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EPA issues a ruling on epinephrine salts

Hey everyone, it’s Scott Wallask checking in with an interesting note from the EPA. It appears ephineprine salts are officially off the list of P-listed wastes that the agency regulates.

Click here to read the decision.

Sounds like that’s a welcome announcement.

The data that drives your BMP during a survey

There are a couple of important points with The Joint Commission’s building maintenance program that somehow seems to get lost in the shuffle:

  • The critical role of data in this process
  • The practical application of the BMP during a survey

As the decisions you make regarding inspection frequencies and related activities should be validated by the data you’ve collected, remember that the findings of Joint Commission surveyors also are rendered based on the data collected during survey. This data collected during survey is a significantly smaller sample size than you would be using to validate your program (your entire inventory of a device versus the number viewed during survey).


As a result, you must be prepared to demonstrate the compliance of your program as a function of the post-survey clarification process. A rated door that doesn’t latch here, an exit sign that is not illuminated there, a couple of penetrations somewhere else-you can get into RFI territory very quickly.


My consultative advice for starting this process is the following:

  1. Pick whatever BMP elements you’re going to manage in this fashion (the current list if items you may include can be found on Page 3-15 of the Statement of Conditions)
  2. Identify an inventory of the devices in each category (that’s really the only way to be able to demonstrate that you have a 95% compliance rate for that device)
  3. Determine what frequency you can attain given current resources, though I would counsel at starting frequency of no less than quarterly

Again, there are elements that are not going to require as much attention, but you need to make that decision based on the failure data collected during BMP activities. That can be another challenge: getting the folks doing the inspections to tell you when they found something that wasn’t working properly. Frequently they will just do the repair work and move on without documenting, but the key data is knowing how often the device is not working correctly.


For some additional information, almost akin to a glimpse behind the velvet curtain, you can access the technical paper about the BMP that George Mills (senior engineer at The Joint Commission) and some other folks penned for the American Society for Healthcare Engineering some time ago.


While the paper is somewhat outdated in terms of specific compliance concerns (for example, it references the 1997 Life Safety Code

Fit to be (tied and) tested

I’m sure many of you are watching, with various degrees of trepidation, the pending federal budget that, among other things, will once again let loose the hounds of the Occupational Safety and Health Administration in pursuit of fresh fines. I’m talking about Congress letting OSHA enforce annual tuberculosis fit-testing for respirators.

We could probably spend a good long time (and mayhap one day we will) discussing the efficacy of the practical application of the respiratory protection standard (CFR 1910.134) as a function of managing occupational exposures to TB, or indeed whether there was a significant shortcoming in the nondevelopment of a TB standard for healthcare workers. That said, it appears that enforcement of annual TB fit-testing is going to become a way of life for hospitals.

Hopefully-and you definitely want to do a little assessment here to make sure-you have your new hire process under control from a fit-testing perspective (though I do know of more than a few organizations that are a little soft in this area). Clearly starting at the front end of the process is the way to establish a solid foundation for your program.

Ideally, you will be able use the practical experience from the new hire process to identify an appropriate level of resources for expanding the respiratory protection program to include annual TB fit-testing and all its component pieces (medical evaluations, pulmonary function tests, and the like).

I’m guessing that there aren’t many of you out there with sufficient existing resources to carry this off (if you do-good for you!). It is more than likely that in the near future, you will have to submit some sort of business plan to your organization’s leaders in order to obtain those additional resources, including a fairly well-detailed accounting of the process (this is likely going to be a shared responsibility within the organization, but, make no mistake, this is the organization’s responsibility).

My best advice would be to get a group together, flowchart the process, determine a per-unit expense, and get that request to your organization’s leaders before the compliance canines beset your house.

Things that go BMP in the night

I’m seeing an interesting phenomenon relating to the life safety surveys, the building maintenance program (BMP) as outlined in the SOC, and how the two (sort of) co-exist during surveys.

I know a lot of folks are really working towards a point where they can take advantage, so to speak, of the BMP. That said, I’m not so sure that the BMP is something to be taken advantage of, at least in the classic sense-though an advantage can clearly be gained by adopting this most practical of strategies for managing certain specific elements of your life safety equipment and building features.

The issue with the BMP is that, in and of itself, there is not a great deal of guidance in how one is to set it up. Ideally, the goal of the program is to ensure that it is 95% compliant at any given point in time with the listed items that you’ve chosen to include.

Ultimately, the frequencies with which you’d be checking will be dictated by the performance data you collect during your inspection activities. That can mean there are certain elements that will need to be inspected at greater frequencies than others.

As an example, a client of mine utilizes rolling fire doors to isolate the elevator lobbies. However, given their proximity to the elevators and the very nature of a lot of the traffic using the area (food carts, linen carts, storeroom carts, etc.), these doors receive a more than equitable share of abuse.

Consequently, these doors experience a much greater rate of failure to close and latch than other rated doors in the organization. To manage such a condition using a BMP, it is likely that a greater inspection frequency would need to be employed than, say, fire doors leading into stairways.

As another example, there might be fire doors adjacent to areas like the kitchen, the storeroom, or environmental services that get banged around more and would probably need to be inspected more frequently.

In conversation with George Mills, The Joint Commission’s senior engineer, he described it thusly: You may have X number of fire doors in your facility and 90% of those doors may work correctly every time, but that other 10% of your door inventory is where you need to be more attentive.

You might need to inspect the 10% on a quarterly, monthly, weekly, or even daily frequency depending on what the data tells you. And you might be able to do the remaining 90% on a semiannual or even annual basis (I don’t think you could ever get to a point where a frequency of less than a year would be diligent).

OSHA isn’t checking for annual TB fit-testing yet

Hi everyone —

It’s Scott Wallask up at HCPro. Just an FYI, an OSHA spokesperson confirmed for me today that the agency has not started inspecting for annual fit-testing for tuberculosis (TB), despite what you might have read elsewhere.

OSHA, like all of us, is awaiting final approval of the funding budget for fiscal year 2008. When that happens, it is almost certain that the annual TB fit-testing enforcement will be in effect.

Since 2004, Congress has prohibited OSHA from using budget funds to enforce annual fit-testing provisions for TB, which falls under the respiratory protection standard. But politics and that fellow who snuck back into the country with TB in May shifted the landscape.

Scott W.

A shift in the thinking behind closing hospitals during a disaster

Within The Joint Commission’s revised emergency management standards, an important consideration (and this is clearly derived from the Gulf Coast experience) is to know when your organization can no longer safely sustain patient care and thus must take steps to cease operations, either partially or completely.

This may involve relocation of your operations, the migration of your patients to another facility, or even a mix of the two. Every circumstance has a tipping point and the new defining preparedness characteristic for hospitals is a level of self-awareness that can recognize and act upon that point.

In the past, I think that there was a tacit understanding on the part of everyone involved (hospitals, regulators, communities, etc.) that hospitals would not close, or more to the point, could not close. We need look no further than the legal imbroglios regarding the disposition of patients in the aftermath of Katrina to see that, as an industry, a critical part of our continuity plans is to know when continuation is not possible and, I daresay, could be considered dangerous.

With luck, we will never have to face such circumstances again, but I don’t think the odds are in our favor.

How the revised emergency management standards tie into federal rules

If anything, the Joint Commission’s updated emergency management standards represent a much clearer picture of what might be considered best practices for the structure of your emergency operations plan (which used to be called your disaster or emergency response plan in the standards). The revisions take effect January 1.

Clearly, in this (still) post-9/11 world, the hierarchy of regulatory oversight continues to have the requirements of the federal government at its apex. If your organization has any hopes of funding additional improvements to your preparedness activities, adoption of a response structure that is compliant with the National Incident Management System (NIMS) must be your primary goal. Fortunately, the following six critical areas identified in the new EC.4.13 through EC.4.18 are readily “folded” into NIMS-compliant structures:

  • Communications
  • Resources and assets
  • Safety and security
  • Staff responsibilities
  • Utilities management
  • Patient clinical and support activities

That said, there’s really very little in the way of surprises in the new standards. When the Joint Commission updated the elements of performance under EC.4.20 (the standard requiring disaster drills) last year, several of the above-bulleted critical areas were identified succinctly (communications, resource mobilization, and patient care activities). The remaining newbies primarily resulted from post-Katrina reviews of hospital response in New Orleans and the rest of the Gulf Coast.

The expectation of The Joint Commission is that if your organization is able to get and keep its act together relative to those six areas, then you should be able to manage events of every stripe and magnitude.

Update on TB fit-testing requirements

Hi everyone –

It’s Scott Wallask over here at the Hospital Safety Center with a quick note.

There’s been a lot of reports swirling around about annual fit-testing requirements for tuberculosis (TB) in hospitals.

In 2004 as part of OSHA’s budget approval, Congress prohibited the agency from using those funds to enforce fit-testing provisions for TB, which falls under the respiratory protection standard. That prohibition has continued for the past several years.

While it seems likely that the fit-testing ban for TB will end with the fiscal year 2008 budget, it is not official quite yet.

FY 08 technically started today, but at this point, the full Congress has not passed various appropriations bills to send the funding along, Dan Glucksman, a spokesperson for the International Safety Equipment Association in Arlington, VA, told to me this afternoon. The American Hospital Association reported about this aspect as well last week.

So, reports that mandatory annual fit-testing for TB begins today may be a bit premature.

I’m waiting to hear back from OSHA about this whole issue. When I do, I’ll let you know.


Scott W.

ID badge content is mostly up to you

I was asked about whether there are any national standards that specify the contents of employee ID badges, and there are none that I know of.

Certainly The Joint Commission requires each organization to identify (as appropriate) “patients, staff, and other people entering the hospital’s facilities” (EC.2.10, EP #5), which, of course, leaves each organization the determination of “as appropriate.”

That said, you probably want to check your state public health regulations–frequently there are specific pieces of information that they require you to have available to patients via the ID badge (various name components, licensure, etc.). Also, as an added incentive, since the state folks are the ones usually tasked with CMS validation activities, it’s probably a good idea to make sure that you’re on their page.

What’s lurking with the storage revisions in the EC proposal?

One other item that I found interesting in the proposed revisions to the EC standards was in the revised design and maintenance of the environment (currently EC.8.10, EP #1, soon to be EC.7.01).

The revision states that the “organization provides sufficient storage space to meet patient needs.”

Now you might say, “So what, that’s already in there!” and you wouldn’t be incorrect. But the current EP under EC.8.10 speaks to specific design elements relating to space for patient personal property, while a requirement for “sufficient storage space to meet patient needs” can be extrapolated into the rest of the environment, maybe to include corridor clutter and stuff like that.

Now it may be that the pending Life Safety Code compliance chapter will preclude the use of this EP as a “general duty clause” relating to storage issues in healthcare. I’m guessing that the building maintenance program will take a larger profile in the new LS chapter-and I know there has been some discussion relative to expanding the BMP to include maintaining corridor widths-so perhaps that’s how this will end up as a compliance issue.

That said, I can’t help but think that as I travel around the country, I have yet to see new construction in healthcare that really provides an appropriate “answer” for the storage of patient-support equipment. It’s been a past practice to invoke the facilities master plan concept as a response to regulatory scrutiny of less-than-ideal storage accommodations. This revision for EC.7.01 may represent a ratcheting up of what will be tolerated.

I guess we’ll have to keep an eye on this one.