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One score and no years ago: Guess who’s 20?

John Palmer, who edits Briefings on Hospital Safety, among other nifty periodicals, asked me to weigh in on the 20th anniversary of the EC chapter, with a particular emphasis on how (or where) things are now in comparison to the (oh so very dark) pre-EC days. And he did this in full recognition of my tendency to respond at length (imagine that!). At any rate, I decided that these thoughts would be good to share with all y’all (I can’t absolutely swear to all the dates; I think I’m pretty close on all of them, but if there are temporal errors, I take full responsibility…)

Prior to the “creation” of the Environment of Care as a chapter (you can trace the term Environment of Care back to 1989), The Joint Commission had a chapter in the accreditation manual known as Plant Technology and Safety Management (PTSM). The PTSM standards, while significantly more minimalistic than the present-day requirements, did cover the safety waterfront, as it were, but with the advent of Joint Commission’s Shared Visions/New Pathways marketing (you may assume that I am using “marketing” as the descriptor with a little bit of tongue in cheek) of their accreditation services, I guess the term I would use most is a modernization of the various standards chapters began, including the “birth” of the EC chapter in 1995. With that, things became a little more stratified, particularly with the “reveal” of the seven EC functions (safety, security, hazmat, emergency, life/fire, medical equipment, utility systems). This raised the profile of the physical environment a bit, but a true concerted focus on the EC really didn’t occur until 2007, when the Life Safety surveyor program was introduced, primarily in response to data gleaned by CMS from validation surveys. The Joint Commission survey process, prior to 2007, really didn’t have a reliable means of capturing life safety and related deficiencies. Since then, the survey focus on the physical environment has continued to grow, much to the point that now it very much eclipses the clinical component of the survey process, at least in terms of the number and types of findings.

Are things “better”? I suppose one could make the case that things have improved incrementally over time, but it’s tough to say how much direct influence the EC chapter has had on things (and the subsequent “peeling off” of the Life Safety and Emergency Management chapters). Clearly, the healthcare environment is significantly different than 20 years ago, both in terms of the inherent risks and the resources available to manage those risks. (Increased technology is pretty much a good thing, but reductions in spending, probably not so much. I’m sure you can come up with a pretty good list of pros and cons without too much difficulty.) You could also make the case (purely based on the number of findings…and I think TJC has a dog in that fight) that if hospitals are safer, it’s because of the level of scrutiny. I tend to think that the “true” answer resides on the development of the healthcare safety professional as a vocational endeavor, with the added thought that unsafe places tend not to stay in business for very long these days. So perhaps somewhere in the middle…

Better? Worse? Different…definitely! I will say that I firmly believe that the amount of survey jeopardy being generated at the moment leans towards the hyperbolic; there are certainly organizations that need to get their acts together a little more fully than they do at present. But not every organization that ends up in the manure is completely deserving of that status. I recognize that TJC has to be super-diligent in demonstrating their value to the accreditation process. But being accredited can’t become the be-all, end-all of the process. The responsibility of each healthcare organization (and, by extension, each caregiver) is to take care of patients in the safest possible manner and being attentive to the survey process can’t come at the expense of that responsibility. Sometimes, I fear, it does just that. I could probably say something pithy about job security, but…

If being accredited by you is wrong, I don’t want to be right…

I’ve recently encountered some survey results that gave me pause and I wanted to take a moment to share some thoughts on the perceived infallibility of regulatory surveys (and consultants), some of whom are pretty much unassailable (the most dangerous of situations for an organization—if you read this as the organization represented by the moniker Charlie Mike Sierra, you’d not be far off the mark), others somewhat less so, but you need to be very careful when taking on any of the three-letter accrediting agencies. While they may be in error in citing something, it is of critical importance that you are sufficiently conversant with what compliance looks like to make your case.

I’m going to start with a somewhat non-EC related finding, but it serves as a pretty good example of how a survey finding can go awry. A recent survey (the surveyor in question had been a perioperative clinical director prior to becoming a surveyor) cited an organization for inappropriate storage of a medication in a secure dispensing system (you know, those big honking boxes that create such a lovely heat load in your medication rooms). The citation was very clear, very nicely framed, etc., but it was based on information that was out of date relative to the medication cited (at issue was the stability/expiration of the product when it was stored at room temperature). It seems that in the past, this particular product was only viable for 14 days once it was removed from refrigeration, so that became the nature of the finding. However, the organization knew (and was able to present documentation from the manufacturer) that the stability of the product was good for up to 91 days after being removed from refrigeration. Now, we’ve spoken a fair amount lately of the importance of manufacturers’ Instructions For Use (IFU) when it comes to appropriately managing storage and using equipment and such, so this would be the point where you would invoke the clarification process to have the finding removed from your survey report. That said, the point I really wanted to focus on was that the surveyor presented what appeared to be an unassailable (and thus, infallible) finding, but (at least in this case) that infallibility was very clearly in the past. Who knew infallibility was transient?

Another area where surveyors can raise a ruckus is in the behavioral health environment, particularly when you are dealing with a surveyor who is not a specialist in behavioral health. The tipping point is that behavioral health professionals recognize that is pretty much impossible to provide a completely risk-free physical environment for behavioral health patients (and I’m talking just about the way the facility is built, etc.) so the key to appropriately managing those risks is working towards minimizing the risks to the extent possible and then identifying the mitigation strategies (and this typically is where staff oversight and monitoring comes in). But then you have surveyors who see ligature points everywhere they look in the behavioral health environment and they start “dinging” you for all those “risks.” Strictly speaking, the only way that you can defend yourself is by making sure that you have a comprehensive risk assessment of the behavioral health environment, based on your state guidelines or on a resource such as the Design Guidelines for the Built Behavioral Health Environment (now available from our friends at the Facilities Guidelines Institute), in your back pocket. But (and this is perhaps the most important piece of this) you also need to periodically revisit the assessment. I don’t know about your experiences, but mine have shown that the behavioral health patient population is not anything close to being static—the types of patients seen, the acuity and diagnoses—and, by extension, the risks will change over time. My consultative recommendation would be to include specific mention of the behavioral health environment when you do your annual evaluation of the safety management program at your organization (I’m a big fan of using the annual evaluation process to affirm/reaffirm the validity of your risk assessment processes). I know things can get a little crazy when it comes to this stuff, but there’s also be a spate of survey findings relating to risk assessments not completed for a specific concept (for example, where your organization chooses to have emergency medical response equipment and procedures beyond calling 911—talking about off-site clinics, etc.) or not updating the risk assessment in response to a regulatory survey finding.

(I have a hard time getting my head around this one: A “competing” regulator comes in, cites you for a condition, you engage in a corrective action plan with that regulator and then, about six months later, you get cited for not having updated the risk assessment to reflect the findings from the earlier survey. It just seems like a bit of “piling on” to me.)

At any rate, every time you do hazard surveillance rounds, you are (hopefully) collecting compliance data. Make sure you use that data to perform an analysis of “the state of the environment” and make the determination of whether risk is being managed appropriately/effectively. As I tell folks about once a week (and sometimes more), regulatory surveyors will always reserve the right to disagree with anything they (or anyone else) have told you, or, indeed, any decision that you have made relative to the management of risk (I guess this blooms out of the whole infallibility thing). And while you don’t necessarily want to get into a urination competition with a surveyor at the time of survey, as long as you “know” and can demonstrate that you are appropriately managing the risk and have a process for periodic evaluation of the risk management process, then you are in a position to use the post-survey clarification process. Surveyors can be incorrect (or, as a kinder, gentler descriptor) or mistaken about how a condition they encounter in your organization is in compliance with the standards, but you have to be quite clear within yourself how what you are doing is in compliance. It’s the only way to push back. Surveyors can be exquisitely convincing in the moment—and make you doubt what you’re doing—but you know what works best in your organization. You have intimate knowledge of the organization’s culture, how processes work (or not), etc. They’ve only just met you and while they have a job to do, you also have a job that you’ve been doing. That, in my mind, gives you a bit of a leg up on the outsiders…but that may just be me!

After all these years, it’s true: Your mother doesn’t work here

Over the years, once or twice I’ve ventured into staff areas as I’ve toured various facilities—sometimes you find some things that are a little disconcerting (electric grills, various electric food-preparation appliances), but sometimes you find things that can bring a little levity to the moment. One of the time-honored postings is a variation on that old saw “Pick up your mess, your mother doesn’t work here.” While I know that is not always a factual statement (my mom worked at the same hospital as I did for rather a while, though she was not particularly keen on cleaning up messes in either place), I think there is a grain of something that is instructive in how we need to move forward in the management of the physical environment. It all ties back to the finder/fixer dynamic that can work so very efficiently when you get enough participation, with a little bit of incident command tossed in for good measure. Ideally, the level of response to any condition would be in direct proportion to the resources needed to resolve that condition, with the thought being that whoever first identifies the condition is thus “in command” of mustering those resources. So, a paper towel or a plastic bag or some other debris on the floor becomes the point of contact relative to that response. My personal philosophy in this regard (and I apologize if I’ve spouted off on this in the not-distant-enough past) is that if I encounter a condition that I can resolve by my own actions, then that is my obligation. I am no big fan of leaving things for others to do, and I know that tendency exists to one degree or another in most people (I know better than to think everyone is so inclined), but the question I keep asking myself is: How do we get folks to act on it? Someone’s walking along with a cafeteria tray and a napkin blows off the tray—there are thems that will stop and pick up the napkin and there are thems that do not. I guess the overarching question is whether or not it is foolish to think that we can get batter at this, but doggone it, don’t you think we should be able to? Oi!

On a completely unrelated note, word came down from Mount TJC last week that a new module has been uploaded to the Environment of Care portal dealing with that even more time-honored undertaking, the integrity of egress. In looking over the materials (and I encourage you to do so as well—it won’t take very long), the focus appears to be corridor clutter and the locking of doors in the path of egress. Now, the example given on the portal page indicates that it is an example of improved compliance for EP 1 (locked egress doors) and EP 13 (corridor clutter), but the example seems to be a rather odd confluence of discussion points. Both topics are addressed, for sure, but I’m not entirely certain how instructive this is, particularly the piece about locked doors. Maybe you folks see things differently; I’d love to get your feedback.

That said, one thing I noticed was missing (can you really notice something missing?) was no coverage of findings related to Exit and NO Exit signs—maybe some sense of how you can evaluate your facility in this regard. It seems to me that I’ve encountered a slew of findings relating to egress signage (more not having NO Exit signs than not having enough exit signs), including concerns with non-compliant signs (for example, the 2000 Life Safety Code® has very specific instructions relative to NO Exit signs: “7.10.8.1 No Exit. Any door, passage, or stairway that is neither an exit nor a way of exit access and that is located or arranged so that it is likely to be mistaken for an exit shall be identified by a sign that reads as follows: NO EXIT Such sign shall have the word NO in letters 2 in. (5 cm) high with a stroke width of 3/8 in. (1 cm) and the word EXIT in letters 1 in. (2.5 cm) high, with the word EXIT below the word NO.” ). It just seems to me that there could be a little more information to help organizations better prepare their facilities for inspection, but also (and in my mind, this is rather more important) provide a safer care environment. Maybe I need to adjust my expectations on this process…

If you set things up correctly…they will still find stuff!

Those of you who are frequent readers of this little space are probably getting tired of me harping on this subject. And while I will admit that I find the whole thing a tad disconcerting, I guess this gives me something to write about (the toughest thing about doing the blog is coming up with stuff I think you folks would find of interest). And so, there is an extraordinary likelihood that you will have multiple EC/LS findings during your next triennial Joint Commission visit—and I’m not entirely convinced that there’s a whole lot you can do to prevent that from happening (you are not powerless in the process, but more in that in a moment).

Look at this way: Do you really think that you can have a regulatory surveyor run through your place for two or three days and at the end “admit” that they couldn’t find any deficiencies? I’ve worked in healthcare long enough to remember when a “no finding” survey was possible, but the odds are definitely stacked against the healthcare professionals when it comes to this “game.” And what amazes me even more than that is when folks are surprised when it happens! Think about, CMS has been taking free kicks on TJC’s noggin for almost 10 years at this point—because they weren’t finding enough issues during the triennial survey process. BTW, I’m not saying that there’s a quota system in place; although there are certainly instances in which surveyors over-interpret standards and performance elements, I can honestly say that I don’t find too many findings that were not (more or less) legitimate. But we’re really and truly not talking about big-ticket scary, immediate jeopardy kind of conditions. We are definitely talking mostly about the minutiae of the safety world—the imperfections, if you will—the slings and arrows of outrageous fortune that one must endure when one allows humans to enter one’s hallowed halls. People mess stuff up. They usually don’t mean to (though there are some mistakes, and I think you can probably think of some examples in your own halls), but as one is wont to say, feces occurs. And there’s a whole segment of each healthcare organization charged with cleaning up that feces—wherever and however it occurs.

So what it all comes down to is this: you have to know what’s going on in your building and you have to know where you stand as a function of compliance, with the subset of that being that you have to have a robust process for identifying conditions soon enough and far enough “upstream” to be able to manage them appropriately. We’ve discussed the finder/fixer dynamic in the past (here’s a refresher), so I won’t belabor that point, but we need to use that process to generate compliance data. Strictly speaking, you really, really, really need to acquaint yourselves with the “C” Elements of Performance; compliance is determined as a rate and if you can demonstrate that your historical compliance rate is 90% or better, then you are in compliance with that standard/EP. But if you’re not using the surveillance process, the finder/fixer process, the tracer process, the work order process, the above the ceiling permitting process, ad nauseum, to generate data that can be used to determine compliance, then you are potentially looking at a very long survey process. Again, it goes back to my opening salvo; they are going to find “stuff” and if you are paying good attention to what goes on in your organization, then they shouldn’t be able to find anything that you don’t already know about.

The management of the physical environment is, at its heart, a performance improvement undertaking. As a support process for hardwiring ongoing sustained improvement, a process for the proactive risk assessment of conditions in the physical environment is essential. As an example, the next assessment would use the slate of findings from your most recent surveillance rounds to extrapolate the identification of additional risks in the physical environment. For all intents and purposes, it is impossible to provide a physical environment that is completely risk free, so the key focus becomes one of identification of risks, prioritizing the resolution of those risks that can be resolved (immediate and long-term), and to develop strategies for managing those risks that are going to require resource planning and allocation over an extended period of time. The goal of the process is to ensure that the organization can articulate the appropriate management of these risks and to be able to provide data (occurrence reporting, etc.) to support the determination of that level of safety. By establishing a feedback loop for the management of risk, it allows the organization to fully integrate past actions into the improvement continuum. If you think of the improvement continuum as a football field (it is, after all, the season for such metaphors) or indeed any game “environment,” you need to know where you are in order to figure out where you need to go/be. The scrutiny of the physical environment has never been greater and there’s no reason to think that that is going to change any time soon. Your “power” is in preparing for the survey by being prepared to make full use of the post-survey clarification process—yup, they found a couple of doors that didn’t close and latch, a fire extinguisher that missed a monthly inspection or two, and on and on. Anticipate what they’ll find based on what you see every time you “look” (again, it’s nothing “new” to you—or shouldn’t be) and start figuring out where you are on the grid. That way, they can find what they want (which they will; no point in fighting it anymore) and you can say, thanks for pointing that out, but I know that my compliance rate for doors/fire extinguishers/etc. is 90%, 91%, 92%, etc. We want them to work very hard to find stuff, but find stuff they will (that’s a little Yoda-esque). We just have to know what do “aftah.”

Reducing the length of stay: Not yours, but somebody who visits but once in a three-year cycle…

One of the most interesting parts of my job is helping folks through the actual Joint Commission survey process. Even as a somewhat distant observer, I can’t help but think that the average survey (in my experience) is about a day longer than it needs to be. Now, I recognize that some of that on-site time is dedicated to entering findings into the computer, so I get that. But there are certain parts of the process, like, oh I don’t know, the EC/EM interview session, that could be significantly reduced, if not dispensed with entirely. Seriously, once you’ve completed the survey of the actual environment, how much more information might you need to determine whether an organization has its act together?

At any rate, I suppose this rant is apropos of not very much, but the thought does occur to me from time to time. So I ask you: is there anybody out there who feels the length of the survey was just right or, heaven forbid, not long enough? As I’ve always maintained, TJC (or, for that matter any regulatory survey type—including consultants) tend to look their best when you see them in the rear view mirror as you drive off into the future. I know the process is intended to be helpful on some level, but somehow, the disruption never seems to result in a payoff worth the experience. But hey, that may just be me…

Any thoughts you’d like to share would be most appreciated.

The final countdown

One of the things I’ve noticed in my journey through the highways and byways of healthcare is that we do an awful lot of education. The one compelling example that springs to mind is the challenges we’ve had over the last decade involves the appropriate storage/management of compressed gas cylinders. For years we struggled with getting folks to place the cylinders in an appropriate stand or rack; in some instances, we had to share folks some of those lovely videos of what can happen when an unrestrained cylinders becomes violently “active” (something like this one).

Now, I am happy to report that  it appears that we eventually got folks to come to grips with this (though I still periodically run into pockets of resistance), but now we have a new “foe” in the management of compressed gas cylinders—segregating full and not full cylinders. Now I know that we’ve discussed this in the past, but the thought that I have circling what’s left of my brain is this: recognizing how long it took to get folks to play nice, (so to speak) with appropriately securing those pesky e-cylinders, is there a way we can gain compliance in a more accelerated fashion?

To that end, I would ask you to think about how we did the cylinder restraint education and to come up with a way (or perhaps you already have, in which case, please share) to evaluate the education process. Again, we do a ton of education and yet we still have staff (and others; can’t forget some of those lovely contractors) who do stuff that we don’t want them to do. I harbor no illusion that we can completely eliminate undesirable behaviors, but I think we should be able to improve our “situation” to the point that perhaps only five of the most frequently cited standards reside in the physical environment. Do I hear four? Three? Two? One? What do you think?

Cue the drum roll: Ladies and gentlemen, I give you the Portal of Perception!

Not so very long ago, The Joint Commission and ASHE announced the creation of an information resource to assist with all those pesky EC/LS findings that have been reproducing like proverbial rabbits (here’s coverage of that announcement  and coverage of those rapidly reproducing findings).

Well, since that announcement, the elves have been very busy cobbling together bits and pieces of this and that, with the end result being a rather interesting blend of stuff (please note that I did not employ the more severe descriptor—stuff and nonsense), with titles like “Is Your Hospital’s Air Ventilation System Putting Your Patients At Risk?” (this one’s in the Leadership module, so I guess they’re asking the question of organizational leadership). I truly hope that your response to that particular query would be “absolutely not,” but I’ve also been working this part of the street long enough to know (absolutely, if you will allow me a brief moment of hyperbole) that there are few absolutes when it comes to the management of the physical environment.

Which leads me to the follow-up thought: Recognizing that there is always the potential for the performance of air ventilation systems to drift a little out of expected ranges, at what point does the performance of air ventilation systems actually put patients at risk? And perhaps most importantly, have you identified those “points” in the performance “curve” that result in conditions that could legitimately cause harm to our patients? And please know that I understand (in perhaps a very basic sense, but I think I can call it an understanding) how properly designed and maintained HVAC systems contribute to the reduction of HAIs, etc. But with any fluid situation, there is an ebb and a flow to conditions, etc., that, again, may veer into the “red” zone from a compliance standpoint. But let me ask you—particularly those of you who have experienced out-of-range conditions/values—have those conditions resulted in a discernible impact on your infection control rates, especially those relating to surgical site infections?

BTW, I’m asking because I really don’t know what you folks are experiencing. And, for those of you that have identified shortcomings on the mechanical side of things, are your Infection Control folks keeping a close (or closer) eye on where those shortcomings might manifest themselves as a function of impact to patients? From the information posted in the Portal (I think I’m going to capitalize), remedying compliance issues in this regard is a simple four-step process (You can find the example of improved compliance there). Who knew it would be so easy? (I could have had a V8!) I don’t think anyone in the field is looking at this as a simple, or easy, task.

At any rate, despite the best efforts of the Portal, until we have buildings (and staff) that are a little closer to perfect, I think we’re going to continue to see a lot of EC/LS findings during survey. Ohboyohboyohboyohboyohboy!

Also, as I think about it, please be sure to check out the Clarifications and Expectations column in the September issue of Joint Commission Perspectives; there are some interesting points to be gleaned, the particulars of which we will cover in a wee bit, so watch this space!

Same as it ever was… same as it ever was… same as it ever was…

As the back-to-school sales reach their penultimate conclusion, I look back on the year so far and am amazed at how quickly we’ve blown through fully two-thirds of 2015—yow! For a while it seemed like winter was never going to release us from its icy grasp and now we’re looking forward to its return, so I guess we have naught to do but look forward towards the onslaught of 2016. I hope, for all our sakes, it is a kinder and gentler new year.

But before the past little while takes on the rosy hue of nostalgia (as it almost always does), our friends in Chicago have provided an excellent opportunity to reflect on the “sins” of the past by revealing the most frequently cited standards during the first six months of 2015. And to almost no one’s surprise, four out of the top five most frequently cited standards (at the moment, the “reveal” is only for the top five—I guess we’ll find out about the rest of the top 10 at some point) are smack dab in the middle of the management of the physical environment, with the top three most frequently cited standards for hospitals being EC.02.06.01 (#1 with 59% of hospitals surveyed being cited), IC.02.02.01 (#2 and 54%) and EC.02.05.01 (#3 and 53%; looks like a real fight for that #2 spot), all of which reflect elements tying together the management of the physical environment with the control and prevention of infection (not everything cited is in the physical environment/infection control bucket, but from what I can gather, rather a fair amount is related to just that).

At this point (and I full recognize that this is a rather reiterative statement), I’m going to crawl out on a limb and say that the single greatest survey vulnerability for any (and every) healthcare organization is the management of the surgical/procedural/support environments. The hegemony of this aspect of the survey (and regulatory compliance) process comes very close to defying understanding. At this point, there’s no real surprise that this is an (if not the, and I would argue “the” is the word) area of intense survey scrutiny, so what’s the deal?!? Forty percent of the hospitals surveyed from January to June appear to have done okay on this, or is that number really a red herring? It would not surprise me that 100% of the hospitals surveyed ran afoul of one of the top three. Anybody out there surveyed so far this year that managed to escape, relatively, scott-free on this?

I’ve certainly done a lot of yammering in this regard over the past few months (years?) and it appears that I am raging against the dying of the light to minimal effect. I have a lot of ideas about this, but I guess I’m putting it out there: has anybody really got this under control? I think we all have a stake in this thing and the sooner we can get our hands on an effective process for managing this, the better. I will admit that it is entirely possible that, particularly given the age of a lot of hospital infrastructure components, this is not going to go away until they stop focusing as much on it. At this point, I haven’t run into too many folks that have been cited under the big three for whom infection rates are anything other than what would normally be expected—though perhaps infection control rates are higher than they “should/can” be—I guess we could be in the midst of a paradigm shift on this. I don’t want to have to wait to find out.

Letting the days go by…

Try not to breathe

I know that we’ve visited (and revisited) this topic once or twice over the last little while, but it continues to be (at least in my mind’s eye), the most significant vulnerability for every healthcare organization that uses The Joint Commission (TJC) for accreditation services: the management of temperature, humidity, and air pressure relationships (THAPR—How’s that for an acronym? It’s pronounced “thapper” or, if you’re from Boston, “thappah”) in the care environment. Folks continue to be cited for issues in this regard; other folks are jumping on board (a little late, but better than never) but are in the closing section of their survey window; and others still have not quite grasped the importance of having a stranglehold (if you will) on those areas for which there are THAPR requirements. Those of you who’ve accompanied me in the blogosphere for a while know that I do not do a lot of product marketing (even my own product), but I will encourage you once again: if you do not have a copy of ASHRAE 170—2008 Standard for Ventilation of Health Care Facilities, you are not in possession of what may be (at least at the moment) the single most important slab of information in the physical environment pantheon (yes, we will always have a place in our hearts for the 2000 edition of NFPA 101 Life Safety Code®; probably for too long, based on the ever-so-slow-to-adopt new things track for the 2012 edition).

While I’m not suggesting that you memorize ASHRAE 170 (it is fairly brief and those of you with eidetic memories probably won’t be able to keep yourselves from doing so), I am suggesting that you need to go to the table on pages 9-11 and start identifying the areas in your organization that have specific requirements and start figuring out where you stand in relation to those requirements, and perhaps more importantly, come to some sort of sense as to how reliably your systems can support those requirements. And you really need to go through the entire table; TJC certainly is. Just last week, I heard of pressurization issues in lab and pharmacy areas (labs are to be under negative pressure; pharmacies under positive) that added up to condition-level survey results.

Make sure you know where you have sterile storage in your organization; sterile storage areas are to be under positive pressure and should be monitored for temperature and humidity. But the reality of the situation is that you have sterile supplies in locations throughout your organization, so you have to define what does and what does not represent sterile storage (my best advice is to coordinate with your infection control and surgical folks on this one—it’s beginning to look a lot like a risk assessment—everywhere you go!). That way, you have a solid foundation for determining what needs to be managed from an environmental standpoint; it’s the only thing that will keep you out of the hottest water during survey.

Two final thoughts before signing off for this week; make sure that routine bronchoscopies are being performed under negative pressure (urgent or emergency bronchoscopies may not have quick enough access to the appropriate environment, so make sure that folks know what protective measures need to be considered to protect themselves and the patient when they’re aerosolizing potential bugs). There are still instances in which this is being cited during survey, so I think my best advice is to go and check with your respiratory therapy folks, as well as the folks in surgery, critical care, infection control, etc., and ask the question: Are bronchoscopy procedures being performed, and if so, where are they being performed? Then you can start walking it back to a point where you can be assured that they are being done in an appropriate environment.

The last thing is a brief reminder that the process for the survey of the physical environment (again, as it is currently being administered) involves all of the survey team – when it comes down to this are of concern, there is no more “clinical” versus “non-clinical”; everything that occurs within the four walls of your organization are patient care activities, direct or indirect (you may have noticed TJC has been splitting its performance elements using that very same language). Coordination of the various hospital services, etc., has never been more heavily scrutinized and never been found more wanting during survey. There is a paradigm shift afoot, my friends, and we need to get on the good foot.

Leave it better than you found it!

This past week (and this coming week as well), I’ve been on vacation in Maine (code name: A Beautiful Place by the Sea), which affords me the luxury of observing a lot of human behaviors, some interesting, some not so much. Some winning, and others that just grate.

There’s been a movement to reduce the amount of “invasive” plant species that have, in some instances, overtaken the natural landscape (and no, I’m pretty sure that this reduction is going to extend to tourists, though I bet there are moments…). So something of a reclamation project is underway, the result of which will (ideally) be a sustainable and less intrusive beautification. Where things go a little awry is in the areas somewhat off the more deliberately beauteous locales and offers what appears to be too many opportunities for the dark underside of human behavior to hold sway. Each morning, I make a circuit of the area and have noted beer and soda cans tossed into bushes, dirty diapers tossed under those same bushes and all matter of detritus left behind, presumably because the effort to properly dispose of these items was greater than what could be tolerated in the moment. My walk, at least partially, includes collecting some trash (I will admit that I’ve avoided the dirty diapers—I will have to prepare better in the future) along the way, but I have a pretty good sense of where the waste receptacles are along the way, so it’s not like I have to lug the stuff for miles.

At this point, you’re probably asking yourself: What does this have to do with healthcare safety and the myriad related conditions and practices that I might encounter during the workday? Well, the thought that keeps returning to the front of my head goes back to the age-old task of trying to “capture” these conditions at the point at which they occur, or at least when they are identified (yes, it’s another “see something, say something” tale). When we encounter unsafe conditions during rounds—damaged walls, unattended spills, etc.—we “know” that these things did not happen by themselves, so what prevented the originator of the condition from at least saying, “Oh poop, I need to tell somebody about that hole in the wall/spill on the floor so it can be remedied.” Not a particularly difficult thing conceptually, but human behavior-wise, it seems like it is an impossible task. I suppose you could look at it as job security (hahaha!), but having to manage all these little “dings” keeps us away from paying attention to the big and bigger dings that we know are out there. I suspect that I’m probably not supposed to be thinking about this stuff so much when on vacation, but I guess that’s part of my brain that never really shuts off. And don’t get me started about people who leave shopping carts out in the middle of the parking lot at the grocery store (yes, that’s me pushing a line of carts either to the cart corral or back to the store—it is a most consistent manifestation of my OCD). Hope your August is proving to be most splendid!