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As plain as the nose on your emergency response plan…

Periodically, the whole concept of adopting plain language codes for emergency response plan activities/activations percolates to the top of somebody’s to-do list (I’d much rather embrace the concept of the to-don’t list, but that’s a discussion for another day). There was a little bit of that (more by inference than anything else) in the CMS follow-up report to the hospital response to Superstorm Sandy. Jeez Louise, that seems like eons ago…

This discussion always seems to engender a lot of back and forth, mostly regarding the balancing act of providing enough information to direct an appropriate response and not providing enough information to cause a panic. I recognize both sides of the argument, but I must say that I haven’t seen a lot of data to support a wholesale change, particularly as it would require a fair amount of education (and yes, I know that just because something requires education, etc., is not enough to forego adopting a new strategy, etc.). But I will also say that, depending on your organizational palette when it comes to emergency notification, all the different codes relative to workplace violence, active shooter, emergency assistance calls, etc., may well benefit from a more succinct announcement.

Recently, the Texas Hospital Association has weighed in with a recommendation to its members to adopt plain language codes, including a sample policy, an implementation timeline, and some examples (you can find that information here). It appears that there’s a move away from the (fairly standard, though not quite universal) Code Red designation for a fire alarm activation to the plainer language (though somehow not quite as sexy) “fire alarm activation.” It does appear that medical emergencies will remain as the (again, fairly standard, not quite universal) Code Blue (I guess that one’s gotten enough play on medically-oriented TV programs to have become part of the vernacular—where are the TV shows about safety in hospitals?!?), but there are some other terms that are worth of consideration. I don’t know that there’s necessarily a groundswell of support, but sometimes Texas can be something of a bellwether, so it may be a good opportunity to look at the possibilities, particularly if you haven’t in a while.

That said, I have two (relatively moderate) concerns. One being we are still waiting on the unveiling of the CMS final rule on all things emergency management; I had thought perhaps that pursuit had become somewhat dormant, but with the adoption of the 2012 edition of NFPA 99 excluding the chapter on emergency management, I think we have to believe that something regulatory this way comes. At any rate, will CMS push for some standardized notification language, particularly as a function of a focus on interoperable communications capabilities? I think that card has been dealt, I guess we’ll have to see how it gets played.

The other concern is the overarching concept of interoperable communication capabilities; I, for one, do not recommend you go about changing anything in terms of notification until you have some talk-time with the local emergency response authorities. They may or may not feel like they have a stake in this discussion, but you want to be absolutely certain that any modifications you might be entertaining will not somehow fly in the face of established protocols, language, etc. Isolationism, particularly when it comes to emergency management, is not likely to be a winning strategy as it usually requires the cooperation of disparate resources. So don’t forget to keep the community folks in the loop—you never know when they might come in handy!

 

Teddy Roosevelt would likely not cotton to these monkeyshines…

Our former president, one Theodore Roosevelt (when are Simon and Alvin going to run for office? I think their time is nigh…) is famous for a number of things, including the introduction of “bully” as a positive adjective (if you want to check out the manuscript that started it all, you can find it here). Unfortunately, the verb bully is very much a presence in today’s society (reaching near pandemic proportions in the various social media forums), including the healthcare industry. Now, I have certainly kvetched once or twice about the lack/loss of civility in general and our good friends in Chicago have taken up the gauntlet, and I think we can all agree: “bullying has no place in healthcare.”

As I reflect on the past 50 or so years (maybe a little more towards the so, but that’s just between us), I can look back on any number of encounters with bullies (only one black eye and that was rather a long time ago), including the 35+ years in healthcare. Bullies come in all shapes, sizes, social position, jobs, etc., and you can’t always tell right away who might rule in (or out) for this least desirable (well, maybe not least, but purty darn close) of personality flaws. Sometimes it’s folks who are in positions of authority/power, sometimes not, sometimes it even comes with a smile (though I’ve noted that those smiles rarely, if ever, reach the eyes), but I think I can safely say that bullying behavior engenders some of the most unpleasant “environments” that we are likely to experience. In the latest Quick Safety publication, Joint Commission offers some insight into the cultural elements that exist/foment when bullying is present in the healthcare environment. And while the Quick Safety publications are not necessarily enforceable as standards, this does tie back to Sentinel Event Alert #40 (Behaviors that undermine a culture of safety), which is aimed at the appropriate management of various forms of disruptive behavior, including bullying. At any rate, the Quick Safety article specifically references some action items that were included in the Sentinel Event Alert:

 

  • Educate all team members on appropriate professional behaviors that are consistent with the organization’s code of conduct
  • Hold all team members accountable for modeling desirable behaviors
  • Develop and implement policies and procedures/processes that address:
    • Bullying
    • Reducing fear of retaliation
    • Responding to patients and families who witness bullying
    • Beginning disciplinary actions (how and when)

 

So, my question to you is: How are things going in this area of concern? I don’t know that I’ve run into anyone who’s been able to completely eliminate bullying (or, as I think about it, anyone who’s been able to demonstrate a reduction in such behaviors—it just seems to be much more of a constant escalation, but that may just be me). I’m hoping that perhaps someone will have some stories to share with the group, even tales of efforts that fell short of the mark. We know it’s out there and I’m thinking that the release of this Quick Safety article may be a harbinger of future survey focus—how would you respond if the question came up during survey? I think it’s a reasonably safe pontification to say that bullying really doesn’t help to get things accomplished (again, recognizing that there are certain mindsets that might disagree, but I suspect those that disagree might be of the bullying persuasion), but I am interested in hearing about your experiences.

Musings from Rantopolis

There are a couple of developments on the Joint Commission front. They’re deleting some 131 performance elements from across the accreditation manual; a few are EC-related, but none in the EM or LS chapters, I want to take a few moments to look at the tea leaves before I weigh—maybe I’ll include in our upcoming edition of portal chortlings—we’re about due for a fireside chat, but anyways…

This just in: The Clarifications and Expectations column penned by Mr. Mills is “on hiatus,” but scheduled to return in June 2016. Curiouser and curiouser…

Last week I was working with a client on answering a citation that had come up during a TJC survey (not their survey, but someone else’s—sometimes folks will share post-survey intel). The finding was related to the storage of toilet paper and paper towel in a housekeeping closet, based on (presumably) the notion of the housekeeping closet as a “soiled” area and the toilet paper and paper towel being “clean” supplies (remembering that when we use toilet paper, the rolls are right next to the toilet OMG…OMG…OMG!). Now I am reasonably certain that (much like some other conditions and/or practices I will note in a moment) there are no specific regulatory standards that speak to how and where one is to store paper supplies, etc., so, once again, we come up against the assumed role of the surveyor cadre in prescribing practices instead of assessing how well a risk is being managed. Are there housekeeping closets that are somewhat less reputable looking than others? Absolutely! Are there risks associated with storing paper products in housekeeping closets? Absolutely! Are there risks associated with storing paper products in clean utility rooms, including the potential for pests? Absolutely! Is this a discussion that could go on forever? Absolutely!

To paraphrase the late, great Lewis Allen (you probably know him just as “Lou”) Reed, I am sick of it. I am sick of seeing findings like “linen cart cover was not down,” “solid bottom shelf was not in place,” “materials stored under a sink,” “toilet paper and paper towel stored in a housekeeping closets,” “cardboard boxes in clean utility rooms.” The whole concept of the management of the physical environment is supposed to be based on managing the risks is that very same physical environment. Show me how whatever condition being cited is actually resulted in a risk that is being appropriate managed—not merely the possibility of a potentially increased risk if the planets are in the correct alignment, etc., etc., ad nauseum. Every time I think about the “war on cardboard,” I grind my whole being (not just my teeth); yes, there are places where cardboard ought not be broken down (sterile supply areas, etc.) but those locations are very limited. Show me that we’re not managing the cardboard appropriately. Show me real evidence (not online pictures) that we are legitimately dealing with cardboard critter condos. I absolutely, beyond any shadow of doubt, understand and recognize the risk potential of cardboard, but if there’s no evidence that the cardboard boxes are doing anything more than appropriately holding the contents of said boxes, how does that become a citable offence? When I think of the hundreds of thousands of dollars that have been wasted purchasing plastic bins that (channeling T. Swift here) never, ever, ever, ever (is that too many “evers”?)  get cleaned…check ’em out if you don’t believe me. And never mind the kabillion of labor hours devoted to removing all the whatevers from those cardboard boxes and putting them in the plastic bins as opposed to delivering the box full of stuff and then throwing that every same box away when it is empty. In fact, I would submit to you that by getting rid of the cardboard, we have made it exponentially more difficult to manage expiring product. Old days: case with expiration date on it; when case is empty, throw case away—boom! New days: plastic bin almost empty so we dump more product in on top of the old stuff (Oh sure, we’re taking the old stuff out and then placing it in a bag on top of the new stuff to ensure the old stuff gets used first. Yup, that’s what’s happening, yes indeedy…) I’m sure each of you can think of some “practice” that’s being enforced in your organization that is based on not much in the way of logic (logic doesn’t seem to prevail as much as it used to—I can’t think that that’s a good thing). I think we need to take a stand. (“I’m rather unhappy about the current state and I’m not inclined to support it any longer” or the more pointed “I’m mad as hell and I’m not going to take it anymore.” We safety professionals are more inclined towards the genteel first versions when in polite conversation, but deep inside, you know what I’m talkin’ about!)

Okay, that’s probably enough on that topic for the moment (I’m going to guess that there may be one or two heads nodding in the affirmative at this point in my screed, though perhaps there are others that might disagree). If there’s such a strong feeling about this stuff, then the regulators should be very clear about those “clarifications and expectations.” There’s a process for reviewing the survey results before the final results are provided to each organization. Use it to remove these findings that are truly no more than surveyor bias (yeah, it’s like how tough it is to reverse an official decision in sports). Unless, of course, the purpose of the current survey process is to generate as many findings as humanly possible…nah—who’d believe that!

So join us next week as we add another section to our construction of the immortal portal cortile chortle…

Sometimes you have to ignore what your parents told you

Well, maybe ignore is a bit strong…

One of the recurring themes from my childhood was the not-infrequent exhortation from my mother: Don’t go looking for trouble (probably not an uncommon theme for everyone out there in the studio audience). But one of the more common themes that I’ve been running into are those instances in which trouble was lurking in the weeds, but folks weren’t necessarily successful in identifying/locating trouble spots. As near as I can tell, the worst thing that can happen during a survey (from a safety perspective) is when a surveyor identifies a condition or a practice about which you had no clue. It doesn’t happen a lot, but it does happen (usually followed by “Wow, I didn’t know that”).

There are a number of reasons for such a happenstance—sometimes folks really don’t know about something (though, dear reader, you are probably not in that number as we discuss a whole bunch of esoteric stuff). For instance, I still get a lot of folks who (and I have to believe that they are being completely candid) don’t know that hand sanitizer expires (or medicated lotion soap…or disinfectant wipes) or they are supremely confident that that is someone else’s concern (usually EVS when it comes to the many soaps, sanitizers, and disinfectants that populate the healthcare landscape). To my mind, it all goes back to the role of point of care/point of service folks (and I give the caregivers equal billing/accountability with the service-givers on this count) in being able to identify and report or otherwise manage risks in the physical environment.

But we as safety professionals have to be wicked diligent (as I pen this, it’s the day after the Boston Marathon, so that’s my gratuitous reference to Boston cultchah) in really working to ferret out all these little foibles, imperfections, etc. I think I’ve said this before in this forum (and no doubt will again), but whichever regulatory survey team shows up at your front/back/side door, they are going to find “stuff”—the human condition does not easily attain perfection, which leaves us vulnerable, vulnerable, vulnerable.

I recognize that everyone is stretched for time—too many meetings, too many spreadsheets, too many “too manys” to count—which only serves to “push” the maximization of the not-enough’s (not enough time, not enough resources, not enough support) in this adventure. Think of it as a challenge—there are folks out there doing stuff you would rather they not do—sometimes you only see the result (damaged walls and doors, unsealed penetrations, spills, thrills, chills) and we all have to be more effective in keeping on top of things.

Past lessons learned are a wonderful thing, but sometimes you have to go at things a little differently, so go out there and find some trouble spots. You’ll be glad you did!

 

What is the most dangerous place in your organization?

If you asked a dog the question in the title above, would it say, “Woof”? (Though some might say kitchen…I sometimes do.)

I’ve been encountering a fair number of roof-related opportunities and I wanted to give the topic an airing. I’m not entirely certain what prompted my thinking about rooftops (it’s way beyond Christmas), but I can say that I’ve encountered a bit of a run on unsecured roof hatches/access doors in hospitals (and hotels, too—I suppose I spend as much time in hotels as I do in hospitals—a certain inescapable logic coming into play on that count).

I will admit that I’m no fan of hatches from a practical standpoint (being rather stout and not particularly tall in the physique department), but I’m kind of surprised at the number I’ve encountered that are not secured (and I’m not talking about something that’s sort of secured, though I’ve seen some not-particularly-well-secured hatches as well). I know it’s important for Facilities/Plant Ops staff to have access to roofs, as well as emergency responders, but leaving these types of locations without any security seems way beyond a reasonable strategy. We’re certainly no stranger to the stories of patients wandering off (and I suppose you can’t always predict who might be prone to wandering) and I don’t know that I would want to hang my hat on the “remote” likelihood of someone “stumbling” on to an unsecured roof hatch, so I would ask you to please be attentive to the hatches and “batten them down” if they should have any level of uncontrolled access.

But just so we’re clear, it goes beyond hatches. It is of critical importance that you have a very hardened perimeter for all your roof areas. I don’t know how many times I’ve found propped, unattended doors because someone didn’t feel comfortable “trusting” a vendor (e.g., window washers) with the key to the access door. And I think it is a very well-established truism that doors for which folks do not have keys tend to get propped (I bet we could distill that into some sort of mathematical equation) and the likelihood of the propping is in proportion (I’m guessing inverse, but maybe not) to the risks of leaving that door unsecured. It may even be worth considering having roof access doors and hatches on your “Elvis” list (i.e., that list of critical things to check when you know you’ve got surveyors in the building—oxygen cylinders, corridor clutter, etc.). It’s all part of making absolutely sure that no one is inadvertently put at risk (I don’t believe that folks would purposefully leave a roof door unsecured and unattended—and I hope there’s no one out there to challenge that belief with a real life example).

Finally, don’t forget about fall protection for the folks you allow on the roof, particularly if you have minimal or no parapets. Interestingly enough, our good friends at the Occupational Safety & Health Administration have a few choice thoughts regarding fall protection; you can start that journey here. Even if it’s somebody working for a contractor, if you have a fall, your organization is likely to be mentioned as prominently as the contractor—and if you ask me, that’s no way to get on the front page of the local newspaper. So, the secret word for the week is “protection”: protection of patients, protection of staff, protection of contractors—it’s all part of the mix.

Next up (unless my calendar is lying to me), we should have another fabulous edition of Portal Chortling, with perhaps a side of Fireside Chat. Stay tuned!

Brother, can you spare any change…

In the interest of time and space (it’s about time, it’s about space, it’s about two men in the strangest place…), I’m going to chunk the EM and LS risk areas that are now specifically included in the Focused Standards Assessment (FSA) process (previously, the risk areas were only in the EC chapter). Next week, I want to take one more chunk of your time to discuss now the FSA process (particularly as a function of what EPs the folks in Chicago have identified as being of critical importance/status). But for the moment, here are the add-ons for 2016:

Emergency Management

 

  • participation of organizational leadership, including medical staff, in emergency planning activities (you need to have a clear documentation trail)
  • your HVA; (interesting that they’ve decided to include this one—they must have found enough folks that have let the HVA process languish)
  • your documented EM inventory (I think it’s important to have a very clear definition of what this means for your organization)
  • participation of leadership, including medical staff, in development of the emergency operations plan (again, documentation trail is important)
  • the written EOP itself (not sure about this addition—on the face of it, it doesn’t necessarily make a lot of sense from a practical standpoint)
  • the annual review of the HVA (my advice is to package an analysis of the HVA with the review of the EOP and inventory)
  • annual review of the objectives and scope of the EOP
  • annual review of the inventory
  • reviewing activations of the EOP to ensure you have enough activations of the right type (important to define an influx exercise, as well as, a scenario for an event without community support)
  • identification of deficiencies and opportunities during those activations—this means don’t try to “sell” a surveyor an exercise in which nothing went awry—if the exercise is correctly administered, there will always, always, always be deficiencies and/or opportunities. If you don’t come up with any improvements, the you have, for all intents and purposes, wasted your time… (Perhaps a little harsh, but I think you hear what I’m saying)

Life Safety

 

  • Maintenance of documentation of any inspections and approvals made by state or local fire control agencies (I think you could make a case for having this information attached to the presentation of waivers, particularly if you have specific approvals from state or local AHJs that could be represented as waivers)
  • Door locking arrangements (be on the lookout for thumb latches and deadbolts on egress doors—there is much frowning when these arrangements are encountered during survey)
  • Protection of hazardous areas (I think this extends beyond making sure that the hazardous areas you’ve identified are properly maintained into the realm of patient spaces that are converted to combustible storage. I think at this point, we’ve all see some evidence of this. Be on the lookout!)
  • Appropriate protection of your fire alarm control panel (for want of a smoke detector…)
  • Appropriate availability of K-type fire extinguishers (this includes appropriate signage—that’s been a fairly frequent flyer in surveys of late)
  • Appropriate fire separations between healthcare and ambulatory healthcare occupancies (a simple thing to keep an eye on—or is it? You tell me…)
  • Protection of hazardous areas in ambulatory healthcare occupancies (same as above)
  • Protection of fire alarm control panels in ambulatory occupancies (same as above)

 

I would imagine that a fair amount of thought goes into deciding what to include in the FSA (and, in the aggregate, the number of EPs they want assessed in this process has gotten decidedly chunkier—I guess sometimes more is more), so next week we’ll chat a bit about what it all means.

I’m happy, hope you’re happy too…

A couple of weeks ago, HCPro’s Accreditation Insider featured an article that addressed a study published by the American Journal of Infection Control on compliance by nurses with the many and varied requirements of the Bloodborne Pathogens standard.

I guess I’m of two minds about the study; it is a somewhat smallish sample size (116 nurses were studied), though presumably statistically valid (not being wicked up on the whole statistical analysis thang, I wouldn’t even presume to presume, but I’m thinking that it would hardly have been worth publishing if it were not of some note). I think in my heart of hearts that (at this point) I would have hoped for better compliance numbers but again I’m not certain that I was particularly surprised that gloves aren’t worn all the time, hands are not washed as often as is necessary (e.g., after taking care of patients, after taking off gloves), and face shields are not worn as often as would be advisable given the risks (no big surprise on the face shields—it is a struggle, struggle, struggle—not just for the potential of an exposure to blood or other potentially infectious materials (OPIM to those among you that are acronymically inclined), but also for potential chemical exposures. (Everybody wants a freaking eyewash station “in case”, but nobody wants to use appropriate PPE to ensure that “case” doesn’t occur—jeepers!)

I haven’t had a chance to actually read the study (yes, I know—shame!), but the article in Accreditation Insider doesn’t really get into what the compliance barriers might have been (I honestly don’t know if the study gets into some of the causative factors), which I think would have been instructive. Apparently, the study concludes with a recommendation for stricter enforcement of compliance policies and to address problem areas with better monitoring and staff education. Now, those are fine things indeed, but kind of begs the question as to what constitutes better monitoring and staff education. I will go on the record here (I don’t think I have previously, but if I have, mea maxima culpa) as no particular fan of computer-based learning. I “get” that it is more convenient for folks to do and thus, generally results in better “compliance” when it comes down to numbers of folks completing the required “modules,” etc. And I also “get” that it is compliant from a regulatory standpoint (BTW, just because I “get” something doesn’t necessarily mean that I am convinced that such claims are valid). What I don’t find as I travel the highways and byways of healthcare facilities is evidence that this process results in an enhancement of staff competence and knowledge. I don’t necessarily think of myself as a Luddite (in fact, I’m pretty okay with a lot of technology), but I don’t know that convenience is the yardstick by which we should be measuring the effectiveness of education. Rant over…

Before I hop along, I do have one favor to ask (and it sort of relates to the above). I understand that, from a sterile processing perspective, it is important to do some sort of enzymatic pre-treatment of soiled instruments so the OPIM doesn’t get all caked and hardened on the surface of said instruments. The favor (or question) is this: Has anyone identified a product that will appropriately pre-treat instruments but not require emergency eyewash equipment? If you have a risk assessment of that determination, that would be very cool. I’m running into another uptick in the proliferation of eyewash stations—I’m a great believer in having them when they are appropriate, but I’m no fan of eyewash stations “in case” (that sounds somewhat familiar…where have I seen that before?). Any feedback would be most appreciated.

Happy Mardi Gras for those of you disposed towards that kind of celebratory activity…

Jan. 20 webcast highlights how to deal with high-risk patients

Patients with high-risk behaviors pose a danger to healthcare staff and other patients and are difficult for healthcare employees to manage. In this live webcast, expert speakers Tony W. York, MS, MBA, CHPA, CPP, and Jeff Puttkammer, M.Ed., will discuss the patient factors that often lead to violent events in the workplace, provide a clear understanding of environmental influences and triggers that contribute to violence, and supply tools and resources to help you reduce the risk of a violent event in your facility. The program is scheduled for Wednesday, January 20 from 1 to 2:30 p.m. ET.

Employees have the power to influence their own safety, but they often lack the proper training. Give your staff the knowledge they need to deal with high-risk patients and keep themselves and their facility safe!

At the conclusion of this program, participants will be able to:

  • Define high-risk patient behavior (more than just mental health patients)
  • Explain how a balanced approach to patient-focused care and personal safety impacts patient satisfaction and work-related injuries
  • Identify how workspace design and medical equipment placement can promote or reduce the safety of staff, patients, and visitors
  • Define policies, procedures, and practices aimed at reducing safety risks associated with at-risk patients
  • Understand the critical role staff education and training plays in helping provide the culture, tools, and competencies required to successfully reduce and manage patient-generated violence

Visit here for more information and to register.

You know, I really find you quite attractive (human vs. technological magnetism)

Sometimes, particularly around the solstice, I struggle to come up with something (relatively) fresh upon which to pontificate—something that goes a little beyond the typical closing out of the safety year. Fortunately (at least for me; hopefully for you, the readers, as well), there have been enough funky things coming out of Joint Commission surveys this year to provide plenty of material. And today’s topic is the result of what appears to be an uptick in findings relating to MRI safety.

Now, the unfortunate aspect of all this is when the human and technological elements meet in combat, it would seem that it is the TJC surveyors that “win,” which is a very much less than desirable outcome.

At any rate, there’s certainly been a lot of information regarding safety in the MRI environment, first (and probably foremost) being the guidance provided by the American College of Radiologists (ACR). You can find lots of very good information on the topic on the ACR’s MR Safety page. And then, of course, our friends from Chicago felt this was important enough to warrant a Sentinel Event Alert (back in 2008…imagine that!).

Then, effective July 2015, we have the addition of two Elements of Performance (EC.02.01.01, EPs 14 and 16) dealing with some rather specific elements of MRI safety, particularly processes to ensure that folks who access the MRI restricted areas are educated/trained in MRI safety or screened by the folks controlling access to the restricted areas. I think we can reasonably point out that any time TJC adds EPs that indicate specific risks, etc., they are not convinced that hospitals well and truly have their collective acts together. And I guess, to a certain degree, they may have a point, but I think it may be more a question of managing behaviors than anything else (which I’m sure comes as a surprise to everyone in the studio audience).

Based on some TJC reports, the common theme that I’ve noted in recent survey seems to revolve around the management of surveyors when they trace patients into the MRI (and with the pervasive use of MRI in diagnostic medicine, I think I can safely say that if you have an MRI in your “house”, then there will be a patient tracer in to that environment), particularly as a function of screening the surveyors before they enter restricted areas. Now, part of me would like to craft a policy that requires a full screening (and yes, I am talking about a “full” full screening…hah!) of any and all regulatory surveyors—that might get them to shy away from being so obstreperous with these types of findings! That said, I think there is something to say about screening policies/protocols—make sure your MRI staff understand whatever screening process you’ve implemented, and (perhaps more importantly) prepare them for interactions with surveyors as a function of the screening process. Too many findings have come at the hands of surveyors that cited organizations for not having access that is “well controlled” or “adequately secured” based on MRI staff not putting the surveyors through the full screening process.

All that said, I would strongly encourage you to look at the process (and the policy, if you should happen to have a MRI screening/access control policy) for controlling access to the MRI restricted areas, including the mechanism for screening individuals (keeping in mind that “screening” can take different forms). EP 16, among other things, requires hospitals to restrict the access of everyone not trained in MRI safety or screened by staff trained in MRI safety from the scanner room (Zone IV, for those of you keeping score) and the area that immediately precedes the entrance to the MRI scanner room (typically Zone III). Now, you would think (and upon that thought, perhaps make an assumption) that The Joint Commission would provide some level of MRI safety training to their surveyors. That being the case, one could then have a process that does not require screening of the surveyors, based on their training in MRI safety. I think that MRI staff would need to specifically ask the surveyor if he or she had received MRI training before allowing the surveyor to proceed (and I guess the question for you folks in the audience would be whether you think the MRI staff would be comfortable asking the surveyor the question—it might be worth practicing). Even if the surveyor is in the company of folks from your organization that the MRI staff would “know” have been trained in this regard, is that enough to consider the risk as being appropriately managed—that sounds an awful lot like a risk assessment, if you ask me (yes, I know you didn’t, but you know I can’t resist invoking the mighty assessment).

So, it’s probably worth a concerted look during your end-of the-year surveillance activities (unless, of course, you’ve already done your second visit to the MRI this year, but may be worth a revisit); the sentinel event data published most recently by TJC (http://www.jointcommission.org/assets/1/18/2004-2015_3Q_SE_Stats-Summary.pdf) provides no hard evidence (or at least hard, discernible evidence) that hospitals are not appropriately managing the risks associated with the MRI environment, but I think we could probably consider any sentinel event involving the magnet as something to be avoided (much like findings relating to MRI safety). If you have a solid process, then great. But if not, might be a good opportunity to harden that particular survey target.

Come together, right now over…more heavy breathing

Talk about your regulatory supergroups: it’s almost like the second coming of Crosby, Stills, Nash, Young and all manner of goodness or maybe the Fantastic Four (or in this case, the Spectacular Six)! Back on September 21, the modern healthcare environment equivalent of the Justice League (AAMI, ASHE, AORN, ASHRAE, APIC, and FGI) published a Joint Interim Guidance (JIG) on HVAC in the Operating Room and Sterile Processing Department. The intent of this JIG (sometimes acronyms can be fun) is to address what the Spectacular Six deem “the biggest challenge for owners and designers of health care facilities,” which is “to understand the purpose and scope of the various requirements” of the “conflicting and sometimes unclear” standards and guidelines for the management of heating, ventilation, and air-conditioning (HVAC) so “patient and staff safety and comfort can be managed.” You can check out the JIG document here.

Without spoiling too much of your interest in discovering all the particulars, the JIG speaks to the dichotomy inherent between the minimum design requirements and criteria that are used to construct an HVAC system (the FGI/ASHRAE/ASHE side of the equation) and the guidelines that “are intended to guide the daily operation of the HVAC system and clinical practice once the health care facility is occupied (this is where AAMI/AORN/APIC come in). As any number of you have experienced in real (and sometimes really painful) time, this dichotomy is very much at the heart of the regulatory survey process at the moment (somehow in my heart of hearts I knew that we could be continuing this conversation). But mayhap there is a light at the end of the tunnel (that is not an oncoming train!): the Spectacular Six have begun working towards a harmonization of the HVAC guidance in the various standards. They’ve been working on this since late April and the JIG is, for all intents and purposes, their first work product. I think it’s an excellent start and I hope that their work is allowed to continue with minimal interference from outsider influences (who that could be, I have no idea…).

An important part of the JIG is their advice to healthcare organizations (it’s on p. 2 of the document—I’ll let you reflect on it in your spare time) and those of you who’ve been following this space for a while will guess that my fave-o-rite topic is going to feature quite prominently in this movement: our old friend, the risk assessment! (Admit it, you knew it was going to go that route!) The goal of the assessment is to make a determination of HVAC operating parameters for critical areas that meet patient, personnel, and product storage needs, with an eye towards the identification of appropriate corrective measures to mitigate risk, etc. I think we’ve been honking this horn a bit as we’ve traversed this landscape, but I think the critical opportunity/challenge is going to be based on the Spectacular Six’s intent to communicate/advocate directly with the regulatory folks in this regard. I haven’t yet seen anything official from CMS in this regard, but based on its adoption of the tenets of the Joint Quality Advisory from January of this year (again, a number of web locales for info, including this one), I think we can reasonably anticipate some level of guidance to the surveyor corps in the not-too-distant future.

So perhaps we can work through this in relatively straightforward fashion; at the end of the day, our charge is to ensure that we are providing the safest possible environment for patients, staff, and visitors. But in meeting that charge, we also need to make sure that we are not writing checks that our building systems can’t cash. We should be able to identify appropriate, safe performance parameters that appropriately address all the risk factors and identify a response plan that we can effectively implement when we have conditions that increase the risk to unacceptable levels. If you ask me, that sounds like business as usual…