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I heard the bells! Or did I see three ships?

Yet another mixed bag of festive goodies for you this week: I know you’ve all been good (our profession doesn’t really leave a lot of room for anything other than good, so Santa Mac doesn’t even need to make a list and check it once or twice).

First up, a set of HazMat-related items for your consideration:

I’m not sure how many of you folks are still managing ethylene oxide sterilization systems, but it does appear that there’s a movement afoot (or a continuation of an existing movement) to really pare back on the use of ethylene oxide. At present, the proposed rule seems to be aimed at folks using larger quantities of ethylene oxide (more than 1 ton of ethylene oxide per year), but I suspect that the next pass may well start to push down through the smaller-scale users. To that end, the information on the EPA website is probably worth looking at to determine where your current processes and equipment might fall on that continuum. I don’t know any safety professional who is keen to have the stuff in their “house”, but there remains reusable medical equipment that can only be appropriately sterilized (per manufacturer Instructions For Use) with ethylene oxide, so hopefully things will catch up and we can move past this risk.

Next up, an interesting article on increasing climate friendliness in your surgical procedure rooms. I guess anything that can reduce energy costs is worth investigating, though it may work better for those of you planning renovations or new construction of surgical procedure rooms. At any rate, I find that it’s always kind of interesting to see what’s working for folks (recognizing the importance of knowing what doesn’t work as well), so a tale from the land of the New English.

Extending the renovation/construction thought, Becker’s Hospital Review recently published an article discussing healthcare facility construction trends to watch in 2020. I suspect that Becker’s is something that might be on the reading list of the folks in the C-Suite, so it might be worth working their take on construction into your pleas for resources. It certainly can’t hurt.

Finally (I haven’t decided if I’m going to have anything for you next week—I’d rather you enjoy your families), I wanted to share a link to a blog by Peter Martin of Gosselin-Martin Associates that shares some quotes and insights gathered over the last year (and a fitting jumping off point for the (hopefully) next roaring ’20s). If you’re not familiar with Peter and Gosselin-Martin, I would encourage you to do a little checking of the additional blog entries as well as the services they provide. I’ve corresponded fairly often with Peter over the years and I’ve found him to be a consummate professional and a very thoughtful guy—an excellent resource to be sure.

On that note, I will extend my best wishes to each and every one of you for a joyous holiday and that “roaring” start to the ’20s mentioned earlier. Be safe (not that you need me to tell you that) and I’ll be back in almost no time flat!

’Twas the week before Christmas and all through the…

Do you ever find yourself at the end of the year with a list of random items that you just never got to? It’s not that they weren’t (or, indeed, aren’t) important, but somehow…

At any rate, in looking at my box of blog ideas, I found a bunch of stuff relating to emergency power concerns and considerations, so figured an e-power bundle of bloggy goodness is in order. As always, when it comes to the topic of emergency power, I have to tip the safety hat to Dan Chisholm, Sr. and Danny Chisholm of the Motor & Generator Institute for doing such a great job of covering the world of emergency power. Particularly in a time where healthcare employees have been charged with manslaughter after the death of 14 patients during Hurricane Irma (story here), the degree of scrutiny accorded to emergency power inspection, testing and maintenance is likely to continue apace and the Motor & Generator Institute, at least in my mind, is a must-read.

Some of the topics you’ll find (check out MGI’s blog) if you hop over for some end of the year reading are:

  • Confusion on the part of surveyors relating to the interpretation of NFPA 110 and citations resulting from folks not properly “inspecting” their automatic transfer switches and Dan Chisholm Sr.’s proposal to the NFPA 110 technical committee to help reduce that confusion: Find more info here and here.
  • Remember all those findings relating to compliance with the whole emergency generator shutoff buttons outside of the generator space (which vanished from the Joint Commission standards as a specific, but lives on in the hearts of virtually no one)? If you don’t, there’s been some movement (including hope for a brighter future state of compliance) on that front. Check it out here.

Finally for this missive, there are few more critical times in the life of a facility than the period of recovery following natural disasters; and sometimes a checklist can be helpful.

I’ll have something for you next week, but on the off chance that your holiday includes minimal consideration of work-related stuff, please accept my best wishes to you and yours for a most joyous holiday of your choosing and a productive and prosperous 2020!

Do you still BBI? Also, how do you spell survey finding?


While I am not convinced it every truly went away, next month marks the official return of one of the most (in)famous acronyms in surveydom: BBI, which we all know stands for Basic Building Information (details can be found here). So, for those of you for whom survey is imminent, you might (if you have not already done so) want to hop on to your online Statement of Conditions portal to make sure that all your information is up to date, all required responses are in place, etc. Since this is nominally a “new” requirement, I think it best to presume that the Life Safety surveyors are going to be reviewing the contents, so you want to make sure you have a good read on your square footage numbers and all the rest of it. I don’t see this representing a particularly great risk of survey exposure, but I’d hate to see somebody out there in the audience to get tapped for something so simple.

In other news (and I would consider this more troubling in the long term), back in September, the updates to some of the Environment of Care performance elements for office-based surgery practices were published (details here). While the updates relate mostly to invocation of the 2012 edition of the Life Safety Code® and the applicable reference documents, it also (and this may me being a touch paranoid—’tis always the season) may be indicative of a shift in focus for what documentation might be requested for care locations that are nominally business occupancies. I have definitely seen this (though I wouldn’t yet call it a trend, though it’s getting there) in state surveys of larger healthcare organizations, so it may just be a matter of time before evidence of compliance is requested for all the various life safety systems in place at your offsite locations (remembering that this does not mandate the presence of fire alarm systems, sprinkler systems, etc.—it only requires you to appropriately maintain any existing systems).

On a final note for this week, it would seem that some folks are using their work order system to provide evidence of scheduled activities like monthly testing/inspections of battery-powered lights, exit signs, task lighting, etc., and I just wanted to let you know that in the absence of an inventory of devices by location, there are some surveyors (and perhaps even more than just some surveyors) that will not accept a completed/closed out work order as evidence of compliance for these activities. Recognizing that the standards-based requirement for the “inventory” (in all its glory) has not specifically been extended to utility systems equipment (though I have anticipated that extension for a while), I think it may be time to start including the same level of detail as required for life safety systems inspection, testing and maintenance activities:

  • Name of the activity
  • Date of the activity
  • Inventory of devices, equipment, or other items
  • Required frequency of the activity
  • Name and contact information, including affiliation, of the person who performed the activity
  • NFPA standard(s) referenced for the activity
  • Results of the activity

I suppose to a fair degree it makes sense for inspection, testing, and maintenance documentation to have a standard format and it certainly helps to establish compliance in a fashion that is recognizable to surveyors. I guess we’ll just have to keep a watchful eye on this one…

It appears that everything isn’t meant to be OK…

You may recall a few weeks back we were discussing some recent survey findings relative to the placement of eyewash stations once one has determined that one needs an eyewash station (or stations). At the time, my dream was to clarify those findings and have them vanish into the ether (which is pretty much where they belong). But alas, that dream crashed upon the rocks of an overreach—can’t say for sure if this signals a sea change or is based on a reluctance to overturn a judgement call in the field. The ruling from the home office read thusly (but not justly): “The organization must do a risk assessment to determine if substances that may be in the sink would not splash onto the person using the eyewash station and inadvertently be contaminated.”

And so, I guess we add an additional imponderable to the equation: How do we install the eyewash station close enough to the area of greatest risk without placing the eyewash in a location that could be adjudged to be too close to the risk area? I suppose the ultimate goal would be to try to remove the hazard entirely, but with all the focus on disinfection and the likelihood that whatever disinfectant in use is going to be firmly in the high-risk zone, that seems unlikely to win favor during survey. Is it possible to “sell” engineering controls to a surveyor that is looking to find things to cite? I think we can all agree that the use of PPE and other forms of engineering controls are probably never going to be the interventions we would hope for them to be, but it is often so difficult to protect folks from themselves.

That said, I suppose it wouldn’t be the worst idea to do a little global evaluation of your eyewash station locations (much like a conjunction function) and add yet another risk assessment to the mix. If you’ve got a survey coming up in the near future, it may save you some aggravation.


Thank you for being round pegs in a square world…

As this is a somewhat shortened week (in complete recognition that safety never takes a holiday), I just wanted to briefly touch base to thank you all for hanging out (and hanging through) the various twists and turns of the last decade or so. Sometimes being the safety “cop” can be a frustrating endeavor, but this week I’d like to (and I’d like you to do so as well) focus on the folks I encounter who “get it right” all day, every day. That’s not to say that I’ve run into any perfect organizations (and I will count myself among the imperfectionists), but there are those (and I count you all among that number) who understand that the process of improving the safety of an organization is not so much about yesterday as it is about tomorrow (and the next day) and the commitment to those tomorrows is what sets us apart from (and sometimes in opposition to) other folks. It takes a unique set of skills to embrace all that is safety in healthcare (and elsewhere) and I am proud to be able to provide some level of service to your cause.

At any rate, please accept my sincerest wishes to you and your families for a most joyous Thanksgiving—and an enormously safe Friday after for those of you about to shop—I salute you!

More safety goodness next week!

Well that stinks! Or maybe it doesn’t…

I guess we can file this under the “You never know what’s going to pique someone’s interest” category.

In last week’s Joint Commission E-Alert publication, there is a featured set of links to an updated FAQ regarding “Aromatherapy & Essential Oils” (for example, this one). When I first saw it, I was thinking that maybe it was going to discuss some of the intricacies of dealing with all this smelly stuff that seems to crop up in offices and other spaces (everywhere looks like a good place for a stick-up). But when I clicked through the link, I found the question revolved around whether or not aromatherapy and/or essential oils needed to be managed as medications. As usual, the response was “it depends” (admittedly, that is a very much shortened version of their response, but please feel free to click through to embrace the majesty of this FAQ), with the slightly more involved response being “it depends on how you’re using it.” I have to say that I am not typically a fan of a lot of these scents; some of the them just seem like iffy attempts at covering other odors and some of them just seem wrong, but I digress. I know there are (perhaps more than) a few organizations that have adopted a fragrance-neutral/fragrance-free environment (these days, you just don’t know how someone is going to react to various scent-sations—allergies abound), but I can definitely see some folks interpreting this as something of an endorsement of using scents as a strategic intervention.

In other news, TJC also announced the publication of a new book of safety lists, which (based on my past experiences with their book products), may or may not be the answer to your sticky challenges (I pretty much live in the “not” camp, but someone wants to try and convince me that we have a winner, I’m game). Alternatively, you might consider the 2019 edition of the HCPro Hospital Safety Trainer Toolbox, which promises so much more than a bunch of checklists. I personally kind of ebb and flow on the whole concept of checklists, primarily because I find they try to do too much (or perhaps promise too much is the more appropriate descriptor). I see those checklists that go on and on for pages and pages and I’m thinking how in (insert deity of choice)’s name do you operationalize something that big? To that point, I am often asked what I look for when I’m doing consultant survey work and my (admittedly somewhat glib) response is that I don’t look for anything in particular, but rather I look at everything. I suspect it goes back to my EVS days when I looked at things from top to bottom in a (more or less) circular fashion—pretty much looking for stuff that didn’t look right (it is very rare indeed that I find an instance of noncompliance that looks “right,” if you know what I mean). The corollary to that is that a surveyor (and I count myself among that august assemblage) is never more dangerous than when they are standing still—that’s when the little funky detail stuff comes into focus. All the divots, loaded sprinkler heads, dust animals (bunnies, dinosaurs, the lot), become more visible. A moving surveyor (unlike the moving finger…) is a very good thing!

Ready, Set, ICRA!

One of the more frequently recurring questions/concerns/vulnerabilities in my travels relates to when it is appropriate to do a (and I will use this term collectively) pre-construction risk assessment, inclusive of all the usual suspects: Noise, vibration, system shutdowns, etc. Clearly (and I know you know, because I see you knowing), the pieces of this puzzle that can get you into the most trouble in most rapid fashion are those relating to infection control and interim life safety measures.

My (moderately) tongue-in-cheek response to any questions about “when” you would employ has typically been “always” (I remember the first time the question came up at a conference and my response was the same—and I’m sticking to my guns on this). My general philosophy as it relates to risk assessments is that we always assess for risk and we implement only what is necessary to manage those risks.

At any rate, as your “homework” for this week (and I would very much like to hear how you folks are parsing this), please look over the list below and figure out where you’ve placed the dividing line for your risk assessment process (basically, where you’d do an assessment and where you wouldn’t), particularly as a function of the Chicago requirement to “when planning for demolition, construction, renovation, or general maintenance [my bolding], the hospital conducts a preconstruction risk assessment for air quality requirements, infection control, utility requirements, noise, vibration, and other hazards that affect care, treatment, and services.” I firmly believe that this balancing act is going to be become a key component of survey oversight. (I would be more than happy to be wrong about this, but somehow I think things are moving in this direction.)

So please look over these perky little definitions and let me know your thoughts: Categories of Rehabilitation Work. The nature and extent of rehabilitation work undertaken in an existing building. Repair. The patching, restoration, or painting of materials, elements, equipment, or fixtures for the purpose of maintaining such materials, elements, equipment, or fixtures in good or sound condition. Renovation. The replacement in kind, strengthening, or upgrading of building elements, materials, equipment, or fixtures, that does not result in a reconfiguration of the building spaces within. Modification. The reconfiguration of any space; the addition, relocation, or elimination of any door or window; the addition or elimination of load-bearing elements; the reconfiguration or extension of any system; or the installation of any additional equipment.* Reconstruction. The reconfiguration of a space that affects an exit or a corridor shared by more than one occupant space; or the reconfiguration of a space such that the rehabilitation work area is not permitted to be occupied because existing means of egress and fire protection systems, or their equivalent, are not in place or continuously maintained. Change of Use. A change in the purpose or level of activity within a structure that involves a change in application of the requirements of the Code. Change of Occupancy Classification. The change in the occupancy classification of a structure or portion of a structure. Addition. An increase in the building area, aggregate floor area, building height, or number of stories of a structure.

Dance on a volcano: Keeping tabs on those that keep tabs on us…

As we’ve discussed in the past, the world in which we exist—and the stories and challenges contained therein—is never ending. And the subtext of that constancy revolves around our efforts to stay (as it were) one step ahead of the sheriff.

Part of me is railing against my chosen topic this week because I always feel like this space can (and, admittedly, does) have a tendency towards a Joint Commission-centric vision of the compliance universe, but while they may not be the largest primate in the compliance universe (once again violating all manner of metaphoric-mixing indignities), they are (more or less) the organization with the most robust customer-forward presence, through Perspectives to the FAQ pages to the topic-specific offerings we’re covering this week. All things being equal (which, of course, they never really are), I would encourage you to poke around a bit on these sites as there is a mix of stuff that is almost ancient, but some tools, etc. that you might find useful in demonstrating compliance.

The Physical Environment portal is kind of the granddaddy of this whole construct; it started out as a collaboration with the American Society for Health Care Engineering (and may very well continue to be so, but it’s kind of tough to tell) with the goal of providing information on the most frequently cited standards. Unfortunately (for me, but not so much for you), a lot of the information, including “surveyor insights,” is accessible only through your organization’s TJC extranet portal, but there is some stuff that’s worth a look. For example, there is a fire drill matrix that gives a sense of what areas should be considered for your high-risk fire drills (or would it be fire drills in high-risk areas…); the one on the matrix I found of some interest was Cath/EP lab making the high-risk list. I guess the overarching thought is to make sure you carefully consider those areas in which surgical fires a present as a risk.

There are also portals for emergency management, healthcare-acquired infections (I would keep a close eye on that one; lots of indication that this is the next “big thing” for survey), and workplace violence. Keep an eye on them: You never know what might pop up!

You’ve got to get in to get out: New safety adventures in ambulatory care

Hoping that this is more treat than trick, I had cause (albeit minimal) to reflect on what I see as a reasonably significant increase in EC findings being generated in the ambulatory care world. If we accept (and I certainly do) that one of the primary drivers to the survey process is the generation of findings, then it makes all the sense in the world to start “pushing” the survey process in those environments over which we have less control/influence/oversight. I talked a little bit about tools for the ambulatory setting back in January of this year (continuing our program of a self-referential October), and the good folks at ECRI are offering what they are terming a “deep dive” into safe ambulatory care (if you scroll about 1/3 of the way down the ECRI homepage, you’ll find the link to download the report for the low purchase price of some contact information).

The report breaks things down into four key areas: Diagnostic testing, medication safety, falls, and, safety & security. While I recognize the latter two may be of primary interest to this audience, I would encourage you to check out the information relating to diagnostic testing and medication safety. Everything in healthcare (and pretty much any and everywhere else) “exists” in the physical environment (thinking of concentric circles with the patient at the center and the physical environment being the outermost circle), so the interactions between “disciplines” can generate a lot of opportunities when it comes to the practical application of safety and the environment. Taking that with the (at times infuriating) “grayness” of what is required from a regulatory standpoint, it really prompts a level of vigilance that is unlikely to subside any time soon.

To close things out for this week/month, another resource that you might find of interest is a podcast dealing with all things water treatment; you’ve heard (metaphorically speaking) me speak of Matt Freije and the good work he’s spearheading at and he appears on an episode of the ScalingUp podcast. I found it pretty interesting, but that may just be me. That said, I think the focus and attentions paid to water management plans during survey activities is going to continue to rise and I can see a future in which funky water values will drive Condition-level survey results. Now is the time to start educating ourselves to what it all means and I think this podcast is a good start for folks. Check it out!

And a happy and safe All Hallows Eve to you all…

Who remembers pop-o-matic Trouble?

In something of a variation on another bloggy evergreen, I ask the rhetorical question: To what, if any, extent have you included consideration of  board games in your physical environment risk assessments for behavioral health? As I think towards a generation (are they already here?) for which the glories of board games will be forever lost, our friends in Chicago offer the latest challenge in managing risks with our all-too-vulnerable patient populations (for those of you of a certain vintage, the description of a board game is very nearly worth the price of admission).

The article describes the quite inventive use of a plastic board game piece to defeat the reptilian tamper-resistant screws and suggest some alternative products that do not so easily surrender to such efforts. I don’t know that I’ve been privy to a lot of discussion relative to board games in the behavioral health setting, but I suppose this would come under the heading of “everything has an inherent, though perhaps not apparent, risk.” Based on some recent surveys, it seems that Joint Commission surveyors have been rather inventive in looking for physical environment elements that have not been specifically accounted for in the assessment process. The classic example is including medical beds in the risk assessment, but not specifically mentioning the risks associated with the ligature-resistance (or not) of the side rails, bed frame, etc. Sooooooo, if they have not yet been included in your risk assessment activities, it might be a good time to pull a little group together and ponder the use of board games (and perhaps other such items) as a function of the behavioral health physical environment risk assessment.

Should we think about Halloween candy as well?!?

Check and mate!