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You probably already knew this…

I know we talked a bit about fire drills not so long ago, but somehow I seem to have missed this particular “clarification” while I was dodging the COVID-19 virus last summer and I wanted to make sure that you folks who may not have had much time for bedtime reading last (last) summer, I figured it couldn’t hurt to get this one out there (especially since these clarifications seem to be generating some findings).

In the July 2020 issue of Perspectives, there is an article that discusses some of the “asks” (OK, I suppose they’re somewhat more authoritative than asks…) that could come into play during survey when your fire drill program is being evaluated. One of the items applies particularly to folks who are using the two-shift model (as opposed to a three-shift model) with the enjoinder to schedule drills when administrative staff are on site so they can participate in the drill(s)—and have the opportunity to respond acceptably to the drill. So that’s something that could be queried during a survey (if you’ve adopted the two-shift).

The next item concerns the scheduling of drills across quarters. Now I think that this kind of flies in the face of the whole randomized scheduling, but, for example, if you conduct a first-shift drill in February, then the expectation is that the subsequent drills would be in May, August, and November, using the “every three months, plus or minus 10 days” definition. So, if you were to conduct a first-shift drill in January and then a first-shift drill in June (with the intent being to “mix things up”), that would result in a finding. It’s been a long time since I’ve conducted a fire drill, but I suspect I would have been in arrears relative to this expectation.

The Perspectives article also includes some guidance relative to what things to look at during fire drills. For instance, making sure that (when the fire alarm system is activated) locked egress doors unlock appropriately; as well as making sure that you evaluate the component of your fire response plan that deals with the management of visitors, particularly at the point of origin for the fire.

In the end, I don’t know how helpful it was to “release” this particular information when a lot of folks were trying to figure out how to ensure staff didn’t lose sight of the importance of fire drills while still maintaining the social distancing norms of the day. I think we’ve all come to grips (more or less) with the whole hour of separation between drill times, but it almost seems like a case of moving the compliance target just out of reach every time you think you’ve “grasped” the brass ring (somehow the whole “compliance as carousel” vision seems to be more telling every time I think about it). I guess there’s always an opportunity or two floating around, but sometimes I wish they floated within the immediate field of vision…

Now that this has come to light, I think I’m going to go back and check some of those issues of Perspectives to see if there’s any more revelatory content. Until next time!

Deck the halls with boughs of noncombustible construction…

It hardly seems possible that we are rushing headlong into the depths of November (October being almost as I write this), though I will note (as you would no doubt verify) that some of the big box stores have had “those” decorations out on the showroom floor for a couple of weeks. Strange that they don’t have a section of trimmings for hospitals…mayhap one day some illustriously inventive individual will come out with a line of Life Safety Code®-compliant holiday decorations for the healthcare market. To sleep, perchance to dream…

At any rate, it would seem that once again it is time to prepare for the onslaught of non-UL-listed trees and lights and all manner of unauthorized décor modifications (if you don’t believe me, check this out). I think that if I were in a position of waiting on a survey that’s more than 45 days late, I would very much plan on seeing our friends from Chicago before the end of the year and I would spend a wee bit of time coaching the more festive members of your organization in the do’s and don’ts of noncombustible decorations. As I’ve maintained right along, I absolutely understand that there is a therapeutic value (and perhaps never more so than this upcoming season) in having our places look festive during the holidays. Folks are exhausted and are probably not going to react well to any overly Scrooge-y dictates—work with them—if you have any money in your budget, maybe put together some examples of what can be done with code-compliant materials. I think, sometimes, the most powerful message of all is the one you show—and leave the telling to others…

To close the thought on those well within the survey window—the goal of the survey process is to generate findings, particularly in the physical environment—if you have a circuit breaker labeled as “spare” and it’s in the “on” position, they’re gonna find it and write it. If you have some schmutz on a sprinkler head, they’re gonna find it and write it. Something parked in front of an electrical panel—yup! Something parked in front of a fire alarm pull station—you betcha! Doors not latching—oh yeah! There are no perfect buildings and if all they can find are these types of imperfections, that’s what your survey report will look like.

Effective rounding is the only thing that’s going to keep these types of things under control; I’m sure there’s lots of rounding going on—make sure they’re effectively managing the conditions that are most likely to be discovered during survey. You know what to look at (everything!). Get folks out of the habit of looking “for” things—it sometimes leads to missing other things that didn’t make the “checklist.”

Everybody’s talking: I can’t hear a word they’re saying…

Something of a mixed bag of stuff this week, which is sometimes the case, particularly with the ever-shifting compliance landscape. First up, an update to one of TJC’s safety alerts dealing with the management of behavioral health patients in the ED, mostly as it relates to strategies of keeping things moving, and if they’re not moving, keeping things on a (relatively) even keel when inpatients beds are limited supply (which is pretty much all the time, though the degree to which that impacts ED patient flow is distinctly variable). If you’ve not had a discussion relative to the management of behavioral health patients in your ED (and I would certainly understand that pandemic response might just have caused a re-prioritization of discussions and conversations of all manner and variety), it’s probably worth checking out the updated materials with a small group and seeing if there are any improvement opportunities to be had. As with all such things, it’s never really about a “one size fits all” approach, but, in recognition that interpretations of compliance on the part of surveyors is often based on published content, at the very least it puts you in a better position having had the conversation about the “suggestions.” There are no magic bullets for any of this stuff and what works in some areas, works not so well in others, but it never hurts to see what’s in the minds of others (so to speak).

Closing out the week with a couple of COVID-related resources for your consideration. One of the hallmarks of the last 15-18 months of pandemic response has been the modification of existing facilities to support the medical management of infectious patients, etc. While there may have been some “casting about” for answers at the outset/onset of the pandemic, adjustments were made and life went on. But what if you had a facility that was specifically designed for such an event? I don’t know that anyone was sitting that “pretty,” but there’s been a lot of thought put into the design of the next iteration of healthcare facilities. For a glimpse of where things could be headed, there was an article in Health Facilities Management in July that discusses a lot of design considerations. My thought is that some of these might be useful in planning how to manage things in the shorter term (I somehow suspect that we are not all going to get new facilities any time soon) and if you’ve got some renovations in the not-too-distant future, you might find something useful to discuss with the architecture planning folks. For good or ill, we’ve never had so much practical experience as it relates to the management of pandemics, so let’s put it to good use. And just as I finished typing this post, the October 2021 issue of Health Facilities Management showed up in my inbox, featuring an article entitled “Designing The Post-Pandemic Hospital,” so there’s more information to consider. Much of it I suspect you already know, but it’s always good to see that you are not alone in thinking about this stuff.

Another component of pandemic response is the management of medical waste in the time of COVID; as with all such things, guidance is very fluid, but it’s worth bookmarking the Healthcare Environmental Resource Centers COVID medical waste page. There’s some state-specific information on the page as well as a link to a page where you can check on regulations in your home state. I suspect that the information contained therein will be in a near-constant state of update, so checking in on a regular basis is probably a good idea.

The Matrix Unloaded…Overloaded: Somehow stuff keeps happening…

Interesting read in the October 2021 Perspectives relative to some Life Safety chapter considerations that have earned a place in the Consistent Interpretation column. The thing that really caught my eye was the potential for these conditions to show up in the upper right hand corner of Ye Olde (SAFER) Matrix—a fate that befalls only a few choice conditions. I’m not so sure these are the conditions I would have thought could “bump” up into that corner, but I guess it’s all subject to interpretation. Fortunately, they don’t appear to be cited very frequently (from a high of just over 12% to a low of just over 0.5%) so perhaps it’s more a question of the frequency in which these conditions might be identified during a survey. While you’re definitely going to want to look at the details, the types of things identified in the article are things like: missing fireproofing; “missing” sprinkler heads; issues with two-hour walls, particularly occupancy separations; proper fire protection rated components in opening protectives (so, no 20-minute fire doors in 2-hour rated walls); painted-over door labels (How many of these would you need to have to push a high-risk/high-frequency finding? Beats me…).

Again, nothing that gets cited with any great frequency is in the mix (the performance element under which the door label issue would be cited “sits” at about a 10% finding rate), and, as I think about it, none of these are things I see with any frequency, though I suppose you could make the case that some of this extends into the territory of “if you look long enough and hard enough, there’s always one.” For example, in all likelihood, if you have fireproofed steel in your facility, there will be a section of fireproofing that was knocked off/removed/damaged, etc.; same thing with the painted-over door labels—there’s probably one somewhere (which causes me to reflect on the nature of environmental surveys as scavenger hunts). Definitely something to keep an eye on (and encourage your line staff to be on the lookout for them too).

To conclude with a little more LS goodness, I’ve been sitting on this one for a little bit (OK, maybe a little more than a little…since February), but as the intense chaos of the pandemic ebbs and flows (but never really subsides to any great degree), Health Facilities Management published a short article on the importance of the risk assessment process to ensure appropriate management of the risks associated with rapid-cycle facility modifications to accommodate all sorts of shifts in volume, acuity, patient types, etc. While some of the risk assessment would probably have to be retrospective (unless your policy specifically prohibits retrospective review), it might be worth going back to look at modifications to egress and, perhaps, fire protection features when you were creating COVID units from thin air. There are almost always lessons to be learned and the more we can hard-wire into the process moving forward, the safer we’ll all be in the long run.

That’s all for now. See you next week!

Bye bye, business occupancy?

To my fairly certain knowledge, I’ve tried to stay away from anything that might approximate “click bait,” though I will freely admit that this week’s “headline” bumps up against it as a general concept. That said, I do think that the current shifting of survey focuses is such that it may be more sensible in the long run to modify the ways in which we “use” business occupancies as a survey preparation methodology.

What prompted the thought (beyond all the hubbub regarding the new section of the Joint Commission’s Life Safety chapter that deals specifically with business occupancies) is the whole notion of the slow envelopment of the “healthcare facility” descriptor as the go-to term for all care locations, be they inpatient or outpatient in nature/design. It does appear that a day could come in which the business occupancy designation means little or nothing from a compliance standpoint—I shudder to think. When you think about it, the “sharp edge” that separated care locations by occupancy classifications has become rather more blurred than not, some of which is the result of there not being clearly defined expectations/standards. Clearly, the business occupancy section of the LS chapter is a step towards a codification of those expectations—and what that means going forward.

If you look at the overview section of the LS chapter in the online manual, there is a note that the first two standards in the chapter (dealing with general expectations, including the management of life safety drawings, and the practical application of Interim Life Safety Measures) apply to all occupancy types. Truth be told that “note” has been sitting there for a while now, but with the creation of the business occupancy section of the LS chapter, I think we can probably intuit that the “general” requirements are going to be more of a focal point during survey. Past experiences tell us that this stuff won’t all get chased right out of the box, but I think one of the pressure points is going to be what you have for life safety drawings for your outpatient locations. Hopefully, that thought will prove to be most incorrect, but I get this feeling…

Another element in the outpatient setting is the practical application of all things relating to infection control; much as is the case with the physical environment in general, the currently drawn lines are not sharply defined, so it becomes the charge for each organization to define the lines of compliance. A good recent example is this article in Health Facilities Management magazine. I’ll let you read this on your own, but it does speak to a fair level of due diligence in determining what is actually required by code and what is the best strategy for your organization. High-level disinfection, sterilization, management of instruments, etc., is likely to continue as a significant survey touch point—and they’re going to kick those tires fairly exuberantly. You need to have a solid foundation for what constitutes compliance for your organization to present as bulletproof a façade as possible, so if you’ve got any of these IC-related processes “living” in your outpatient settings (and odds are that you do), it’s time to start kicking those tires before the folks with the pointy shoes show up…

Hope you all are well and staying safe through this current transition. While I am optimistic about the future, my personal observations during my travels the past couple of weeks is that hand hygiene numbers are starting to tail off a bit. I guess there are some folks that will only wash their hands if they think it’s a matter of life and death…

Stop making sense: Normalizing abnormality…

A brief foray this week, though I hope that is very much in keeping with you all being able to grab a few moments for yourselves over the holiday weekend. It was rather dreary up here in the land of the New English, but the rain is much needed, so if there was a bit of dampening of the spirits, it should take the edge off any fire risks up this way. I would be happy to share with the more parched regions of the country, but it appears that rain (like many other things) is rather more capricious than not…

First up: If you have not had the opportunity to get back to the grind that is the hunt for expiring/expired product, please remember that a ton of products were purchased about a year ago and it does seem like I’ve been running into a bunch of stuff that is reaching the end of its (sometimes not so) useful life. Wipes and sanitizer proliferated quite extensively last spring into early summer, so make sure someone in your organization is worrying about that one.

Next up, the only EC-related item in the June edition of Perspectives (and it is a little bit of a stretch) deals with the Sentinel Event Alert on infusion pump safety. It seems somehow that improvements to medical equipment technology manage to create more challenges for the folks in clinical engineering. The more a device can do, the more stuff that can go wrong. This is not to say that these are in any way a problem in and of themselves, but it seems like there are always gaps in the education process when these things roll out, so best of luck on that front. Medication safety is clearly going to be a focus moving forward and if we have learned nothing over the last little while is that everything ties across the physical environment eventually.

As a closing reiteration (we did touch upon this a couple of weeks ago), just a reminder to try and capture as much of the last year as you can. Many (if not most) of the lessons learned are pretty hard-wired into our response protocols, etc., but it’s also important to take stock of what didn’t work particularly well so we can avoid repeats in the future. One of the consistent challenges I’ve noted over the years is when an organization learns of a process, etc., that has worked really well at another organization and adopts that process lock, stock, and barrel. And a lot of times, that “perfect” process involved a fair amount of stumbling around to get to the point of perfection—and for some reason, folks don’t always share the missteps. It reminds me of that oft-told aphorism regarding doom and repeating history, but let us leave doom to others…

Hope you all are well and making the most of the moment!

Risk assessments: Don’t leave home without one!

An interesting phenomenon I’ve been encountering of late relates to the whole notion of having to do environmental risk assessments in locations that are not specifically designated for the management of behavioral health patients. At this point, I don’t know of any healthcare organizations that would be able to say that they would not be managing behavioral health patients, even if they don’t have inpatient bed capacity, though I suppose you might be able to set up a transfer policy with another local organization that does have inpatient capacity. But those beds are typically in fairly sort supply and might well end up with having to “hold” a behavioral health patient for a prolonged period of time. Maybe you can manage that continuum in your ED, but what if you had a surge of, hmmm, let’s say infectious patients. Is there a possibility that a behavioral health patient could end up on an inpatient unit? And could you say absolutely in either direction without having a risk assessment in your back pocket?

So you could make the case that moving the environmental concerns relating to behavioral health patients from the Environment of Care standards to the National Patient Safety Goals section of the accreditation program has clarified (to a degree) the expectations relative to the management of at-risk patients, but that clarity brings with it some mandates. The mandate comes in three pieces (so to speak): a thoughtful evaluation of the environment; a plan; and available resources to guide staff when you have to put at-risk patients in an environment that is not designated for managing that type of patient.

To my eyes and ears, a thoughtful evaluation of the environment sounds an awful lot like a risk assessment; the FAQ goes on to describe some examples of resources that could be provided to staff, including the use of an on-site psych professional to complete the environmental risk assessment if staff are not sufficiently competent to do so. Which means that, if you do use in-house staff, you might be pushed to identify how you know that the folks doing the evaluation of the space immediately before a patient is placed are competent to do so. Though I suppose that also means you might have to demonstrate how you evaluated the on-site psych person… ah, it never really ends, does it?

At any rate, if you have not done a quick (but thoughtful—gotta be thoughtful!) risk assessment of your non-BH patient spaces, it’s almost certainly worth your time to do so. To my mind, the best risk assessment of all is the one they don’t ask for because the effectiveness of the process is in evidence. But sometimes we don’t get credit for “doing the math in your head,” so the possession of the risk assessment is your best bet.

Thanks for tuning in. Please be well and continue to stay safe. Until next time…

Will meeting in person ever come back?

And perhaps more importantly: Does it make a difference?

As I’ve been working with folks over the past few months, it’s been kind of interesting to see how much impact social distancing and its component elements have had on the management of the care environment, at least from an oversight standpoint. Folks have been able to keep their eye on the prize for the most part, but it’s tough to figure out how effective meetings are when participation and other more traditional metrics are almost impossible to determine, never mind measure. For you folks out there reading this: Has this been something discussed during meetings, included in annual evaluations, or have you kept your head down and plowed through the past year (I suspect there’s a fair amount of plowing)? COVID has been such an attention-seeker in so many ways and remains the center of attention for so many folks—it seems impossible to think that we won’t be unraveling things for quite some time to come.

Turning to the May edition of Perspectives, it’s interesting to note that our friends from Chicago say they managed to conduct over 1,100 surveys in hospitals during 2021 (Does that means 1,100 hospitals were surveyed? Somehow, I’m thinking not). What is also interesting is that the presentation of the survey findings data has taken something of a turn in that the focus is not only on specific performance elements, but also on those findings that generate the findings of greatest survey criticality (read: adverse survey decisions). From looking at the hospital data, it appears that only a couple of findings of immediate threat to health/life were in the mix (mostly relating to the management of patients with suicidal ideation, though there was on related to infection control), but it would seem that there are a whole bunch of findings in the “red” (the highest risk category in the matrix). By my reckoning, now that the physical environment is not occupying all the top spots, the hot spots for high risk in the care environment are ventilation, safe, clean areas for patients, and the management of chemical risks (hmmm, could that be a euphemism for eyewash stations?), with a side order of whatever relates to infection control concerns like high-level disinfection and the management of patient care equipment.

I don’t know that there’s anything that is particularly shocking about the slate of focus areas; that said, it will be interesting to see how findings shift (or not) now that the onsite surveys are back on line with the intent of poking around more in the outpatient settings. As an indicator, can we intuit anything from the Ambulatory Care Top 10? Indeed, I think there is—and that “anything” is anything in the environment that has an impact on infection control—disinfection, ventilation, cleanliness, ITM of sterilizing equipment. The common themes do emerge without too much scrutiny.

I think we know what we have and I think we know where they are going with all of this, though it makes me sad that loaded sprinkler heads won’t be at the top of the list. Although I suspect that it will remain among the most frequently cited single conditions; how could it not?

So, that’s this week’s missive. I hope you all continue to be well and are working to stay safe. If you’re finally thinking about embracing travel, please take measures to protect yourself. I’m seeing a lot of variation when it comes to masking, but I can’t tell who has been vaccinated and who hasn’t (unless everyone starts wearing a t-shirt…).

Be well and I’ll be back at you next week, which, if my calendar is correct, will be May. Who’d a thunk it?

Water is wet: How about your ORs?

Howdy folks, as our friends from Chicago return to the field, a couple of items have come to my attention that I felt were worth sharing. There’s also an updated resource that we’ve mentioned in the past (though it seems that there are always many things that we’ve mentioned in the past—go figure).

First up, as we know from our diligent perusal of the intricacies of NFPA 99, Section 6.3.2.2.8.4 indicates that “(o)perating rooms shall be considered to be a wet procedure location, unless a risk assessment conducted by the health care governing body determines otherwise.” Consequently, the Life Safety surveyors are asking to see the risk assessment that determined otherwise or validation that your ORs are appropriately protected in accordance with the requirements for wet locations (isolated power, etc.). In previous discussions, I did note that “health care governing body” would seem to indicate that the assessment needs to include, at least to some degree—it doesn’t specify—hospital leadership. My general thought is that if your ORs aren’t considered wet locations and weren’t designed that way, you should be able to use the initial design/build aspect of the ORs to represent an assessment of those risks and, nominally, as construction activity, would have involved hospital leadership. I guess that then begs the question of how often you would need to revisit the assessment. It might be a(nother) good use of the annual evaluation process; I’m a big fan of using that process to “plant” things where you know they are likely to be viewed during survey. Much as the comments section of the eSOC is a good place to memorialize waivers, equivalencies, and the like, the annual evaluation is a good place to revisit important historical decisions. At any rate, it appears that wet locations are high on the “ask list,” so be prepared.

Another consideration that appears to be on the table is a risk assessment regarding what type(s) of fire extinguishers are in your ORs (could surgical fire management be a theme?). Our friends from the Windy City have something to say about this, and it appears that there was a recent update (though what got updated is not immediately apparent) to the FAQ, so probably worth a visit. I don’t doubt that these elements came into play when extinguishers were first chosen, but (again!) it never hurts to review…

Lastly this week, while this hasn’t necessarily been a survey hot topic, somehow it feels like water management programs are going to start to become more heavily surveyed. I think we can agree that this is a significant risk to be managed and while there is minimal evidence that these risks are not being appropriately managed in U.S. hospitals, any time something “new” comes along, it tends to represent a shift in survey focus. In the past, I’ve recommended checking out Matt Freije’s work at HC Info for really useful information on water management concerns. He does a great job of keeping an eye on water management across the globe, but also keeps an eye on our friends. If you’ve not settled into a water management program yet (and you really do need to get on it), it is definitely worth checking out the HC Info website.

On that note, I will bid you adieu for now; hope you all are doing well and staying safe. See you next week!

You gotta keep one eye looking over your shoulder…

And so with the onset of Spring, our friends in Chicago are laying out some more fun stuff to deal with over the next 12-18 months. In looking at the April edition of Perspectives, I don’t know that there’s anything I would call a surprise, though I suppose one of the announcements (pronouncements?) might prove to be problematic over the long haul (the “free pass” one sometimes receives for questionable practices in areas designated as suites might be harder to come by, but I think we’ll chat about that next week). But then again, if you have an effective survey management strategy, perhaps not; at worst, probably something to practice…

First up, effective January 2022, we have something of a shift in the requirements for water management programs—a shift to the extent that they done birthed a new standard just for water management. We’ve chatted about this topic in the past will take you to everything from last October back to the very beginning of time (or so it seems), so anyone who has been paying attention, particularly to the CMS stand on such matters, should be in reasonable shape. Here’s what you need:

  • A program/plan for managing waterborne pathogens, including Legionella
  • The identity of the individual or team charged with the responsibility for the program/plan
  • A basic diagram of your water system, including all water supply sources, treatment systems, processing steps, control measures, and end-use points (that will be a lengthy list for most folks—hope you’ve started that)
  • Documentation of testing/monitoring activities; corrective actions and procedures when your testing/monitoring results are outside of acceptable limits; documentation of corrective actions when control limits are not maintained
  • Review of the program at least annually, including any time there’s a modification to the water system than could add risk, including new equipment or systems

To my eye (and mind), I don’t see anything here that has not already been in the mix and, to be honest, if you haven’t been working through this process, you may be running the risk of bad survey mojo, particularly if the survey is the result of a waterborne pathogen outbreak at your facility. Again, this one isn’t giving me any fits as I look at the details, but we can probably intuit that they’ll be kicking the water management tires a little more frequently (and perhaps with greater vigor).

As we close out this week’s epistle, I wanted to share with you a resource aimed at assisting folks in hospitals with creating programs for sustainable energy use. As we edge ever closer to whatever the “new normal” is going to represent, I have no reason to think that managing energy costs/expenses will fall by the wayside. If you’re starting to look at energy sustainability, this might be right up your alley.

Next week, we’ll talk about communicating spaces in suites and bid adieu (yet again) to the Building Maintenance Program, so until next time, I hope you continue to be well and stay safe!