I always view with great interest the weekly missives coming from The Joint Commission’s various house organs, particularly when there’s stuff regarding the management of the physical environment. And one of the more potentially curious/scary “relationships” is that between the good folks in Chicago and the (I shan’t editorialize) folks at the Occupational Safety & Health Administration. They’ve had a nodding acquaintance over the years, but there is evidence in some quarters (I’ve seen a decided uptick in survey findings relating to hazardous materials and waste inventories—as we’ve noted before, a list of your Safety Data Sheets is not going to be enough on its own to satisfy a finding of compliance with the Hazard Communications standard), that concerns relative to occupational health and safety are becoming a target area during Joint Commission surveys.
At any rate, last week, buried in last Wednesday’s action-packed edition of Joint Commission Online, there was an item highlighting the OSHA updates of key hazards for investigators to focus on during healthcare inspections.
Now I can’t imagine that the list of key hazards would come as a surprise to anyone in the field (in case you were wondering, they are: musculoskeletal disorders (MSD) related to patient or resident handling; bloodborne pathogens; workplace violence; tuberculosis; and slips, trips and falls—surprise!), as these are pretty typically the most frequently experienced occupational risks in our industry. What remains to be seen, and what I suspect we need to be keeping in mind as the wars for accreditation supremacy continue, is whether this OSHA guidance translates across to TJC survey methods and practices (I don’t think TJC is as “beholden” to OSHA as they are to CMS, but who knows what the future may hold). That said, I don’t think it would be unwise or in any way inappropriate to shine as much “light” as possible on your organization’s efforts to manage these occupational risks. I’m guessing your most frequently experienced occupational illness and injury tallies are going to include at least two or three of the big five (I suspect that TB may be the least frequent for hospitals, though if you count unprotected/unanticipated exposures, the numbers might be a little higher). Perhaps (if you have not already done so) some performance indicators relating to the management of these risks (successful or unsuccessful) might be a worthwhile consideration as we continue through the EC/safety evaluation cycle (I know some of you are doing your evaluations based on the fiscal year cycle, of which many are wrapping as we speak). And remember, there’s no rule that says you can’t develop and implement new indicators mid-cycle. Take a good look at the numbers you have and figure out whether your organization is where it needs to be from a performance standpoint. If the numbers are good—it might behoove you to ask the question or whether that level of performance is the result of good design or good fortune (there’s nothing wrong with good fortune, though it does tend to be less reliable than good design). As with so many of our critical processes, the more we can hardwire compliance/good practice, the easier our jobs can be. Perhaps that’s an overly optimistic thought, but as I gaze out over Boston Harbor this morning, optimism doesn’t seem to be misplaced—optimism is good to have when flying!
This past week, my travels brought (or, more appropriately, returned) me to the environs of the New English, where I got to work a little out of my normal scope of practice: a health center setting. Now typically, as business occupancy settings, health center environments (I thought) tend to be a little less complicated than hospitals and ambulatory surgery centers, etc., but I learned last week that even business occupancies can experience the “bliss” of competing jurisdictions—oh, what fun!
So, typically using Chapter 38 (new) or 39 (existing) from NFPA 101 as my baseline expectation for compliance, we started the document review (this particular organization is looking at embarking upon Joint Commission accreditation). A couple of tweaky things in the fire alarm testing documentation, but nothing of great concern; some tweaks relative to some utility systems testing, but again, nothing major. Then we started looking at the documentation of fire inspection reports and I ran into a somewhat unanticipated condition: the local fire inspector was using the state fire code (in this case, Massachusetts), which is based primarily on NFPA 1 Fire Code. I will freely admit that my familiarity with NFPA 1 as a specific document is rather limited, but I was able to make use of NFPA’s free access to important codes and standards through its online portal. Interestingly enough, there are a lot of common threads between 1 and 101, but for those of you with business occupancies separate from your main campus, it might behoove you to acquaint yourself with some of the basics, particularly if your state fire code is based on NFPA 1 (if I was good, I’d figure out which states those were—maybe another time).
Anyhoo, where things got kind of interesting was that the regional authority having jurisdiction for this particular organization was the state Department of Public Safety (DPS), who it appears are using NFPA 101 as their consensus standard for life safety. This organization is in what I will call a reclaimed warehouse (circa early 1900s), where things like egress may have been considered, but not to the degree in present day. The basement level is more than one-half story below the level of exit discharge (actually, the stairwell goes two levels below the level of exit discharge), so the DPS inspector told them they have to install a gate in each of two stairwells to prevent folks from heading down past the level of discharge. I think you’re probably familiar with that condition. Well, when the local inspector saw the gates, he cited the organization for obstructing egress (I looked at the area where the gates were installed and they were well out of the way of the egress route, but close enough to prompt departure from the stairwell). Now, I did look in NFPA 1 and cross-referenced it to the state fire code (there are certain elements of NFPA 1 that the state code does not adopt, but this wasn’t one of them) and the allowance (actually, I guess it is really a requirement) for the gates in the stairwells is clearly indicated in this particular situation. I encouraged the plant ops director to try and figure out a solution in coordination with the local guy when he returns for his re-inspection. I suspect (hope) that this was just an interpretation based on a partial familiarity with the code in question (that’s never happened before, has it?) and that all will end well. I’ll keep you posted if I hear anything.
As it happens, I like to share topics and concerns that I encounter while engaged in consulting activities in many of the nooks and crannies of these United States, and I’ve recently run into a common theme that I think warrants your consideration, if not action (though it may ultimately come to just that). But it does appear that this particular vulnerability has reared its shaggy head because of an improving condition relative to infection control concerns—I guess there really is a dark cloud to go with every silver lining.
Over the years, hospitals have been struggling with the management of Clostridium difficile, a very pesky germ typically identified by its street name: C. diff. And one of the key struggles therein revolves around the cleaning of the environment of patients with C. diff, for which the CDC recommends the use of an EPA-approved spore-killing disinfectant in rooms where C. diff patients are treated. And one of the more common (probably most common, but I can’t say that I’ve collected a ton of data in this regard, so this is merely an impression; feel free to validate or not) products used is one euphemistically known as the “yellow top” disinfectant wipes (I’m sure you’ve seen them, but if you’re not sure, you can find images, etc., here).
At any rate, over the past couple of weeks, I have run into a fair number of expired containers of these disinfectant wipes, enough so that it really kind of jumped out at me (and this has been the case in different parts of the country: north, south, east, and west). Inevitably, when one finds a confluence of vulnerabilities, it tends to become a topic of conversation at the various organizations in which the expired products were found (it’s always nice to be able to make some sort of determination relative to a root cause). And the results of those conversations of late leads me to the (completely unscientific) conclusion that hospitals and other healthcare organizations appear to be making some inroads in the management of C. diff patients, resulting in a reduced need for this particular product (uniformly, this product has been earmarked solely for use in cleaning C. diff patient environments, and not much else). Hence, the increased number of expired containers of this product.
So, good news on the management of C. diff patients and their environment, and the identification of an opportunity relative to the management of product expirations. I suppose you could make the case that it is ever thus when it comes to the management of conditions in the physical environment, but if your organization is using this particular product (or, I suppose, whichever disinfectant wipes you’re using for C. diff patients), you may want to issue an APB to ensure that folks are keeping an eye on those expiration dates. Yes, I know that they are, but this could legitimately be described as a recent development…just trying to keep you ahead of the curve.
Now that we have almost reached the summer solstice, I guess it’s time to start thinking/talking about 2016 and what it might bring from an accreditation perspective—it will be here almost before we know it (time flies when you’re having fun—and we’re having too much fun, are we not?)
One of the developments that I am watching with a bit of interest (if only because it is not at all clear how this is going to be administered in the field) is the next step in the clinical alarm National Patient Safety Goal (for those of you keeping score, that’s NPSG.06.01.01 if you need to find it in your accreditation manual—and I’m sure you’re sleeping with that under your pillow…). Presumably at this point, you have covered the elements that are in full surveyability—establishment of alarm system safety as an organizational priority (pretty simple, that one) and identification of the most important alarm signals based on:
- input from medical staff and clinical departments (Have you got documentation for that?)
- risk to patients if the alarm signal is not attended or if it malfunctions
- whether specific alarm signals are needed or unnecessarily contribute to alarm noise and alarm fatigue
- potential for patient harm based on internal incident history
- published best practices and guidelines (Can you say AAMI and ECRI? Sure you can!)
Everyone out there in radioland should have this much of the package in place. Now, it’s time to do something with that process.
Starting January 1, 2016, each organization is on the hook for establishing policies and procedures for managing the alarms identified through the process noted above. The policies/procedures need to address elements such as clinically appropriate settings for alarm signals, when the alarms can be disabled; setting, changing and management of alarm parameters; monitoring and responding to alarm signals, etc. And, of course, we need to education staff and LIPs about the purpose and proper operation of alarm systems for which they are responsible (that’s a pretty good swath of education, I’m thinking).
At any rate, I’m curious about a couple of things—how are you folks coming with this process? And while I understand the importance of the safe use of clinical alarms, how much of a deal is this really? I completely recognize that in the zero tolerance world of healthcare in the 21st century, one event that traces back to an issue with the appropriate use, etc. of a clinical alarm is one too many events, particularly as a function of patient safety. Perhaps the question should be this: has mandating this process resulted in your hospital being safer? I know this is a “have to,” though there is certainly enough gray to allow for some customization of approach (I suspect that a cookie cutter approach is not the best strategy—too many different alarms in too many different environments), what’s this going to look like in the hands of our friends from Chicago when they darken our collective doors. If anyone has some feedback on how this is playing during survey, that would be wonderful, even if you just share the story with me (I’ll remove any identifying remarks), I (and the blogosphere) would be forever in your debt.
Happy Flag Week (it hardly seems reasonable to hold it to just a day)!
One of the benefits of doing a lot of traveling and having a fairly well-developed case of OCD is having plenty of time to ponder ponderables and imponderables (I think it may be more fun than it sounds, but there are days when I’m not at all sure). At any rate, one of the things I’ve been tossing around in my head is the whole deal with the testing of defibrillators, particularly in areas that are not open 24/7. I suspect that, in most, if not all, instances, defibrillators are considered to be in the high-risk/life support category (I don’t think I’ve run into anyone that is managing them otherwise), so the question becomes this: in light of the Joint Commission performance elements indicating that high-risk/life support equipment is to be maintained in accordance with the Original Equipment Manufacturer (OEM) recommendations, if you have defibrillators in your inventory that require daily user testing (or some similarly constructed variation) and have those defibrillators in areas that are not open 24/7, how are you ensuring compliance relative to the OEM recommendations? I know of at least one hospital (which shall remain nameless) that does the user test on a once-monthly basis and I am curious as to how that might play out during a survey. Minimally, I think it would be a good idea to review the defibrillators you have in the inventory and see if there are any funky requirements/recommendations beyond the traditional preventive maintenance cycles. And please include the blogosphere when you figure out what you have; my fear is that this could become a means of generating more unpleasant findings during surveys if we don’t get out ahead of this thing. High risk and life support combine to make a very scary survey scenario in my mind’s eye (can you say immediate jeopardy?) and in the hands of a by-the-book, pain in the keister surveyor (not that there are any of those)…
This year has brought a lot of CMS work this year, both in preparation for impending visits and in response to endured visits. There’s just nothing particularly pleasant about the process, but I guess there’s naught that can be done for it.
One of the interesting, and extra not-pleasant developments in this realm is the use of the Plan for Improvement (PFI) process during CMS surveys to bludgeon facilities professionals into pretty much abandoning any pretense of being able to plan/prioritize the resolution of existing Life Safety Code® (LSC) deficiencies. As I think we’ve discussed, one of the changes in the Joint Commission final report is that (if your surveyor remembers to accept them) it includes a listing of all your PFIs, which gives the CMS LSC surveyors a ready-made starting point for their report (CMS has really never bought in to the whole PFI process for managing LSC deficiencies, which is very unfortunate). Recently, I worked with a client who had to complete all their damper repairs that were being managed through the PFI process and I started thinking about a number of folks who are managing their inaccessible dampers, etc., through the PFI process and then I start thinking, “Wouldn’t that suck a ton of eggs if the PFI report becomes a roadmap for CMS to have their way with folks?”
I guess this is all part of having to deal with the various authorities having jurisdiction (AHJ) and while I suppose not every AHJ is going to be prickly about this stuff, I am reasonably certain that there are those would who be more than happy to give folks a good regulatory thumping. We are in a time of great uncertainty and chaos as we are held to standards that are increasingly best noted as antiquities. But until we can get can somehow suborn a more rapid cycle of code/standard adoption, I guess we’re just going to have to spend far too much time and energy on things other than taking care of our patients.
Last week, I had the opportunity to make a presentation to some members of the Colorado Hospital Association (Many thanks to everyone who attended. It was a great pleasure having the opportunity. You guys rocked!) regarding the whole Physical Environment/Environment of Care focus during regulatory surveys of late. One of the items we discussed was the issue of The Joint Commission’s exhortation of folks to review/revise their smoking policy(s) in light of recent technological innovations in the realm of nicotine delivery systems and how to account for the risks associated therewith.
What I hadn’t planned on was a turn in the conversation towards the legalization of marijuana in Colorado and having to deal with that set of risks (I’m thinking snack sales in the hospital gift shops may get a wee bit of a boost) from a smoking policy perspective. Upon further thought (as I tend to do), while I was bicycling this morning the thought occurred to me that there’s potentially a whole host of risks associated with occupational safety, particularly as a function of impaired employees. We didn’t really talk about this piece of the puzzle last week, but I would assume (and yes, I know exactly what happens when one assumes) that you have to “run” with a general prohibition on consumption during work hours, much akin to a general prohibition of alcohol consumption during work hours. At any rate, I was wondering if any folks out there in radioland had given this much thought and whether anyone is prepared to share any nifty thoughts or plans they might have. I have a sneaking suspicion that as the movement to legalize cannabis gains momentum, this may figure in the future (maybe not so prominently—could be no big deal). Is anybody trying to get out in front on this?
Thanks again to the Colorado Hospital Association for last week’s presentation and for planting the seed for this blog entry (small pun intended).
In full recognition that the Internet (including, I daresay, this august space) is a constant barrage of information (okay, information may be a more generous descriptor than some of the Web is entitled to, but…), every once in a while something comes flying through the ether that captures my thoughts and/or imagination (next week I’m going to share with you the latest in fire suppression techniques) and I feel inclined (I never want to think of this as an obligation) to share with you.
Now, some of you may be “old” enough to have experienced the time when Dwight David Eisenhower was president of these United States (as opposed to the “other” United States) and while he is famous for having facilitated the creation of a lot of far-reaching programs (the interstate highway system and NASA, to name but two), there was one productivity initiative that bears his name: the Eisenhower box. This derives from Eisenhower’s observation that “what is important is seldom urgent and what is urgent is seldom important.” I think I was generally familiar with the quote, though I can’t say that I’d ever seen it attributed to him.
At any rate, yesterday’s Flipboard email brought with it (among other things—Flipboard is a very interesting app and provides kind of off-the beaten-path content) an article from the Huffington Post outlining the Eisenhower box concept. I can’t provide the image in this space, so I encourage you to give it a look-see. The “box” is pretty much a 2 x 2 matrix outlining four possible actions—do, decide, delegate, delete—based on the important/not important, urgent/not urgent metric. For those of you in the studio audience with operational responsibilities, I can see where this might be a very useful tool for sorting through the flood of information that is your “day” (and I can’t think of too many folks who are in the position of having to manage the exact right amount of information and tasks every day). So I’d ask you to give a whirl and let the rest of this community know if it helped at all.
Over time, I’ve developed certain thoughts relative to the management of the survey process, one of which relates to the ever-changing (maybe evolution, maybe mutation) regulatory survey process and I think it boils down to a couple of basic expectations (at least on my part):
- You always run the risk of having a surveyor disagree with any (and every) decision you’ve ever made relative to the operational management of risk, particularly as a function of standards-based compliance
- Your (or indeed any) Authority Having Jurisdiction always reserves the right to disagree with anything they, or anyone else, has ever told you was “okay” to put into place (and this includes plan review for new or renovated spaces)
Recent survey experiences are littered with the remains of practices and conditions that were never cited in the past, but in the latest go-round have become representative of a substandard approach to managing whatever risk might be in question. For example, just consider how the survey of the surgical environment has changed (and changed very rapidly, if you ask me) from what was typically a fairly non-impactful experience (there were any number of instances in which the Life Safety surveyor didn’t even dress out to go into the OR proper) to the area generating the top three most frequently cited standards during TJC surveys in 2014. That, my friends, is a whole lot of schwing in the survey process.
The bottom line message is, more or less, based on the adage “Future expectations are not necessarily indicative of past experiences.” You have to look at everything you are doing as a function of how your practices/conditions actually comply with the standards. Just as there are many ways to skin the proverbial catfish (skinning a catfish makes more sense to me in this modern era than skinning a feline), there are many ways to comply with what are typically rather open-ended compliance standards. As long as you can “trace” the practice or condition back to compliance with the standards/performance elements, then, even if you have a surveyor who disagrees with your approach to things, you can feel comfortable that you can “go to the mat” post-survey, using the clarification process to demonstrate how your organization achieves compliance relative to the finding. As a somewhat related aside, it is important to remember that you are only required to respond to what is actually written in the finding. Very often I run into folks who want to respond to more than what is actually in the report, usually because they remember what the surveyor “said” during the survey. Surveyors, like everyone, have opinions about how and what and where, etc., and they certainly have every right to hold those opinions (sometimes in higher regard than is warranted, but I digress). Opinions are rarely based on an absolute standards-based requirement. So, the tip-off comes in different forms: Maybe they say you “should” do something in a certain way or something similarly non-definitive. They typically stay away from things that you “must” or “have to” do. You “have to” comply with the standards and you “have to” comply with your organization’s policies and procedures, but beyond those points, you have to chart your course of compliance. You know best what will work to effectively ensure that you have an appropriately managed care environment (and, presumably, the performance data to back up that knowledge).
While I would never want to be accused of overusing my little bully pulpit, I did want to bend your ears a bit by way of encouraging you to really consider signing on for next week’s webinar, Surgical Environment Compliance: Meet CMS and Joint Commission Requirements. The program is on Friday, May 8 @ 1 p.m. EDT (you can register here). Plus (and this may really sweeten the pot), I’m not the only speaker, so you won’t have to listen to me yap for the whole program. Sounds like a win to me…
To catch up a bit, I haven’t yet given you a rundown on the most frequently standards during TJC surveys in 2014 as there were some other pretty compelling topics (at least in my mind)—mostly because the year-end tally looked so very much like the mid-term results I figured the sense of urgency might not be quite as acute as it could be. But an interesting thing is happening in 2015 and it keys very much on the top three most-cited standards: EC.02.06.01, EC.02.05.01, and IC.02.02.01, all of which figure in the management of environmental conditions in (you guessed it!) in surgery (and other procedural areas). By the way, as a quick aside, who would ever have guessed that the EC-related standard to go to #1 on the charts wouldn’t have been Integrity of Egress (LS.02.01.20), which sits at a lowly #4. It’s almost like a boy band past its sell-by date, but I digress.
TJC is still looking at the issues related to the surgical/procedural environment and, doggone it, they’re still finding stuff that’s getting folks into trouble (that is, if you think, as I do, that having to endure a second visit from the Joint is rather more troublesome than not). I won’t tell you that I have a magic bullet for this, but my colleague Jorge Sosa and I will be discussing how this issue fits into the grand scheme of things as well as hopefully helping identify the potential pitfalls. And, perhaps most useful of all, you’ll have the opportunity to ask questions that may be the difference between sailing through your next survey or getting hung up because one portal in your OR isn’t pressurized in the right direction (and believe me, it happens way more than you probably think). Lots of stuff to consider and the time and place to consider it.
Be there or be somewhere else that won’t be nearly as entertaining (unless you’re not at work…)