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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.

Time to bust a cap in your…eyewash station?!?

Howdy folks! A couple of quick items to warm the cockles of your heart as winter starts to make its arrival a little more obvious/foreboding (at least up here in the land of the New English) as we celebrate that most autumnal of days, All Hallows Eve (I’m writing this on All Hallows Eve Eve)…

The first item relates to some general safety considerations, mostly as a function of ensuring that the folks who rely on emergency equipment to work when there is an emergency are sufficiently prepared to ensure that happens. It seems that lately (though this is probably no more true than it usually is, but perhaps more noticeable of late) I’ve been running into a lot of emergency eyewash stations for which the protective caps are not in place. Now I know this is partially the result of too many eyewash stations in too many locations that don’t really need to have them (the reasoning behind the desire for eyewash stations seems to lean towards blood and body fluid splashes, for which we all know there is no specific requirement). At any rate, my concern is that, without the protective caps, the eyewash stations are capable of making the situation worse if someone flushes some sort of contaminant into their eyes because stuff got spilled/splashed/etc. on the “nekkid” eyewash stations. The same thing applies to making sure the caps are in place for the nozzles of the kitchen fire suppression system (nekkid nozzles—could be a band name!—can very quickly get gunked up with grease). We only need these things in the event of an emergency, but we need them to work correctly right away, not after someone wipes them off, etc. So, please remind the folks at point of care/point of service/point of culinary marvels to make sure those caps are in place at all times.

The other item relates to the recent changes in the fire safety management performance element that deals with your fire response plan. Please take a moment to review the response plan education process to ensure that you are capturing cooperation with firefighting authorities when (periodically) instructing staff and licensed independent practitioners. One of the ages-old survey techniques is to focus not so much on the time-honored compliance elements, but rather to poke around at what is new to the party, like cooperation with firefighting authorities (or 1135 waiver processes or continuity of operations plans or, I daresay, ligature risk assessments). It would seem that one of the primary directives of the survey process is to generate findings, so what better way to do that than to “pick” on the latest and (maybe not so) greatest.

Have a safe reorientation of the clocks!

I’ve been there, I know the way: More Executive Briefings goodness

You’ve probably seen a smattering of stuff related to the (still ongoing as I write this) rollout of this year’s edition of Joint Commission Executive Briefings. As near as I can tell, during the survey period of June 1, 2017 to May 31, 2018, there were about 27 hospitals that did not “experience” a finding in the Environment of Care (EC) chapter (98% of hospitals surveyed got an EC finding) and a slightly larger number (97% with a Life Safety chapter finding) that had no LS findings. So, bravo to those folks who managed to escape unscathed—that is no small feat given the amount of survey time (and survey eyes) looking at the physical environment. Not sure what he secret is for those folks, but if there’s anyone out there in the studio audience that would like to share their recipe for success (even anonymously: I can be reached directly at stevemacsafetyspace@gmail.com), please do, my friends, please do.

Another interesting bit of information deals with the EC/LS findings that are “pushing” into the upper right-hand sectors of the SAFER matrix (findings with moderate or high likelihood of harm with a pattern or widespread level of occurrence). Now, I will freely admit that I am not convinced that the matrix setup works as well for findings in the physical environment, particularly since the numbers are so small (and yes, I understand that it’s a very small sample size). For example, if you have three dusty sprinkler heads in three locations, that gets you a spot in the “widespread” category. I don’t know, it just makes me grind my teeth a little more fiercely. And the EP cited most frequently in the high likelihood of harm category? EC.02.02.01 EP5—handling of hazardous materials! I am reasonably confident that a lot of those findings have to do with the placement/maintenance of eyewash stations (and I’ve seen a fair number of what I would characterize as draconian “reads” on all manner of considerations relating to eyewash stations, which reminds me: if you don’t have maintenance-free batteries for your emergency generators and you don’t have ready access to emergency eyewash equipment when those batteries are being inspected/serviced, then you may be vulnerable during your next survey).

At the end of the day, I suppose there is no end to what can be (and, clearly, is) found in the physical environment, and I absolutely “get” the recent focus on pressure relationships and ligature risks (and, soon enough, probably Legionella–it was a featured topic of coverage in the EC presentation), but a lot of the rest of this “stuff” seems a little like padding to me…

Changing (not so much) perspectives on survey trends: Infection Control and Medication Safety

By now I suspect that you’re probably seen/heard that the survey results for the first half of 2018 are only surprising to the extent that there are no surprises (well, maybe a small one, but more on that in a moment). There’s a little bit of jockeying for position, but I think that we can safely say that the focus on the physical environment (inclusive of environmental concerns relating to infection control and prevention) is continuing on apace. There’s a little bit of shifting, and the frequencies with which the various standards are being cited is a wee bit elevated, but the lion’s share of the survey results that I’ve seen are indicative of them continuing to find the stuff they will always be able to find in this era of the single deficiency gets you a survey “ding.” The continuing hegemony of LS.02.01.35 just tells me that dusty sprinklers, missing escutcheons, stacked-too-high storage, etc., can be found just about anywhere if the survey team wants to look for it.

One interesting “new” arrival to the top 10 is IC.02.01.01, which covers implementation of the organization’s infection control plan. I have seen this cited, and, interestingly enough, the findings have involved the maintenance of ice machines (at least so far) and other similar utility systems infection control equipment such as sterilizers (for which there is a specific EP under the utilities management standards). I suspect that what we have here is the beginning of a focus on how infection control and prevention oversight dovetails with the management of the physical environment. I know that this is typically a most collaborative undertaking in hospitals, but we have seen how the focus on the “low hanging fruit” can generate consternation about the overall management of programs. As I’ve noted countless times, there are no perfect environments, but if don’t/can’t get survey credit for appropriately managing those imperfections, it can be rather disheartening.

Couple other items of note in the September issue of Perspectives, mostly involving the safe preparation of medications. As you know, there are equipment, utility systems, environmental concerns, etc., that can influence the medication preparation processes. The Consistent Interpretations column focuses on that very subject and while the survey finding numbers seem to be rather modest, it does make me think that this could be an area of significant focus moving forward. I would encourage you to check out the information in Perspectives and keep a close eye on the medication preparation environment(s)—it may save you a little heartache later on.

Conflagrations of unknown origin: Surgical fire prevention trends

Well, it appears that there remain opportunities for providing a fire-safe experience for surgical patients, at least based on the latest missive from the FDA. The safety communication (released at the end of May 2018) indicates that reports continue to be received by FDA of preventable surgical fires. I can’t think of too many circumstances—OK, none—in which a surgical fire could legitimately be considered unpreventable, though I have no doubt that you all have tales to tell of clinicians who feel that everything was done correctly and there was still a fire. I’d be interested in hearing some of those.

At any rate, the communication indicates several component strategies for appropriately managing the risk(s) associated with surgical fires—and if you guessed that a risk assessment figures into that equation, it may be that we have covered this ground before. So:

  • A fire risk assessment at the beginning of each surgical procedure
  • Encourage communication among surgical team members
  • Safe use and administration of oxidizers
  • Safe use of any devices that may serve as an ignition source
  • Safe use of surgical suite items that may serve as a fuel source
  • Plan and practice how to manage a surgical fire

I don’t think there’s anything that is particularly revelatory—these are by no means new expectations (for us or by us). It does appear that the FDA is going to be leaning on the various accreditation organizations (TJC, DNV, HFAP, CIHQ, AAAHC, etc., though TJC is the only organization specifically mentioned—aren’t they special!), so I think we may see yet another round of ratcheting things up in regards to surgical fire drills, providing education to clinicians, etc. I don’t know how much reaching out you might do relative to actual events in your surgical procedure areas (I can’t say that I always see a ton of information beyond fire drill and education documentation), but I think you’ll want to be able to speak to this as a proactive undertaking. Somebody must be monitoring these types of things and if it’s not you, you need to figure out who it is and keep yourself informed.

As something of a preemptory thought, I ran across a podcast entitled “Nurses for Health Environments” (you can find some background and links to the podcast here). I haven’t had a chance to check it out (I listen to podcasts as I work towards my 10K steps before breakfast, but I always seem to have a backlog of stuff to listen to), but I do believe that (particularly as a very large percentage of the healthcare culture) partnering with nurses and other clinicians in managing the environment makes a great deal of sense. Stewardship of the environment has to happen at every level of every organization, so I would urge you to check it out and maybe recommend it as a listening opportunity for the clinicians in your organization. I’ve always believed that marketing is an important piece of what we do as safety professionals and any (and every) insight into what folks are thinking about, etc., is worth consideration.

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.

CMS Ligature Risk Update: Not quite finished…

Cast aside the doubt that nothing good came come this way again!

On July 20, 2018, CMS issued further information regarding its expectations for ensuring that behavioral health patients are being provided a safe and appropriate environment. There had been some indication that CMS might be undertaking their own analysis of the current state of things, but it appears that CMS is going to incorporate the outcomes of The Joint Commission’s (TJC) suicide panel (in which CMS representatives participated) into a comprehensive ligature risk interpretive guidance. The memorandum does not indicate when we can expect the finalized interpretive guidance, but things do seem to be moving at a pretty good clip, so I’m thinking (maybe, just maybe), we’ll see that information before the end of the year. As a point of information (and you know I’m all about the points), the Joint Commission guidance cited in the CMS memorandum can be found here: and some clarifying FAQs issued by TJC last month (but not specifically referenced in the CMS memorandum) can be found here: (the information specific to ligature risks is about half way down the page). I know we’ve covered this over the past few months, but I can never be sure at which point in the conversation folks tune in, so I figured it doesn’t hurt to have links for what is current (at the moment…).

For those of you who have not yet tackled all of the particulars relating to the guidance issued from Joint Commission (mostly because you do not use TJC for deemed status accreditation purposes), I do think that the compliance path appears to be fairly reasonable and straightforward from an implementation standpoint. That said, until the interpretive guidance is finalized by CMS, there will likely continue to be some surveyor interpretation in the mix, particularly on the part of those accreditation and regulatory organizations other than Joint Commission (DNV, CIHQ, HFAP, state agencies, etc.). Which means it will be incumbent upon pretty much all hospitals to know where they stand relative to TJC recommendations, particularly as a function of how the strategies and facilities modifications they’ve made meet the intent of the recommendations. Some recent non-TJC survey activities indicate that the “other” accreditation organizations are starting to focus on this topic and, right now, are very much where TJC was in early 2017 when surveyors were inclined to identify anything and everything as a potential, unmanageable risk. And lots of re-surveys following in the wake of those determinations

Beyond a familiarity/assessment relative to the TJC recommendations, the “other” piece of which you need to be mindful is that whatever fixes they identify need to be completed before survey or there will likely be some back and forth relative to Immediate Threat, the need for re-survey, etc.  As we’ve discussed in the past (and this surely goes beyond ligature-resistant hardware), a lot of folks with a significant number of fixes are very much at the mercy of the supplies of needed hardware, etc. At a minimum, hospitals that haven’t completed their “laundry list” of fixes must have a risk assessment in place that outlines not only what is to be done from a facilities standpoint, but what strategies are in place to ensure that the risk to patients is being properly managed in the interim (this is very similar to the survey methodology dealing with Interim Life Safety Measures). As I’ve told folks time and again, you don’t get credit for doing the math in your head—at the end of the day, when you have a survey team “in the house,” the only “good” risk assessment is a risk assessment that is fully documented, approved by the appropriate organizational authorities, etc. If you don’t have an assessment ready to go for survey, it’s likely to be a very tough slog.

At any rate, it does appear that this one is going to be winding down in terms of survey activity, which will bring no small measure of relief to the survey preparation process, but it does beg the question of whether this is the last big environmental dope-slap or if there’s something else waiting in the wings to make us crazy. Any thoughts?

Odds and Sods: Clearing out the Safety Brain

Once again, I come face-to-face with my depository for blog postings and the like, so we have something of a mixed bag this week, with very little in the way of a common theme…

I’m sure folks saw the news story regarding the dead woman found in a stairwell of a hospital power plant and it got me to thinking about the increasing importance of ensuring that all your unmonitored perimeter points are as secure as they can be. It appears that the woman was able to gain access to the stairwell and was either too confused or otherwise compromised to make her way back out. The hospital has since hardened the perimeter of the power plant, but I think this points out that you really need to encourage folks to be on the lookout (security rounds can really only go so far) for unusual circumstances/ folks in their environments. It may be that there was nothing that could be done to prevent this tragedy, but I think it serves as a reminder that you really can’t be too secure.

As something of a parallel pursuit, HCPro recently re-aired a webinar presented my good friend and colleague Ken Rohde on the topic of occurrence reporting and its impact on operations, including the safety realm. Ken is an awesome presenter with a completely useful take on how safety operations impact, and are impacted, by how we manage occurrence reporting, particularly as a source of data for making improvements. If you have some monies in your budget for education, I really encourage you to check out the On-Demand presentation and let Ken help you improve your safety program.

In other parts of my noggin, I was looking at the crosswalk that TJC provides in the online version of their accreditation manual and was contemplating what is referenced as the applicable CMS requirement that “drives” the documentation requirements under EC.02.03.05 EP #28. In all candor, what prompted me to look was this nagging feeling that there are a lot of other required process documentation elements in other parts of the Environment of Care standards and whether there is a likelihood of those documentation requirements being carried over to things like generator testing, medical gas and vacuum system testing, etc. (for you pop culture enthusiasts, I consulted the magic 8 ball and it says “signs point to yes”; for those of you not yet familiar with the amazing technology that is the Magic 8 Ball, find more here). And when I looked at the TJC/CMS crosswalk, I noted that not only is the Life Safety Code® invoked as a referenced requirement, but also the Emergency Preparedness Condition as a function of the provision of alternate sources of energy for maintaining fire detection, extinguishing, and alarm systems. It may not be an imminent shift, but I think you would do well to consider adopting the documentation format outlined under EC.02.03.05 EP #28—it will help organize compliance and maybe, just maybe, keep you a half-step ahead of the sheriff…

On a closing note, I have (yet another) summer reading recommendation for folks: I think we can all agree that the use of effective communications is one of the most powerful tools that we can bring to our safety practices. As you all know every well (I’ve been inflicting this on you all for many, many…), I do tend towards more florid descriptors (that’s one there; I mean who uses “florid” anymore?), which can make comprehension difficult across a multi-faceted audience if you do not take into consideration the entirety of the audience. At any rate, I recently finished Alan Alda’s latest If I Understood You, Would I Have This Look on My Face?, which deals with the science of communications and provides a lot of thought-provoking suggestions on how we might improve the effectiveness of interpersonal communications at every level of life. For me, the most compelling insight was the notion that is the responsibility of the person doing the communicating to make sure that the audience is comprehending what is being communicated. That prompted me to reflect on any number of conversations I’ve had over the years, more or less revolving around the frustration with an audience that “just doesn’t get it” and the thought that perhaps the audience (in all its parameters) merits more consideration when things don’t work out in the way it was planned. At any rate, I found a lot of interesting perspectives on communications and (it’s a pretty quick read) I think you might find a nugget or two for your own use.

Wagging the dog: Can Accreditation Organizations influence each other?

In last week’s issue of HCPro’s Accreditation Insider, there was an item regarding the decision of the folks at the Healthcare Facilities Accreditation Program (HFAP) to update their Infection Control standards for acute care hospitals, with the intent of alignment with CMS expectations (you can find the article here) We’ve certainly covered the concerns relative to Legionella and the management of risks associated with aerosolizing water systems and this may only be a move to catch up on ground already covered by other accreditation organizations (our friends in Chicago already require the minimization of pathogenic biological agents in cooling towers, domestic hot- and cold-water systems, and other aerosolizing water systems), but I’m thinking it might also be something of a “tell” as to where survey focus might be drifting as we embark upon the second half of 2018. Certainly, waterborne pathogens are of critical importance to manage as a function of patient vulnerability (ideally, we want folks to get better during their hospital stays), so it makes perfect sense for this to be on the radar to some degree. At this point, the memorandum from CMS outlining their concerns has been with us for about a year, with an immediate effective date, so hopefully you are well-entrenched in managing those water systems. If this one is still on your to-do list, I think it’s probably advisable to making it a priority to get it to your “to-done” list. But you should definitely check out the latest “clarification” from CMS. While the memo indicates that this does not impose any new expectations or requirements, it does make it a little clearer as to what surveyors are supposed to be checking.

As I think Mr. Gershwin once opined about summer and the easiness of living, it would be nice to be able to set a spell and take one’s shoes off, but vigilance is always the order of the day.

On a somewhat lighter note, I just finished reading Our Towns – A 100,000 Mile Journey Into The Heart of America, which outlines the efforts of a number of (mostly smallish) municipalities across the United States in positioning themselves for a positive future (positive positioning—I kind of like that). The focus is mostly on the socioeconomics of different parts of the country, with a focus on how diversity can be employed in bettering a community (that’s probably a little ham-handed as a descriptor, but you can find an excerpt here if you like). As my work allows me to travel to a lot of places, while I haven’t been to a lot of the same destinations as the Fallows, I do recognize a lot of the stories and a lot of the challenges facing folks lately (and I think you might, too). I would describe the tone of the book as hopeful, so if you’re looking for something to read at beach/pond/summer cottage, etc., you might consider giving Our Towns a shot.

 

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!