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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!

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!