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Sticker shock: Compliance your way (not someone else’s)!

As we continue our October re-visitation of some of your more evergreen topics and I was thinking that I had covered this particular topic recently, but it turns out it was rather a long time ago—2012, to be exact (my, my, my, how time flies!).

I guess the general thought/concern relates to whether any particular piece of equipment has to have a due date sticker or some variation thereof. And, interestingly enough, while this still surfaces from time to time, the requirement (or lack thereof) has not really changed in the last seven or so years. Is there a benefit to having a due date so line staff can include a visual when they are using a piece of equipment? Absolutely! If you use color-coded outdate stickers, can it make it easier to discern when something is in arrears? It sure can! Can an outdate sticker call into question the efficacy of your process if there are too many of the “wrong” color floating around? Yup!

If you’re going to use them, then by all means make full use of them. Make sure line staff understand what information is contained on the sticker. Make sure they understand that if a sticker gets removed during the cleaning process, that is an important piece of information to communicate to clinical engineering or whoever is responsible for maintaining the equipment. And, please—for the love of all that is good and practical—try to stay away from policies that speak to the necessity of a sticker being present; another evergreen survey truth is that non-compliance with an internal process is one of the toughest survey findings to clarify. Everything (and anything) you do that is not specifically required by code and regulation should make sense from an operational standpoint. If there’s a program element that has, shall we say, evolved (or mutated) over time and is giving you compliance fits, take it out, dust it off, and make sure that whatever it is brings value to the process. And if it doesn’t? Time to move on!

In a world of magnets and miracles: Shifting the sands of compliance

At the risk of engaging in non-sequiturial (which autocorrect keeps insisting should be non-equatorial) content, I want to touch on a couple of short items that came across my desk over the last couple of days. I don’t know that they specifically relate to each other, but I can imagine a sufficiently powerful pattern recognition program that could link the two (think really, really big picture).

First up, we have some conversation relative to CMS’ efforts to increase the validity of the process by which CMS oversees (or validates) the work of the various accreditation organizations (AO) as they engage in the deemed status survey process. Until recently, the CMS validation process involved a survey visit close on the heels of the AOs (typically within 60 days or so) to see how closely the completed survey met the expectations of CMS vis-à-vis the Conditions of Participation. Historically, there have always been gaps between what was found by the AOs and what was found by CMS, with a lot of pushback on the part of the AOs relative to the timing of things—healthcare organizations are, if nothing else, fluidity personified. So, in response to the timing pushback, CMS has started co-surveying with TJC in real time; so, instead of dealing with your usual complement of TJC surveyors, you also get to host—at the same time—a group of CMSers. Ostensibly, the purpose of the CMS team is to observe the survey efficacy of the Joint Commission team,  but I think you can see where what has never been a “pleasant” experience could really go sideways. I personally have not heard any tales of folks having experienced this type of event, but I feel certain that someone I know will be able to share some stories of daring do and horror-filled antics. Any takers? It would seem (based on a blog post from TJC) that some organizations have expressed gratitude for not having to go through two separate survey events, and there’s a general sense that the CMS/AO survey findings are of a piece, so I guess that’s a good thing. But somehow…

At any rate, at the moment, if your organization is going to have this extra special survey experience, there will be prior notification, but there appear to be plans afoot to end up at a point in which these extra special surveys will be completely unannounced. It also appears that moving in that direction will require some modification to the language in the Conditions of Participation that authorize the validation surveys. According to the blog, the current process is in place through federal FY 2020 (October 1, 2019 through September 30, 2020), so I guess we’ll have to wait and see how things go.

To take this in a completely different direction (well, maybe not completely…) I came across an article providing some advice on conducting one-on-one meetings with staff. As a consultant, it’s been rather a while since I’ve had to administer one-on-one staff meetings, so this may be old hat to you folks with current operational oversight of line staff, but it did prompt me to think about past practices and I can see where this might be helpful in a lot of different ways. I am a firm believer in trying to make every encounter more useful and I think this might be a strategy worthy of your consideration. So, if you need something to read as we start the wind-down of summer (it’s the last week of August—how did that happen?!?), I think this would be worth your time (and please let me know if you think otherwise—any and all feedback is most appreciated!).

Have a safe and festive Labor Day!

Don’t forget to leave room for amazement: The perils of occupational fatigue

If you’ll bear with me, friends, this week deals not so much with the harsh realities of our vocation, but with the hope that those harsh realities can be effectively managed.

One of the true blessings of my work as a consultant is the opportunity to change things up on a regular basis—meeting new people and seeing new places while still renewing acquaintances encountered on the journeys of the past 18 years. And, as I think about it, I do hope (at least some of the time) this blog provides you with some level of diversion, but occupational fatigue (aka work burnout) is more common than serves anyone’s benefit.

I am in the habit of collecting things that interest me, and sometimes I’ll encounter something of sufficient interest that I want to share it with you folks. In wandering around the internet in the wake of the anniversary of the first moon landing, I came across a blog post (written by Brad Stulberg) describing some ways of dealing with work burnout that I felt was worth sharing.

As with so many things that “occur” to me, it’s not so much the revelatory aspect of the piece (though there is that to some degree), but rather the “tone” of the article that really caught my attentions to the extent that I wanted to share this with you. It doesn’t necessarily relate to safety in a global sense (though I could make the case that it does relate to personal safety to a fair degree), but I think anything that can shift the direction of conversation, even for the briefest of moments, is time well spent.

So, a short one this week, but that should give you some time to seek out a little amazement—you can never have too much magic in your life!

Maybe there’s a hole in there somewhere: Keeping your critical equipment running!

An interesting line of questioning is emerging in some recent survey activity (mostly during state visits, but the accreditation organizations are moving in this direction, particularly those with a focus on ISO processes) relates to the management of “high mortality” utility systems components, particularly emergency power supply system parts. If you look at this as a function of high reliability, ensuring that you have close to immediate access to a means of repairing those things that are most likely to break (and I suspect that everyone out there in the reading audience know which of your utility systems are most likely to give you fits—from experience, elevators always seem to figure in on that count).

I think in most instances it would require some level of working with your service providers to identify the things that are most likely to go wrong and then to set up a process for ensuring ready access to parts and service. Let’s face it, there are few more angst-filled moments than when you have to tell your boss that a critical piece of equipment is going to be down because parts need to be ordered, etc. And I don’t know of too many service vendors that are maintaining a broad-range of replacement parts, etc. on their shelves (I’m sure there are some and that’s great for you if they “live” in your neighborhood); inventory can be an expensive undertaking. But maybe there’s a way to build that into your next service contract—something to think about—your incumbent is probably going to have the most specific failure data relative to your equipment, but I would think there are sufficient commonalities of systems and equipment to allow for competitive proposals if you choose to go that route.

Some other contractual considerations (and this is more on the compliance front than anything, but still)—a “hard” touch whenever folks are onsite servicing equipment—at the very least, they can let you know if they see anything that might prove troublesome, so you don’t have to hunt for it when the paperwork arrives (hopefully sooner rather than later—that’s another contractual consideration—turnaround time for service reports/records). I don’t know that we’ll ever have enough granularity of data from the regulatory folks, but I am absolutely convinced (based on what I’ve seen) that the reason that findings in and around fire safety (and other) systems documentation relates to stuff being buried in vendor reports: the “classic” smoke detector that didn’t get tested or the heat detector in an elevator shaft that someone terms “inaccessible.” We (as a collective) are on the hook for ensuring that 100% of your devices and equipment are inspected, tested, and maintained in accordance with code and regulation. Our vendors really don’t have any “skin” in the game.

I’m sure this is all rather self-evident to you folks, but where I’m sitting at the moment, there’s not a lot of “new” stuff floating around and it was a miserable rainy day, so this is what the connection of head and fingers conjured up.

People get ready: There’s a (survey) train a-coming!

When it comes right down to it, I think it is nigh on impossible to have access to too many resources or, indeed, to have access to too many perspectives on the various and sundry processes that make up our little EOC world (OK, maybe not so little), so I’m always on the lookout for stuff that I think might be worth sharing with you folks. (It’s one way I’ve managed to not run out of things to say over the past 600+ weeks since I started this journey.)

Our good friends over at ASHE’s Health Facilities Management magazine recently published an article describing some of the ways facilities and safety professionals can effectively manage the accreditation process, primarily as a function of survey preparedness/readiness. I don’t know that there was anything of great surprise contained therein (with the important note that surveying hospitals is pretty much my life’s work, at least at the moment), but I think the authors did a nice job of providing an overview of the survey process with some key information points that may give you a “leg up” on your next survey.

The one thing we “know” is that we really don’t know when they’re coming next, so the general concept of continuous survey readiness is one that really needs to be taken to heart. But one of the key components of which you need to be mindful is that CMS is definitely ratcheting up on the “looking over the shoulder” aspect of the validation survey process. Where previously, CMS would conduct a validation of survey of the various accreditation organizations within 60 days of the accreditation survey activity, now CMS resources are observing the accreditation organization process as it happens. At the moment, any organization encountering the “enhanced” (my characterization) survey process are notified ahead of time, so you can do a little planning (not sure how much notice is given—if anyone out there can shed some light, based on experience, I’d love to hear from you). But there will come a time when it will be a (more or less) complete surprise!

At any rate, if you want to read about the opening salvo in this little endeavor, you can find it here, and the latest news on this front can be found here, which includes a link to the proposed rule change that deals with changes of ownership, etc. of accreditation organizations. Not very exciting stuff…yet! But I think the pendulum is going to continue swinging in the direction of more oversight (and probably, intervention) for the next little while…

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.