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Tired of waiting for a Joint Commission survey?

Well, up here in the Northeast, there’s a wee hint of fall in the air, and a not-so-young man’s fancy turns to thoughts of what’s in store in the closing months of the year and the opening of the 2008 unannounced survey season (which I suspect is the last year that we can depend on our survey “years” actually being a 12-month timeframe).

As I look around the healthcare safety world, I sense the stirrings of a couple of different “emotions”:

  1. Impatience by those organizations that have not yet been surveyed this year (those of you who have already received your visitors, I would have to count you as being luckier than those playing the waiting game)
  2. Concern by those organizations for whom the window opens on January 2, 2008, or thereabouts (though we’re not in panic mode, yet)

For both groups, this past Monday amounted to something of a line of demarcation. Even with some leeway on the calendar, summer is pretty much over, and so it’s time to ratchet things up-the British are coming, the British are coming!

Some folks are looking at three months to get things going in the right direction, while others know with a certainty that their survey window is closing little by little and every day the survey looms a little larger.

For the 2008 group, if you have not done so in the past six months or so, I would encourage you to conduct as comprehensive an assessment of your safety program as possible. If you have issues at the moment, you’re going to have a most difficult time establishing a reasonable track record, so best to jump on it now.

If you will, conduct a mini-periodic performance review of your organization’s compliance at the EP level – dot every “i” cross every “t.”

For the 2007 folks, my sympathies, for I’ve been working with a couple of clients who are expecting their Joint Commission visit any day now and have been since this past January. I’ve experienced the “ramp up” of intensity each week until the first day of the week passes (Mondays for the organizations with 5-day surveys; Tuesday for the 4-days, etc.), and then everyone breathes a collective sigh of relief when the surveyors don’t come that week.

This roller coaster may well be the most challenging survey “risk” to manage, at least for the first time out. Afterwards, it’s all constant readiness, right? Right! And, as I’ve said any number of times, the Joint looks much better in the rearview mirror as you drive away!

By the authority granted to me…

An item that I’ve been encountering a more frequently of late revolves around the charge-or perhaps, more appropriately, the authority-of the safety officer or, indeed, the safety committee.

Now EC.1.10, EP #3, requires each organization to identify a “person(s) to intervene whenever conditions immediately threaten life or health or threaten damage to equipment or buildings.”

That’s pretty heady stuff, which leads me to a couple of questions for all you reading to think about:

  • How comfortable are you, as a safety professional, with the extremes of this interventionary authority? How “immediate” would the threat need to be before you felt comfortable with stopping work, sending someone home, etc.?
  • How much support would your boss give you if you played this card?
  • Have you ever had to invoke this authority?

Let’s talk more about this next time.

Steve Mac.

Watch for the subtleties of the EC standards

Another trend I’ve noticed is a failure mode relative to the familiarity of frontline staff with the expectations and requirements outlined in the standards and EPs.

I recently worked with a client that ran afoul of the new requirements under EC.7.40 for a four-hour generator test. The client had, in fact, operated the generator in question for a period well in excess of four hours, but had failed to provide acceptable documentation to the surveyors. This left the facility in the position of conducting the four-hour test again, which they did.

Ahh, but here’s where things got a little bit off track. In reviewing the documentation, I noted that for the first hour of the test, the generator did not meet 30% of its nameplate rating. When asked, the individual responsible for the testing responded, “we averaged 30% for the four hours, but it took us a bit to get up to where we needed to be.”

The element of performance in question, however, requires a test at 30% for four continuous hours, a subtle difference to be sure. But it was a difference that required them to conduct yet another generator test.

Risk assessments and Swiss Army knives

Here’s a quick word, of no doubt many to come, about risk assessments.

If you have a condition, regardless of its nature, that requires something of a formal invocation of the risk assessment process, I cannot advise more strongly that you periodically take the assessment out and look at it.

Yes, I know that The Joint Commission standards do not indicate a recurring frequency for risk assessments (though that is changing – check out the revised emergency management standards). However, as a safety professional, do you really believe that a single risk assessment lasts forever? I didn’t think so.

I can tell you with something approaching certainty that the conditions you assess today (or assessed two years ago) are not static. Your patient population is likely to go through incremental, if not dramatic, changes in diagnosis, acuity, etc.

For example, my primary base of practice is in Massachusetts, and I can tell you that as the municipal system for managing behavioral health patients has evolved (though “devolved” is probably the more appropriate descriptor), the challenges facing community hospitals has changed dramatically. Keeping patients and staff safe is not a one-time proposition.

First use the risk assessment process to identify improvement opportunities for your EC program. Then, use the data collected in the wake of interventions to drive your annual EC evaluations. There is not a risk or practical application for which you could not employ the risk assessment. The risk assessment acts as a veritable Swiss Army knife for the safety professional.

Steve Mac.

Don’t use a safety solution’s expense as an excuse to delay implementation

Last time I checked in, I mentioned the need to review your environment of care committee’s meeting minutes to make sure past concerns had been acted upon.

Here’s another suggestion when it comes to your EC paperwork: Make sure that your reports and other documents accurately reflect an appropriate management of issues. For example, say you’ve completed a risk assessment of your outpatient behavioral health unit of the potential for suicide. You’ve identified some quick fixes, some staff educational concerns, etc., but there are a couple of items that are going to have to wait until funding is available.

Please, please, please make sure (and I only mention this because I saw this scenario with my own two eyes) that you do not somehow characterize the decision as having been solely the result of an expense level.

Yes, it is absolutely acceptable to include the financial impact of any intervention as part of the debate–in fact, it is the responsible thing to do. However, you have to stipulate that any choice to hold off on an improvement is not being done at the expense of patient safety. You can never place a high enough price tag on patient safety.

If you identify an action or idea that needs to be improvement, you can (and should) prioritize its implementation, but you must also give equal time to what interim measures you are employ until such time as you can effectively remedy a problem. If you have an identified risk, you do not have the luxury of waiting to do anything. There’s always some incremental measure that can be used as a stop-gap instead of merely saying, “We don’t have the funds to carry this solution out.”

Steve Mac.

There’s gold in them thar minutes

Howdy folks,

I’ve been doing a fair amount of post-survey work with hospitals this year, and I can tell you that the stories you’ve heard about the environment of care being subject to a lot of attention are absolutely on the up and up.

And you know what? The focus isn’t necessarily the result of the life safety surveyor. Everybody on the survey team is looking very closely at the EOC.

I have noted a couple of trends that I’d like to share with you. Hopefully they will help keep you out of hot survey waters.

Let’s start with safety committee meeting minutes.

My personal practice has been to periodically go back (at least once a year, though I like every six months or so) and review your EOC committee minutes — including those reports that maybe didn’t get covered in full during the regular meeting.

A key point is to verify that you don’t have any unresolved issues lurking around in the past (before they take on the rosy hue of nostalgia).

Make sure that any interventions resulted in the improvements you were expecting, and confirm any monitoring of performance did in fact occur. Also, check that there are no issues for which action was deferred until a later date (that later date is probably in the past) without any further resolution.

The review of your committee minutes is designed to ensure that you have a process for making improvements in the environment. Don’t let that review be an opportunity for surveyors to point out where those improvements didn’t occur.

I’ll have more to say about this topic later this week.

Steve Mac.

Getting back to whether surveyors are always correct

Since I sort of went off on a tangent in my last posting, I neglected to come right out and answer the question of whether surveyors are always correct. The answer to which is, of course, a great big fat NO.

Let’s back up and trace what happens: A surveyor will see something at an organization that he or she really likes, for whatever reason. Maybe it’s something different, nifty, or simple. The surveyor asks for a copy of the policy, form, etc., and then–flash, bam, alakazam–that form becomes the “standard” for that particular surveyor.

Just now, as I was penning this missive, I received an e-mail from a survey coordinator feeling the hot, fetid breath of a surveyor on his neck. The issue? The organization couldn’t document performance and safety testing of medical equipment between patient uses. Crikey–that’s some standard!

Just step back for a moment and consider EC.6.20, element of performance #2, which states that the “hospital documents performance and safety testing of all equipment identified in the equipment management program before initial use.”

It appears the surveyor in question has extrapolated “before initial use” to equate with “before initial use on each patient.” Can you imagine how big your clinical engineering staff would have to be to meet this mandate? How could you possible capture every single piece of equipment in the program, like infusion pumps and blood pressure devices? Can you imagine the chaos? In a flash, why you’d probably need to have as many clinical engineering techs as nurses. Ouch!

You need to have a very clear sense of what makes the mark and what doesn’t. There are surveyors who are fond of the devil’s advocate question, just to see how comfortable you are with your process. If they cite something out in the environment that is clearly not compliant, you can certainly take your lumps.

But if surveyors start chasing you about “how” you are doing things, then keep all your options open, such as:

  • Special resolution time with that particular surveyor or with the team leader
  • Red-flagging the citation for review at Joint Commission headquarters
  • Making full use of the clarification process post-survey

Don’t make the error in thinking that because you are not perfect, you are thus not in compliance with a standard. A lot of the elements of performance are rate-based, but surveyors only need to find three instances of noncompliance with any “C” element to issue a requirement for improvement. For “C” elements, if your compliance level is greater than 90%, then you are considered compliant; you don’t have to be perfect.

I can tell you from personal experience, there are few things more frustrating than trying to “fix” something that is not truly broken. You’ve got more than enough to do–don’t go looking for more work (last clich

Are the surveyors always correct?

In looking over various survey results from the past six months or so, I keep running into instances in which the surveyors either:

  • Over-interpreted a standard, usually in the form of requiring a process that is not specifically called for in the standard or,
  • On at least one occasion, the surveyor “ignored” (I use quotation fingers for this as I wouldn’t want to unjustly accuse anyone of ignorance) instructions given to them by The Joint Commission

A close review of the standards reveals a fairly limited number of prescriptive standards–including annual program evaluations, the frequencies for the various life safety equipment inspections, hazard surveillance rounds, and so on.

The rest of the elements o performance involve such matters as:

  • “The hospital ensures that a process exists . . .”
  • “The hospital controls access to and egress from . . .”
  • The all-purpose “The hospital identifies and implements ________ procedures”

Thus, it’s up to you, as the person designated by leadership to oversee safety, to decide what “ensures,” “controls,” and “identifies and implements” mean for your organization.

I have a number of sayings that, if truth be told, are probably as much clich