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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!

Folks back home surely have called off the search…

We knew it was going to happen eventually, but our friends in Chicago have made it official (just in time for the implementation of Daylight Savings Time—for those of you participating), the return of the (more or less) completely unannounced surveys by The Joint Commission (see the first article in the March 10 edition of Joint Commission Online). To be honest (and I try never to be anything but), I really can’t say how far behind they are on the survey front. I can’t imagine that there’s not going to be some serious catching up to do, and, since the public health emergency is still in play, I’m not sure how much time they’ll be given by the feds to reach some sort of survey plateau.

Presumably, they will continue to rely on the CMS COVID data (we talked about that a little while back; if you’ve somehow managed to misplace that link, you can find it here) to determine where the trouble spots might be (if you look at the latest data, the results are promising; hopefully we won’t be remembering the beginning of March as the—yet another—calm before the storm), so if you’re in a “red” county, that may be enough to avoid being in the first wave. I suppose the other dynamic is how survey teams will they be able to field—it sounds like this is going to be a busy week for folks, so if they show up on your front door step, please know that this community is standing by with best wishes for success.

As an adjunct to the return of the survey, TJC unveiled the 2021 Survey Activity Guide, which, among other things, formally speaks to the elimination of the Environment of Care interview session, indicating that topics previously covered in the session will find their way into the EC/LS tracer activities. Thus, effectively giving the LS surveyors another hour or so to wander the halls, with the implication being that they may go to/get to places in your house where they’ve not previously been. I’m not entirely certain, though I suppose if you have a fair amount of square footage there may be one or two spots that might not have been ransacked before, but I’m guessing you have a pretty decent idea of where they’ve not been, so it might be worth kicking those tires, so to speak. We know for a pretty fair certainty that they will be visiting the kitchen (after all, there’s a checklist and far be it for a checklist to go unchecked…).

They’ve also updated/revised the list of documents, including the return (don’t call it a comeback!) of the Statement of Conditions and Basic Building Information, something of a focus on water management programs (make sure you have your ASHRAE and CDC ducks in a row) and the management of line isolation monitors (if you have them). And, of course, the perennial attentions to the Management Plans (I’m not going to say anything more about those for a bit…) and annual evaluation process. Oddly enough, it appears that the document list also includes things that are not required to be documented, but rather are in place to remind you and the surveyors of some specific expectations like, oh, how ’bout, managing safety risks. I almost forgot about that…

So, hopefully the survey process will be less lion and more lamb as we get things rolling again. I think most organizations are experiencing some variation of PTSD and I don’t think that kicking folks in the head is going to be very helpful. The fact that healthcare has managed to keep things going over the past 12 months is a testament to the effectiveness of our processes, etc. I’m not expecting pats on the back (as deserved as they may be), but I do expect some reason in the administration of the survey process—or at least, that’s my hope—especially for everyone that’s in the barrel for this coming few weeks.

Please be well and stay safe—and keep doing what you’re doing. You folks are amazing, and don’t forget it!

From the sky, the highway’s straight as it could be!

But other things, maybe not so much…

In the continuing odyssey of “what goes around, comes around,” I had to cast some tea leaves to recall the last time we chatted about eyewash stations (for those of you keeping track, it was October 2019) as I reviewed the current (March 2021) edition of Joint Commission Perspectives, particularly what I view to be the most interesting aspect (and if you want to interpret that as the only interesting aspect, I would not argue the point) of the publication, the Consistent Interpretation column (I think it’s fair to call it a column, though perhaps not always a load-bearing one). The March Interpretation article deals generally with the minimizing the risks associated with managing hazardous chemicals (for which about 50% of the hospitals surveyed in the last year of the 20-teens were cited). I would encourage you to check out the details. It may save you some future heartache, especially if you have dental clinics in the mix—dental amalgam would seem to be the “pet rock” of some surveyors.

One very useful interpretation is that “simple storage” of corrosive chemicals is (more or less—we’ll see how the play on the field reflects this) off the table in terms of having to have an eyewash station (fortunately for all of us, containers of corrosive chemicals tend not to explode on their own…). Where you do need to provide access (or at least consider) are locations where corrosive chemicals are used/mixed/ dispensed. And this is where it is of critical importance to do your due diligence when it comes to the risk assessment; corrosive (and caustic) chemicals that are injurious to the eye (and other parts) are where you cross the line into eyewash stations. And given the recent funkiness regarding disinfectant cleaners and a return to bleach as a frequently used disinfectant agent, I suspect that there’s going to be a lot of attention to where bleach is being, well, used, mixed and/or dispensed. This is going to present more than its share of challenges in the field, I suspect…

Interesting point in the explanatory section of the piece; there’s a link to an OSHA interpretation that is instructive, but could be confusing as it deals specifically with electric battery storage charging and maintenance areas. Clearly, the focus is (and should be) on managing those most hazardous chemicals, etc. that we might use in the workplace, so it will be interesting to see how this unfolds over the next survey cycle.

As a closing thought (and this it definitely out of left field), I’m not sure how many EVS folks are out there in the audience, but one condition I’ve been encountering with a fair amount of frequency (and not just in hospitals—I look at this stuff wherever I go) are baby changing tables for which the safety belts have either gone missing or been damaged, etc. I know it’s not a big thing (unless you’re a parent with a squirmy infant), but (if you look at it wearing your ugly surveyor hat) you could make the case that if it’s something provided by the manufacturer, then the expectation is for the equipment, etc., to be maintained in accordance with the manufacturer’s Instructions For Use. It’s not something you have to do all the time (unless somebody is swiping them), but it might be worth scheduling a “sweep” of your changing tables from time to time.

Until next time: Be well and stay safe!

Gimme a break…or a spare circuit breaker

One of the more common findings (as it were) over the past few years has been the condition in which a circuit breaker is in the “on” position and it is either not labeled or labeled as a “spare.” It would seem that the codified guidance in this regard is sufficiently “gray” to push our friends in Chicago to issue an official interpretation. In olden times, this information would be shared either in Perspectives, the FAQs or the standards manual(s) and I can’t seem to find mention of it anywhere other than from ASHE. Perhaps it’s nothing (from a process standpoint, this is going to be a pain in the butt; from a practical standpoint, how many circuit breakers do you have?) but, like the ubiquitous “loaded” sprinkler head, there always seems to be one breaker that’s not going in the right direction. And I suppose if a surveyor is willing to put in the time to find it, all you can do is thank them…

At any rate, I did want to take a moment to thank each and every one of you for keeping things together (both figuratively and literally) over the past months. I know these have been among the most trying times imaginable and we’re certainly going to be “in it” for a while longer, but you folks have done what needed doing and are still doing everything you can do to keep everyone safe and your facilities operational. I am proud to be associated with such a fine bunch of folks. We’ve got this!

Until next time, be well and stay safe!

The roar of the ’20s continues: Optimism abounds!

I trust that you all were able to carve out some downtime over the holidays. While there was (seemingly) much less rushing around than normal, in many ways, the past month or so has been no less exhausting. At any rate, I hope this finds you well and ready for the climb up (out?).

As mentioned the last time we “gathered,” our friends in Chicago are in the process of modifying the survey of the physical environment as it extends to behavioral health organizations. As fate would have it, the changes revolve around ongoing efforts to align Joint Commission standards and performance elements with the requirements of NFPA 101-2012 Life Safety Code® (LSC) and NFPA 99-2012 Health Care Facilities Code, including clarification of fire drill requirements. A couple of items of particular note follow:

  • Behavioral healthcare facilities that use door locking to prohibit individuals from leaving the building or spaces in the building are considered healthcare occupancies. I don’t see this as an issue for inpatient units as this already the “mark,” but it may come into play in your outpatient clinic settings and perhaps any residential care settings. With all the changes in the survey process relating to care locations outside of the main hospital, I think proper identification of occupancy classifications is going to be under greater scrutiny than ever.
  • If you do have residential board and care facilities in your organization, they’ll be looking for at least six fire drills per year for each building and that means evacuation (unless otherwise permitted by the LSC; please check out NFPA 101-2012: 32/33.7.3 for details and exceptions), two of which need to be conducted at night when residents are sleeping. For some strange reason, the pre-publication standard indicates that “at least two annual drills” would be conducted during the night; I think this is probably one more word—that being “annual”—than it needs to be. I don’t know, it just seems less clear than saying, perhaps, at least two drills per year would be conducted at night or something like that. But that may just be me.
  • Depending on the capacity of the branches of your essential electrical system, you may have some flexibility relative to the number of required transfer switches; your system must still be divided into three branches (life safety, critical, equipment), but if your system is 150kVA or less, then you don’t need to have at least one automatic transfer switch for each branch. I suspect that most folks that have facilities that were constructed, had a change in occupancy type, or undergone a major electrical system upgrade since 1983 are probably all set with this, but I think we can anticipate the question being asked—better to know what you have going in, and probably a useful piece of information to include on your Statement of Conditions.

The LS chapter changes appear to be aimed at ensuring that the requirements for new and existing occupancies are appropriately noted; at this point, I don’t see anything particularly problematic, but, as they so often note in the fine print, actual results may vary. You can find the details here.

As I look out the window, it’s snowing, which reminds me that we’ve got to keep turning with the world, so I will let you get back to it. Until next time, hope you are well and staying safe. For those of you who are in the process of receiving the vaccine, thank you for your service!

Just in time for the holidays: Shoes are dropping all over the place, including business occupancies!

Just when you thought that maybe, just maybe, 2020 had run out of surprises, our friends in Chicago have taken one last (hopefully) opportunity to create a little chaos in the future by introducing us to their latest brainchild—the Life Safety chapter standards and performance elements prescribing the management of business occupancies.

I don’t know that there’s anything particularly surprising in the mix, and, ultimately, may help healthcare organizations endure the scrutiny of surveyors that insist on applying healthcare occupancy requirements to business occupancies. In some ways, it also helps to clarify certain general concepts (for example, the protection of hazardous areas—I suspect you’ll be installing some door closers before too long) that were always applicable, but not always meted out during surveys. There are approximately 30 new performance elements (I count 29, but I can never tell when my math skills will legitimately start to deteriorate…) to chew on, but the “good” news is that these are not coming online until July 1, 2021, so perhaps you will have had enough time to really kick the tires in your clinics, etc.

These changes will be in play for behavioral health and critical access hospitals as well, you can find the links for each of those here.

There are also some EC and LS changes coming to behavioral health, but I think we’ll dig into those next time.

In the face of all of this, I hope that each of you has a safe and joyous holiday season and that we all get a really spiffy New Year. I think we’re earned it!

We’re only immortal for a limited time…

Just taking a quick cruise the FAQ pages and came across one or two items of interest; commentary as applicable…

Our friends in Chicago have given the thumbs up to using the current pandemic response to meet the emergency management exercise(s) requirements. Make sure you document the evaluation in accordance with the six critical areas of response:

  • Communications—what worked well and what did not
  • Resources and assets—what resources were abundant, adequate or lacking
  • Safety and security—what issues arose and how were they resolved
  • Staff responsibilities—what issues arose and how were they resolved
  • Utilities—what issues arose and how were they resolved
  • Patient clinical and support activities—what was abundant, adequate or lacking.

There is an indication that they may be “leaning” on EM when the survey process returns in earnest (and we all know how important that is…).

Moving on to the world of equipment management, specifically diagnostic imaging equipment, there is some relief relative to the completion of performance evaluations for certain systems (CT, MRI, NM, PET, but not mammography) for the duration of the declared state of emergency. I’d be curious as to how folks have been managing this in general; I suspect that some folks had these on the schedule before things came to a screeching halt, but we’re rounding the corner on a year’s worth of pandemic delight so probably want to keep an eye on where things stand. As with many things, the clock will be ticking once the state of emergency is discontinued, at which point you’ll have 60 days to get things scheduled. I bet there will be a lot of competition for external resources at that point…

We’ll close out this week’s edition with some fodder for the HVAC-heads in the crowd. I have to admit that the question being asked and the response don’t seem to match up particularly well and I do think there probably ought to be some mention of the manufacturers’ instructions for use (nothing like a little IFU to make one’s day). The question seems more along the line of “what should we be doing now,” but the response seems to focus a little more on “here’s what you do when this is all over,” when it comes to maintaining HVAC equipment being used to support COVID units. Again, I suspect the IFUs have a big part of where we should be at the moment. Hopefully, you’ve had enough ebb and flow of patients to be able to attend to something close to a normal preventive maintenance schedule and it probably couldn’t hurt to reach out to equipment manufacturers’ if we have significantly modified the use of existing systems and equipment. That said, I would certainly recommend including the bulleted items noted in the FAQ once we’re in a position to start returning things to “normal.”

Won’t you be glad when normal doesn’t have to be in quotation marks?

Hope you all remain safe and well!

Someone’s in the kitchen, but there are no banjos involved…

In the never-ending quest for generating new and challenging survey findings, our friends in Chicago have thrown down the gauntlet (or perhaps more aptly, the oven mitt) for a new focus area: the kitchen! Certainly, the kitchen has always been part of the fabric of most regulatory survey visits. If you think about it, kitchens are among the most risk-laden environments in healthcare. You’ve got all the classic physical environment risks—slips, trips, falls, fire, sharps, heat, humidity, chemical hazards, sanitation/cleaning, a lot of entry-level positions—the list goes on and on. You could make the case that the kitchen environment is among the least risk-free environments in any healthcare organization. I will stop short of calling it dangerous, but it sure is hazardous.

To that end, this week’s Joint Commission blog posting outlines some of the major focus areas for the survey process as it relates to the kitchen; the blog also includes a link to a checklist for reducing fire and other risks in the kitchen. If you don’t have a formal process for doing rounds in your kitchen(s), might be work kicking the tires on this one.

Hope you all are well and staying safe. While I think we’re starting to make the adjustments to the “new normal,” the post-Thanksgiving spike (if there is one, and there’s no reason to think there won’t be) should be arriving shortly, so keep up the good work and we’ll get through this!

We know it will never be easy, but will it ever get easier?

It’s always interesting (and perhaps a bit thrilling) when an announcement comes flying over the transom from our friends in Chicago unveiling “modifications” to the Environment of Care (EC) survey process for healthcare occupancies (e.g., ASCs, hospitals, critical access hospitals), but this ended up being a little less breaking news and a little more of a good news/less-good news situation.

For quite some time now, I have mulled over the general thought that the EC interview session portion of the accreditation survey process really doesn’t yield a lot of findings. My sense of the session is that it’s more of an evaluation of group participation than anything else and it appears that others in a position to do something about it are in agreement, at least as a function of identifying survey vulnerabilities.

At any rate, The Joint Commission recently announced that the EC interview session is going away (good news) to provide more time for surveying in the field, including even more focus on EC stuff for the clinical surveyors during tracers (less-good news). I am certainly not worried about folks getting into “big” trouble during this extra hour of time, but it is another hour of wandering around that is likely to generate at least a few more “dings” in the physical environment.

As the Chicagoans continue to battle the forces of CMS in their pursuit of deemed status and reported shortfalls in the surveying of the physical environment, there is a certain inevitability at play here, so I guess we’ll have to wait and see. My immediate prediction is that there will be an increase in EC/Life Safety findings over the next little while (and perhaps a little while after that…).

Now, if they would only remove the requirements to maintain the safety, security, HazMat, fire, medical equipment, and utility systems management plans—I don’t think they generate very many findings and they really don’t serve any real operational purpose for healthcare organizations. Fire response plans and emergency response plans make sense to me, but the rest of it should be captured through the annual evaluation process. Is it really that big a “step” to go from evaluating effectiveness of the EC plans to evaluating the effectiveness of the EC programs in whole? Somehow I don’t think so…

Hope you are all well and staying safe!

I feel like we’ve crossed this bridge before…fire drills are all the RACE!

While the numbers are fairly small (though at almost 30% for a noncompliance rate during 2019 surveys, you could certainly make the case that almost any deficiencies in this area is too much), there remain a couple of common stumbling points when it comes to conducting fire drills. According to the August 2020 issue of Perspectives (get it at your newsstand now!), there continue to be issues with:

  • Not completing/documenting quarterly drills on every shift. I don’t know that there’s a whole lot of mystery here—sometimes you miss a drill. You don’t want to miss a drill; nobody wants to miss a drill! But sometimes the quarter expires so quickly that you don’t realize that a drill was missed until it’s too late. The links below will take you to The Joint Commission’s guidance on the topic, but my best advice is to set a reminder for March 10, June 10, September 10, and December 10 to check fire drill status. That way, you’ve got a couple of weeks if you need to get one in.

https://www.jointcommission.org/resources/news-and-multimedia/podcasts/take-5-the-environment-of-care-fire-drill-matrix-tool/

https://www.jointcommission.org/resources/patient-safety-topics/the-physical-environment/

  • The fire alarm signal was not transmitted on the third shift drills. I absolutely understand why this is still in the mix (as TJC has noted, the allowance for a coded signal for drills between 9P and 5A, does not preclude the transmission of the fire alarm signal). My best advice is to have a line item on your fire drill critique form that goes a little something like: Fire alarm signal transmitted – Yes   No. That way you are providing a surveyor documentation of the signal transmission where you know they’ll be looking.

https://www.jointcommission.org/standards/standard-faqs/hospital-and-hospital-clinics/environment-of-care-ec/000001235/

  • Not enough variation of times when fire drills are conducted; not too much more to say that hasn’t already been said—you have to mix it up—and make sure that the folks conducting the drills understand that once you’ve set up a fire drill schedule, it is to remain unchanged without approval. I know that sounds kind of draconian (and I suppose it is), but our surveyor friends have been rather inflexible on this count and you don’t want to get dinged for a measly 15 or 30 minutes of overlap in your drill times. In the words of the inimitable Moe Howard, when it comes to fire drills—SPREAD OUT! Or, if you’d rather use George Mills’ take on it, you can find that here (with some other Life Safety bon mots).

Now, at the moment, the survey process is not focusing on fire drills as a function of the 1135 Waivers in effect due to the COVID-19 maelstrom. So it would seem that we have a little bit of time to work on the finer points of fire drill compliance. I think the overarching focus is going to end up being (and I think this is likely to be the case with emergency management exercises) is how well you are doing relative to ensuring that “all staff” are participating. For the purposes of the education and training component, I would like to think that if we can demonstrate that everyone in the organization (including the folks in administration) participated, to some degree, over a two-year period, that will result in a finding of compliance during survey. Is it even possible for most places of size to get to everyone, every year? I’m thinking not, but feel free to disagree. I think it may end up going the route of hazard surveillance round frequency—you have to do as many as you have to do to cover the territory you need to cover. So, if in order to be effective, you have to do more than one fire drill per shift per quarter, then that becomes part of the algorithm used for your annual evaluation (or to use the annual evaluation as a place to ensure your clear assessment of the effectiveness of the program). There is always the potential for a surveyor to disagree with your fire drill schedule, as it relates to effective education of staff. Use the annual evaluation to document your assessment of the effectiveness—it may be the only way to keep the survey wolves away from the flock.

So, let’s get the flock out of here…

As always, hope you are well and staying safe. I’ve been traveling some over the past few weeks and, humans being humans, I think we’ve got a ways to go before we wrestle this thing to the ground, so keep those shields up!