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Why can’t we have anything nice? Hardwiring safety improvements: Finding fault vs. facilitation

It seems of late I’ve been encountering tales of much fingerpointing, heavy sighs, and the like in the lead-up to a date with our friends from Chicago. To my way of thinking, if there are outstanding/longstanding issues relating to compliance (and it can be just about anything relative to compliance), how much help can it be to keep pointing out the deficiency without working with folks to find some sort of rational/operational strategy for managing their environment? For example, where can one put stuff? I’ve been working the consulting beat for almost 17 years (as I wrap up my 40th year in healthcare—more on that as we approach that momentous July anniversary) and I can tell you with pretty much absolute certainty that there is not a single hospital anywhere that has enough (which would equate to too much) storage space. Clearly some of that deficit is a function of revenue generation potential as an algorithm for space allocation, but even your biggest money-makers tend to have more stuff than space. But I come back to the reality of kicking department managers for the same compliance concern(s) time and time again and (again, this is my interpretation) it just seems like a buck-passing exercise for the folks conducting the rounds— “well, I told them they couldn’t do that—and they keep doing it.” And try as I might, I can’t equate that type of process with anything that approaches performance improvement.

While I recognize (and observe in certain instances) that organizations have made, and continue to make, improvements over time, what is important is not to lose sight of the hardwiring of processes that are designed to sustain those improvements. As noted in the storage example, the physical plant is traditionally not considered a revenue generating concern, but the impact of ongoing maintenance of the physical environment on the delivery of excellent patient care has never been scrutinized more closely. It is of critical importance to develop and implement strategies that allow for those tasked with maintaining the physical environment to focus on those tasks, utilizing point-of-care/point-of-service staff to the fullest extent in the not just identifying, but facilitating management of “imperfections” in the environment.

Not to belabor the point, but the current level of focus on conditions in the physical environment, particularly as a function of the environment’s impact on infection control and prevention, calls for a greater degree of coordination amongst the primary stakeholders. While there is no specific dictate relating to the circumstances under which infection control risk assessments must be conducted; risk management strategies implemented (either through a hardwiring of basic risk reduction in standard operating procedures for certain activities, including repair and renovation activities on patient units), and a reliable process for notification of, and follow-up for, conditions that might nominally be described as “breaks” in the integrity of the environment. Certainly, the proliferation of leaks, stained ceiling tiles, damaged wall and flooring surfaces, etc., would indicate that the current management of this process does not provide enough of a “safety net” to serve the organization and its mission of continuous survey readiness. At this point, the administration of the survey process is clearly aimed at the removal of the “final” barriers between “clinical” and “non-clinical” functions in hospitals. The survey process is based on a clear sense/understanding that the entire hospital staff is engaged in patient care, regardless of their role in that care. The organizations that fare the best during survey are the organizations that have been able to grow the culture in a direction that results in a truly seamless management of the environment as the outer “ring” of the patient care continuum. Each staff member is a caregiver; each staff member is a steward of the physical environment.

I don’t think we can ever hope to be successful until we starting working towards a sheriff-less approach (based on that old saw “There’s a new sheriff in town”). One of the fundamentals of just culture is holding folks accountable, but not without working with them to achieve that nirvana state. I think if punishment (I consider reiteration of sins to be punishment) worked, we’d have a lot fewer findings in the physical environment. I can remember a time when you could get away with a more dictatorial approach to managing the environment, but I don’t think that time is coming back any time soon.

Unfortunately, the regulatory folks aren’t quite poised to embrace the facilitation/consultation model of accreditation surveying, which leads me to my closing thought/suggestion for this week. I am still “anxious” about the whole water management program issue as a function of the accreditation survey process and how it will play out. I’ve heard (but not seen) that TJC has cited folks for (presumably) inadequate water management programs, and I’ve learned over time that these types and numbers of findings tend to escalate before they de-escalate. Certainly, this is something we have to “do” very well, because to do otherwise puts people at risk. As I have in the past, I would encourage you to check out Matt Freije’s latest thoughts on all things water management programs. I suspect that everyone is a different point along the “curve” with this one, but I know one thing—you don’t want to have an outbreak relating to the management of waterborne pathogens. Talk about being “sheriffed”…

What the world needs now: Effective management of workplace violence

By now I’m sure you’ve all noted the unveiling of the latest Sentinel Event Alert (#59 for those of you keeping count) from our friends in Chicago; this particular SEA represents the third swing at concerns and considerations relative to workplace safety, inclusive of workplace violence. But, as I look at the information and guidance provided in the May 2018 issue of Perspectives, it makes me wonder what pieces of this remain elusive to folks, beyond the “normal” operational challenges of providing effective safety education to staff on a regular basis.

So, my questions for the group are these:

  • Have you clearly defined workplace violence?
  • Have you put systems into place across your organization that enable staff to report workplace violence events, inclusive of verbal abuse?
  • Have you identified all the potential sources of data relative to workplace violence occurrences?
  • Are you capturing, tracking, and trending all reports of workplace violence, inclusive of verbal abuse and attempted assaults, when no harm occurred?
  • Are you providing appropriate follow-up and support to victims, witnesses, and others impacted by workplace violence, including psychological counseling and trauma-informed care?
  • Are you reviewing each case of workplace violence to determine the contributing factors?
  • Are you analyzing data related to workplace violence, and worksite conditions, to determine priority situations for intervention?
  • Have you developed any quality improvement initiatives to reduce incidents of workplace violence?
  • Have you provided education to all staff in de-escalation, self-defense, and response to emergency codes?
  • Are you evaluating on an ongoing basis the effectiveness of your workplace violence reduction initiatives?

If your response to any of these questions is “no” or “not sure,” it’s probably worth (at the very least) some discussion time at your EOC and/or organizational QAPI committee, but I have a strong suspicion that most of you have already identified the component pieces identified above in your own efforts. That’s not to say that there aren’t improvement opportunities relative to workplace violence (as there likely always will be), but I do think we’ve made some pretty decent strides in this regard over the past few years. There was a time when the incidence rate was sufficiently concentrated to certain healthcare environments (cities, urban areas, etc.), but, and this is probably the toughest risk element to truly manage, it appears that workplace violence can happen at any time, anywhere. In some ways, it reminds me of the early days of the Bloodborne Pathogens standard and Universal Precautions; it was frequently a struggle for safety and infection control folks to sufficiently encourage good behaviors (and lord knows hand washing can still be a struggle), but much of what was initially viewed as foreign, inconvenient, etc. has finally been (something close to) hardwired into behaviors.

Again, I’m not convinced that this revisitation of covered territory helps anything more than increasing the risks of getting hammered during a survey if you can’t specifically identify how your program reflects their expert advice, but maybe it will help to gently remind organizational leaders that this one’s not going to go away.

It was a fine idea at the time: Safety story of the week!

Now it’s a brilliant…

I think we’ve hung out together long enough for you to recognize that I have some geeky tendencies when it comes to safety and related things, sometimes straying beyond the realm of health care. And this is (pretty much definitely) one of those instances.

Over the weekend, while listening to NPR, I happened upon a story regarding safety concerns at the Tesla factory out in California and how operating at the brink (cusp?) of what’s possible can still fall victim to some time-honored realities of the workplace. The story, coordinated by The Center for Investigative Reporting, and aired on their program Reveal (you can find the story, and a link to the podcast of the story here) aims at shedding some light on some folks injured while employed at Tesla. While I can’t say that there’s the figurative “smoking gun” relative to decisions made, but it does seem to fall under the category of “you can make the numbers dance to whatever tune you’d care to play.” I thought it was a very well-done piece and while there may not be specific application to your workplace, I figure you can always learn from what others are (or aren’t) doing. At any rate, I can’t tell the story as well as they have (the podcast lasts about 55 minutes; the SoundCloud link is about halfway down the page), so I would encourage you to give it a listen.

One other quick item for your consideration: We chatted a few weeks ago about the shifting sands of compliance relative to emergency generator equipment and I wanted to note that I think it would be a pretty good idea to pick up a copy of the 2010 edition of NFPA 110 (it’s not that large a tome) or at the very least, go online and use NFPA’s free access to their code library, and familiarize yourself with the contents. Much as I “fear” will be the case with NFPA 99, I think there are probably some subtleties in 110 that might get lost in the shuffle, particularly when it comes to the contractors and vendors with whom we do business. Recently, I was checking out an emergency generator set that was designed and installed in the last couple of years and, lo and behold, found that the remote stop had not been installed in a location outside of the generator enclosure. Now I know that one of the things you’re paying for is a reasonably intimate knowledge of the applicable code and regulation, and emergency power stuff would be no exception (by any stretch of the imagination) and it perturbed me that the folks doing the install (not naming names, but trust me, this was no mom & pop operation that might not have known better) failed to ensure compliance with the code. Fortunately, it was identified before any “official” survey visits, but it’s still going to require some doing to get things up to snuff.

I have no reason to think that there aren’t other “easter eggs” lurking in the pages of the various and sundry codified elements brought on by the adoption of the 2012 Life Safety Code®, so if you happen to find any, feel free to give us all a shout.

The exodus is here: Are you prepared?

Some say not so much.

First off, many thanks to the standards sleuths out there that assisted on solving last week’s missing EP caper; it’s nice to know that I am not merely orating into the void (oration being a somewhat hyperbolic description of this blog—lend me your eyes!).

Now, on to our continuing coverage of emergency management stuff.

The ECRI report outlining the Top 10 Patient Safety Risks for 2018 (if you missed it last week, you can download it here), does make mention of all-hazards emergency preparedness as #7 on the Top 10 list, though I have to say that their description of the challenges, etc., facing hospitals was whatever word is the opposite of hyperbolic (I did a quick search for antonyms of hyperbolic, but nothing really jumped out at me as being apropos for this discussion), pretty much boiling down to the statement that “facilities that were prepared for…disasters fared better than those that were not.” And while there is a certain inescapable logic to that characterization, I somehow expected something a bit weightier.

That said, the ECRI report does at least indicate that there may have been hospitals that were prepared, which is a little more generous than hospital preparedness was described in the report from our friends at the Johns Hopkins Bloomberg School of Public Health Center for Health Security (you can find the report here). The opening of the Hopkins report goes a little something like this: “Although the healthcare system is undoubtedly better prepared for disasters than it was before the events of 9/11, it is not well prepared for a large-scale or catastrophic disaster.” Now that is a rather damning pronouncement, and it may be justified, but I’m having a bit of a struggle (based on reading the report) with what data was used in making that particular pronouncement. I’m not even arguing with their recommendations—it all makes abundant sense to me from a practical improvement standpoint—and I think it will to you as well. But (I’m using a lot of “buts” today), I’m having a hard time with the whole “is not well prepared” piece (in full recognition that it is healthcare as a single monolithic entity that is not well prepared). Could hospitals be better prepared? Of course! Will hospitals be better prepared? You betcha! Could hospitals have more and better access to a variety of resources (including, and perhaps most importantly, cooperation with local and regional authorities)? Have the draconian machinations of the federal budgeting process limited the extent to which hospitals can become prepared? Pretty sure that’s a yes…

Could the nation (or parts therein) experience catastrophic events that significantly challenge hospitals’ ability to continue to provide care to patients? Yup. Will the nation (or parts therein) experience catastrophic events that significantly challenge hospitals’ ability to continue to provide care to patients? Probably, and perhaps (given only the weather patterns of the last 12 months or so) sooner rather than later. There have always been (and there always will be) opportunities for hospitals to improve their level(s) of preparedness (preparedness is a journey, it is not a destination), including building in resiliency to infrastructure, resources, command leadership, etc. And while I appreciate the thought and preparation that went into the report, I can’t help but think that somehow this is going to be used to bludgeon hospitals on the regulatory front. In preparation for that possibility, you might find it useful to turn your emergency management folks loose on a gap analysis relative to the recommendations in the report (again, I can’t/won’t argue with the recommendations—I like ’em), just in case your next accreditation surveyor tries to push a little in this realm.

Cylindrical musings and nudging as a compliance strategy

Howdy, folks. After surviving the battering of this past weekend’s tumultuous weather in the Northeast (I got to experience it twice—once in Indiana and again back home), I’m going to be (relatively) brief for this week’s missive.

First up, hopefully most of you are familiar with the TED Talks concept (all the info you need about that you can find here) and NPR has a weekly program that kind of crystallizes some of the TED offerings in their TED Radio Hour. This past weekend (no TV, so we had to huddle around the radio, just like in olden times), the program revolved around the use of gentle pushes or nudges to change behaviors (you can hear that broadcast here). As safety professionals, I think we are all acquainted with the various attempts to get folks to do our bidding when it comes to safe practice (that sounds a little authoritarian, but it’s kinda what we’re up against) and I thought the entire program really gave me some food for thought in how we might come at compliance from a slightly different perspective. I thought some of the ideas were fascinating and definitely worth sharing, so if you have a spare 55 minutes or so (the webpage above does break it out into the individual sections of the broadcast—I think it’s all good, but whatever description seems most interesting to you would be a good starting point), you might give it a whirl…

I also want to bring you some hopeful news on the cylinder storage segregation front; when this whole focus started, quite a few folks were cited for storing non-full (empty or partial) cylinders in the same location as full cylinders. I don’t know when The Joint Commission posted the updated FAQ on cylinder storage, but, and I quote, “Full and partially full cylinders are permitted to be stored together, unless the organization’s policy requires further segregation.” I know this whole thing was the bane of a lot of folks’ existence, particularly after we had to work so diligently to get folks to secure the cylinders properly, only to have this little paradigm shift towards the edge of darkness. I believe that this will make things somewhat simpler in the execution (make sure your policy reflects the allowance for full and partials to be stored together—they’ll be looking to review that policy).

As a final, non-safety note, I just flew cross-country and was able to watch Gary Oldman’s performance as Winston Churchill in Darkest Hour. I’ve always been something of a history buff, with World War II as a central theme and must tell you that I thought it was a really great performance and a fine movie (or is it a film?). It really points out the power of consensus and the use of the spoken word to galvanize folks (which kind of ties back to the nudging—though Sir Winston’s nudge packed a lot of wallop). At any rate, I thought it was very well done (no surprise about the Best Actor Oscar) and probably my favorite since Lincoln (the movie, not the car or President…though Lincoln in the Bardo was a very interesting book…).

’Tis the season…for more emergency management goodness!

Recognizing the somewhat hyperbolic nature of this week’s headline (you need only listen to current news/weather feeds to be able to determine that emergencies are not quite as seasonal as perhaps they once were…), I did want to share one more emergency management-related nugget with you (I do try to mix things up, but until I start seeing some “hard” survey results—or some regulatory panjandrum makes some sort of announcement, I’m going to keep seeding this space with various and sundry bits of stuff), this coming to us from the left coast, aka California.

While I have little doubt that you Californians in the audience are familiar with the California Department of Public Health (CDPH—four scary letters, though perhaps not as scary as OSHPD for the facilities folks in Cali) requirements for workplace emergency plans (which is highlighted in this month’s CDPH Occupational Health Watch), I think that there might well be some useful information for folks in other parts of the country (I have found, over some few years of experience, that regulatory tsunamis can start in California and find their way to all manner of locales). To be honest (and why else would we be here?), the plan elements required (or at least the ones the surveyors want to see) by the usual regulatorily-inclined suspects, are frequently not quite as useful from an operational preparedness/mitigation/response/recovery standpoint (they provide a useful structure for the aforementioned quartet, but when it comes down to doing the do, again, sometimes not so much).

At any rate, the Cal/OSHA Emergency Action Plan requirements, provide (at least in my mind—feel free to disagree) a good basic sense of the pieces to have in place that are not necessarily as patient-focused. When the fecal matters starts impacting the rapidly rotation turbine blades, it’s important to have a structure in place that addresses the employee aspect, particularly for those of you with offsite non-clinical operations (billing, finance, HR, etc.: a lot of folks don’t have enough space at the main campus for all the moving pieces that constitute a healthcare organization). So, here’s the California stuff (and please feel free to share any good stuff your state might have on the books—this is all about getting prepared and staying prepared—every little bit helps):

(b) Elements. The following elements, at a minimum, shall be included in the plan:

(1) Procedures for emergency evacuation, including type of evacuation and exit route assignments;

(2) Procedures to be followed by employees who remain to operate critical plant operations before they evacuate;

(3) Procedures to account for all employees after emergency evacuation has been completed;

(4) Procedures to be followed by employees performing rescue or medical duties;

(5) The preferred means of reporting fires and other emergencies; and

(6) Names or regular job titles of persons or departments who can be contacted for further information or explanation of duties under the plan.

(c) Alarm System.

(1) The employer shall establish an employee alarm system which complies with Article 165 (link to that info here).

(2) If the employee alarm system is used for alerting fire brigade members, or for other purposes, a distinctive signal for each purpose shall be used.

(d) Evacuation. The employer shall establish in the emergency action plan the types of evacuation to be used in emergency circumstances.

(e) Training.

(1) Before implementing the emergency action plan, the employer shall designate and train a sufficient number of persons to assist in the safe and orderly emergency evacuation of employees.

(2) The employer shall advise each employee of his/her responsibility under the plan at the following times:

(A) Initially when the plan is developed,

(B) Whenever the employee’s responsibilities or designated actions under the plan change, and

(C) Whenever the plan is changed.

(3) The employer shall review with each employee upon initial assignment those parts of the plan which the employee must know to protect the employee in the event of an emergency. The written plan shall be kept at the workplace and made available for employee review. For those employers with 10 or fewer employees the plan may be communicated orally to employees and the employer need not maintain a written plan.

 

I hope this provides you with some useful (and perhaps even thoughtful) information as we roll through emergency year 2018. I am hoping for a time of minimal impact for communities this year (I think we had just about enough last year), but the oddness of the weather patterns over the past couple of months gives me pause. (I live in the Boston area and Houston and its environs had snow before we did!)

You don’t have to be a weather(person)man to tell: Kicking off survey year 2018!

Your guess is as good as mine…

Just a couple of brief items (relatively—you know how I do go on, but I will try) of interest. I don’t know that there’s a common theme besides an effort to anticipate in which direction the survey winds might blow in 2018:

  •  Previously in this space, I’ve mentioned the work of Matt Freije and his team at HCInfo as they have done yeoman’s (yeoperson’s?) work in the field of water systems management and the “fight” against In response to last year’s letter of intent by CMS to take a more focused look at how hospitals and nursing homes are providing appropriately safe water systems for their patients, Mr. Freije has developed a checklist to help folks evaluate their current situations and has posted the checklist online for comment, suggestions, etc. I’m having a hard time thinking that this might not become something of a hardship for folks arriving late to the party, so if you’ve not yet embraced poking around this subject (and even if you have), you’d do well to check out the checklist.
  •  A couple of inspection items relative to the ongoing rollout of the various and sundry changes wrought by the adoption of the 2012 Life Safety Code®, some of which have yet to migrate in detail to the accreditation organization publications (at least the ones that I’ve seen), but have popped up during recent CMS surveys:
    • Make sure you fire alarm circuit breakers are clearly marked in red (check out NFPA 72 10.5.5.2 for the skinny on this).
    • Make sure your ILSM/fire watch policy/process reflects the appropriate AHJs—you need to make sure that you know for sure whether your state department of public health, et al, want to be notified. They do in California, and probably elsewhere.
    • In NFPA 25, chapters 5 and 13 indicate some monthly inspections of gauges, valves for condition, appropriate position (open or closed) and normal pressures—again, they’re not specifically listed in the accreditation manuals yet, but I suspect that they’ll be coming to a survey report near you before too long.
    • A final note for the moment in this category, NFPA 70 (2011 edition) 400.10 indicates that “flexible cords and cables shall be connected to devices and to fittings so that tension is not transmitted to joints of terminals.” Keep an eye on power strips, particularly in your IT and communications closets for those dangling power strips (and some of them aren’t so much dangling as they are pulled across open spaces, etc. I suspect you know what I mean.) I know the folks who manage this stuff think that we are just being pains in the butt, but now you may have a little codified leverage.
  •  In my post a couple of weeks ago, I don’t think I played the personal protective equipment (PPE) card with sufficient gravity; part of folks’ understanding of the hazards of using chemicals is recognizing the importance of actually using appropriate PPE as identified on the product SDS. When you think about it, the emergency eyewash station is not intended to be the first line of defense in the management of exposures to chemical hazards, but rather what happens when there is an emergency exposure. If the use of PPE is hardwired into the process, then the only time they’ll need to use the eyewash equipment is when they do their weekly testing. At that, my friends, is as it should be.

 

It’s knowing (hoping) that this can’t go on forever: A little bit of regulatory mishegas…

It being only the third week of the New Year, it’s a little early for any trends to fully manifest themselves, so a couple of odds and ends to get you caught up on (or, upon which to get you caught up, for any hard-core grammarians in the crowd…).

The latest issue of Health Facilities Management has a couple of articles (and a risk assessment available to ASHE members—gotta love a new risk assessment) that should prove of some value/interest over the next little bit:

  •  ASHE issues update on CMS ligature-risk policy – this is basically a recap of the CMS memo issued in December (details here) but also includes mention of an environmental ligature risk tool (updated to include a worksheet for EDs) that is available to ASHE members. I’m not sure if the “hand in glove” relationship between ASHE and TJC will remain the same with the departure of George Mills, but there is every reason to feel that ASHE’s position as an advocacy group will continue. In that light, probably a good idea to check out the ligature risk tool and adopt any elements that you may not have yet considered. I still feel that you have to rule everything in as a risk until you can start ruling stuff out, but I also think that we should be checking out any and all available resources.
  • An interesting article on airflow in the OR; to be honest, I love this kind of digging around into the corners of what makes the surgical environment such a bear from a compliance standpoint and where regulatory scrutiny might be headed as a function of increasing attention to the infection control impact of the environment. I’m not suggesting you have to mimic the study, but it might help you anticipate some pointed survey questions or requests.
  • Also in the latest issue of HFM, there’s an update on the CMS interpretations relative to rolling latches and related concerns as well as a request for volunteers to assist in gathering information, policies, etc. on how folks are keeping things quiet at night.

Moving on to our friends from Chicago, in the continuing unfolding of information regarding the management of ligature risks, the latest issue of Joint Commission Online includes further guidance relating to “other” (my quotation marks) behavioral health environments such as residential treatment, partial hospitalization, intensive outpatient and outpatient treatment programs. The guidance indicates that these settings are not required to be ligature resistant, but then goes on to indicate that a risk assessment should be conducted in these environments, and then policies and procedures implemented to address how to manage patients in these settings that may experience and increase in symptoms that could result in self-harm or risk of suicide. The piece also indicates that the expert panel met again in December and there will be additional guidance relating to suicide risk assessment and safe monitoring of high-risk patients. And so the conversation continues…

An invitation to the regulatory dance—and the band keeps playing faster…

About a year ago, we chatted a bit about the likely changes to the regulatory landscape under a new administration, most of which (at least those related to the changing of the guard) never really materialized to any great extent. But one thing held true—and continues as we embark upon the good ship 2018—the focus on management of the physical environment is very much at the forefront of preparatory activities.

We also chatted a bit about The Joint Commission’s previous exhortations to healthcare leaders to focus more attention on the management of the physical environment (I was going to provide a link to TJC’s leadership blog regarding our little world, but it appears that the page is not so easily found, though I’m sure it has nothing to do with revisionist history…). But it does appear that there’s no reason to think that the number (and probably types) of survey findings in the environment are going to be anything but steady, though hopefully not a steady increase. Remember, we still have two years in the survey cycle before everyone gets to have undergone their first survey with the loss of the rate-based performance elements.

Which brings us squarely to 2018 and our continuing storm of regulatory challenges; I had made a list of stuff that I believed would play some role of significance in 2017 and (strangely enough) appear to be poised to do the same in the coming year (or two…or three?!?):

 

  1. Physical environment standards remain among the most frequently cited during TJC surveys (Nine of the 10 most frequently cited standards for the period January through June 2017). Please check out the September 2017 issue of Joint Commission Perspectives for the details! Just so you know (and I do believe that I’ve mentioned this in the past), I “count” IC.02.02.01 as a physical environment standard. Yes, I know it’s under the Infection Control chapter, but disinfection, the management of equipment and supplies? That all happens in the environment!
  2. CMS, in its report card to Congress, identified the physical environment as the largest “gap” of oversight during all accreditation organization surveys
  3. Also in its report card to Congress, CMS singled out TJC as lagging behind its competition when it comes to improving identification of deficiencies relative to the Conditions of Participation. I firmly believe that the report card to Congress was the proverbial “spark” that fanned the flames of regulatory focus in the environment. I don’t know when we can expect an updated edition of the report card (I suspect that it may be a while), but knowing that CMS is “concerned” can only mean continued focus…
  4. CMS adoption of the 2012 Life Safety Code® (effective survey date of November 1, 2016) definitely did create some level of confusion and uncertainty that always accompanies “change.” And 2017 demonstrated very clearly that it’s not just “us” that have to learn the practical application of the new stuff—the surveyors have to catch up as well! I am definitely starting to see the impact of the adoption of the 2012 Health Facilities Code (NFPA 99)—if you don’t have a copy in your library, it might just be time.
  5. TJC is in the process of revising its Environment of Care and Life Safety chapters to more closely reflect CMS requirements. January 2018 continues the rollout of the standards/performance elements updates—and they’re still not done. As we’ve discussed over the last few weeks, there’s still a lot of shifting requirements (some we always knew were in place, others merely rumored).
  6. Recent TJC survey reports indicate an increasing focus (and resulting vulnerabilities) on outpatient locations, particularly those engaging in high-level disinfection and/or surgical procedures. The physical environment in all areas in which patients receive care, treatment, and services are generating up to 60% of the total physical environment findings in recent surveys. That was just as true in 2017 as in 2016—each care location in the organization has to be prepared for multi-day scrutiny.
  7. CMS published its final rule on Emergency Preparedness (including Interpretive Guidelines, effective November 2016, with full implementation of requirements due November 2017). While organizations in compliance with current TJC Emergency Management standards will be in substantial compliance with the new rule, there will be some potential vulnerabilities relative to some of the specific components of the rule. The key sticking points at the moment appear to relate to the Continuity of Operations Plan (COOP) and the processes for delegating authority and leadership succession planning during extended events.
  8. Introduction of TJC’s SAFER matrix, which did indeed result in every deficiency identified during the survey process being included in the final survey report. Formerly, there was a section called Opportunities For Improvement for the single findings that didn’t “roll up” into a Requirement For Improvement. With the SAFER matrix, everything they find goes into the report. And there did seem to be a preponderance of findings “clustered” (make of that descriptor what you will) in the high risk sections of the matrix.
  9. As a final “nail” in the survey process coffin, effective January 2017, TJC will no longer provide for the clarification of findings once the survey has been completed. While this didn’t result in quite the devastation in the process as it might have first appeared (mostly because I think it forced the issue of pushing back during the survey), it also appears that clarification only during survey was not the hard line in the sand it appeared to be when this first “dropped.” That said, there very definitely seems to be a reluctance on the part of the folks at the Standards Interpretation Group (SIG) to “reverse the call on the field” once the survey team has left the building; just as there is a reluctance to vacate physical environment findings once the LS surveyor has hit the bricks. If you feel that a finding is not valid, there is no time like the present when it comes to the pushback.
  10. One unexpected “change” during 2017: The focus on ligature risks in the various environments in which behavioral health patients receive care, treatment, and/or services. We’ve discussed the particulars fairly extensively in this space and while I didn’t see it “coming,” it has certainly leaped to the top of the concern pile. The recent guidance from the regulators has (perhaps) helped to some degree, but this one feels a lot like the focus on the procedural environment over the past couple of years. I don’t think they’re done with this by any stretch…

 

In my mind, still working from the perspective of CMS calling out the physical environment as an area of concern, the stuff noted above indicates the likely result that the next 12-24 survey months will show a continued focus on the physical environment by the entire survey team (not just the Life Safety surveyor) and a likely continued plateau or increase in findings relating to the physical environment. I still believe that eventually the regulatory focus will drift back more toward patient care-related issues, but right now the focus on the physical environment is generating a ton of findings. And since that appears to be their primary function (generating findings), there’s always lots to find in the environment.

As I like to tell folks (probably ad nauseum, truth be told), there are no perfect buildings/environments, so there’s always stuff to be found—mostly fairly small items on the risk scale, but they are all citable. The fact of the matter is that there will be findings in the physical environment during your next survey, so the focus will shift to include ensuring that the corrective action plans for those findings are not only appropriate, but also can demonstrate consideration of sustained compliance over time. Preparing for the survey of the physical environment must reflect an ongoing process for managing “imperfections”—not just every 36 (or so) months, but every day.

Try to run, try to hide: Some random thoughts to open the 2018 Physical Environment campaign

I suspect that I may return to the coming changes to the Life Safety standards and EPs dealing with outpatient occupancy, but I wanted to toss a couple of other thoughts your way to start things off with a lesser potential for headaches derived from over-stimulation of the regulatory madness response.

Some of the funkiest findings that arise during survey are those relating to the euphemistic “non-intact surfaces.” The overarching concerns relate to how effectively non-intact surfaces can be cleaned/disinfected, with the prevailing logic being “not particularly well.” One of the surfaces that will encounter scrutiny during survey is the omnipresent patient mattress and I suspect a recent study by ECRI is only going to increase attentions in this regard because, to be honest, what they found is kind of disturbing. As we’ve discussed in the past, ECRI publishes an annual list of technology challenges, and #3 on the hit list this year involves the risks associated with “mattress ingress,” which roughly translates into blood and body fluids seeping into mattresses with non-intact surfaces. I think part of the dynamic at work is that mattresses are somewhat (and in some instances, very much) more expensive than in the “old days,” which decreases the ability for organizations to have a ready supply of backup mattresses for replacement activities. Of course, you have to have a robust process for identifying mattresses to be replaced and that process generally hinges on the active participation of the folks in Environmental Services. As one might imagine, this can become a costly undertaking if you’ve got a lot of cracked or otherwise damaged mattresses, but if you need some additional information with which to encourage the importance of the process, Health Facilities Management magazine has something that I think you’ll find useful.

Another one of those funky findings that I see bubbling up from time to time are those related to the use (including availability) of appropriate Personal Protective Equipment (PPE). From a practical standpoint, I know it can be a wicked pain in the butt to get folks to do what they’re supposed to when it comes to PPE use (especially when they are engaged in the inappropriate mixing of chemicals—yow!). While it is too early to tell whether this is going to be helpful or another bludgeon with which regulatory surveyors can bring to bear on safety professionals, the tag team of CDC and NIOSH have come up with a “National Framework for Personal Protective Equipment Conformity Assessment – Infrastructure” to help achieve some level of standardization relative to PPE use. It does (of course!) include the use of processes that very much resemble those of a risk assessment, including identification of risks and hazards and identification of PPE types needed to address those risks and hazards. Part of me is fearful that this is going to be just one more opportunity for field surveyors to muddy the waters even more than they are now (is that even possible? I hope not…). At any rate, this is probably something with which you should be at least passingly familiar; you can find the details, as well as the downloadable document, here.

As you’ve probably noticed over the last little while, these pages tend to focus more on TJC and CMS than most of the accreditation organizations, but I was happy (Pleased? Intrigued? Something else?) to see that the Health Facilities Accreditation Program (HFAP) had published a summary of its most frequently cited standards/conditions during 2017 in its annual Quality Report. I’ll let you look over the document in its entirety, but some of the EC/EM/LS findings were kind of interesting. In no particular orders, some topics and thoughts:

  • Business continuity: Effective recovery from an emergency/disaster is the result of thoughtful planning. The road to recovery should be clearly charted.
  • Emergency supplies: Apparently there is a move towards maintaining emergency supplies as a separate “entity”; also an inventory is important.
  • Security of supplies: Make sure there are provisions for securing supplies; I suspect this is most applicable during an emergency, particularly an extended-time event.
  • Personal Protective Equipment: Don’t forget PPE in your emergency planning activities.
  • Decontamination/Triage/Utilities/Volunteers: Make sure you have a handle on these in your emergency plan.
  • Environment of Care: Eyewash stations, ligature risks, dirty and/or non-intact surfaces, clustering of fire drills, past due inspections of medical equipment, air pressure relationships, open junction boxes, obstructed access to electrical panels, etc., risk assessment stuff, making sure that all care environments are demonstrably included in the program.
  • Life Safety: Improper installation of smoke detectors, exit/no exit signage concerns, fire alarm testing issues (not complete, no device inventory, etc.), egress locking arrangements, unsealed penetrations, rated door/frame issues.

Again, the link above will take you to the report, but there’s really nothing that couldn’t be found anywhere if there are “lapses of concentration” in the process. Right now, healthcare organization physical environments are being surveyed with the “bar” residing at the perfect level. I have encountered any number of very effectively managed facilities in the 16 years I’ve been doing this, but I can count the number of perfect buildings on the finger of no fingers. Perhaps you have one, but if you’ve got people scurrying around the place, I suspect perfection is the goal, but always a distance away…