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On your marks, get set, sweat!

But hopefully not a Billy Idol kind of sweat…

Our friends in Chicago are once again tweaking the survey process, with the result being less time for surveyors to wait for organizations to muster their troops at the outset and pretty much no time at all before they are out and about doing tracers. Basically, what used to be the surveyor planning session in the morning of the first survey day is now being flipped and combined with the special issue resolution session at the end of the day. For organizations to adapt their process to the changes, folks should be prepared to do the following:

  • Prompt alert of/to the leadership team of any on-site survey to facilitate their availability for a prompt opening conference (I can’t think of too many folks who are not already doing this)
  • Prepare all required documentation and deliver those documents to the survey team immediately after the team is escorted to their “base” (the list of required documents is available in the Survey Activity Guide, although it begs the question as to whether this includes the life safety documentation…)
  • Gather the scribes together so they are ready to hit the pavement as soon as the (ever-so-brief) opening conference is completed

Somehow I think this may all tie across with the folks from CMS accompanying the Joint Commission folks as part of the validation process—anyone who has dealt with a state and/or CMS survey will tell you, there’s not a lot of time (or indeed, inclination) for pleasantries. The job of being prickly requires a lot of inflexibility, which does seem to be the hallmark of the current survey process.

These changes to the survey process are effective March 2020.

I sit at my table and wage war on myself—and earn an OSHA citation!

While I have a sneaking suspicion that this Top 10 list doesn’t change a whole lot from year to year (other than position in the hierarchy), I thought it would be of interest to trot out which occupational safety considerations are manifesting themselves across industries. I can certainly see where any of these might crop up in healthcare.

And so, to the list:

10: Personal Protective and Lifesaving Equipment – Eye and Face Protection

9: Machine Guarding

8: Fall Protection – Training Requirements

7: Powered Industrial Trucks

6: Ladders

5: Respiratory Protection

4: Lockout/Tagout

3: Scaffolding

2: Hazard Communication

1: Fall Protection

Again, no big surprises, but I guess it does point out some areas for future consideration, mostly as a function of initial and ongoing safety education. These are the types of things, especially when dealing with contractors, that can result in a very uncomfortable situation if something goes sideways on your campus—even if it’s not your staff. Once the Big O gets through the door, it’s tough to contain their interest in all things safety.

Closing out this week, one of the questions that seems to be coming up with greater frequency during Joint Commission surveys relates to how your organization determines that the individual(s) tasked with doing your rated door inspections are knowledgeable/competent (we know from our intense scrutiny of NFPA 80 that these folks do not need to be certified; it is a handy way to demonstrate that an individual is knowledgeable, but you can certainly evaluate/validate competency in other ways). And pondering that equation made me a little more interested in the following news story than might normally have been the case (there isn’t a time when I wouldn’t have been interested, but this was an especially telling confluence). It seems that an individual has been accused of defrauding some VA hospitals by billing them for work that had not been performed; a little more detail can be found here. I know a lot of folks have struggled over the years with vendors who prefer to “come and go as they please,” which typically results in less control over the process, including timely notifications of discrepancies. I’m curious as to how this ends up when it makes its way through the courts, but I can see a time when those pesky surveyors might start to ask about how one knows that the service for which they have documentation actually occurred. Hopefully this case is all a big misunderstanding and there were no real gaps in oversight…

What we all want: If everything is priority one, then everything is priority none

As our friends from Chicago appear to be embarking in earnest on their charge to be as unpredictable as possible (I know of one instance in which a triennial survey “landed” about 10 months early—if that doesn’t merit a “yow,” I’m not sure what does…), the general concept of constant readiness would seem to be in flux (I think we all “knew” that the true survey window was considerably more limited than what it could be).

To that point, lately I’ve been working with folks who are well and truly within a survey window (lots of folks poking around in healthcare organizations these days…) and I’ve been noticing a tendency for folks requesting things to use “tomorrow” (or something similarly unrealistic) when identifying a requested completion date. And then raising a fuss when things are not repaired/replaced/refurbished almost instantly, which puts the folks who actually have to get the work done in a rather precarious position, depending on how quickly/dramatically the fussiness gets escalated. I think we can agree that expectations like instantaneous gratification do not lend themselves to thoughtful assessment of risk, or even (truth be told) basic triaging of tasks. I know that in crisis mode things can become a little unhinged, but the way the survey process is starting to turn, if we don’t find a way to really hardwire that classic finder/fixer dynamic as a way of like, the potential for chaos as a way of life is fairly strong.

So, the question I have for you out there in the studio audience is this: Does anybody have any unique methodologies they’d be inclined to share? I will freely admit to being at something of a disadvantage in that it has been a very, very long time (other than some interim gigs) since I’ve had day-to-day operational responsibilities in a hospital so there are probably technology solutions, etc., that could be leveraged in pursuit of focused order. But I also know that there is still a fair amount of what I like to call the “corridor work order request,” which, in my younger years, was probably not that big a deal, but now, as I approach my dotage, I find that I am not able to instantly recall quite as much “stuff” (I’m still pretty good, but the seams are much more apparent now).

I’m sure you are all following (with perhaps varying degrees of trepidation) the events unfolding in China relative to the Wuhan coronavirus; if you’re not making a regular stop at the CDC website for updates, etc., I would highly suggest it be a touch point at least every day or so. It’s starting to manifest itself a  bit stateside and I suppose, given the omnipresence of travel these days, it’s only a matter of time before it starts showing up in less-populated regions of the country. You can find as much information as is available here. Hopefully, this one subsides quickly, but preparedness, it seems, is everything these days.

Don’t get soaked by your water management program!

I don’t know about you, but lately I’ve been finding the most interesting stuff being published in Perspectives are the articles entitled “Consistent Interpretation” because I am fascinated by the data they are collecting that drives taking particular note of the standard or performance element being featured. For example, the January 2020 issue covers the intricacies of managing the risks associated with waterborne pathogens, a topic that I’ve been keeping an eye on if only because of the attentions paid to that topic by our friends at CMS (if you’ve lost track of where they are in the fray, feel free to make the jump—but don’t forget to come back!). I figure there are just enough peculiarities involved for this to wreak some havoc during accreditation surveys, and while there are ways for survey findings to be generated, it would appear (based on the just under 4% citation rate during the first half of 2019) that you folks out there in the field are making pretty good headway.

So, where things can go awry include: Not having a water management plan to deal with waterborne pathogen risks (not sure how someone would have missed that, but perhaps it was a question of a slower than normal implementation track); failing to include a new piece of equipment (for instance, a brand new cooling tower) in the program (I should think the time for risk assessment and inclusion is during the commissioning of new equipment); failing to maintain the water in the system in accordance with the levels called for in the water management plan; failing to document scheduled testing and monitoring; and failing to establish acceptable ranges and/or control measures to be taken when levels are out of range.

It would seem that decorative water features, ice machines, and water dispensers were in the mix as well, including issues with equipment not being maintained in accordance with the manufacturers’ instructions for use, but in looking at all the different ways water management concerns could be cited, I suspect a lot of the cited conditions (you can find more specifics in the January Perspectives) were not widely observed.

That said, since a lot of the nuts and bolts implementation of water management programs may be accomplished by “others,” I think that going forward, the surveyors will be especially attentive to reviewing your water management plan and any deliverables from testing and monitoring activities. There are a lot of moving parts in this endeavor; best to be ahead of the curve and keep a close eye on those reports.

Do you still BBI? Also, how do you spell survey finding?


While I am not convinced it every truly went away, next month marks the official return of one of the most (in)famous acronyms in surveydom: BBI, which we all know stands for Basic Building Information (details can be found here). So, for those of you for whom survey is imminent, you might (if you have not already done so) want to hop on to your online Statement of Conditions portal to make sure that all your information is up to date, all required responses are in place, etc. Since this is nominally a “new” requirement, I think it best to presume that the Life Safety surveyors are going to be reviewing the contents, so you want to make sure you have a good read on your square footage numbers and all the rest of it. I don’t see this representing a particularly great risk of survey exposure, but I’d hate to see somebody out there in the audience to get tapped for something so simple.

In other news (and I would consider this more troubling in the long term), back in September, the updates to some of the Environment of Care performance elements for office-based surgery practices were published (details here). While the updates relate mostly to invocation of the 2012 edition of the Life Safety Code® and the applicable reference documents, it also (and this may me being a touch paranoid—’tis always the season) may be indicative of a shift in focus for what documentation might be requested for care locations that are nominally business occupancies. I have definitely seen this (though I wouldn’t yet call it a trend, though it’s getting there) in state surveys of larger healthcare organizations, so it may just be a matter of time before evidence of compliance is requested for all the various life safety systems in place at your offsite locations (remembering that this does not mandate the presence of fire alarm systems, sprinkler systems, etc.—it only requires you to appropriately maintain any existing systems).

On a final note for this week, it would seem that some folks are using their work order system to provide evidence of scheduled activities like monthly testing/inspections of battery-powered lights, exit signs, task lighting, etc., and I just wanted to let you know that in the absence of an inventory of devices by location, there are some surveyors (and perhaps even more than just some surveyors) that will not accept a completed/closed out work order as evidence of compliance for these activities. Recognizing that the standards-based requirement for the “inventory” (in all its glory) has not specifically been extended to utility systems equipment (though I have anticipated that extension for a while), I think it may be time to start including the same level of detail as required for life safety systems inspection, testing and maintenance activities:

  • Name of the activity
  • Date of the activity
  • Inventory of devices, equipment, or other items
  • Required frequency of the activity
  • Name and contact information, including affiliation, of the person who performed the activity
  • NFPA standard(s) referenced for the activity
  • Results of the activity

I suppose to a fair degree it makes sense for inspection, testing, and maintenance documentation to have a standard format and it certainly helps to establish compliance in a fashion that is recognizable to surveyors. I guess we’ll just have to keep a watchful eye on this one…

Well that stinks! Or maybe it doesn’t…

I guess we can file this under the “You never know what’s going to pique someone’s interest” category.

In last week’s Joint Commission E-Alert publication, there is a featured set of links to an updated FAQ regarding “Aromatherapy & Essential Oils” (for example, this one). When I first saw it, I was thinking that maybe it was going to discuss some of the intricacies of dealing with all this smelly stuff that seems to crop up in offices and other spaces (everywhere looks like a good place for a stick-up). But when I clicked through the link, I found the question revolved around whether or not aromatherapy and/or essential oils needed to be managed as medications. As usual, the response was “it depends” (admittedly, that is a very much shortened version of their response, but please feel free to click through to embrace the majesty of this FAQ), with the slightly more involved response being “it depends on how you’re using it.” I have to say that I am not typically a fan of a lot of these scents; some of the them just seem like iffy attempts at covering other odors and some of them just seem wrong, but I digress. I know there are (perhaps more than) a few organizations that have adopted a fragrance-neutral/fragrance-free environment (these days, you just don’t know how someone is going to react to various scent-sations—allergies abound), but I can definitely see some folks interpreting this as something of an endorsement of using scents as a strategic intervention.

In other news, TJC also announced the publication of a new book of safety lists, which (based on my past experiences with their book products), may or may not be the answer to your sticky challenges (I pretty much live in the “not” camp, but someone wants to try and convince me that we have a winner, I’m game). Alternatively, you might consider the 2019 edition of the HCPro Hospital Safety Trainer Toolbox, which promises so much more than a bunch of checklists. I personally kind of ebb and flow on the whole concept of checklists, primarily because I find they try to do too much (or perhaps promise too much is the more appropriate descriptor). I see those checklists that go on and on for pages and pages and I’m thinking how in (insert deity of choice)’s name do you operationalize something that big? To that point, I am often asked what I look for when I’m doing consultant survey work and my (admittedly somewhat glib) response is that I don’t look for anything in particular, but rather I look at everything. I suspect it goes back to my EVS days when I looked at things from top to bottom in a (more or less) circular fashion—pretty much looking for stuff that didn’t look right (it is very rare indeed that I find an instance of noncompliance that looks “right,” if you know what I mean). The corollary to that is that a surveyor (and I count myself among that august assemblage) is never more dangerous than when they are standing still—that’s when the little funky detail stuff comes into focus. All the divots, loaded sprinkler heads, dust animals (bunnies, dinosaurs, the lot), become more visible. A moving surveyor (unlike the moving finger…) is a very good thing!

Ready, Set, ICRA!

One of the more frequently recurring questions/concerns/vulnerabilities in my travels relates to when it is appropriate to do a (and I will use this term collectively) pre-construction risk assessment, inclusive of all the usual suspects: Noise, vibration, system shutdowns, etc. Clearly (and I know you know, because I see you knowing), the pieces of this puzzle that can get you into the most trouble in most rapid fashion are those relating to infection control and interim life safety measures.

My (moderately) tongue-in-cheek response to any questions about “when” you would employ has typically been “always” (I remember the first time the question came up at a conference and my response was the same—and I’m sticking to my guns on this). My general philosophy as it relates to risk assessments is that we always assess for risk and we implement only what is necessary to manage those risks.

At any rate, as your “homework” for this week (and I would very much like to hear how you folks are parsing this), please look over the list below and figure out where you’ve placed the dividing line for your risk assessment process (basically, where you’d do an assessment and where you wouldn’t), particularly as a function of the Chicago requirement to “when planning for demolition, construction, renovation, or general maintenance [my bolding], the hospital conducts a preconstruction risk assessment for air quality requirements, infection control, utility requirements, noise, vibration, and other hazards that affect care, treatment, and services.” I firmly believe that this balancing act is going to be become a key component of survey oversight. (I would be more than happy to be wrong about this, but somehow I think things are moving in this direction.)

So please look over these perky little definitions and let me know your thoughts: Categories of Rehabilitation Work. The nature and extent of rehabilitation work undertaken in an existing building. Repair. The patching, restoration, or painting of materials, elements, equipment, or fixtures for the purpose of maintaining such materials, elements, equipment, or fixtures in good or sound condition. Renovation. The replacement in kind, strengthening, or upgrading of building elements, materials, equipment, or fixtures, that does not result in a reconfiguration of the building spaces within. Modification. The reconfiguration of any space; the addition, relocation, or elimination of any door or window; the addition or elimination of load-bearing elements; the reconfiguration or extension of any system; or the installation of any additional equipment.* Reconstruction. The reconfiguration of a space that affects an exit or a corridor shared by more than one occupant space; or the reconfiguration of a space such that the rehabilitation work area is not permitted to be occupied because existing means of egress and fire protection systems, or their equivalent, are not in place or continuously maintained. Change of Use. A change in the purpose or level of activity within a structure that involves a change in application of the requirements of the Code. Change of Occupancy Classification. The change in the occupancy classification of a structure or portion of a structure. Addition. An increase in the building area, aggregate floor area, building height, or number of stories of a structure.

Dance on a volcano: Keeping tabs on those that keep tabs on us…

As we’ve discussed in the past, the world in which we exist—and the stories and challenges contained therein—is never ending. And the subtext of that constancy revolves around our efforts to stay (as it were) one step ahead of the sheriff.

Part of me is railing against my chosen topic this week because I always feel like this space can (and, admittedly, does) have a tendency towards a Joint Commission-centric vision of the compliance universe, but while they may not be the largest primate in the compliance universe (once again violating all manner of metaphoric-mixing indignities), they are (more or less) the organization with the most robust customer-forward presence, through Perspectives to the FAQ pages to the topic-specific offerings we’re covering this week. All things being equal (which, of course, they never really are), I would encourage you to poke around a bit on these sites as there is a mix of stuff that is almost ancient, but some tools, etc. that you might find useful in demonstrating compliance.

The Physical Environment portal is kind of the granddaddy of this whole construct; it started out as a collaboration with the American Society for Health Care Engineering (and may very well continue to be so, but it’s kind of tough to tell) with the goal of providing information on the most frequently cited standards. Unfortunately (for me, but not so much for you), a lot of the information, including “surveyor insights,” is accessible only through your organization’s TJC extranet portal, but there is some stuff that’s worth a look. For example, there is a fire drill matrix that gives a sense of what areas should be considered for your high-risk fire drills (or would it be fire drills in high-risk areas…); the one on the matrix I found of some interest was Cath/EP lab making the high-risk list. I guess the overarching thought is to make sure you carefully consider those areas in which surgical fires a present as a risk.

There are also portals for emergency management, healthcare-acquired infections (I would keep a close eye on that one; lots of indication that this is the next “big thing” for survey), and workplace violence. Keep an eye on them: You never know what might pop up!

Who remembers pop-o-matic Trouble?

In something of a variation on another bloggy evergreen, I ask the rhetorical question: To what, if any, extent have you included consideration of  board games in your physical environment risk assessments for behavioral health? As I think towards a generation (are they already here?) for which the glories of board games will be forever lost, our friends in Chicago offer the latest challenge in managing risks with our all-too-vulnerable patient populations (for those of you of a certain vintage, the description of a board game is very nearly worth the price of admission).

The article describes the quite inventive use of a plastic board game piece to defeat the reptilian tamper-resistant screws and suggest some alternative products that do not so easily surrender to such efforts. I don’t know that I’ve been privy to a lot of discussion relative to board games in the behavioral health setting, but I suppose this would come under the heading of “everything has an inherent, though perhaps not apparent, risk.” Based on some recent surveys, it seems that Joint Commission surveyors have been rather inventive in looking for physical environment elements that have not been specifically accounted for in the assessment process. The classic example is including medical beds in the risk assessment, but not specifically mentioning the risks associated with the ligature-resistance (or not) of the side rails, bed frame, etc. Sooooooo, if they have not yet been included in your risk assessment activities, it might be a good time to pull a little group together and ponder the use of board games (and perhaps other such items) as a function of the behavioral health physical environment risk assessment.

Should we think about Halloween candy as well?!?

Check and mate!

If you don’t signal, how will I know where you want to go? Emergency management and its discontents (Just What You Needed)!

Kind of a mixed bag this week, though it all fits under the heading of emergency management, so here goes nothing…

A few weeks ago, USA Today did a story on the preparedness levels of the United States based on an analysis of state-by-state metrics. The story was based on a study, the National Health Security Preparedness Index, prepared by the Robert Wood Johnson Foundation and covers a lot of ground relative to trends in preparedness, including governmental spending on preparedness and some other stuff. The reason I “noticed” this was the indication that my home state was “best prepared” for disasters, etc., but the overarching message was that, even in the face of some setbacks in individual regions, the nation continues to improve emergency preparedness. Of course, it being USA Today, there are color slides indicating where each state ranks among the fabulous 50, so if you thought there was no scorekeeping on this front…

OK, maybe not keeping score, but a certain accreditation agency is keeping an eye on all things relating to preparedness. In this blog post, Jim Kendig (field director for the Life Safety Code® surveyors at The Joint Commission, and a very knowledgeable fellow when it comes to this stuff) provides a really good overview of the Preparedness Index and describes it in terms of how the various pieces can (and do) fit together and provide the foundation for an effective emergency management program. I see no reason why we can’t expect something more of a deep dive in the coming survey cycle and I think you’ll find the information Jim shares to be really helpful.

As a final thought for this week, it is always the case that what constitutes a mass casualty incident varies from organization to organization, but if you want to catch a glimpse of how this gets framed within the context of one of the largest metropolitan areas on the planet, the Greater New York Hospital Association developed a Mass Casualty Incident Response Toolkit that you might find worth checking out. There’s a ton of information, tools/forms, and links to more tools/forms, etc., to review in this space, but I encourage you to give the materials a look-see. It does appear that the nature of what we can expect to show up at our collective front doors is shifting and anything that facilitates better positioning to deal with an emergency is worth our time and energies.