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Since I am already on the subject of BMPs…

As a final note on the building maintenance program-and I will admit to having a little obsessive-compulsive disorder about this topic- it is important to periodically review your program’s data.

While the 95% compliance rate might seem like a pretty comfortable margin with which to work, it is important in this less-than-perfect world to validate your assumptions. It is more than likely that 90% of your rated doors function appropriately every time. But it’s those other 10% of “trouble” doors that can get you into hot water.

For the “good” 90%, you might be able to get away with an annual inspection frequency (if the data supports that frequency), but those other 10% might need checking more often.

Remember, the goal is 95% at any given moment in time. If you’ve got maintenance challenges, it is imperative that you identify them and take appropriate actions to ensure proper operation of items in question.

Stay safe,
Steve Mac.

And now for something completely related…

Let’s talk more about The Joint Commission’s building maintenance program. Be forewarned that a BMP is not necessarily a panacea during survey.

Yes, there are some surveyors that might cut you some slack if you have a BMP, but, strictly speaking, if they find three Life Safety Code deficiencies during survey that cannot be reconciled with the items on your current PFI, and cannot be identified as having an approved equivalency, then you can receive an RFI under EC.5.20.

“What?” you might say, “That’s now how I understood it to work!”

Ah, my fine colleague, but what do we actually know about this process? If you look at the Statement of Conditions, it indicates that an organization may choose to resolve each of the noted deficiency types through a building maintenance program and goes on to describe an effective BMP as maintaining the noted life safety features at a 95% compliance rate.

What it doesn’t say is that there is no way, unless you have a very small inventory of a particular item, that a surveyor could inspect a sufficiently-sized sample to render a verdict on your actual compliance percentage.

But don’t jump off the ledge just yet! Where your maintenance data comes in to play is when you have to make your case on the back end, most likely during the clarification phase (each organization has a period of time post-survey in which they can provide The Joint Commission with data to support a finding of compliance).

At that point, through your organization’s survey coordinator, you would submit your BMP data for review by the folks at The Joint Commission’s Chicago headquarters. By the way, the commission has hired additional engineers to assist with the management of all things EC, including review of the electronic Statements of Conditions and PFIs.

Stay safe,
Steve Mac.

Effective building maintenance programs involve the front line

As we move closer and closer to some sort of mandate for The Joint Commission’s building maintenance program (I don’t know that we’ll ever get all the way there, but I am absolutely convinced that eventually, you won’t be able to comply with all the Life Safety Code’s elements without a BMP), it becomes clear that you need to explain the expectations of the program to frontline staff members engaged in maintenance activities.

Frequently, there is reluctance among frontline workers to report negative or deficient findings during their inspections. These folks need to be comfortable (and I suppose you do as well) that there will be no punitive aspect to this reporting, within reason.

Your organization needs that failure data to assess the performance of your BMP. You need to know:

  • What doors “fail” on a regular basis
  • Locations where those mysterious cable guys are not quite good about filling penetrations
  • If there are outdoor egress routes that suffer from an elevated level of snow and ice

Frontline staff members can help you do this if they feel confident of their roles. More about the BMP next time.

Steve Mac.

When you implement a new EC program, don’t forget to look back

A client facility of mine has a really neat process for managing penetrations in rated partitions. They have a little clipboard at the location of each partition (above the ceiling) and the maintenance folks are charged with inspecting these locations on an ongoing basis.

This works really well, up to a point. Any time there’s a penetration, it gets fixed right away, which is very cool.

However, where things broke down is that until the implementation of this process, a lot of penetrations had been filled in without using rated firestopping materials–and sure enough, those unprotected penetrations were the ones found during survey and given an RFI.

This facility’s penetration management process had reported really good compliance, but the building maintenance program couldn’t be invoked to resolve the RFI because of the number of penetrations (and these were probably filled years ago) that were not “properly” sealed.

Stay safe,

Steve Mac.

Watch for the subtleties of the EC standards

Another trend I’ve noticed is a failure mode relative to the familiarity of frontline staff with the expectations and requirements outlined in the standards and EPs.

I recently worked with a client that ran afoul of the new requirements under EC.7.40 for a four-hour generator test. The client had, in fact, operated the generator in question for a period well in excess of four hours, but had failed to provide acceptable documentation to the surveyors. This left the facility in the position of conducting the four-hour test again, which they did.

Ahh, but here’s where things got a little bit off track. In reviewing the documentation, I noted that for the first hour of the test, the generator did not meet 30% of its nameplate rating. When asked, the individual responsible for the testing responded, “we averaged 30% for the four hours, but it took us a bit to get up to where we needed to be.”

The element of performance in question, however, requires a test at 30% for four continuous hours, a subtle difference to be sure. But it was a difference that required them to conduct yet another generator test.

Risk assessments and Swiss Army knives

Here’s a quick word, of no doubt many to come, about risk assessments.

If you have a condition, regardless of its nature, that requires something of a formal invocation of the risk assessment process, I cannot advise more strongly that you periodically take the assessment out and look at it.

Yes, I know that The Joint Commission standards do not indicate a recurring frequency for risk assessments (though that is changing – check out the revised emergency management standards). However, as a safety professional, do you really believe that a single risk assessment lasts forever? I didn’t think so.

I can tell you with something approaching certainty that the conditions you assess today (or assessed two years ago) are not static. Your patient population is likely to go through incremental, if not dramatic, changes in diagnosis, acuity, etc.

For example, my primary base of practice is in Massachusetts, and I can tell you that as the municipal system for managing behavioral health patients has evolved (though “devolved” is probably the more appropriate descriptor), the challenges facing community hospitals has changed dramatically. Keeping patients and staff safe is not a one-time proposition.

First use the risk assessment process to identify improvement opportunities for your EC program. Then, use the data collected in the wake of interventions to drive your annual EC evaluations. There is not a risk or practical application for which you could not employ the risk assessment. The risk assessment acts as a veritable Swiss Army knife for the safety professional.

Steve Mac.

Don’t use a safety solution’s expense as an excuse to delay implementation

Last time I checked in, I mentioned the need to review your environment of care committee’s meeting minutes to make sure past concerns had been acted upon.

Here’s another suggestion when it comes to your EC paperwork: Make sure that your reports and other documents accurately reflect an appropriate management of issues. For example, say you’ve completed a risk assessment of your outpatient behavioral health unit of the potential for suicide. You’ve identified some quick fixes, some staff educational concerns, etc., but there are a couple of items that are going to have to wait until funding is available.

Please, please, please make sure (and I only mention this because I saw this scenario with my own two eyes) that you do not somehow characterize the decision as having been solely the result of an expense level.

Yes, it is absolutely acceptable to include the financial impact of any intervention as part of the debate–in fact, it is the responsible thing to do. However, you have to stipulate that any choice to hold off on an improvement is not being done at the expense of patient safety. You can never place a high enough price tag on patient safety.

If you identify an action or idea that needs to be improvement, you can (and should) prioritize its implementation, but you must also give equal time to what interim measures you are employ until such time as you can effectively remedy a problem. If you have an identified risk, you do not have the luxury of waiting to do anything. There’s always some incremental measure that can be used as a stop-gap instead of merely saying, “We don’t have the funds to carry this solution out.”

Steve Mac.

There’s gold in them thar minutes

Howdy folks,

I’ve been doing a fair amount of post-survey work with hospitals this year, and I can tell you that the stories you’ve heard about the environment of care being subject to a lot of attention are absolutely on the up and up.

And you know what? The focus isn’t necessarily the result of the life safety surveyor. Everybody on the survey team is looking very closely at the EOC.

I have noted a couple of trends that I’d like to share with you. Hopefully they will help keep you out of hot survey waters.

Let’s start with safety committee meeting minutes.

My personal practice has been to periodically go back (at least once a year, though I like every six months or so) and review your EOC committee minutes — including those reports that maybe didn’t get covered in full during the regular meeting.

A key point is to verify that you don’t have any unresolved issues lurking around in the past (before they take on the rosy hue of nostalgia).

Make sure that any interventions resulted in the improvements you were expecting, and confirm any monitoring of performance did in fact occur. Also, check that there are no issues for which action was deferred until a later date (that later date is probably in the past) without any further resolution.

The review of your committee minutes is designed to ensure that you have a process for making improvements in the environment. Don’t let that review be an opportunity for surveyors to point out where those improvements didn’t occur.

I’ll have more to say about this topic later this week.

Steve Mac.

Is the clock ticking when it comes to NFPA fire watches?

Hi again everyone. A reader asked me recently about the rules for fire watches–specifically whether there any other codes that indicate watches should be done every 15 or 30 minutes, as opposed to hourly.

The place to look is the NFPA’s Life Safety Code. Upon review, I have to admit that the code is a little less draconian in its demands than I had thought (a good thing, if you ask me).

Paragraph in the code states:
Where a required fire alarm system is out of service for more than four hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service.

An annex note to says that fire watches should include “special action beyond normal staffing, such as assigning an additional security guard to walk the areas affected. These individuals should be specially trained in fire prevention and in occupant and fire department notification techniques, and they should understand the particular fire safety situation for public education purposes.”

So as you see, the code doesn’t really set time frames for fire watch frequencies.

I’d advise folks to look over their fire watches process and see if anything “falls out” compliance-wise when compared to the guidelines from the code.

Crocs, OSHA, and you

Hi everyone, it’s Scott Wallask over here at HCPro, filling in for Steve Mac, who’s on the tail end of his vacation.

I figured I’d chime in because I am once again amazed at the publicity that Crocs footwear gets from the hospital industry.

Many of you probably saw an Associated Press news report this week noting that Mercy Hospital in Pittsburgh had banned staff members from wearing Crocs. Proponents of the ban told the AP that the holes in Crocs could pose a safety hazard should a dropped syringe “hit the target,” so to speak. Naysayers have different views on that idea.

Regardless, it reminds me of an unofficial OSHA note that made the rounds last year about Crocs.

From OSHA’s informal perspective, Crocs aren’t appropriate in a hospital setting if there is a reasonable expectation that blood or other potentially infectious materials could land on an employee’s feet, the agency said last August is its e-mail forum.

Such exposures are likely to occur in the OR, ER, and labs, for example. The bloodborne pathogens standard requires hospitals to provide appropriate personal protective equipment.

However, OSHA also informally indicated that it’s the hospital’s responsibility to:

  • Ascertain whether there is reasonable likelihood of exposure to blood or other fluids
  • Determine what constitutes appropriate footwear in the absence of exposure to any recognized hazards

In other words, employees could wear Crocs if the hospital determined that they didn’t face exposures on the job to blood and other bodily fluids.

So, the debate rages . . . over shoes.