RSSAll Entries in the "Uncategorized" Category

Don’t just implement ILSMs–analyze them, too

Let me don my performance improvement robes for a moment as it concerns interim life safety measures (ILSMs).

If we start with the thought that the implementation of ILSMs evolves out of the risk assessment process, can we not further carry it into the realm of process improvement? And, as a function of process improvement, do we not periodically monitor and evaluate the effectiveness of, and potentially rethink, the interventions already in place?

But, of course we do–or for the Francophiles, mais certainment!

You can’t always pick a winner, but as you collect and analyze ILSM data, you can develop a pretty good track record over time. That’s where your surveillance rounds support your decisions because that’s the data upon which you make future ILSM determinations.

It’s not so much about the frequency of the inspections (though don’t forget the daily inspection of egress routes from the construction area if you use that particular ILSM), but the quality of the data collected as the result of those inspections.

You have the means of effectively evaluating the effectiveness of your ILSMs, so you might just as well use them.

A hundred pennies for your thoughts

I was talking among my colleagues recently about incentives you might offer employees as part of EC training efforts.

One year while I was still working at a Boston area hospital, the survey coordinator bought something like $1,500 worth of $1 coins and handed them out for correct answers to Joint Commission-themed questions during survey prep time. (I, of course, wanted to do it during the actual survey as well, but got overruled.)

Anything you can do to get folks engaged in the process is good.

What ideas for incentives have you seen that you liked?

Which came first, the assessment or the assessment?

An interesting recurring theme during surveys revolves around the age-old question of, “What did you know and when did you know it?” and the definition of “proactive.”

Every challenge you might be called upon to manage has some sort of sequence. Well maybe not every challenge–sometimes things really hit the wildly spinning fan blades all at once. Hope you’re not having one of those days.

Take construction/renovation projects, for example. You start by:

  • Looking at what’s involved
  • Identifying the risks
  • Assessing the risks
  • Determining the interventions most likely to succeed
  • Going from there

Please, please, please make sure that somewhere in the vast wasteland of documentation, you’ve indicated succinctly that the risk assessment occurred upstream of the project start-up.

If you have a discussion prior to start-up that involves the identification of risk, assessment of the risk, identification of interventions–that’s a proactive risk assessment–don’t be afraid to say so.

Ring the church bells, hang lanterns in the steeples, send the white smoke up the chimney: “We have a new risk assessment!”

There seems to be a movement afoot that if you don’t call it a “proactive risk assessment” then Joint Commission surveyors can jump ugly with you. Granted, it’s not a very nice way of going about anything, but you need to be mindful of this possibility.

Distant early warning

How long will you have to mobilize on the first day of your Joint Commission (formerly JCAHO) survey? Presuming that your organization has someone monitoring your Joint Commission extranet site on a regular basis, then how early are they looking? How long will it take for the word to reach you, whoever you might be?

This is a point where one of those nasty little cliches comes into its own: You only have one chance to make a good first impression, and the sooner you can “get to it,” the better.

Try to take advantage of some pro-activity as well because setting the stage is key. For example, make sure that there’s a process for neatening up those high-profile public restrooms early in the day. Even surveyors have to take a break, and you don’t want them to walk into the proverbial pigsty.

Also, ask your security staff on the overnight shifts to keep an eye out for law enforcement officers with a patient in tow. Make sure that the officers at least receive some sort of briefing as to the ways and means of your organization. A number of folks have had success with cobbling together a little brochure to hand out to forensic staff (and contractors, too) to provide them with a broad-stroke overview of your processes.

For some reason, surveyors seem to be attracted to forensic/law enforcement officers, so ensure the experience is a positive one for all involved. You and your HR department (that Joint Commission EP lives in HR standards) will be glad you did.

Pharmacy locking: Stand-alone system or part of the bigger picture?

There was a question on our Safety Talk discussion group today about whether there is a regulation that mandates a pharmacy must have a stand-alone locking system, or whether it can be part of a bigger system.

I’ve seen some different configurations of systems, and the question also brought to mind a condition I found recently during a consulting engagement. And it also brings to mind that most favorite of subjects, the risk assessment.

In the hospital where I grew up, the folks in the pharmacy were always very insular when it came to their security systems. Every aspect was managed by them, through them, etc., with absolutely no interface whatsoever with the organization at large.

I admit that at first I was a little tweaked by that, but over time I came to realize that pharmacy is an enormous undertaking and the fewer fingers in that pie, the better the likely outcome. During today’s discussion on Safety Talk, some folks cited state-level requirements, which should definitely be the starting point for this stuff. But what about those instances in which the state-level guidance is non-existent or just plain not helpful?

Why then you’d do a risk assessment, which kind of leads me back to the initial question of whether the pharmacy’s access system should be stand-alone.

Ultimately, I think the decision point is a determination of how impregnable your general access system would be and if there is a chance that someone could violate the pharmacy through the general system. You need to determine your comfort level with how “remote” that chance might be. If that chance exists to a degree, then you need to make sure that there is sufficient “separation” to ensure appropriate security levels.

To take the example in a slightly different direction, recently I visited a hospital in which the “brains” of their infant security system were in a cabinet (albeit a locked one) in a soiled utility room. There were no other defenses other than the locked cabinet–the utility room was unlocked, there were no cameras or other monitoring devices, etc.

Now, we can absolutely stipulate that there is no specific Joint Commission requirement for this one. But the question sort of becomes: Is this really the way we want to set this up?

I know that sometimes you need to go with what your infrastructure can support, but at other times you just have to say, “We’ve got to find a better way of doing this.”

So the question you have to ask yourself–besides, “Do you feel lucky, punk?”–amounts to whether this is the best we can do (whatever “this” might happen to be). And, you know the answer you’d be looking for…

EP 5 is a growing influence under EC.1.10

I’ve noticed a general change relative to citations initially falling under EP 4 of EC.1.10 (conducting a risk assessment) and then morphing towards EP 5 (implementing procedures to offset identified risks).

I suspect it’s because EP 5 (as an EP with a C score) is a lot more difficult to clarify than EP 4.

EP 4, as an EP with a B score, is sort of a one and done kind of thing, and it’s very easy for most healthcare organizations to demonstrate that they’ve conducted a risk assessment.

In a way, these two EPs together are very clear from a cause and effect standpoint. For instance, EC.1.20 requires you to have a surveillance tour process, but, in and of itself, it doesn’t really require it to be effective (the requirement is to conduct safety rounds). Now I absolutely recognize that there is an expectation that you would evaluate that process, but it doesn’t necessarily say it in EC.1.20.

When you flip back to EC.1.10, you could skate around EP 4 if you had a process that wasn’t so good. Thus, if EP 4 stood by itself, you could argue your way out of things.

With the shift from EP 4 to EP 5, the benchmark becomes much more difficult to attain because the requirement has gone from a mere “conducts a risk assessment” to the much more challenging “selects and implements procedures and controls to achieve the lowest potential for adverse impact.”

This latter wording leaves the surveyor in the position of determining whether a condition has been managed such as to achieve the lowest potential for adverse impact. That determination effectively makes anything fair game for a citation if the surveyor doesn’t like the looks of it.

EC.1.10 as a haven of surveyor preference

Hi everyone, Steve Mac here. I’m posting as the “blog administrator” today due to some technical glitches.

During a Joint Commission survey that I’m familiar with, there was a finding related to a missing outlet cover in a pediatric waiting area. Access to the outlet was completely blocked by a fairly substantial couch which took two adults to move out of the way.

Surveyors also found a lead apron folded over on itself at an outpatient site, so that was finding two.

They also threw corridor storage into the mix (that was the nurse surveyor’s little crusade), so the three findings together ended up being a requirement for improvement under EC.1.10.

Goes back to the whole general duty clause aspect of EC.1.10–this becomes a haven for surveyor preference and interpretation. Havens to Betsy!

Check extinguisher safety near MRIs during fire drills

Last week, I mentioned the idea that fire extinguishers installed near MRI suites aren’t always MRI-safe.

As a quick follow-up to that discussion: If I happen to see ferrous extinguishers in areas immediately adjacent to an MRI suite, I always ask whether the organization has done fire drills in the area.

During those drills, I’d check to see if members of the response team show up with equipment that would not be safe in MRI rooms.

Train keeps a-rollin’ with EC activities

Well, I guess by now you are well and truly ensconced in the activities of the new year (ah, those holidays are but a distant memory). For many, thoughts are turning to the annual evaluation of the EC program. As you embark on this journey, I’d like to offer you a few words of encouragement and advice.

While the process of reviewing your EC management plans is an important activity, the plans function only as guidance documents for your program–an executive compliance summary of each function’s key components, if you will. Update ’em if you need to, absolutely, but what I’d ask you to do is to start focusing on what improvement opportunities might be lurking in them thar hills.

Ideally, you want your annual evaluation process to be the engine that drives your improvement activities in the coming year. Pull out those hazard surveillance rounds forms and pull ’em apart. Are they trying to tell us and show us that we have some processes that could use a little attention?

And for those occurrence reports that trickle through to your desk–I know there aren’t enough to be more than a trickle, right?–is there something there for the improving?

And what about those capital improvement projects that were approved for this fiscal year? If you had to demonstrate that those projects actually brought value to the organization, would you have data to support or refute such a finding?

The evaluation process should be about getting better. No stone should be unturned, no vital sign unassessed, no event unscrutinized. You and I both know that your organization’s care environment is not in perfect shape. You’re doing a good job, sure, but there are always opportunities.

Start digging now and enjoy the fruits of improvement when we speak of this next year (and we surely will).

MRI concerns aren’t new to us

The Joint Commission’s new Sentinel Event Alert about MRI safety isn’t all that new of a concern. Considering the severity of these incidents, I’ve been expecting this as an alert for quite some time.

The amount of MRI procedures has probably prompted the alert. It’s a high-volume, moderate-to-high-risk process to me.

I talk about MRI safety during mock readiness surveys. I sometimes note that the closest fire extinguishers to an MRI area are not MRI-safe items, which is a potential problem to watch for in your own house.