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Carbon-dating compliance: What happened when…

…and how responsible are you for the sins of the past (turns out, quite a bit).

Kind of a mixed bag of things this week, so please bear with me.

First up, in looking back over the last little while of survey activity, I keep looping back around to one (possibly unanswerable) question: How many of the survey findings being generated are the result of conditions that pre-existed the prior survey? I think we can all agree that there are noncompliant conditions lurking throughout our buildings (including that pesky loaded sprinkler head we talked about a couple of weeks ago), some of which (and perhaps quite a few) are the result of actions or inactions occurring a long time ago (in a galaxy almost too close to home). I’m going to guess there are few of us that have not encountered the angst of having a surveyor pop a ceiling tile or wriggle into some crawl space and find some condition that had previously escaped prying eyes (I suspect that the most common previously undetected finding relates to things attached to sprinkler piping and supports, which supports LS.02.01.35 being the most frequently cited Joint Commission standard). And, as onerous as it may be on the face of it (and every other aspect), we are on the hook for all of it (grandfathering of conditions can help in very limited ways, but there’s really very little in the way of grandfathering noncompliant conditions and practices).

For better or worse (likely more the latter than the former), in these increasingly resource-challenged times, it is almost impossible to ferret out every little imperfection. Particularly in the sense that noncompliance happens in three dimensions—square footage just doesn’t work for this process. So, the questions I ask of you, dear readers, are these:

  • Do you proactively attempt an exhaustive search of your facility from top to bottom (and all the nooks and crannies)?
  • Do you “roll the dice” and correct deficiencies as they appear and if there’s stuff out there, let the surveyors find them?

I’m keen to see how this is going to “split.” I know if we could we would take the higher road of proactivity, but not everyone is in that position.

One other item I’ve been hanging on to for probably longer than I should relates to the management of medical gas and vacuum systems. I would hardly think that this blog is the only resource for information, commentary, etc. (though I do like to think it’s an entertaining and perhaps randomly enlightening one), there is one dedicated to the management of medical gas systems, etc., that I think you’ll find useful (and since it doesn’t publish as often, it’s an easy one to add to your bloggy queue) is sponsored by Compliant Healthcare Technologies (CHT). Recently, Tim Richards at CHT penned a blog post on upcoming changes in NFPA 99 relative to medical gases, etc. As I’ve noted once or twice in the past, I really see NFPA 99 compliance as a likely source of heartburn for facilities and safety folks in the coming survey cycles, so any resource that can increase our operational understanding of what is actually required, etc. gives us a leg up on the survey front. I encourage you to check out the information.

As a final note, it appears that we are gearing up for another wild summer of weather and I wanted to take a moment to send best wishes to those in areas already in the throes of severe weather and those that may find themselves in the same. I do believe that, as an industry, we have done some extraordinary work in the practical preparations to deal with emergencies (I would feel better if appropriate preparedness would “drive” regulatory compliance a little more closely, but perhaps in time) and I trust that we all manage the coming season with minimal impact and disruption.

Like the dust that settles all around me: I got those low-down TJC FAQ blues

I don’t know if there’s anything to be inferred by the fact that the latest updates on the ligature resistance front are “buried” on p. 8 of the May 2019 Perspectives (after an onslaught of what I characterize as Joint Commission advertisements), but it would be nice to think that perhaps folks are going to be allowed to move on at their own “pace” as a function of risk assessments, abatement and mitigation strategies and monitoring for gaps in safety, but I guess we shall see what we shall see.

At any rate, the May Perspectives (on p. 8—imagine that!) provides two topics, one of which, video monitoring we discussed a few weeks back (I guess they like to repurpose content as much as anyone…) and a clarification on the (admittedly somewhat awkwardly worded) requirement that self-closing and self-locking (both, not one or the other) doors are required for the separation of areas required to be ligature resistant and those that are not, with the intent being to eliminate reliance on staff to close and lock those doors to prevent patient harm. The FAQ also prohibits the use of hold-open devices of any kind on these doors, so do keep that in mind. This applies to “staff controlled” areas on a behavioral health unit, like med rooms, utility rooms, consult rooms, etc. This is all based on Recommendation #1 published in the November 2017 Perspectives and the guidance that patient rooms, patient bathrooms, corridors, and common patient areas are to be ligature resistant. If this is news to you (I don’t know that we’ve discussed this particular piece of the puzzle), I can’t say that I am surprised as it really didn’t stand out at the time and really required too much in the way of cogitation to figure out what they were getting at, particularly the descriptor (“Nursing stations with an unobstructed view (so that a patient attempt at self-harm at the nursing station would be easily seen and interrupted) and areas behind self-closing/self-locking doors do not need to be ligature-resistant and will not be cited for ligature risks.”) as it was probably a little too all-inclusive. I think I would have separated them into two bullet points:

  • Nursing stations with an unobstructed view
  • Areas behind self-closing/self-locking doors

But hey, as long as we get there in the end, right? Yeah, sure, fine…

In other news, ASHRAE is in the public comment process relative to proposed changes to ASHRAE 170 Standard for Ventilation of Health Care Facilities (you can see the proposed draft here). Given that NFPA 99 defers to ASHRAE on the ventilation front, I can’t help but think that this is going to continue to be a cornerstone compliance document during survey activities. I don’t know that I noted anything particularly egregious, etc., in the proposed update, but I always try to encourage the folks in the field to review and weigh in when these things are open for comment. Before we got to ligature-resistant considerations, the management of procedural environments as it relates to temperature, humidity, air pressure relationships, etc. was the hot-button topic, so any changes might have a similar impact on the industry. Unfortunately, I just got wind of this last week and the comment period ends May 6, so act fast!

Ticking away the moments that make up a dull day: EOC orientation and ongoing education

Going to touch on a couple of things this week. First up? Ed-yoo-ma-cation!

A week or so back, I received an email encouraging me to list what educational competencies are most important relative to preparing for the survey process. Off the top of my head, the list (in no particular order) goes a little something like this (and I will stipulate that competency is the key focal point for these):

  • Fire response, including (and perhaps most importantly) department-level protocols
  • Emergency response, including how to summon assistance in an emergency
  • How to report an Environment of Care (EOC) problem or condition (I like to include “How to recognize an EOC problem or condition” as a subset of this one)
  • How to manage their own care environment (this is a bit of a stretch as it is not specifically mandated by code or regulation, but I will characterize this as something of a distillation of the general duty clause, kind of…)

After that, things get kind of gray, but if you look really closely at that last one, it comes down to everyone being able to demonstrate competency relative to what skills and knowledge are required for them to do their job appropriately (safely, timely, etc.). From knowing how long disinfectant has to keep a surface wet to appropriately disinfect whatever surface you’re disinfecting (say that 10 times fast!) to making sure that folks who are charged with providing on-to-one safety observation of at-risk patients are conversant with what to look for, how to summon assistance, when it is appropriate to intervene, etc. There does appear to be a growing focus on the processes involved in ensuring that folks are competent to administer their job responsibilities. While the list above gives you a sense of the “umbrella” under which organizationwide orientation provides a framework, the devil (as they say ) is in the details—and those details “live” at the department level.

To that end, it may be useful (if you are not already a participant in the department-level safety orientation) to “audit” some of the department programs to see if what folks are receiving matches up with what your expectations are of the entire orientation process. Most of the folks I’ve chatted with over time have found their “time” at orientation to be shrinking almost as quickly as those new pants in a hot water wash—it may be time to leverage some other opportunities to get the safety word out.

The other item for discussion relates to survey findings and the question of how much folks “expand” their surveillance in response to a survey finding. Minimally, you’re on the hook for resolving whatever the specific finding might be and now, with the submission of the corrective action plans to The Joint Commission (or whomever), there’s that whole concept of how you’re going to sustain the processes necessary to maintain compliance. Most of the action plans I’ve seen have a good framework for long-term monitoring, etc., but what about between right now and, say, next week? Or, even, next month? There seems to be a lot of follow-up surveying going on in the healthcare world and how far do you go to prepare for that potential “sooner than later” next visit. As with pretty much all of this stuff, there is very little in the way of guidance, but I was wondering if we could dig up some “best practices” in the name of (perhaps) introducing some non-EOC stuff into next year’s top 10 lists…just sayin’.

Have a most delightful week!

We are hope, despite the times: Steve Mac’s top 10 most troublesome EC challenges

First a quick (moderately revelatory) story: While traveling last week, I had the opportunity to see Creed II on the plane (I found it very entertaining, though somewhat reminiscent of another film—but no spoilers here). Interestingly enough, the image that stayed with me was during a scene on a maternity unit in a hospital where I observed a nicely obstructed fire extinguisher (there was some sort of unattended cart parked in front of the extinguisher). I guess that means I can never turn “this” (and you can call it what you will) off… but enough digression.

About a month or so ago, an organization with whom I had not worked before (they’re on the upcoming schedule) asked for a top 10 list of what I’ve seen as the most challenging physical environment standards, etc. I will admit to having been taken off guard a wee bit (I usually depend on others for top 10 lists), but then I figured it was probably about time that I put a little structure to all the various and sundry things that I’ve seen over the last decade or so.

To that end, here are Steve Mac’s Top 10 Things that will get you in the most trouble in the quickest amount of time (I don’t think there are any surprises, but feel free to disagree…):

Top 10 Critical Process Vulnerabilities – Physical Environment

  1. Inadequately mitigated ligature/safety risks in behavioral health environments
  2. Management of surgical and other procedural environments (temperature, humidity, air pressure relationships)
  3. Construction management process—lack of coordination, inconsistent implementation of risk management strategies
  4. ILSM policy/assessment/implementation—including “regular” LS deficiencies
  5. Management of hazardous materials risks, particularly those relating to occupational exposure (eyewash stations, monitoring, etc.)
  6. Life safety drawings (accuracy, completeness, etc.)
  7. Management of infection control risks in the environment (non-intact surfaces, expired product, high, intermediate and low-level disinfection)
  8. Management of contractors/vendors (documentation, activities, etc.)
  9. Effectiveness of surveillance rounds; integration of work order system, etc., to address compliance concerns
  10. Stewardship of the environment—participation of point-of-care/point-of-service staff in management of the environment.

Now I don’t know that there’s anything here that we haven’t covered in the past, but if you folks would like a more in-depth analysis of anything in the list above (or, indeed, anything else), please let me know. I suspect that I will be returning to this list from time to time (particularly during slow news weeks).

One of your sprinkler heads is loaded: Can you find it before they do?

And now, to the recap of the 10 most frequently cited standards during all of 2018 (in hospitals; other programs are a little more varied), as chosen by somebody other than you (or me): the survey troops at TJC.

The top 10 are as follows:

  • EC 02.01.35—The hospital provides and maintains systems for extinguishing fires (88.9% noncompliance percentage).
  • EC 02.05.01—The hospital manages risks associated with its utility systems (78.7%).
  • EC 02.06.01—The hospital establishes and maintains a safe, functional environment (73.9%).
  • LS 02.01.30—The hospital provides and maintains building features to protect individuals from the hazards of fire and smoke (72.9%).
  • IC 02.02.01—The hospital reduces the risk of infections associated with medical equipment, devices, and supplies (70.9%)
  • LS 02.01.10—Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat (70.7%).
  • LS 02.01.20—The hospital maintains the integrity of the means of egress (67.4%).
  • EC 02.05.05—The hospital inspects, tests, and maintains utility systems (64.7%).
  • EC 02.02.01—The hospital manages risks related to hazardous materials and waste (62.3%).
  • EC 02.05.09—The hospital inspects, tests, and maintains medical gas and vacuum systems (62.1%).

The ongoing hegemony of the top 10’s EOC-centric focus (and I still consider IC.02.02.01 the point upon which infection control and the physical environment intersect—sometimes with spectacular results) leaves little to the imagination (both ours and the surveyors). While you can still get into some significant trouble with certain processes, etc. (more on that next week—I figure if they can have a Top 10 list, then so can I…), the reason that these particular standards continue to jockey for position is because they represent the kinds of conditions (to some degree, I hesitate to call them deficiencies) that you can find literally any (and every) day in your organization. Just think about LS.02.01.35 for a moment: How far would you have to go before you found schmutz on a sprinkler head, something within 18 inches of a sprinkler head, a missing escutcheon (or an escutcheon with a gap), or even something (likely network cabling) lying atop, wire-tied to, somehow “touching” sprinkler piping or supports? I’m going to intuit that you probably won’t have to range too far afield to find something that fits in that category. The only thing I can say is whoever was surveying the “other” 11.1 % of the hospitals in 2018 must not have felt like poking around too much.

At any rate, I don’t know that there is a lot to glean from the 2018 results (same as it ever was…), but if someone out there has a question or concern that they’d like to share, I’m all ears!

Keeping an eye on things: Managing behavioral health patients

What, again?!?

Recently, our friends in Chicago added a new FAQ to the canon, this time reflecting on the use of video monitoring/electronic sitters for patients at high risk for suicide (you can find the details here). For those of you paying attention over the years—and I think that’s everybody within the sound of my “voice”—the situational requirements are based on a clear invocation of the “it depends” metric. I think it is pretty clear (and pretty much the standard “problem” relative to the management of behavioral health patients at serious risk for suicide) that providing sufficient flexibility of staffing to be able to provide 1:1 observation of these patients is where folks are looking for that flexibility in technological monitoring and the FAQ pretty much puts a big stop on that front. I think the quote that comes into focus for this aspect is, “The use of video monitoring or ‘electronic-sitters’ would not be acceptable in this situation because staff would not be immediately available to intervene.” So, as a general practice, a 1:1 observation means that somebody (a human somebody) is “immediately available to intervene,” which means all the time, at any time.

At this point in the discussion, I think the important piece of this is (and is likely to remain so) the clinical assessment of the patient, inclusive of the identification of the risk level for suicide. I don’t think that the “reality” of having to deal with way more of these patients than we would prefer is going to change any time soon, and with it, the complete unpredictability of that patient volume as a function of staffing (full moons notwithstanding).

The FAQ goes on to discuss the use of video monitoring in those instances in which it is not safe for staff to be physically located in the patient’s room, but the use of video monitoring has to result in the same level of observation, immediacy of response, etc. It also indicates that video monitoring for patients that are not at high risk for suicide is at the discretion of the organization, indicating that there are no “leading practices” in this regard. I guess that means that you’re really going to have to make your own way if you chose the video monitoring route, which should include (as also noted in the FAQ) provisions for reassessment of the patient(s). Interesting times, my friends, interesting times…

As a final (and almost completely unrelated) note, I wanted to bring to your attention some discussion over at the Motor & Generator Institute (MGI) relating to recent CMS guidance regarding expected temperatures in the care environment during normal power outages and how, if you have a long-term care facility in your mix, a risk assessment might not be enough. You can find the details here and the folks at MGI are encouraging feedback, so I think it might be worth checking out and weighing in.

 

Eat, drink, and be safe: Some guidance on the care and feeding of staff

One of the more universal conditions I find is the whole issue of where staff can grab something to eat or drink in the midst of busy periods, particularly when staffing levels don’t necessarily dovetail with leaving the work space to go to the cafeteria, etc. And there’s always the specter of someone, somewhere having invoked the “You can’t eat there, it’s against TJC regulations” or “You can’t drink there, it’s against regulations” and so forth and so on. And what better strategy than to use a regulatory presence from outside the organization to be the heavy.

Many’s the time I’ve tried to convince folks that, from a regulatory perspective (with some fairly well-defined exceptions, like laboratories), there is nothing that approaches a general prohibition when it comes to the how, when, and where of eating and drinking in the workplace (and yes, I absolutely understand that prohibition is the easiest thing to “police,” but I think prohibitions also tend to “drive” more creative workarounds). And in the March 2019 edition of Perspectives, our friends in Chicago provide a couple of clarifications for folks, and if you think that there’s a risk assessment involved, then you would be correct.

So, the clarifications are two in number:

  • There are no TJC standards that specifically address where staff can have food or drink in the work areas.
  • You can identify safe spaces for food and drink as long as those locations  comply with the evaluation (read: risk assessment) of the space and your exposure control plan as far as risks of contamination from chemicals, blood, or body fluids, etc.

The guiding light in all of this, if you will, are the regulations provided by the Occupational Safety & Health Administration, and while they have a lot to say about such things (Bloodborne Pathogens and Sanitation), a careful analysis should yield a means of designating some spaces. I have seen a lot of designated “hydration stations,” particularly in clinical areas, to help keep folks hydrated over the course of the working day, so clearly some folks are working towards providing some flexibility based on a risk assessment. This is a good thing both in terms of staff support, but also in not drawing a line in the sand that they don’t have to. Prohibitions can bring about some of your toughest compliance challenges, so if you can work with folks to build in some flexibility, it could mean fewer headaches during rounding activities.

Making a checklist, making it right: Reducing compliance errors

As you may have noticed, I am something of a fan of public radio (most of my listening in vehicles involves NPR and its analogues) and every once in a while, I hear something that I think would be useful to you folks out in the field. One show that I don’t hear too often (one of the things about terrestrial radio is that it’s all in the timing) is called “Hidden Brain”, the common subject thread being “A conversation about life’s unseen patterns.” I find the programs to be very thought-provoking, well-produced, and generally worth checking out.

This past weekend, they repeated a show from 2017 that described Dr. Atul Gawande’s (among others) use of checklists during surgical (and other) procedures to try to anticipate what unexpected things could occur based on the procedure, where they were operating, etc. One of the remarks that came up during the course of the program dealt with how extensive a checklist one might need, with the overarching thought being that a more limited checklist tends to work better because it’s more brain-friendly (I’m paraphrasing quite a bit here) than a checklist that goes on for pages and pages. I get a lot of questions/requests for tools/checklists for doing surveillance rounds, etc. (to be honest, it has been a very long time since I’ve actually “used” a physical checklist; my methodology, such as it is, tends to involve looking at the environment to see what “falls out”). Folks always seem a little disappointed when the checklist I cough up (so to speak) has about 15-20 items, particularly when I encourage them not to use all the items. When it comes to actual checklists that you’re going to use (particularly if you’re going to try and enlist the assistance of department-level folks) for survey prep, I think starting with five to seven items and working to hardwire those items into how folks “see” the environment is the best way to start. I recall a couple of years ago when first visiting a hospital—every day each manager was charged with completing a five-page environmental surveillance checklist—and I still was able to find imperfections in the environment (both items that they were actually checking on and a couple of other items that weren’t featured in the five-pager and later turned out to be somewhat important). At the point of my arrival, this particular organization was (more or less) under siege from various regulatory forces and were really in a state of shock (sometimes a little regulatory trouble is like exsanguination in shark-infested waters) and had latched on to a process that, at the end of the day, was not particularly effective and became almost like a sleepwalk to ensure compliance (hey, that could be a new show about zombie safety officers, “The Walking Safe”).

At any rate, I think one of the defining tasks/charges of the safety professional is to facilitate the participation of point-of-care/point-of-service folks by helping them learn how to “see” the stuff that jumps out at us when we do our rounds. When you look at the stuff that tends to get cited during surveys (at least when it comes to the physical environment), there’s not a lot of crazy, dangerous stuff; it is the myriad imperfections that come from introducing people into the environment. Buildings are never more perfect than the moment before occupancy—after that, the struggle is real! And checklists might be a good way to get folks on the same page: just remember to start small and focus on the things that are most likely to cause trouble and are most “invisible” to folks.

Don’t bleed before you are wounded, and if you can avoid being wounded…

…so much the better!

Part of me is wondering what took them so long to get to this point in the conversation.

In their latest Quick Safety utterance, our friends in Chicago are advocating de-escalation as a “first-line response to potential violence and aggression in health care settings.”  I believe the last time we touched upon this general topic was back in the spring of 2017 and I was very much in agreement with the importance of “arming” frontline staff (point of care/point of service—it matters not) with a quiver of de-escalation techniques. As noted at the time, there are a lot of instances in which our customers are rather grumpier than not and being able to manage the grumpies early on in the “grumprocess” (see what I did there?!?) makes so much operational sense that it seems somewhat odd that we are still having this conversation. To that end, I think I’m going to have to start gathering data as I wander the highways and byways of these United States and see how much emphasis is being placed on de-escalation skills as a function of everyday customer service. From orientation to periodic refreshers, this one is too important to keep ignoring, but maybe we’re not—you tell me!

At any rate, the latest Quick Safety offers up a whole slate of techniques and methods for preparing staff to deal with aggressive behaviors; there is mention of Sentinel Event Alert 57 regarding violence and health workers, so I think there is every reason to think that (much as ligature risks have taken center stage in the survey process) how well we prepare folks to proactively deal with aggressive behaviors could bubble up over the next little while. It is a certainty that the incidence rate in healthcare has caught the eyes and ears of OSHA (and they merit a mention in the Quick Safety as well as CDC and CMS), and I think that, in the industry overall, there are improvements to be made (recognizing that some of this is the result of others abdicating responsibility for behavioral health and other marginalized populations, but, as parents seem to indicate frequently, nobody ever said it would be fair…or equitable…or reasonable…). I personally think (and have for a very long time, pretty much since I had operational responsibilities for security) that de-escalation skills are vital in any service environment, but who has the time to make it happen?

Please weigh in if you have experiences (positive or negative are fine by me) that you’d feel like sharing—and you can absolutely request anonymity, just reach out to the Gmail account (stevemacsafetyspace@gmail.com) and I will remove any identifying marks…

Manage the environment, manage infection control risks

In looking back at 2018 (heck, even in looking back to the beginning of 2019—it already seems like forever ago and we’re only a week in!), I try to use the available data (recognizing that we will have additional data sometime towards the end of March/beginning of April when The Joint Commission (TJC) reveals its top 10 most frequently cited standards list) to hazard a guess on where things are heading as we embark upon the 2019 survey year.

First up, I do believe that the management of ligature risks is going to continue to be a “player.” We’re just about two years into TJC’s survey focus on this particular area of concern; and typically, the focus doesn’t shift until all accredited organizations have been surveyed, so I figure we’ve got just over a year to go. If you feel like revisiting those halcyon days before all the survey ugliness started, you could probably consider this the shot heard ’round the accreditation world or at least the opening salvo.

As to what other concerns lie in wait on the accreditation horizon, I am absolutely convinced that the physical environment focus is going to expand into every nook and cranny in which the environment and the management of infection control risks coexist. I am basing that prediction primarily on the incidence of healthcare-associated infections (HAI) and related stuff (and, as was the case with ligature risk, I suspect that having a good HAI track record is not going to keep you from being cited for breakdowns, gaps, etc.). We’ve certainly seen the “warning shots” relating to water management programs, the inspection, testing, and maintenance of infection control utility systems, management of temperature, humidity, air pressure relationships, general cleanliness, non-intact surfaces, construction projects, etc. Purely from a risk (and survey) management perspective, it makes all the sense in the world for the survey teams to cast an unblinking eye on the programmatic/environmental aspects of any—and every—healthcare organization. Past survey practice has certainly resulted in Condition-level deficiencies, particularly relative to air pressure relationships in critical areas, so the only question that I would have is whether they will be content with focusing on the volume of findings (which I suspect will continue to occur in greater numbers than in the past) or will they be looking to “push” follow-up survey visits. Time will tell, my friends, time will tell.

But it’s not necessarily just the environment as a function of patient care that will be under the spotlight; just recently there was a news story regarding the effects of mold on staff at a hospital in New York. TJC (as well as other accreditors including CMS) keeps an eye on healthcare-related news stories. And you can never be certain that it couldn’t happen in your “house” (it probably won’t—I know you folks do an awesome job, but that didn’t necessarily help a whole lot when it came to, for example, the management of ligature risks). Everything filters into how future surveys are administered, so any gap in process, etc., would have to be considered a survey vulnerability.

To (more or less) close the loop on this particular chain of thought (or chain of thoughtless…), the Centers for Disease Control and Prevention are offering a number of tools to help with the management of infection control risks in various healthcare settings, including ambulatory/outpatient settings. I think there is a good chance that surveys will start poking around the question of each organization’s capacity to deal with community vulnerabilities and these might just be a good way of starting to work through the analysis of those vulnerabilities and how your good planning has resulted in an appropriately robust response program.