RSSAll Entries in the "Hospital safety" Category

In the realm of possibility: More listening, less posturing!

An interesting anomaly that I encounter periodically is the time-honored “first opinion,” particularly when it exists outside of a second opinion. All too often I hear clients tell me that  “X told us we have to do something a particular way,” often with a wake of disruption because whatever strategy, etc., that was identified didn’t take into full consideration elements of organizational culture, resources, practice, etc. But what I don’t understand is when I look at Environment of Care committee minutes, etc., I don’t see any discussion about whether the recommendation(s) were useful, germane, etc., to appropriately manage whatever the condition might be. I think it is very important to use any survey activity (regulatory, consultative) as an opportunity to identify best practices and ensure that policy and practice are in alignment. That way, you’ll have some experience in being able to sort out what is truly required from a regulatory perspective and what is solely in the land of surveyor interpretation.

In all the years I’ve been involved in healthcare safety, the one defining truth I’ve found is that compliance is rarely a black and white endeavor. And while I absolutely understand that managing anything as a “black and white” is a whole lot easier to police, from an operational standpoint, absolutes (either positive or negative) are not always easily, or practically, implemented.

The other dynamic is (and this is very much the case with response to regulatory surveys) that often we “over-promise,” particularly in terms of frequency of monitoring. Don’t set yourself up for failure, for example, by indicating in a corrective action plan that there will be weekly inspections of electrical panels for inappropriately configured circuit breakers. Unless you know that folks are mucking around in the panels on a frequent basis, is there really a compelling reason to embrace an inspection frequency that is not a regulatory requirement? I would tend to think: Not so much.

As we have established beyond any reasonable doubt, there will always (always, always, always) be imperfections in the environment, but don’t go crazy trying to chase all these things yourself (or have your staff do the chasing). As I’ve said any number of times (before any number of audiences), all this stuff “lives” at the point of care/point of service and if you can’t get the folks that “live” in those areas to help feed the gaping maw of work order system, you are managing a process that is not as efficient as it might otherwise be. With the ongoing impact of the “do more with less” mantra, it’s not so much about working smarter (though there is certainly an element of that), but about working collaboratively. Everyone is caregiver—everyone is a steward of the environment—and by judicious application of only what is actually required by code and/or regulation, you can start to break down the barriers between mutually assured noncompliance and an environment that appropriately supports care. Compliance is the byproduct of consistently doing the right thing.

Update: Defunct Links to/in the FAQ-niverse!

Greetings, fellow travelers!

With special thanks to Claire Rebouche for bringing this to my attention, it appears that the links to the new ligature risk FAQs that appeared in this week’s blog post no longer direct you to the content of the latest information (I swear to you that the links were working Monday), but rather direct you to the FAQ homepage. Now, that wouldn’t be such an awful thing if the latest FAQ (for the record, TJC describes it thusly: “Ligature Risks – Assessing and Mitigating Risk For Suicide and Self-Harm”) were readily discernible, but alas (at least for the moment), this particular FAQ is among the missing.

Rest assured, top people are working on trying to find out what’s going on, and hopefully this is but a temporary circumstance (I figure if we can’t find the information, the surveyors might be having a tough time as well—helps to level the playing field). One other thing to note is that where previously the ligature-related FAQs could be found in the EC section of the FAQ homepage, they’ve all been moved to the NPSG section (and, interestingly enough, increased the number of FAQs dealing with ligatures to just over 20), so you may want to keep an eye on any changes in that section (from a practical standpoint, I understand the shift, but I don’t know that they couldn’t have shown up in both sections as a transition, though perhaps they did—I don’t spend a lot of time monitoring the NPSG section of the FAQ page).

At any rate, what I suspect may be happening is that, in their efforts to “clean up” the FAQ page, it would seem that some of the internal links are no longer working, so I’m hoping that we’re just working through a funky transition period and everything will be up and running soon.

That said, there are a couple of other new items relative to the management of this at-risk patient population that I want to share (while they are still available): this one and this other one, which deal with how the process for managing at-risk patients can result in catastrophic gaps in care. I think they’re pretty straightforward in terms of information, but with everything else going on this week, I would encourage you to check ’em out sooner rather than later.

Déjà vu all over again: A new ligature resistant FAQ!

Using the Hospital FAQ page as the baseline, I reckon we’ve got about a dozen FAQs dealing with ligature resistance with this latest offering. For some reason, the “visual” I get from all of this FAQing is the difference between looking at something from a distance (for example, a celestial body) and seeing that same thing up close and personal. What started out as a sphere of incomprehensibility has become (slowly, ever so slowly, over time) a much more nuanced endeavor—an endeavor that continues to represent survey vulnerabilities for accredited organizations.

One of the interesting things to me is how the narrative has evolved over the last couple of years relative to how hospitals are to deal with all the intricacies of managing ligature risks as a survey vulnerability (which is different than managing the risks to patients, but more on that in a moment). This FAQ reveals some specifics as to what you are required to include in the mitigation strategy for those risks that are not yet removed/resolved/corrected/adjudicated, etc. Now, I don’t know that this is truly ground-breaking stuff, but I think this is cray-cray important because this is what the surveyors are going to be looking for, both in terms of structure, but also as a function of an ongoing process. I’m not going to quote verbatim from the FAQ. I know youse guys are excellent readers and such, so a quick summary:

  • Leaders and staff have to know what risks are currently in the mix and somebody has to be responsible for telling them (and documenting that they were told…)
  • Identification of patients at risk for suicide/self-harm, with appropriate risk-based interventions
  • A process for ongoing assessments and reassessments of organization-defined at-risk behavior
  • Staff education re: management of patient risk and implementation of appropriate interventions
  • Ensuring this whole program/process is integrated into the organization’s quality assurance/performance improvement (QAPI) program (sounds like it might be a good time to include this as a standing agenda item at your QAPI committee meetings)
  • Making sure that any equipment that poses a risk, but is necessary for safe treatment of behavioral health patients (the example given is medical beds with siderails on a geriatric unit), is considered, as a risk, in the patients’ overall suicide/self-harm risk assessments, with appropriate interventions to minimize the identified risks

As I reflect over the seemingly endless amount of survey angst that this topic has wrought over the past couple of years, I keep coming back to the reality that while we can always do better (would we have done as much as quickly without enduring survey bludgeoning?), there is minimal data to support that, while not perfect, hospitals were not doing a good job in managing these at-risk patients. Purely from a risk management perspective, this would be a subject of great interest and concern to any healthcare organization as the burden of managing these patients has shifted over time. I suppose it ultimately gets filed under the “abdication of responsibility” that comes with the disenfranchising of difficult patient demographics and the subsequent “arrival” of those patients in the acute care settings, but it seems to me that (and yes, I recognize that this is part of doing business in healthcare) a little more collaboration during this process (as opposed to pointing fingers and assigning “blame”) might have yielded a better end-product. Hopefully, at some point, we will be given credit for the good work that has been done (and quantified), but I don’t think we are quite there yet.

Secret Club for Members Only: Some FAQing for your reading pleasure

This week finds us (once again) visiting with our friends from Chicago as they stand astride the accreditation world like some ancient colossus. (I am hopeful that my purple prose will subside at this point, but sometimes the fingers take me in odd directions.)

First up, we have some additional guidance relative to how one might go about managing compressed gas cylinders, particularly those pesky oxygen cylinders that can cause so much grief during survey. So now we have a Joint Commission performance element that establishes the expectation that each organization will have a policy regarding the storage of oxygen and other compressed gas cylinders, said policy is to include the amount of gas at which segregation of full and empty cylinders would take place. You may recall that the initial “take” required full cylinders to be segregated from empty and partially full cylinders, but that “interpretation” of NFPA 99 has shifted a bit to allow for the storage of partially full cylinders in the company of full cylinders.

And now, we have a new FAQ that provides some guidance relative to how one might go about determining the amounts representative of full/partial/empty, depending on whether the cylinder(s) you are using have an integral pressure gauge. The FAQ also introduces the concept of “depleted volume content,” which ( as near as I can tell), is the amount of gas left in the cylinder that requires storage with the empty (as opposed to the full) cylinders. There is also a (maybe) handy table that walks you through the various segregatory considerations—I’ll let you parse those in your spare time.

My takeaway is that you need to make sure that if your current policy (if you don’t have one, it is a standards-based requirement, so best get on it) doesn’t pretty closely mirror how things shake out in this FAQ, you should consider modification of current policy/practice or be prepared to discuss how what you’re doing to be in compliance with the NFPA 99-2012 requirements. The other “thing” I noticed is the discussion of the labeling of empty cylinders as a function of the segregation process—if you have the empties in a separate rack that is labeled as such, then you should be fine. But if you have a single rack with full and empty cylinders cohabitating, then the empty cylinders have to be labeled; unfortunately, this does not appear to allow for the marking of the rack itself (I’ve seen red tape and red paint to identify the empty “slots”), so if that’s your practice you might get some pushback from a literalist surveyor looking for the empty cylinders to be labeled.

Next up, we have some information relative to the management of behavioral health patients, in this case, discussions of the various methodologies for determining the risks of each patient to be managed. I do believe that the regulatory focus on environmental considerations will start to diminish somewhat as we kick into the “next” survey cycle,  but I believe that the focus on the management of at-risk patient populations will continue as a function of: now that we have a “safer” environment, how are we making sure that the patients are being appropriately cared for, which is driven by the assessment process. Assessment stuff can be found here.

As an additional piece of the puzzle (I guess time will tell whether it is more piece than puzzle or the reverse…), TJC has established an information portal to assist organizations in compliance with the July 1, 2019 changes to the National Patient Safety Goal on Suicide Prevention, including links to the issues of Perspectives in which the initial (and ongoing) guidance, etc. can be found. As a one-stop-shop, it looks like a pretty useful thing to have in your back pocket. As I’ve noted any number of times (and I think once or twice in this forum), a lot of the TJC surveyor knowledge comes to them the same way it comes to you, so I think it a positively splendid idea to take a gander at the links contained herein.

Carbon-dating compliance: What happened when…

…and how responsible are you for the sins of the past (turns out, quite a bit).

Kind of a mixed bag of things this week, so please bear with me.

First up, in looking back over the last little while of survey activity, I keep looping back around to one (possibly unanswerable) question: How many of the survey findings being generated are the result of conditions that pre-existed the prior survey? I think we can all agree that there are noncompliant conditions lurking throughout our buildings (including that pesky loaded sprinkler head we talked about a couple of weeks ago), some of which (and perhaps quite a few) are the result of actions or inactions occurring a long time ago (in a galaxy almost too close to home). I’m going to guess there are few of us that have not encountered the angst of having a surveyor pop a ceiling tile or wriggle into some crawl space and find some condition that had previously escaped prying eyes (I suspect that the most common previously undetected finding relates to things attached to sprinkler piping and supports, which supports LS.02.01.35 being the most frequently cited Joint Commission standard). And, as onerous as it may be on the face of it (and every other aspect), we are on the hook for all of it (grandfathering of conditions can help in very limited ways, but there’s really very little in the way of grandfathering noncompliant conditions and practices).

For better or worse (likely more the latter than the former), in these increasingly resource-challenged times, it is almost impossible to ferret out every little imperfection. Particularly in the sense that noncompliance happens in three dimensions—square footage just doesn’t work for this process. So, the questions I ask of you, dear readers, are these:

  • Do you proactively attempt an exhaustive search of your facility from top to bottom (and all the nooks and crannies)?
  • Do you “roll the dice” and correct deficiencies as they appear and if there’s stuff out there, let the surveyors find them?

I’m keen to see how this is going to “split.” I know if we could we would take the higher road of proactivity, but not everyone is in that position.

One other item I’ve been hanging on to for probably longer than I should relates to the management of medical gas and vacuum systems. I would hardly think that this blog is the only resource for information, commentary, etc. (though I do like to think it’s an entertaining and perhaps randomly enlightening one), there is one dedicated to the management of medical gas systems, etc., that I think you’ll find useful (and since it doesn’t publish as often, it’s an easy one to add to your bloggy queue) is sponsored by Compliant Healthcare Technologies (CHT). Recently, Tim Richards at CHT penned a blog post on upcoming changes in NFPA 99 relative to medical gases, etc. As I’ve noted once or twice in the past, I really see NFPA 99 compliance as a likely source of heartburn for facilities and safety folks in the coming survey cycles, so any resource that can increase our operational understanding of what is actually required, etc. gives us a leg up on the survey front. I encourage you to check out the information.

As a final note, it appears that we are gearing up for another wild summer of weather and I wanted to take a moment to send best wishes to those in areas already in the throes of severe weather and those that may find themselves in the same. I do believe that, as an industry, we have done some extraordinary work in the practical preparations to deal with emergencies (I would feel better if appropriate preparedness would “drive” regulatory compliance a little more closely, but perhaps in time) and I trust that we all manage the coming season with minimal impact and disruption.

Let’s begin again, begin the begin: CMS ligature risks codified!

While I have little doubt that we will yet again revisit the management of ligature risks and behavioral health patients, it would seem that chapter and verse are getting towards stone tablet form—but you have a chance to influence the future state. I suspect we will also be looking back to determine how much influence the field has on the final, final or whether the party line from Chicago holds sway (kind of looks like that at the moment, but there is still time):

  • Back on April 19 (and I do apologize for not picking up on this sooner—I need to get a better strategy for monitoring all these goings-on), CMS issued a draft clarification of the interpretive guidelines relating to ligature risk (you can find the skinny here). All things being equal, I suppose the “newest” thing is the formal introduction of the Ligature Risk Extension Request (LRER—just what we needed, another acronym), which outlines a process for correction of ligature risks that will take longer than the official 60-day turnaround time for the correction of deficiencies. One thing is very clear (well, maybe a couple of things): State agencies and/or accreditation organizations are not allowed to grant LRERs. They can, and in most instances, will act as intermediary between the organization seeking the extension and CMS, and will (basically) advocate for approval based on their analysis of the issues. This is not a Life Safety Code® waiver as ligature risks are not a compliance deficiency relative to life safety requirements. From the process outlined, it does appear that this is to be a reasonable process, (potentially) making allowances for obtaining approval of the governing body, engaging in competitive bidding, applying for funding, obtaining permits for physical changes, and lack of or delays in obtaining products and supplies needed for corrective actions. Needless to say, with the invocation of the LRER, there will be
    • Mitigation strategies to implement
    • Progress reporting to be done
    • A re-survey to verify that the deficiencies have indeed been corrected by the state agency or accreditation organization
  • As has been the case pretty much from the get-go, there are two assessment processes that need to dovetail (or perhaps they are concentric circles): An assessment of the environment and the assessment of patients to determine the level of risk for suicidal behaviors. I do believe that eventually we will be left with the latter upon which to focus, but I suppose there will need to be an ongoing due diligence relative to monitoring the environment. Ultimately, it seems to come down to striking the balance between seeing every aspect of the environment as a big hairy monster as opposed to an element in the environment that can be managed by appropriate means. At the very least, I am hoping that the survey focus returns to general patient care and infection control, with perhaps a side of medication management—I think that’s where the meaningful improvements are hiding (in plain sight).

As a final note, we do have until June 6, 2019 to weigh in on the proposed changes, so I would suggest you gather together a little working group, and if the spirit moves you, weigh right in. The data supports this being a whole bunch of ado about very little (approaching a whole bunch of doodoo), so the sooner we can refocus on the “real” challenges, the better.

 

Like the dust that settles all around me: I got those low-down TJC FAQ blues

I don’t know if there’s anything to be inferred by the fact that the latest updates on the ligature resistance front are “buried” on p. 8 of the May 2019 Perspectives (after an onslaught of what I characterize as Joint Commission advertisements), but it would be nice to think that perhaps folks are going to be allowed to move on at their own “pace” as a function of risk assessments, abatement and mitigation strategies and monitoring for gaps in safety, but I guess we shall see what we shall see.

At any rate, the May Perspectives (on p. 8—imagine that!) provides two topics, one of which, video monitoring we discussed a few weeks back (I guess they like to repurpose content as much as anyone…) and a clarification on the (admittedly somewhat awkwardly worded) requirement that self-closing and self-locking (both, not one or the other) doors are required for the separation of areas required to be ligature resistant and those that are not, with the intent being to eliminate reliance on staff to close and lock those doors to prevent patient harm. The FAQ also prohibits the use of hold-open devices of any kind on these doors, so do keep that in mind. This applies to “staff controlled” areas on a behavioral health unit, like med rooms, utility rooms, consult rooms, etc. This is all based on Recommendation #1 published in the November 2017 Perspectives and the guidance that patient rooms, patient bathrooms, corridors, and common patient areas are to be ligature resistant. If this is news to you (I don’t know that we’ve discussed this particular piece of the puzzle), I can’t say that I am surprised as it really didn’t stand out at the time and really required too much in the way of cogitation to figure out what they were getting at, particularly the descriptor (“Nursing stations with an unobstructed view (so that a patient attempt at self-harm at the nursing station would be easily seen and interrupted) and areas behind self-closing/self-locking doors do not need to be ligature-resistant and will not be cited for ligature risks.”) as it was probably a little too all-inclusive. I think I would have separated them into two bullet points:

  • Nursing stations with an unobstructed view
  • Areas behind self-closing/self-locking doors

But hey, as long as we get there in the end, right? Yeah, sure, fine…

In other news, ASHRAE is in the public comment process relative to proposed changes to ASHRAE 170 Standard for Ventilation of Health Care Facilities (you can see the proposed draft here). Given that NFPA 99 defers to ASHRAE on the ventilation front, I can’t help but think that this is going to continue to be a cornerstone compliance document during survey activities. I don’t know that I noted anything particularly egregious, etc., in the proposed update, but I always try to encourage the folks in the field to review and weigh in when these things are open for comment. Before we got to ligature-resistant considerations, the management of procedural environments as it relates to temperature, humidity, air pressure relationships, etc. was the hot-button topic, so any changes might have a similar impact on the industry. Unfortunately, I just got wind of this last week and the comment period ends May 6, so act fast!

We are hope, despite the times: Steve Mac’s top 10 most troublesome EC challenges

First a quick (moderately revelatory) story: While traveling last week, I had the opportunity to see Creed II on the plane (I found it very entertaining, though somewhat reminiscent of another film—but no spoilers here). Interestingly enough, the image that stayed with me was during a scene on a maternity unit in a hospital where I observed a nicely obstructed fire extinguisher (there was some sort of unattended cart parked in front of the extinguisher). I guess that means I can never turn “this” (and you can call it what you will) off… but enough digression.

About a month or so ago, an organization with whom I had not worked before (they’re on the upcoming schedule) asked for a top 10 list of what I’ve seen as the most challenging physical environment standards, etc. I will admit to having been taken off guard a wee bit (I usually depend on others for top 10 lists), but then I figured it was probably about time that I put a little structure to all the various and sundry things that I’ve seen over the last decade or so.

To that end, here are Steve Mac’s Top 10 Things that will get you in the most trouble in the quickest amount of time (I don’t think there are any surprises, but feel free to disagree…):

Top 10 Critical Process Vulnerabilities – Physical Environment

  1. Inadequately mitigated ligature/safety risks in behavioral health environments
  2. Management of surgical and other procedural environments (temperature, humidity, air pressure relationships)
  3. Construction management process—lack of coordination, inconsistent implementation of risk management strategies
  4. ILSM policy/assessment/implementation—including “regular” LS deficiencies
  5. Management of hazardous materials risks, particularly those relating to occupational exposure (eyewash stations, monitoring, etc.)
  6. Life safety drawings (accuracy, completeness, etc.)
  7. Management of infection control risks in the environment (non-intact surfaces, expired product, high, intermediate and low-level disinfection)
  8. Management of contractors/vendors (documentation, activities, etc.)
  9. Effectiveness of surveillance rounds; integration of work order system, etc., to address compliance concerns
  10. Stewardship of the environment—participation of point-of-care/point-of-service staff in management of the environment.

Now I don’t know that there’s anything here that we haven’t covered in the past, but if you folks would like a more in-depth analysis of anything in the list above (or, indeed, anything else), please let me know. I suspect that I will be returning to this list from time to time (particularly during slow news weeks).

One of your sprinkler heads is loaded: Can you find it before they do?

And now, to the recap of the 10 most frequently cited standards during all of 2018 (in hospitals; other programs are a little more varied), as chosen by somebody other than you (or me): the survey troops at TJC.

The top 10 are as follows:

  • EC 02.01.35—The hospital provides and maintains systems for extinguishing fires (88.9% noncompliance percentage).
  • EC 02.05.01—The hospital manages risks associated with its utility systems (78.7%).
  • EC 02.06.01—The hospital establishes and maintains a safe, functional environment (73.9%).
  • LS 02.01.30—The hospital provides and maintains building features to protect individuals from the hazards of fire and smoke (72.9%).
  • IC 02.02.01—The hospital reduces the risk of infections associated with medical equipment, devices, and supplies (70.9%)
  • LS 02.01.10—Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat (70.7%).
  • LS 02.01.20—The hospital maintains the integrity of the means of egress (67.4%).
  • EC 02.05.05—The hospital inspects, tests, and maintains utility systems (64.7%).
  • EC 02.02.01—The hospital manages risks related to hazardous materials and waste (62.3%).
  • EC 02.05.09—The hospital inspects, tests, and maintains medical gas and vacuum systems (62.1%).

The ongoing hegemony of the top 10’s EOC-centric focus (and I still consider IC.02.02.01 the point upon which infection control and the physical environment intersect—sometimes with spectacular results) leaves little to the imagination (both ours and the surveyors). While you can still get into some significant trouble with certain processes, etc. (more on that next week—I figure if they can have a Top 10 list, then so can I…), the reason that these particular standards continue to jockey for position is because they represent the kinds of conditions (to some degree, I hesitate to call them deficiencies) that you can find literally any (and every) day in your organization. Just think about LS.02.01.35 for a moment: How far would you have to go before you found schmutz on a sprinkler head, something within 18 inches of a sprinkler head, a missing escutcheon (or an escutcheon with a gap), or even something (likely network cabling) lying atop, wire-tied to, somehow “touching” sprinkler piping or supports? I’m going to intuit that you probably won’t have to range too far afield to find something that fits in that category. The only thing I can say is whoever was surveying the “other” 11.1 % of the hospitals in 2018 must not have felt like poking around too much.

At any rate, I don’t know that there is a lot to glean from the 2018 results (same as it ever was…), but if someone out there has a question or concern that they’d like to share, I’m all ears!

Making a checklist, making it right: Reducing compliance errors

As you may have noticed, I am something of a fan of public radio (most of my listening in vehicles involves NPR and its analogues) and every once in a while, I hear something that I think would be useful to you folks out in the field. One show that I don’t hear too often (one of the things about terrestrial radio is that it’s all in the timing) is called “Hidden Brain”, the common subject thread being “A conversation about life’s unseen patterns.” I find the programs to be very thought-provoking, well-produced, and generally worth checking out.

This past weekend, they repeated a show from 2017 that described Dr. Atul Gawande’s (among others) use of checklists during surgical (and other) procedures to try to anticipate what unexpected things could occur based on the procedure, where they were operating, etc. One of the remarks that came up during the course of the program dealt with how extensive a checklist one might need, with the overarching thought being that a more limited checklist tends to work better because it’s more brain-friendly (I’m paraphrasing quite a bit here) than a checklist that goes on for pages and pages. I get a lot of questions/requests for tools/checklists for doing surveillance rounds, etc. (to be honest, it has been a very long time since I’ve actually “used” a physical checklist; my methodology, such as it is, tends to involve looking at the environment to see what “falls out”). Folks always seem a little disappointed when the checklist I cough up (so to speak) has about 15-20 items, particularly when I encourage them not to use all the items. When it comes to actual checklists that you’re going to use (particularly if you’re going to try and enlist the assistance of department-level folks) for survey prep, I think starting with five to seven items and working to hardwire those items into how folks “see” the environment is the best way to start. I recall a couple of years ago when first visiting a hospital—every day each manager was charged with completing a five-page environmental surveillance checklist—and I still was able to find imperfections in the environment (both items that they were actually checking on and a couple of other items that weren’t featured in the five-pager and later turned out to be somewhat important). At the point of my arrival, this particular organization was (more or less) under siege from various regulatory forces and were really in a state of shock (sometimes a little regulatory trouble is like exsanguination in shark-infested waters) and had latched on to a process that, at the end of the day, was not particularly effective and became almost like a sleepwalk to ensure compliance (hey, that could be a new show about zombie safety officers, “The Walking Safe”).

At any rate, I think one of the defining tasks/charges of the safety professional is to facilitate the participation of point-of-care/point-of-service folks by helping them learn how to “see” the stuff that jumps out at us when we do our rounds. When you look at the stuff that tends to get cited during surveys (at least when it comes to the physical environment), there’s not a lot of crazy, dangerous stuff; it is the myriad imperfections that come from introducing people into the environment. Buildings are never more perfect than the moment before occupancy—after that, the struggle is real! And checklists might be a good way to get folks on the same page: just remember to start small and focus on the things that are most likely to cause trouble and are most “invisible” to folks.