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You can post comments to Mac’s blog now

Hi folks —

It’s Scott Wallask checking in. I just wanted to let all of you know that the “comments” function is finally up and running for Mac’s Safety Space.

To post a comment, you need to log in as a subscriber or trial user to the Hospital Safety Center, though anyone can read the comments without logging in.

Please let us know what you think of Mac’s postings by submitting a comment or share your experiences on a particular topic.


Scott W.

Examples of immediate threat to life and safety, Joint Commission style

In my last posting, I talked about when surveyors invoked an immediate threat to life and safety. Let’s take a stroll through the list of “threats” we’ve encountered during client surveys, shall we?

Consider these:

  • Lack of master alarms for medical gas systems
  • An unreliable fire pump
  • Inoperable fire alarm system
  • Fire doors throughout the facility not closing and latching
  • Penetrations in fire walls not sealed with a fire-rated material
  • Main circuit breaker not tested or maintained and raw sewage leaking from pipes in a crawl space beneath a hospital
  • Lack of procedures to identify and maintain fire protection (i.e., lack of an effective means to transmit a fire signal to an external point and the responsible person not knowledgeable on the use of the fire alarm system)
  • No means of exit in an emergency and lack of implementation of interim life safety measures

Do you see a pattern developing? Well, neither do I–just kidding. Some of these situations seem fairly straightforward, but thinking about the fire doors and penetrations (not to mention how one would define an “unreliable” fire pump), there does appear to be some room for surveyor interpretation. As they might say here in the Boston area, that’s a shockah!

I think if I had to give you a piece of advice, it would be to make sure that everyone on your team has a pretty good understanding of how EC issues interrelate and how your organization ensures that all of these working parts come together and result in the safest possible environment for patient, staff members, and visitors.

And staff members may need to articulate this when you’re not around (unless you’re planning on no vacations until the next survey–I know I’d be tired).

If your survey will be between now and the end of the year, then start preparing now. If your survey was last week, start now. If your survey won’t be until at least 2009, start now. This is one of those things that is not at all well-served by procrastination.

Are you threatening me? Do I look like I’m threatening you?

One of the more precipitous aspects of the survey process is the invocation of an immediate threat to health or safety. This would the moment of a survey in which your entire world turns into manure.

Hopefully, such a plight will never darken the hallowed halls of your organization, but there is some indication that this problem has been occurring more frequently of late, so it seemed a good opportunity to cast a little light into this shadowy corner of accreditation lore.

Basically, the ball starts rolling when surveyors believe that they have encountered a situation that has, or may potentially have, a serious effect on someone’s health or safety, and thus requires immediate action to remedy the condition.

The survey comes to a screeching halt, your CEO gets to hear the fabulous news, Joint Commission headquarters near Chicago gets a call, even “appropriate government authorities” are in the loop-it’s all just too lovely. Of course, the impact on your accreditation status can be swift and painful, too. I’ll take root canals for $1,000 please, Alex.

Then there are the things you have to do to get out from underneath this damnation:

  • Take immediate action to completely remedy the situation
  • Prepare a thorough and credible root cause analysis
  • Adopt systems changes that prevent future recurrence of the problem

There are a number of conditions I’ve heard about in the environment of care that have resulted in the invocation of an immediate threat to life and safety. I’ll get into them in my next posting.

Stay safe,

Steve Mac.

Elevator problems cause a scare at a Seattle hospital

Hi everyone –

It’s Scott Wallask checking in here at the Hospital Safety Center.

Those of you who use ISIS model elevators manufactured by ThyssenKrupp should read this story about a hospital that had an elevator failure in Seattle. Luckily, the elevator’s safety brakes worked and no one was injured.

ISIS models use Kevlar ropes that don’t require a machine room. In a letter available at the link above, ThyssenKrupp has outlined a series of actions it will take across the country in response to the hospital mishap.

24 + 24 + 24 + 24 = ?

In visiting with hospitals across the country since the unveiling of the new emergency management standards, there’s been an increasing murmur relative to the presence of a certain temporal indicator that you can find under EC.4.12, EP #6.

96 hours. Four days. 5,760 minutes.

That time span brings with it some questions:

  • Is this a long time to be without the support of the local community?
  • Does it vary within the six critical areas of EC.4.13 through EC.4.18 (communications, resource and asset management, safety and security, management of staff, management of utilities, and management of clinical and support activities)?
  • Does it mean I need to have four days worth of stuff in my warehouse?
  • What if I don’t have a warehouse?
  • How prepared is prepared?

These are all excellent questions for which your organization is going to have to identify answers. For good or ill, there are no correct responses for these questions, and the practical applications are going to vary from organization to organization.

What’s important to remember is that this particular EP is not telling you that you have to do one thing or another (like having 96 hours worth of stuff in your warehouse). What is required is that you have a sense of what would happen if you were cut off from support for those 96 hours. Some organizations might be able to do 96 hours on their own with very little difficulty, while others might struggle to get to 48 or even 24 hours (probably not many in that group, but it is possible). The ultimate questions are: How far can you go? And what do you do when you’ve gone as far as you can go?

One of the clear lessons learned in the aftermath of Hurricane Katrina is that holding on past the point of reason is, well, not a reasonable strategy. But prior to recent tragedies, it’s almost as if the “defend-in-place” strategy of life safety management was carried across to the annals of emergency response. Right or wrong, getting out appeared to be entertained very infrequently in our response plans.

Now we know that in order to even approximate the safe management of a catastrophic event, we must consider the inconsiderable, think the unthinkable, try to gain some measure of control over situations that are, for all intents and purposes, uncontrollable.

What would we do if faced with an event of such magnitude? How far can we go? How do we tell when we’ve crossed that threshold? All questions to answer-and soon.

Use your full compliance data when clarifying RFIs

In my last post I talked about the advantages of using The Joint Commission’s clarification process when you receive an RFI.

Just to give you an example of how this could manifest itself, say you have a couple of off-site clinics that are visited during a hospital survey and surveyors find 10 fire extinguishers that missed a monthly inspection. (By the way, frequently survey verdicts are based on sample size-for all intents and purposes, if surveyors find three or more noncompliant conditions within an EP or standard, they have to score it as a “0” or noncompliant.)

It appears the surveyors have the hospital in a bad situation. As they might say in the U.K., “It’s a fair cop!” But, if you look at that EP (EC.5.40, EP #12), why, it’s a “C” score. Can we do something here? You betcha!

We know how many extinguishers we have in our inventory: 75 extinguishers at the main hospital and another 10 at all of the off-sites, for a total of 85 devices. Ah, but we still don’t make the mark-10 out of 85 is a compliance rate of 88.2%, which may be enough to downgrade to a supplemental citation, but not enough for outright removal of an RFI.

But is that really the case? I’m thinking perhaps not.

As you know, compliance is generally measured as a function of 12-month periods. If you take your fire extinguisher program to the 12-month parameter, you end up with a total number of monthly inspections as a function of the number of extinguishers (85) and the number of inspections per year per extinguisher (12), which yields 1,020 activities.

With that number in mind, if you only missed 10 inspections, then you still have a compliance rate of better than 99%. No RFI for you, my friend. Your compliance data is most useful in the clarification process.

One further note about auditing: You need to base the timeframe for review on the date of your survey. The only sure way to vacate an RFI is to demonstrate that you were in compliance during the survey.

Now you may say my extinguisher anecdote is an extreme example, but I can assure you that this solution absolutely works in real life (this falls under the “been there, done that” category).

But what if my hospital isn’t in any real accreditation jeopardy? What’s the point of chasing these rainbows? Well, turning once more to Joint Commission official Darlene Christianson in her remarks at the Executive Briefings conference, we learn that, beginning in 2008, the number of RFIs you receive during your triennial survey can influence how soon (or not) you can expect your next survey.

Remember, the survey window will be opening to any time from 18-39 months after your most recent survey-a mighty big window, yes? I’d rather see the 39-month-sized window.

And perhaps most importantly, do you really want to submit an “evidence of standards compliance” response and be responsible for fixing a process that wasn’t broken in the first place? Don’t you have enough to do fixing things that ought to be fixed? I thought so…

Butter isn’t the only thing you can clarify…

Okay, Elvis has left the building (picture a Joint Commission surveyor with sideburns, sunglasses and a big ‘ol belt buckle-bell-bottoms optional) and you’re the proud owner of a handful of EC RFIs.

You tried, tried, tried to negotiate a favorable result during the survey, but a couple of things would not go away. Adding insult to injury, your organization is looking at an adverse decision of conditional accreditation (CON) or even preliminary denial of accreditation (PDA) and the rest of the team is giving you the hairy eyeball because you were supposed to have everything under control-right?!?

Well, the departure of the survey team does not signal the end of things. And, importantly, if your organization is facing an adverse accreditation decision, you need to start digging yourself out of that CON or PDA hole.

The best tool for the job? The clarification process.

But don’t spend too much time moping around because the clock is ticking.

Organizations faced with an adverse decision have a mere 10 business days from your final report to submit clarifications for findings during survey. You need to carefully analyze each finding to identify any RFIs for which clarifying evidence will reverse one or more citations. But which one (or ones) do you choose?

At a recent Joint Commission Executive Briefings conference, Darlene Christianson, executive director of accreditation and certification services at the Joint, urged the audience at a minimum to perform a post-survey audit on all RFIs involving C elements of performance and submit the results as a clarification if the audit demonstrates 90% compliance or better.

What’s that? A score of 90% is all I need? Yes, my friends, you heard it right. And, to sweeten the clarification pot even more, an audit compliance percentage of 80%-89% can, in certain cases, result in a reduction from an RFI to a supplemental recommendation.

So I ask-what are you waiting for? More on this in my next posting . . .

Steve Mac.

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.