should be thinking about (or already acted on) setting up conversations with your testing vendors to ensure that your fire protection systems testing, inspection, and maintenance documentation reflects the requirements as outlined in EC.02.03.05, Element of Performance #25. Your vendor (and, as the end game, you) is on the hook to provide the following information:

-          The name of the activity

-          The date of the activity

-          The required frequency of the activity (i.e., quarterly, annually, etc.)

-          The name and contact information, including affiliation of the person who performed the activity

-          The NFPA standard(s) referenced for the activity

-          The results of the activity (usually pass or fail)

I’m sure you’ll remember past discussions regarding testing documentation. If you need a refresher, click here. We know that there continues to be a fair amount of survey vulnerability when it comes to this area—it’s still in the top 10 most frequently cited standards for 2011. Clearly, there are some very specific expectations in play here. The actual content and context of those expectations might still be a wee bit murky, but hey, what are you going to do? Ithink it’s time to make sure that our testing vendors are singing from the same hymnal.

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