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My heart is black and my lips are cold

Crash carts on flame with rock and roll!

I figured I’d start out the newly minted 2017 with a few brief items of interest: a device warning from FDA, some thoughts regarding post-Joint Commission survey activities, and a free webinar that some of you might find of interest.

On December 27, the Food & Drug Administration (FDA) communicated a warning letter to healthcare providers regarding potential safety issues with the use of battery-powered mobile medical carts. The warning is based on FDA’s awareness of reports of “explosion, fires, smoking, or overheating of equipment that required hospital evacuations associated with the batteries in these carts.” Apparently, the culprits are those carts powered by high-capacity lithium and/or lead acid batteries and it also appears that there is a distinct possibility that you might just a few of these rolling around in your facility. Fortunately, the warning (you can see the details here) also contains some recommendations for how to manage these risks as a function of the preventive maintenance (PM) process for the battery-powered mobile medical carts; as well as recommendations for what to do in the event a fire occurs (might be a good time to think about testing your organization’s fire response plan as a function of response to a Class C electrical fire). The warning letter also contains some general recommendations for managing the mobile medical carts. So, if you were wondering whether you were going to have anything interesting to put on the next EOC Committee agenda, this one might just fit the bill. As a final thought on this, I think it very likely that our comrades in the regulatory surveying world might be interested in how we are managing the risks associated with these carts—and if you’re thinking risk assessment, I couldn’t agree more!

Moving on to the post-survey activity front, TJC division, for those about to be surveyed (I salute you!), I have some thoughts/advice for preparing yourselves for a slight, but nevertheless potentially dramatic, shift in what you will need to provide in your Evidence of Standards Compliance—a plan for ongoing compliance. Now I will admit that in some instances, being able to plot a course for future compliance makes a lot of sense; for example, managing pressure relationships in procedural areas. If you get tagged for that during a survey, I think it’s more than appropriate for them to want to know how you’re going to keep an eye on things in the future. But what about the million and one little things that could come up during a survey (and with the elimination of the C elements of performance, I think we all know that it’s going to seem like a million and one findings): doors that don’t latch, barrier penetrations, dusty sprinkler heads, etc. There already exist processes to facilitate compliance; are we going to be allowed to continue to use surveillance rounds as the primary compliance tool or is the survey process going to “push” something even more invasive? It is my sincere hope that this is not going to devolve into a situation in which past sins are held in escrow against future survey results—with compounding (and likely confounding) interest. Sometimes things happen, despite the existence/design/etc. of a reasonably effective process. As I’ve said before (probably too many times), there are no perfect buildings, just as there are no perfect plans. Hopefully perfection will not become the expectation of the process…

As a final note for this week, one of the bubbling under topics that I think might gain some traction the new year is the management of water systems and the potential influence of ASHRAE 188: Legionellosis: Risk Management for Building Water Systems. I know we’ve touched on this occasionally in the past and I think I’ve shared with you the information made available by our good friend at the Centers For Disease Control and Prevention (check it out, if you haven’t yet done so), but in the interest of providing you with some access to a little more expertise than I’m likely to muster on the topic, there is a free webinar on January 19 that might be worth your time. In the live online event, “Following ASHRAE 188 with Limited Time, Money, and Personnel: Pressure for Building Operators and Health Officials,” respected expert Matt Freije will briefly discuss the pressure facing building operators as well as health officials regarding compliance with ASHRAE 188 to minimize Legionella risk, suggest possible ways to reduce the pressure, and then open the conversation to the audience. The 60-minute webcast begins at 1 p.m. EST. It’s free but space is limited; you can register here.

So that’s the scoop for this week. I hope the new year is treating you well. See you next week!

Hortle didn’t hear a portal (with apologies to one T. Geisel)

As I get a little longer in the tooth, I find that I need to create reminders for myself of subjects to cover during our weekly visits. Typically, I will capture an idea as a draft email and return to it as time permits. At any rate, as you are very much aware, there’s been a lot of material in recent weeks that have precluded the need to dig into my archives, but in the interest of keeping my draft emails at a manageable level, as well as making sure that I cover all the discussion points that I wanted to share, over the next little bit (unless something breaks big or bad in the compliance world) I’m going to set the wayback machine for stun and run a few timeless classics (at least I think they’re timeless—please feel free to disagree). Let’s hark back to July to revisit a concept that occupies a lot of my waking time: stewardship and accountability for the management of the physical environment.

As I was lurking about Joint Commission’s Physical Environment Portal (PEP) to see if there were any updates to be found, I stumbled upon a missive in TJC’s leadership blog that I did not recall seeing. This dates back to October 2015 in those halcyon days of the early chortlings of the portal… (insert going back in time sound effects here).

In looking at this particular missive (penned by one G. Mills, Director, Department of Engineering—you can find the whole magillah here), there is some ground covered that is among my most favoritest of topics: the universality of the responsibilities when it comes to the management of the physical environment (and for those you who are keeping count, I have no idea how many times I’ve discussed this particular topic, but I’m going to guess it’s well into double digits. And that’s not even counting the number of times I’ve had variations of this conversation with clients). In the blog, Mr. Mills notes that “…the patient care environment is not owned by one group in the healthcare setting.” I couldn’t agree more and yet I still (still, still, still!) encounter organizations that have not fully embraced that concept—which results in very little surprise on my part that eight of the 10 most frequently cited standards are in the physical environment. Mr. Mills goes on to say, “(W)e cannot look to one group to keep the area clean, another to keep the area warm/cool, and then another group to treat patients independently.” But organizations continue to do just that, get bounced around during surveys, and still (still, still, still!) fail to grasp the team concept of managing the environment.

Now it’s certainly not every organization that has these issues, but until every organization gets “down” with this as a way of conducting the business of healthcare, the EC/LS findings will continue to pile up. The silos of clinical and non-clinical functions in healthcare organizations are no longer a tenable model—I’ve said it before and I will (no doubt) say it again—every individual working at every level in every healthcare organization is a caregiver. I’ll give you the direct/indirect split, but taking care of the patient in the bed is the role and responsibility of everyone. It is past time for a new paradigm. Let’s make it happen—even without updates to the PEP!

As a closing thought, I was rather remiss in my discussion of the final CMS emergency preparedness rule. I neglected to indicate that the new regulations are effective 60 days after publication in the Federal Register (which plunks us into November 2016—you can make a reference to turkeys if you like) and implementation must be completed by November 15, 2017 (again, I will stand by my stand that this is not going to be a very big deal for hospitals—I have yet to find anything that is well and truly new and/or different in what is actually required. As with all things, I suspect that the worm will turn on the interpretive dances of the surveyors).

At any rate, if you don’t have plans for next Tuesday at 1:30 pm EDT, you might want to check out the public call to discuss the new rule, hosted by CMS’ Medicare Learning Network. The call is scheduled to last 90 minutes and you can register here. I will be doing client work that day, but I suspect that there might one or two folks from the editorial world that may tune in, so I am looking forward to finding out what the “skinny” might be on all this stuff. Much ado about nothing or something wicked this way comes? I guess we’ll find out soon enough…

What is it they say about the best-laid plans? A chortle-free, portal-free zone!

Well, I don’t know that I’m disappointed, per se, but I was expecting The Joint Commission to add something new to its physical environment portal, but that appears not to be the case. I guess this calls for an extended drum roll…

But that’s not to say that our friends in Chicago have not been busy—anything but. In fact, it’s been quite a preponderance of stuff this past few days, starting with the 2015 Top 5 most-cited standards. Anyone who bet the under on findings in the physical environment came up a bit short, but surely that can’t be very much of a surprise. We’ve covered the particulars pretty much ad nauseum, but if there’s anybody out there in the studio audience that has any specific questions regarding our top 5, I would be happy to do so again.

So we have the following:

 

EC.02.06.01—Maintaining a safe environment

IC.02.02.01—Reducing infection risk associated with equipment, devices. and supplies

EC.02.05.01—Managing utility system risks

LS.02.01.20—Maintaining egress integrity

LS.02.01.30—Building features provided and maintained to protect from fire and smoke hazards

 

I suppose a wee bit of shifting in terms of the order of things, but I can’t say that there are any “shockahs” (after all, I am from Bawston) in the mix. Again, if someone has something specific they’d like me to discuss, I would be more than happy to do exactly that. Check out the online stuff; alternatively, you can also refer to the April edition of Perspectives.

But wait, there’s more…

We also have some new/updated resources for Life Safety Code® compliance, including guidance on how the facility tour is going to be administered, a comprehensive list of documents that would be included in the survey process, information regarding PFI change and equivalency requests, and a bunch of other stuff. You can find all this information online. Something tells me that, at some point, you may be able to link to all this stuff from the Portal (if that is not already the case, that’s what I would do).

And, to finish off a big week of new information, there is a new posting to help the Emergency Management cause. Namely, some resources having to do with the management of active shooter incidents, etc., featuring the joint resource for healthcare providers issued by the Departments of Homeland Security and Health and Human Services to assist with situational awareness and preparedness in the aftermath of the terrorist attacks in Brussels. The focus/intent being to use recent events as an opportunity to reinforce the importance of vigilance and security in our organizations. It is certainly an area for some concern (and, as always, an area of opportunity) and I think that it is very likely that this will continue to be a big piece of the survey puzzle when it comes to emergency management. The risks associated with acts of violence appear to be relatively unabated in society at large and it comes back to the healthcare safety and security professionals to ensure that our organizations are appropriately managing those risks to the extent possible and working towards an emergency response capability that keeps folks safe.

That’s the wrap-up for this week; not sure if any fireside chats are looming close on the horizon, but rest assured, we will keep you apprised of any and all portal-related activity.

Welcome Spring!

Cue the drum roll: Ladies and gentlemen, I give you the Portal of Perception!

Not so very long ago, The Joint Commission and ASHE announced the creation of an information resource to assist with all those pesky EC/LS findings that have been reproducing like proverbial rabbits (here’s coverage of that announcement  and coverage of those rapidly reproducing findings).

Well, since that announcement, the elves have been very busy cobbling together bits and pieces of this and that, with the end result being a rather interesting blend of stuff (please note that I did not employ the more severe descriptor—stuff and nonsense), with titles like “Is Your Hospital’s Air Ventilation System Putting Your Patients At Risk?” (this one’s in the Leadership module, so I guess they’re asking the question of organizational leadership). I truly hope that your response to that particular query would be “absolutely not,” but I’ve also been working this part of the street long enough to know (absolutely, if you will allow me a brief moment of hyperbole) that there are few absolutes when it comes to the management of the physical environment.

Which leads me to the follow-up thought: Recognizing that there is always the potential for the performance of air ventilation systems to drift a little out of expected ranges, at what point does the performance of air ventilation systems actually put patients at risk? And perhaps most importantly, have you identified those “points” in the performance “curve” that result in conditions that could legitimately cause harm to our patients? And please know that I understand (in perhaps a very basic sense, but I think I can call it an understanding) how properly designed and maintained HVAC systems contribute to the reduction of HAIs, etc. But with any fluid situation, there is an ebb and a flow to conditions, etc., that, again, may veer into the “red” zone from a compliance standpoint. But let me ask you—particularly those of you who have experienced out-of-range conditions/values—have those conditions resulted in a discernible impact on your infection control rates, especially those relating to surgical site infections?

BTW, I’m asking because I really don’t know what you folks are experiencing. And, for those of you that have identified shortcomings on the mechanical side of things, are your Infection Control folks keeping a close (or closer) eye on where those shortcomings might manifest themselves as a function of impact to patients? From the information posted in the Portal (I think I’m going to capitalize), remedying compliance issues in this regard is a simple four-step process (You can find the example of improved compliance there). Who knew it would be so easy? (I could have had a V8!) I don’t think anyone in the field is looking at this as a simple, or easy, task.

At any rate, despite the best efforts of the Portal, until we have buildings (and staff) that are a little closer to perfect, I think we’re going to continue to see a lot of EC/LS findings during survey. Ohboyohboyohboyohboyohboy!

Also, as I think about it, please be sure to check out the Clarifications and Expectations column in the September issue of Joint Commission Perspectives; there are some interesting points to be gleaned, the particulars of which we will cover in a wee bit, so watch this space!

On top of ol’ yellow top

As it happens, I like to share topics and concerns that I encounter while engaged in consulting activities in many of the nooks and crannies of these United States, and I’ve recently run into a common theme that I think warrants your consideration, if not action (though it may ultimately come to just that). But it does appear that this particular vulnerability has reared its shaggy head because of an improving condition relative to infection control concerns—I guess there really is a dark cloud to go with every silver lining.

Over the years, hospitals have been struggling with the management of Clostridium difficile, a very pesky germ typically identified by its street name: C. diff. And one of the key struggles therein revolves around the cleaning of the environment of patients with C. diff, for which the CDC recommends the use of an EPA-approved spore-killing disinfectant in rooms where C. diff patients are treated. And one of the more common (probably most common, but I can’t say that I’ve collected a ton of data in this regard, so this is merely an impression; feel free to validate or not) products used is one euphemistically known as the “yellow top” disinfectant wipes (I’m sure you’ve seen them, but if you’re not sure, you can find images, etc., here).

At any rate, over the past couple of weeks, I have run into a fair number of expired containers of these disinfectant wipes, enough so that it really kind of jumped out at me (and this has been the case in different parts of the country: north, south, east, and west). Inevitably, when one finds a confluence of vulnerabilities, it tends to become a topic of conversation at the various organizations in which the expired products were found (it’s always nice to be able to make some sort of determination relative to a root cause). And the results of those conversations of late leads me to the (completely unscientific) conclusion that hospitals and other healthcare organizations appear to be making some inroads in the management of C. diff patients, resulting in a reduced need for this particular product (uniformly, this product has been earmarked solely for use in cleaning C. diff patient environments, and not much else). Hence, the increased number of expired containers of this product.

So, good news on the management of C. diff patients and their environment, and the identification of an opportunity relative to the management of product expirations. I suppose you could make the case that it is ever thus when it comes to the management of conditions in the physical environment, but if your organization is using this particular product (or, I suppose, whichever disinfectant wipes you’re using for C. diff patients), you may want to issue an APB to ensure that folks are keeping an eye on those expiration dates. Yes, I know that they are, but this could legitimately be described as a recent development…just trying to keep you ahead of the curve.

This one belongs on your shelf…big time!

In the nearly six months I’ve been back in the consulting world, one trend during Joint Commission surveys stands out as the most likely to result in survey heartache (and heartburn). And that trend, my friends, has everything to do with the management of environmental conditions in surgical (and other environments). Clearly, the folks at TJC have struck a motherlode of potential findings—and I have no reason to think that these strikes will be abating any time soon. My advice to you is to start cracking the books—one tome in particular (okay, not so much a tome because it’s really not quite long enough, but if we were to somehow measure its impact…).

For those of you who have not yet procured a copy of the American Society of Heating, Refrigeration and Air-Conditioning Engineers ASHRAE-170 Standard for Ventilation of Health Care Facilities, I cannot encourage you too much to bite the bullet and get yourself a copy of this august standard. I can almost guarantee that doing so will decrease the likelihood of survey ugliness, perhaps even for the foreseeable future.

Now, this volume—a mere 14 pages in length—contains a lovely table (pages 9-12, for those of you keeping score at home) that identifies all the areas in a hospital (hey, maybe even your hospital…imagine that!) in which there are specific design parameters for temperature, humidity, air flow, air exchange rates, pressurization. Pretty much everything that is causing so much pain during TJC surveys of late (I’ve seen a significant increase in the number of Condition-level TJC survey results, which is almost exclusively the result of managing these conditions).

Once you have this volume in your hot little hands, turn to page 9 and start looking at all the places where you can expect scrutiny (word to those facing survey in the near future, there is an indication that the focus is expanding to include any areas in which invasive procedures are performed. Can you say interventional radiology and IVF? I knew you could.). My recommendation is to start working through the list (and, rest assured, it’s a pretty lengthy list) and identify where you are compliance-wise relative to the design parameters listed. And if you should find that you have some compliance vulnerabilities in these areas, please, please, please reach out to your infection control practitioner to start working on a risk assessment/response protocol to manage the risks associated with those non-compliant conditions. It may be the only thing standing between you and an awful journey into the darkness of a condition-level finding—a journey none of us would want to make.

It was the worst of times, it was the worst of times—or perhaps not

It appears that we are soon to be basking in the presence of an interesting confluence. It appears that CMS is looking very closely at requiring hospitals to conduct four-hour generator tests every year. Don’t know that that is a particularly surprising development given the focus on the reliability of emergency power, though I’m not sure how much the brain trust for NFPA 110 was consulted in this regard. At any rate, you will definitely want to take a look at the Federal Register for December 27, 2013 for the proposed rules (the emergency generator piece can be found on pages 79173-4, but the whole proposed rule has to do with hospitals and emergency preparedness; I suspect we’ll be chatting about this stuff for a while). Go to the Federal Register webpage where you can download the PDF of the proposed rule (and get yourself some snacks, it’s 120 pages long). The comment period ends on February 25, so you might want to get in on the action, the options for commenting are on the webpage.

Moving on to the other piece of this lovely regulatory (governmental?) maelstrom, we have the EPA, which is enacting fairly significant requirements for emergency generator emissions (you can find a story on this topic from Health Facilities Management magazine). You can find more information about the specifics of the emissions requirements at the EPA website.

It appears that we will be looking at additional generator testing with stricter emissions requirements—sounds like way too much fun!

 

(Fire) Pump it up!

Just a thought relative to a finding from a recent survey – a quick show of hands, if you will. For those of you blessed (cursed?) with having a fire pump (or two, or three, or…), when your folks conduct the weekly churn test, are they documenting the pressures at the pump as required by NFPA 25-1998, 5-4.3.2.1?

It seems that there are some instances in which the run time for the test is all that is being documented, so if you think you might be among those who aren’t documenting the pump pressures, consider yourself informed. For those of you who don’t have fire pumps, well, one less thing to worry about, which leaves about 999,999 things to worry about. You take one down, pass it around…

Sign of the times

I recently received a question regarding the bona fides for the person(s) in an organization who are charged with signing hazardous materials manifests when the hazardous materials in question are hauled off for final disposal, so I thought it might be useful to give this topic the once over and maybe generate some discussion. [more]

Panic in Detroit – Panic at the Disco – Panic at the Surgery Center…Fire in the Hole!

I’m presuming (and please don’t attempt to disabuse me of this notion) that you are all dutifully conducting security risk assessments on a regular basis. As you conduct them, I’m sure you find risks of some events that are greater than some other areas. So, I to ask: When you’ve completed your security risk assessment, do you identify specific strategies, including the use of technology, for minimizing those risks to the extent possible? If you’re not including that facet in the risk assessment process, you might want to consider doing so.

Recently, I was looking at a survey report in which an ambulatory surgery center was cited during a TJC survey because they had not installed a panic alarm “at the registrar’s desk in order to obtain immediate assistance in an emergent or hostile situation.” Now, as with so many things that have been popping up during surveys, I don’t disagree with the concept of having panic alarms at those customer service/interaction points where unhappy folks (or folks of any ilk) can experience the need to vent their frustrations, etc. But in that disagreement, I think I’d first be looking at what tools have been provided to staff to actively manage, if not de-escalate, these negative encounters. I would much prefer to avoid having to use a panic alarm by appropriately managing the encounter, much like I would just as soon not “need” to have an emergency eyewash station.

I’m a great believer in the proactive management of risk, but I’m also a great believer in implementing risk management and response strategies that make operational sense. So, the question to the studio audience is: Where have you installed panic alarms and where have you not installed panic alarms, and why? There’s always the risk that some surveyor will disagree with your strategy, but if that strategy was derived through thoughtful analysis of the involved risks, does that not meet the intent of all this?

I like the concept of best practice as much as anyone, but I also recognize that there is a tremendous amount of variability in the safety landscape. Just because something works in one place does not necessarily mean that it will work in all cases—that’s the mystical, magical, and ultimately mythical power of the panacea. One size doesn’t fit all—never has, never will. But if we’re going to be held to that type of an expectation, how does that help anyone? Ok, jumping down from soapbox for now, but rest assured, you’ll see me back up here before too long.