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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!

 

Workplace Violence: One Can Never Have Too Much Info…

I will freely admit that sometimes it takes me a while to get to everything that I want to share with you folks and this is one of those instances…

Back in May (yes, I know—mea culpa, mea culpa, mea maxima culpa—it was even longer ago that I was an altar boy), ECRI Institute published some information on violence in healthcare facilities that includes a white paper, some guidance on how to share the risk landscape of your facility as it relates to workplace violence and some other information that is accessible upon enrolling in a membership program (they have quite a few different programs, this week’s stuff comes from the Healthcare Risk Control program). I suspect that the provided information may be representative of a loss-leader to drive traffic to their website and service programs (much as this blog is a labor of love and obsession, its function is rather much the same—I don’t know that they would put up with my yammering otherwise), but the information available through the above links are certainly worth checking out (there are also free newsletters; as noted in this week’s headline, information coming directly to you saves having to hunt it down).

Another item on my mental to-do list (and it may very well be that it is on my to-done list, but a little reiteration never hurt anyone) was to encourage you to keep an close eye on The Joint Commission’s standards FAQ page (you have to do a lot of scrolling to get to the Hospitals section—they’ve changed the formatting of this section of their website and it just feels quite clunky to me). At any rate, there are way more FAQs than there used to be (maybe more than there needs to be, but if you make the presumption that the characterization of these questions as being frequently asked, then it is what it is) and you can’t really tell which ones have changed (they do highlight new FAQs; lots of pain management stuff on there right now). They used to include a date so you could more or less keep track of stuff. I’m going to guess that there’s going to be a lot of following up relative to the whole management of ligature risks—and make sure you talk to your organization’s survey coordinator to make sure you access the Suicide Risk Booster (there just seems to be something odd about that as a descriptor). As much as any issue there’s ever been in the physical environment, the management of ligature risks is one for which you cannot be too well prepared (think an infinite number of Boy Scouts and you’ll be moving in the right direction).

 

These are a few of my favorite things: Safety Risk Assessments!

A somewhat mixed bag of news items for you this week: a cornucopia of compelling content, if you will…

The Center for Health Design has published a pretty cool safety risk assessment tool that is available free on its website, although you do have to register (also free). The web page offers an introductory video describing the risk assessment, so you can check it out before you register.

In other news, Maine became the first state to ban flame retardants in upholstered furniture. As I travel the highways and byways of these United States, I see a fair amount of holiday decorations that have been treated with flame retardant sprays of various manufacture as folks try to provide a cheery environment for patients and not run afoul of the safety Grinches (and I use that term with all due respect and affection, having been a Grinch myself once or twice in the past). I don’t know if we’ll be able to say “as Maine goes, so goes the nation,” but this might have some interesting impact on the field-treating of combustible decorations.

As our final note this week, data from the U.S. Nurses’ Health Study II suggests that there is an increased risk of Chronic Obstructive Pulmonary Disease (COPD) among nurses with frequent exposure (at least once a week) to disinfectants in certain tasks (cleaning of surfaces, etc.): https://www.ersnet.org/the-society/news/nurses-regular-use-of-disinfectants-is-associated-with-developing-copd . The study indicates some of the “culprits” as glutaraldehyde, bleach, hydrogen peroxide, alcohol, and quaternary ammonium compounds. The article on the link also indicates that a recent European study of folks working as cleaners also showed an increased risk for COPD (somehow, not a surprising revelation to me). I think the bottom line on this (and perhaps our charge moving forward) is (and the article doesn’t really mention this) ensuring that folks are using appropriate PPE when they are using those types (or any type) of disinfectant products. PPE is always a tough thing to “sell” to folks, and while I think folks do understand that there are risks involved (just as there are risks associated with all sorts of behaviors—smoking springs to mind), there does seem to be a reluctance to take proper precautions every time one engages in these types of activities. I know this stuff isn’t particularly “sexy” when it comes to the topics of the day, but reinforcing basic protective measures can’t be a completely lost cause, can it?

 

 

Lazy days of autumn: CMS does emergency management (cue applause)!

I suppose you could accuse me of being a little lazy in this week’s offering, but I really want you to focus closely on what the CMS surveyors are instructed to ask for in the Emergency Management Interpretive Guidelines (more on those here; seems like forever ago), so I’ve done a bit of a regulatory reduction by pulling out the non-hospital elements (I still think they could have done a better job with sorting this out for the individual programs) and then pulling out the Survey Procedures piece—that’s really where the rubber meets the road in terms of how this is going to be surveyed, at least at the front end of the survey process.

I suspect (and we only have all of recorded history to fall back on for this) that as surveyors become more comfortable with the process, they may go a little off-topic from time to time (surprise, surprise, surprise!), but I think this is useful from a starting point. As I have maintained right along, I really believe that you folks have your arms around this, even to the point of shifting interpretations. This is the stuff that they’ve been instructed to ask for, so I think this is the stuff that you should verify is in place (and, really, I think you’ll find you’re in very good shape). There’s a fair amount of ground to cover, so I will leave you to it—until next week!

BTW, I purposely didn’t identify which of the specific pieces of the Final Rule apply to each set of Survey Procedures. If there is a hue and cry, I will be happy to do so (or you can make your own—it might be worth it to tie these across to the requirements), but I think these are the pieces to worry about, without the language of bureaucracy making a mess of things. Just sayin’…

Survey Procedures

  • Interview the facility leadership and ask him/her/them to describe the facility’s emergency preparedness program.
  • Ask to see the facility’s written policy and documentation on the emergency preparedness program.
  • For hospitals and critical access hospitals (CAH) only: Verify the hospital’s or CAH’s program was developed based on an all-hazards approach by asking their leadership to describe how the facility used an all-hazards approach when developing its program.

Survey Procedures

  • Verify the facility has an emergency preparedness plan by asking to see a copy of the plan.
  • Ask facility leadership to identify the hazards (e.g., natural, man-made, facility, geographic, etc.) that were identified in the facility’s risk assessment and how the risk assessment was conducted.
  • Review the plan to verify it contains all of the required elements.
  • Verify that the plan is reviewed and updated annually by looking for documentation of the date of the review and updates that were made to the plan based on the review.

 

Survey Procedures

  • Ask to see the written documentation of the facility’s risk assessments and associated strategies.
  • Interview the facility leadership and ask which hazards (e.g., natural, man-made, facility, geographic) were included in the facility’s risk assessment, why they were included and how the risk assessment was conducted.
  • Verify the risk assessment is based on an all-hazards approach specific to the geographic location of the facility and encompasses potential hazards.

Survey Procedures

Interview leadership and ask them to describe the following:

  • The facility’s patient populations that would be at risk during an emergency event
  • Strategies the facility (except for an ASC, hospice, PACE organization, HHA, CORF, CMHC, RHC, FQHC and end stage renal disease (ESRD) facility) has put in place to address the needs of at-risk or vulnerable patient populations
  • Services the facility would be able to provide during an emergency
  • How the facility plans to continue operations during an emergency
  • Delegations of authority and succession plans

Verify that all of the above are included in the written emergency plan.

Survey Procedures

Interview facility leadership and ask them to describe their process for ensuring cooperation and collaboration with local, tribal, regional, state, and federal emergency preparedness officials’ efforts to ensure an integrated response during a disaster or emergency situation.

  • Ask for documentation of the facility’s efforts to contact such officials and, when applicable, its participation in collaborative and cooperative planning efforts.
  • For ESRD facilities, ask to see documentation that the ESRD facility contacted the local public health and emergency management agency public official at least annually to confirm that the agency is aware of the ESRD facility’s needs in the event of an emergency and know how to contact the agencies in the event of an emergency.

Survey Procedures

Review the written policies and procedures which address the facility’s emergency plan and verify the following:

  • Policies and procedures were developed based on the facility- and community-based risk assessment and communication plan, utilizing an all-hazards approach.
  • Ask to see documentation that verifies the policies and procedures have been reviewed and updated on an annual basis.

Survey Procedures

  • Verify the emergency plan includes policies and procedures for the provision of subsistence needs including, but not limited to, food, water and pharmaceutical supplies for patients and staff by reviewing the plan.
  • Verify the emergency plan includes policies and procedures to ensure adequate alternate energy sources necessary to maintain:

o Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions;

o Emergency lighting; and,

o Fire detection, extinguishing, and alarm systems.

  • Verify the emergency plan includes policies and procedures to provide for sewage and waste disposal.

 

Survey Procedures

  • Ask staff to describe and/or demonstrate the tracking system used to document locations of patients and staff.
  • Verify that the tracking system is documented as part of the facilities’ emergency plan policies and procedures.

 

Survey Procedures

  • Review the emergency plan to verify it includes policies and procedures for safe evacuation from the facility and that it includes all of the required elements.
  • When surveying an RHC or FQHC, verify that exit signs are placed in the appropriate locations to facilitate a safe evacuation.

 

Survey Procedures

  • Verify the emergency plan includes policies and procedures for how it will provide a means to shelter in place for patients, staff and volunteers who remain in a facility.
  • Review the policies and procedures for sheltering in place and evaluate if they aligned with the facility’s emergency plan and risk assessment.

 

Survey Procedures

  • Ask to see a copy of the policies and procedures that documents the medical record documentation system the facility has developed to preserves patient (or potential and actual donor for OPOs) information, protects confidentiality of patient (or potential and actual donor for OPOs) information, and secures and maintains availability of records.

 

Survey Procedures

  • Verify the facility has included policies and procedures for the use of volunteers and other staffing strategies in its emergency plan.

 

Survey Procedures

  • Ask to see copies of the arrangements and/or any agreements the facility has with other facilities to receive patients in the event the facility is not able to care for them during an emergency.
  • Ask facility leadership to explain the arrangements in place for transportation in the event of an evacuation.

 

Survey Procedures

  • Verify the facility has included policies and procedures in its emergency plan describing the facility’s role in providing care and treatment (except for RNHCI, for care only) at alternate care sites under an 1135 waiver.

 

Survey Procedures

  • Verify that the facility has a written communication plan by asking to see the plan.
  • Ask to see evidence that the plan has been reviewed (and updated as necessary) on an annual basis.

 

Survey Procedures

  • Verify that all required contacts are included in the communication plan by asking to see a list of the contacts with their contact information.
  • Verify that all contact information has been reviewed and updated at least annually by asking to see evidence of the annual review.

 

Survey Procedures

  • Verify that all required contacts are included in the communication plan by asking to see a list of the contacts with their contact information.
  • Verify that all contact information has been reviewed and updated at least annually by asking to see evidence of the annual review.

 

Survey Procedures

  • Verify the communication plan includes primary and alternate means for communicating with facility staff, federal, state, tribal, regional and local emergency management agencies by reviewing the communication plan.
  • Ask to see the communications equipment or communication systems listed in the plan.

 

Survey Procedures

  • Verify the communication plan includes a method for sharing information and medical (or for RNHCIs only, care) documentation for patients under the facility’s care, as necessary, with other health (or care for RNHCIs) providers to maintain the continuity of care by reviewing the communication plan.

o For RNCHIs, verify that the method for sharing patient information is based on a requirement for the written election statement made by the patient or his or her legal representative.

  • Verify the facility has developed policies and procedures that address the means the facility will use to release patient information to include the general condition and location of patients, by reviewing the communication plan

 

Survey Procedures

  • Verify the communication plan includes a means of providing information about the facility’s needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee by reviewing the communication plan.
  • For hospitals, CAHs, RNHCIs, inpatient hospices, PRTFs, LTC facilities, and ICF/IIDs, also verify if the communication plan includes a means of providing information about their occupancy.

 

Survey Procedures

  • Verify that the facility has a written training and testing (and for ESRD facilities, a patient orientation) program that meets the requirements of the regulation.
  • Verify the program has been reviewed and updated on, at least, an annual basis by asking for documentation of the annual review as well as any updates made.
  • Verify that ICF/IID emergency plans also meet the requirements for evacuation drills and training at §483.470(i).

 

Survey Procedures

  • Ask for copies of the facility’s initial emergency preparedness training and annual emergency preparedness training offerings.
  • Interview various staff and ask questions regarding the facility’s initial and annual training course, to verify staff knowledge of emergency procedures.
  • Review a sample of staff training files to verify staff have received initial and annual emergency preparedness training.

 

Survey Procedures

  • Ask to see documentation of the annual tabletop and full scale exercises (which may include, but is not limited to, the exercise plan, the AAR, and any additional documentation used by the facility to support the exercise.
  • Ask to see the documentation of the facility’s efforts to identify a full-scale community based exercise if they did not participate in one (i.e., date and personnel and agencies contacted and the reasons for the inability to participate in a community based exercise).
  • Request documentation of the facility’s analysis and response and how the facility updated its emergency program based on this analysis.

 

Survey Procedures

  • Verify that the hospital, CAH, and LTC facility has the required emergency and standby power systems to meet the requirements of the facility’s emergency plan and corresponding policies and procedures
  • Review the emergency plan for “shelter in place” and evacuation plans. Based on those plans, does the facility have emergency power systems or plans in place to maintain safe operations while sheltering in place?
  • For hospitals, CAHs, and LTC facilities which are under construction or have existing buildings being renovated, verify the facility has a written plan to relocate the EPSS by the time construction is completed

For hospitals, CAHs, and LTC facilities with generators:

  • For new construction that takes place between November 15, 2016 and is completed by November 15, 2017, verify the generator is located and installed in accordance with NFPA 110 and NFPA 99 when a new structure is built or when an existing structure or building is renovated.  The applicability of both NFPA 110 and NFPA 99 addresses only new, altered, renovated or modified generator locations.
  • Verify that the hospitals, CAHs and LTC facilities with an onsite fuel source maintains it in accordance with NFPA 110 for their generator, and have a plan for how to keep the generator operational during an emergency, unless they plan to evacuate.

 

Survey Procedures

  • Verify whether or not the facility has opted to be part of its healthcare system’s unified and integrated emergency preparedness program. Verify that they are by asking to see documentation of its inclusion in the program.
  • Ask to see documentation that verifies the facility within the system was actively involved in the development of the unified emergency preparedness program.
  • Ask to see documentation that verifies the facility was actively involved in the annual reviews of the program requirements and any program updates.
  • Ask to see a copy of the entire integrated and unified emergency preparedness program and all required components (emergency plan, policies and procedures, communication plan, training and testing program).
  • Ask facility leadership to describe how the unified and integrated emergency preparedness program is updated based on changes within the healthcare system such as when facilities enter or leave the system.

 

To close out this week’s bloggy goodness, Diagnostic Imaging just published a piece on emergency preparedness for radiology departments that I think is worth checking out: http://www.diagnosticimaging.com/practice-management/emergency-preparedness-radiology . Imaging services are such a critical element of care giving (not to mention one of the largest financial investment areas of any healthcare organization) that a little extra attention on keeping things running when the world is falling (literally or figuratively) down around your ears. I think we can make the case that integration of all hospital services is likely to be a key element of preparedness evaluation in the future—this is definitely worthy of your consideration.

Fall On Me: Keeping Emergency Management Changes in Perspective

As I was ruminating on a topic for this week’s conversation, the October issue of Perspectives came zipping over the electronic transom, and I think there is just enough stuff here to cobble together a relatively cogent offering to you all out there in the blogosphere (that’s right—after 10+ years, I’m working on cogency—who’d a thunk…)

First up is the announcement of proposed changes to the Emergency Management chapter (I say proposed, because the indication is that these changes still require approval by CMS) with an intended survey implementation date of November 15, 2017 (when the Emergency Management final rule takes full effect). From my experiences with folks, I still don’t think they’re barking up a tree for which we cannot (collectively) provide a reasonable response, but if you’re interested in what they think they need to change in the standards, the list of additions includes consideration of:

  • Continuity of operations and succession plans
  • Documentation of collaboration with local, tribal, regional, state, and federal EM officials
  • Contact information on volunteers and tribal groups
  • Documented annual training of all new/existing staff, contractors, and volunteers
  • Integrated health care systems
  • Transplant hospitals

Again, I don’t see anything that strikes me as being particularly daunting, though there’s still a fair amount of angst relative to these changes (as is the case with anything that changes). I know there’s been some consternation relative to managing Memorandums of Understanding (or Memoranda, if that be your preference) and Alternate Care Sites, but I think the important thing to keep in mind is that the journey to the Final Rule started back when the 2008 TJC standards were in full bloom. And I suspect that those of you who have been doing this for a while recall those heady days of focus on MOU’s, ASC’S, COOP’s and the like, concepts that have really kind of faded into the operational ether as the efficacy of those approaches has yielded wildly inconsistent levels of preparation. For some folks, MOU’s, ASC’s and COOP’s are essential, but I’ve also seen evidence that when the feces is striking the rapidly rotating blades, it is often the group that shows up first with the closest thing to cash that has access to resources. When you think about it, things like MOU’s are only an agreement to do the best one can under the circumstances—that’s why the interface with local and regional EM authorities is so very important. At any rate, next we’ll chat a bit about what the CMS survey instructions involve and why I think you folks are going to be in pretty good shape. I am curious as to whether or not there is an intent to modify the emergency response exercise requirements to more closely mirror the Final Rule—I guess all in the fullness of time.

Moving on to other Perspectives topics, it would seem that last month’s Clarifications and Expectations column was indeed the last official communication under George Mills’ direction. The column is on hiatus for the moment—I guess we’ll have to wait and see whether November brings it back (though oy could certainly make the case that EC-EM-LS topics are taking up a fair amount of space in the monthly Perspectives, Clarifications and Expectations columns notwithstanding).

There is a new Sentinel Event Alert (#58!) regarding issues relating to inadequate hand-off communications; the reason I mention it here is that, while the focus in Perspectives is very much on the clinical side of things, I think there is more than a little crossover into the safety / physical environment realm. I’m just planting the seed here, but I suspect that I will have more thoughts on this in the coming little while.

Finally (for this week), there is a piece on Workplace Violence as a function of screening for early detection of risk to harm self or others. I suspect that this may be a harbinger of next steps as it relates to how organizations are managing at-risk patients, particularly as a function of the current focus on ligature risks. In recognition that all the risks that are not medically/clinically necessary have removed, if you don’t have a pretty robust screening process in place, it makes it very challenging to manage the risks that remain. At any rate, I’d keep an eye on this one—much as they’ve been peeling the Infection Control “onion” over the past couple of years, I think this is how they’re going to expand focus in the behavioral health realm.

But, as a subset of that, I did want to muse a bit on those instances when entities that were thought of as “friendly” turn out (under certain circumstances) to be not so much. I suspect that most of you saw the news item back in July regarding the nurse working in the ED of a hospital in Salt Lake City, UT, who was forcibly arrested by local police for not acquiescing to a request that was not allowed by organization policy (if you missed it, you can see some of the story here or here.) I mention this only to point out that the management of this stuff is not always simple (OK, it pretty much never is simple), but this does offer up yet another facet to how facilities safety and security professionals have to proactively advocate for staff (and patient) safety. Some of the images of the arrest are most harrowing and definitely beg the question of how this came to pass in this day and age (or maybe it’s not as questionable an outcome as perhaps it might once have been). At any rate, it’s always important to periodically review what I refer to as the “rules of engagement,” particularly when it comes to interacting with law enforcement folks. If our folks can’t be protected from our “friends,” then what shot do we have against an unknown/unknowable “foe.”

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!

Thoughts and prayers for Houston; plus, thoughts on required ‘policies’

First off, thoughts and prayers going out to the embattled folks in Texas; I do a fair amount of work in Texas, including the Houston area, and while I have absolute confidence in folks’ ability to respond to and recover from catastrophic events, I also know that this is going to be a very tough next little while for that part of the world. Hurricane Harvey will likely fade from the headlines, but the impact will linger past the news cycle, so don’t forget about these folks in the weeks to come. Thanks!

As I was casting about for a subject for this week’s missive, I happened upon a news item in Health Facilities Management This Week (HFMTW) that outlines some of the pending changes to the ambulatory care / office-based surgery medication management standards and the potential further impact of those changes on some of the EC performance elements in those environments. The changes are pretty much focused on emergency power as a function of being able to provide medication dispensing and refrigeration during emergencies.

Now, I have absolutely no issue with making provisions for the safe physical management of medications during power outages, etc.—it is a critical part of the delivery of safe and appropriate care to patients in any setting, and the more we can do to prepare for any outages, etc., the greater the likelihood of continuity of services if something does happen. What really caught my eye in the TJC blog entry cited in HFMTW (you can find the blog here) is something about half-way down the page titled “Emergency Back-Up Policies.”

At the outset of this discussion, I will tell you that, in most instances, I am no big fan of “policies.” In my mind, mostly what a policy represents is an opportunity to get into trouble for not following said policy. So, the question I wrestle with is whether we need to be mandated to have specific policies in order to appropriately manage our facilities, including preparing to respond to emergencies. For example, I am not entirely certain that a policy is going to make the difference in how well hospitals in the Houston area are responding to Hurricane Harvey (at the time of this writing, there are hospitals facing evacuation), though I would be happy to hear otherwise. I just have a hard time believing that having a policy is the answer to life’s problems; I am absolutely fine with requiring hospitals and other healthcare organizations to have a process in place to ensure appropriate management of medications during power outages, etc.—and I’m reasonably confident that those processes already exist in most, if not all, applicable environments.

I don’t know, maybe some folks do need to be told what to do, but I can’t help but think that those folks are fairly limited in number. And the blog even indicates that “there is no specific direction on the content of the policy”, but publishing this blog is going to force the issue during survey. I don’t know, when you look at the Conditions of Participation, etc., there are really very few policies that are required. It seems a bit odd to think that introducing new requirements for policy will somehow address some heretofore unresolved issue (or something). This one just doesn’t feel “right” to me…

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.

Reefing a sail at the edge of the world…

What to do, what to do, what to do…

A couple of CMS-related items for your consideration this week, both of which appear to be rather user-friendly toward accredited organizations. (Why do I have this nagging feeling that this is going to result in some sort of ugly backlash for hospitals?)

Back in May, we discussed the plans CMS had for requiring accreditation organizations (AOs) to make survey results public, and it appears that, upon what I can only imagine was intense review and consideration, the CMS-ers have elected to pull back from that strategy. The decision, according to news sources, is based on the sum and substance of a portion of Section 1865 of the Social Security Act, which states:

(b) The Secretary may not disclose any accreditation survey (other than a survey with respect to a home health agency) made and released to the Secretary by the American Osteopathic Association or any other national accreditation body, of an entity accredited by such body, except that the Secretary may disclose such a survey and information related to such a survey to the extent such survey and information relate to an enforcement action taken by the Secretary.

So, that pretty much brings that whole thing to a screeching halt—nice work of whoever tracked that one down. Every once in a while, law and statute work in favor of the little folk. So, we Lilliputians salute whomever tracked that one down—woohoo!

In other CMS news, the Feds issued a clarification relative to the annual inspection of smoke barrier doors (turns out the LSC does not specifically require this for smoke doors in healthcare occupancies) as well as delaying the drop-dead date for initial compliance with the requirements relating to the annual inspection of fire doors. January 1, 2018 is the new date. If you haven’t gotten around to completing the fire door inspection, I would heartily recommend you do so as soon as you can—more on that in a moment. So, good news on two fed fronts—it’s almost like Christmas in August! But I do have a couple of caveats…

I am aware of 2017 surveys since July in which findings were issued because the inspection process had not been completed, and, based on past knowledge, etc., it is unlikely that those findings would be “removable” based on the extended initial compliance date. (CMS strongly indicates that once a survey finding is issued in a report, the finding should stay, even if there was compliance at the time of survey.) So hopefully this will not cause too much heartburn for folks.

The other piece of this is performance element #2 under the first standard in the Life Safety chapter. (This performance element is not based on anything specifically required by the LSC or the Conditions of Participation—yet another instance of our Chicagoan friends increasing the degree of difficulty for ensuring compliance without having a whole mess of statutory support, but I digress.) The requirement therein is for organizations to perform a building assessment to determine compliance with the Life Safety chapter—and this is very, very important—in time frames defined by the hospital. I will freely admit that this one didn’t really jump out at me until recently, and my best advice is to get going with defining the time frame for doing those building assessments; it kind of “smells” like a combination of a Building Maintenance Program (BMP) and Focused Standards Assessment (FSA), so this might not be that big a deal, though I think I would encourage you to make very sure that you clearly indicate the completion of this process, even if you are using the FSA process as the framework for doing so. In fact, that might be one way to go about it—the building assessment to determine compliance with the Life Safety chapter will be completed as a function of the annual FSA process. I can’t imagine that TJC would “buy” anything less than a triennial frequency, but the performance element does not specify, so maybe, just maybe…