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Tiers of a clown

With all the folderol relating to the changes in the management of life safety conditions in our facilities (Thanks CMS! Thanks TJC!), one of our other favorite regulatory acronyms got into the act when, effective August 1, our good friends at OSHA (the Occupational Safety and Health Administration) increased the tiers of its penalty structure about 78% for citations issued by OSHA on or after August 1, if the related violations occurred after November 2, 2015. So the penalty structure looks a little something like this:


Type of Violation Current Maximum Penalty New Maximum Penalty
Posting Requirements
$7,000 per violation $12,471 per violation
Failure to Abate $7,000 per day beyond the abatement date $12,471 per day beyond the abatement date
Willful or Repeated $70,000 per violation $124,709 per violation


Apparently, this is all based on Congress enacting legislation requiring the various and sundry federal agencies to adjust their civil penalties to adjust for inflation, so I’m guessing there will be other entities jacking up the prices noncompliance. So, I guess the $5471 / $54,709 increases are based on inflation since the last time they did their adjustments (makes me think it’s probably been a while), though they are curious numbers, but I guess it’s not that often that anyone has to pay the top dollar penalty.

The question has been bandied about as to whether or not the increase in the civil penalty is going to increase compliance, but the more I think about it, the more I suspect that compliance will stay right around where it’s always been. I suppose you might have a boss or two who will take greater interest in occupational safety (especially those that read, say, the Wall Street Journal,  and it appears that the penalty structure changes about as often as a new edition of the Life Safety Code® is adopted by CMS), but I’m guessing that interest will be closer to fleeting than not.

I suppose I should clarify my thoughts about compliance: we are not perfect as an industry (and there are those that will take great pains to remind us of our imperfections, including all those acronymic wonders), but when you think about all the moving pieces that we have to deal with on a constant basis, I believe that healthcare generally does a pretty good job on the occupational safety and health front. Again, imperfections abound, and we typically recognize them and work towards reducing incident rates to the extent possible. But I don’t think we do that because we are afraid of being fined by OSHA; I think it’s because, as committed safety professionals (and some days, you really are eligible for commitment with this job), it is the right way of going about managing safety in our organizations.

So the “ding” is bigger if the Big O has an issue with how you’re managing things, but I think the charge to safety professionals is clear and constant. You can read the official “word” from OSHA, including the final rule and some spiffy FAQs. But drink plenty of coffee…


Maybe these maps and legends have been misunderstood…

I don’t know about you folks, but The Joint Commission’s discontinuation of the PFI process has left me in a rather unsettled state. Heretofore, I think many of us (and I will include myself among that number) relied on TJC to provide some level of illumination into the inner workings of compliance as a function of what CMS is requiring. As I think I noted earlier, I was fully cognizant that CMS has been no particular fan of the PFI process as a means of ensuring compliance with the Life Safety Code®, but (presumably) there was always a tacit understanding—falling somewhat short of acceptance—that the PFI process wasn’t causing enough of a ripple in the fabric of compliance to warrant any direct intervention.

And now we find ourselves officially in August and still awaiting the arrival of the latest modular addition to The Joint Commission’s Physical Environment Portal (PEP), which was “scheduled” for a July release (at least that’s been the info posted on the portal site). At this point, I’m starting to think that the life safety modules may be on hold until the updated Life Safety chapter is unveiled later this year (presumably sometime ’twixt now and November). But the greater concern I have (and hopefully this is just a hyperbolic response to the deluge of changes) is whether the information contained in the PEP (and, to some degree, the physical environment FAQs) is as valuable (Useful? Reliable?) when it comes to keeping in line with CMS’ expectations. I think to one extent or another, we all relied on TJC as an arbiter/translator of how the physical environment Conditions of Participation could be interpreted/implemented from a practical/operational standpoint, but now I can’t help but wonder if that status has been torn asunder along with the PFI process. I’m probably over-thinking this, but I don’t have a feeling of comfort with the current state of things. I guess we shall see what we shall see—I, as always, remain optimistic, but, for whatever reason, it seems to be more of a struggle at the moment. But enough of that, for the moment…

As I was checking to see if there was an update to be found, I stumbled upon a missive in TJC’s leadership blog that I do not recall having seen before. So let me take you back about 10 months to those halcyon days of the early chortlings of the portal… (insert going back in time sound effects here).

In looking at this particular missive (penned by one G. Mills, Director, Department of Engineering—you can find the whole magillah here), there is some ground covered that is among my most favoritest of topics: the universality of the responsibilities when it comes to the management of the physical environment (and for those you who are keeping count, I have no idea how many times I’ve discussed this particular topic, but I’m going to guess it’s well into double digits. And that’s not even counting the number of times I’ve had variations of this conversation with clients…). In the blog, Mr. Mills notes that “…the patient care environment is not owned by one group in the healthcare setting.” I couldn’t agree more and yet I still (still, still, still!) encounter organizations that have not fully embraced that concept—which results in very little surprise on my part that eight of the 10 most frequently cited standards are in the physical environment. Mr. Mills goes on to say, “(W)e cannot look to one group to keep the area clean, another to keep the area warm/cool and then another group to treat patients independently.” But organizations continue to do just that, get bounced around during surveys, and still (still, still, still!) fail to grasp the team concept of managing the environment.

Now it’s certainly not every organization that has these issues, but until every organization gets “down” with this as a way of conducting the business of healthcare, the EC/LS findings will continue to pile up. The silos of clinical and non-clinical functions in healthcare organizations are no longer a tenable model—I’ve said it before and I will (no doubt) say it again—every individual working at every level in every healthcare organization is a caregiver. I’ll give you the direct/indirect split, but taking care of the patient in the bed is the role and responsibility of everyone. It is past time for a new paradigm—let’s make it happen—even without updates to the PEP!

Regardless of what happens in regards to the TJC/CMS dynamic, I think that healthcare as an industry needs to embrace this model for management of the physical environment. I know on an individual basis, everyone is wicked busy, but the success or failure of the management of the physical environment is a function of how ingrained the “see something, say something” philosophy is at point of care/point of service. You and I both know that I could say that I will speak of this no more, but you and I also know that the chances of my avoiding this topic are somewhere between slim and none…

Blame it on Cain…

We’ll see how long this particular screed goes on when we get to the end…

In my mind (okay, what’s left of it), the “marketing” of safety and the management of the physical environment is an important component of your program. I have also learned over time that it is very rare indeed when one can “force” compliance onto an organization. Rather, I think you have to coax them into seeing things your way. At this point, I think we can all agree that compliance comes in many shapes, colors, sizes, etc., with the ideal “state” of compliance representing what it is easiest (or most convenient) for staff to do. If we make compliance too difficult (both from a practical standpoint, as well as the conceptual), we tend to lose folks right out of the gate—and believe you me—we need everybody on board for the duration of the compliance ride.

For instance, I believe one of the cornerstone processes/undertakings on the compliance ride is the effectiveness of the reporting of imperfections in the physical environment (ideally, that report is generated in the same moment—or just after—the imperfection “occurs”). There are few things that frustrate me more than a wall that was absolutely pristine the day before, and is suddenly in possession of a 2- to 3-inch hole! There’s no evidence that something bored out of the wall (no debris on the floor under the hole), so the source of the hole must have been something external to the hole (imagine that!). So you go to check and see if some sort of notification had occurred and you find out, not so much. Somebody had to be there when it happened and who knows how many folks had walked by since its “creation,” but it’s almost like the hole is invisible to the naked eye or perhaps there’s some sort of temporal/spatial disruption going on—but I’m thinking probably not.

I’m reasonably certain that one can (and does) develop an eye/sense for some of the more esoteric elements of compliance (e.g., the surveyor who opens a cabinet drawer, reaches in, and pulls out the one expired item in the drawer), but do we need to educate folks to recognize holes in the wall as something that might need a wee bit of fixing? It would seem so…

At any rate, in trying to come up with some sort of catch phrase/mantra, etc., to promote safety, I came up with something that I wanted to share with the studio audience. I’d appreciate any feedback you’d be inclined to share:






I’m a great believer in the power of the silly/hokey concept when you’re trying to inspire folks; when you think of the most memorable TV ads, the ones that are funny tend to be the most memorable in terms of concept and product (the truly weird ads are definitely memorable, but more often than not I couldn’t tell you what product was being advertised). I think that as a four-part vision, the above might be pretty workable. What do you think?

This week in hell: What about the damn dampers?

We are certainly in the (very) early stages of the departure of The Joint Commission’s Plans for Improvement (PFI) process from our midst (Is it possible for a process to have abandonment issues? I suspect we’re going to be feeling something like it for quite some time to come.) and there continues to be much to chew on. This week, I’m going to break it down into a couple of chunks that will hopefully allow us to more easily digest this big mouthful of unpleasantness, but first, a rant (ooooh, big surprise):


  • I honestly don’t have a dog in this particular fight beyond my position as an observer of accreditation and regulatory compliance activities in healthcare, but I continue to “bump” up against the practice of TJC revealing substantive (and substantial) changes in forums that are not completely accessible to everyone with a dog in the fight. I don’t know about you, but my boss is generally inclined for me to be busy doing productive work, so I don’t oft (okay, never) get to the annual ASHE conference (and yes, I recognize the educational value, etc., of such gatherings, but, as you all probably know pretty well, that can be a very tough sell). Consequently, I (and perhaps a whole bunch of “yous” out there in the audience) was not present when the discontinuation of the PFI process was announced. I don’t know if there was a Q&A that followed the announcement, so I have no idea if questions were asked and answered, asked and deferred, asked and not answered, etc. I suspect if we all had known what was coming down the pike this year, between adoption of the 2012 Life Safety Code® (LSC) and PFI getting kicked to the curb, we might all have made a little bit of an extra effort to get to ASHE (well, perhaps you would have—I was having way too much fun tripping around Texas). At any rate, at the very least, I would love to see a transcript of the presentation as well as any Q’s and A’s that might have occurred. As an alternative thought, I also believe that something this monumentally important is deserving of a free webinar from TJC that includes a live Q&A (or if not a live Q&A, answers to pre-submitted questions would be okay)—this has the potential to be enormously painful for facilities and safety folks over the next little while (the optimist in me says “little while,” my fear is fairly long while) and, as customers, I think those same facilities and safety folks deserve a little time with the powers that be.
  • So what do we do with the damn dampers? As near as I can tell (with absolutely no empirical data beyond the number of questions I’ve received on the topic), there are a fair number of folks who have taken advantage of the PFI process for managing inaccessible dampers. When the PFI process goes away, does this mean all those dampers have to be brought in to compliance within the 60-day window? I am truly hoping that something specific to this issue is forthcoming before folks start tying up all the mechanical contractors in the US. Perhaps there’s a categorical waiver in the future for this piece of business—I think that would be a nice surprise. One thing I can tell you is that I know of at least one hospital that CMS required to clean up the damper issues identified on the PFI, so I have no reason to think that leniency will be the order of the day.
  • For those of you that reflect the PFI process in either your management plans or your ILSM plans/policies, you should probably pull those out and update the process as a function of no PFI process (I’m still not quite over the initial shock of that). Certainly for many, many years, a fundamental part of the standards-based requirements relative to ILSM was the management of LSC deficiencies that could not be immediately corrected (or corrected immediately, depending on your perspective), which brings us squarely into the realm of the PFI process. At any rate, make sure you make a quick of any policies/processes (hey, maybe even in your work order system) to make sure that you expunge all evidence of the PFI process.
  • As to the discontinuation of the Basic Building Information component of the Statement of Conditions, one of the things that’s “driven” by the information contained therein is the number of survey days, based on the square footage of healthcare occupancies in your facility. I don’t believe that the square footage question is asked during the organizational application process (might be worth checking with the individual in your organization charged with filing the application to verify what may or may not be in the mix), which makes me wonder how they will make the determination if folks don’t update the eBBI information. I suppose they have a basic starting point now, so it probably won’t change that much, but I also think of the SOC as a great means of communicating certain information to the surveyors—existing waivers/equivalencies (which makes me wonder: are we looking at a day when all the existing waivers/equivalencies granted by TJC go away or at least have to be resubmitted to CMS?), locations and square footage of suites, level of sprinkler coverage, and other unique aspects of the building can all be memorialized in the comment section of the SOC. But if the surveyors aren’t going to look at the SOC any more, do we print out the information and provide it to them directly or does this become one more potential sticking point during a survey? I guess a lot of the same information can be included on the life safety drawings, but I know a lot of folks don’t have the wherewithal to manage the drawings themselves so they use an architect or fire protection engineer for updates, etc.


All that said, I guess we’ll just have to keep our fingers crossed that some level of sanity is restored to the process, but given the state of the world, I don’t think I’m going to be holding my breath while I wait.

Breaking news: PFIs take a flyer!

Well, I suppose there was a certain element of inevitability to this. First, the expulsion of the most global “FIs” in the Joint Commission arsenal—the Requirement for Improvement (RFI) and the Opportunity for Improvement (OFI)—which left only one FI to be expelled, our good friend and (sometimes) benefactor, the Plan for Improvement (PFI). And that day has come (I don’t think there are any intact FIs kicking around, but I could be mistaken…)!

In what will likely end up being filed under the “no good deed goes unpunished” category (I’m more or less characterizing the adoption of the 2012 Life Safety Code® (LSC) as a good deed, though I will submit to you that, if only coincidentally, there has been an unleashing of a most distressing pile of poop), The Joint Commission has announced that, beginning August 1, 2016, it will eliminate the PFI process as a means of managing LSC deficiencies that cannot be immediately corrected and will take longer than 45 days to resolve. Yes, you did not misread that last sentence: say so long, farewell, auf wiedersehen, good bye (can I get an au revoir or adios?!?) to one of the most beloved characters in all of regulatory nuance. So, in place of the PFI process is an expectation for life safety deficiencies to be corrected within 60 days—unless, of course, you want to pursue a time-limited waiver with the friendly folks at your regional CMS office (don’t that sound like a party?). This information comes to us courtesy of the good folks at the American Society for Healthcare Engineering (ASHE), who provided this to members as an advisory released late yesterday afternoon.

When Jay Kumar, my editorial foil at BLR/HCPro asked me for my initial thoughts, there were several expletives that came to mind (and I suspect they are coursing through your collective craniums as well), but I do know that a fundamental means of having some element of control (even if it was somewhat illusory in nature) in managing conditions in the physical environment has pretty much been ripped from our hands. I guess we could look at this as one more piece of the “becoming more like CMS” movement that has been afoot for quite a few years now. Or maybe, as CMS never really accepted the PFI process as an alternative means of LSC compliance, they finally told TJC to cease and desist. I’m thinking this probably also pretty much quashes any thought that the Building Maintenance Program will ever be anything more than it is now (at this point, I’m not really sure what it is beyond a means of organizing the maintenance of certain life safety building features, not a bad thing, but not quite as compelling as it once was).

The process as outlined in the ASHE Advisory goes a little something like this:


  • Deficiencies will need to be corrected within 60 days of being identified unless the CMS regional office approves an extension.
  • All requests for extensions will be handled by CMS regional offices. However, The Joint Commission will allow facilities to submit requests and receive a receipt to show they are in the pipeline waiting for an extension.
  • The Joint Commission will not review open PFI items, and PFIs will not be a part of final reports.

Now before you get overly panicky, apparently we will still be able to use the PFI process as an “internal management process,” so everything’s good—right?

I guess we’re going to have to wait and see how this all unfolds in the field, but I have a sneaking suspicion that, of all the changes we’ve encountered this year, I suspect this one is going to result in the greatest amount of disruption, at least in the short term.

But hey, we work in healthcare—we embrace change! We grab change by the throat, throw it on the ground and kick it ’til it stops moving. We love change!

As plain as the nose on your emergency response plan…

Periodically, the whole concept of adopting plain language codes for emergency response plan activities/activations percolates to the top of somebody’s to-do list (I’d much rather embrace the concept of the to-don’t list, but that’s a discussion for another day). There was a little bit of that (more by inference than anything else) in the CMS follow-up report to the hospital response to Superstorm Sandy. Jeez Louise, that seems like eons ago…

This discussion always seems to engender a lot of back and forth, mostly regarding the balancing act of providing enough information to direct an appropriate response and not providing enough information to cause a panic. I recognize both sides of the argument, but I must say that I haven’t seen a lot of data to support a wholesale change, particularly as it would require a fair amount of education (and yes, I know that just because something requires education, etc., is not enough to forego adopting a new strategy, etc.). But I will also say that, depending on your organizational palette when it comes to emergency notification, all the different codes relative to workplace violence, active shooter, emergency assistance calls, etc., may well benefit from a more succinct announcement.

Recently, the Texas Hospital Association has weighed in with a recommendation to its members to adopt plain language codes, including a sample policy, an implementation timeline, and some examples (you can find that information here). It appears that there’s a move away from the (fairly standard, though not quite universal) Code Red designation for a fire alarm activation to the plainer language (though somehow not quite as sexy) “fire alarm activation.” It does appear that medical emergencies will remain as the (again, fairly standard, not quite universal) Code Blue (I guess that one’s gotten enough play on medically-oriented TV programs to have become part of the vernacular—where are the TV shows about safety in hospitals?!?), but there are some other terms that are worth of consideration. I don’t know that there’s necessarily a groundswell of support, but sometimes Texas can be something of a bellwether, so it may be a good opportunity to look at the possibilities, particularly if you haven’t in a while.

That said, I have two (relatively moderate) concerns. One being we are still waiting on the unveiling of the CMS final rule on all things emergency management; I had thought perhaps that pursuit had become somewhat dormant, but with the adoption of the 2012 edition of NFPA 99 excluding the chapter on emergency management, I think we have to believe that something regulatory this way comes. At any rate, will CMS push for some standardized notification language, particularly as a function of a focus on interoperable communications capabilities? I think that card has been dealt, I guess we’ll have to see how it gets played.

The other concern is the overarching concept of interoperable communication capabilities; I, for one, do not recommend you go about changing anything in terms of notification until you have some talk-time with the local emergency response authorities. They may or may not feel like they have a stake in this discussion, but you want to be absolutely certain that any modifications you might be entertaining will not somehow fly in the face of established protocols, language, etc. Isolationism, particularly when it comes to emergency management, is not likely to be a winning strategy as it usually requires the cooperation of disparate resources. So don’t forget to keep the community folks in the loop—you never know when they might come in handy!


Teddy Roosevelt would likely not cotton to these monkeyshines…

Our former president, one Theodore Roosevelt (when are Simon and Alvin going to run for office? I think their time is nigh…) is famous for a number of things, including the introduction of “bully” as a positive adjective (if you want to check out the manuscript that started it all, you can find it here). Unfortunately, the verb bully is very much a presence in today’s society (reaching near pandemic proportions in the various social media forums), including the healthcare industry. Now, I have certainly kvetched once or twice about the lack/loss of civility in general and our good friends in Chicago have taken up the gauntlet, and I think we can all agree: “bullying has no place in healthcare.”

As I reflect on the past 50 or so years (maybe a little more towards the so, but that’s just between us), I can look back on any number of encounters with bullies (only one black eye and that was rather a long time ago), including the 35+ years in healthcare. Bullies come in all shapes, sizes, social position, jobs, etc., and you can’t always tell right away who might rule in (or out) for this least desirable (well, maybe not least, but purty darn close) of personality flaws. Sometimes it’s folks who are in positions of authority/power, sometimes not, sometimes it even comes with a smile (though I’ve noted that those smiles rarely, if ever, reach the eyes), but I think I can safely say that bullying behavior engenders some of the most unpleasant “environments” that we are likely to experience. In the latest Quick Safety publication, Joint Commission offers some insight into the cultural elements that exist/foment when bullying is present in the healthcare environment. And while the Quick Safety publications are not necessarily enforceable as standards, this does tie back to Sentinel Event Alert #40 (Behaviors that undermine a culture of safety), which is aimed at the appropriate management of various forms of disruptive behavior, including bullying. At any rate, the Quick Safety article specifically references some action items that were included in the Sentinel Event Alert:


  • Educate all team members on appropriate professional behaviors that are consistent with the organization’s code of conduct
  • Hold all team members accountable for modeling desirable behaviors
  • Develop and implement policies and procedures/processes that address:
    • Bullying
    • Reducing fear of retaliation
    • Responding to patients and families who witness bullying
    • Beginning disciplinary actions (how and when)


So, my question to you is: How are things going in this area of concern? I don’t know that I’ve run into anyone who’s been able to completely eliminate bullying (or, as I think about it, anyone who’s been able to demonstrate a reduction in such behaviors—it just seems to be much more of a constant escalation, but that may just be me). I’m hoping that perhaps someone will have some stories to share with the group, even tales of efforts that fell short of the mark. We know it’s out there and I’m thinking that the release of this Quick Safety article may be a harbinger of future survey focus—how would you respond if the question came up during survey? I think it’s a reasonably safe pontification to say that bullying really doesn’t help to get things accomplished (again, recognizing that there are certain mindsets that might disagree, but I suspect those that disagree might be of the bullying persuasion), but I am interested in hearing about your experiences.

Are we there yet? Almost certainly not!

One of the fundamental purposes/charges of any high-reliability organization/program, etc., is to be able to identify improvement opportunities and to act upon those opportunities in a manner that actually results in sustained improvement. In the Boston area, we call that “making things bettah!” So, when it comes to the management of the physical environment, I think we can all agree that sustainable improvement is a good thing and, from an operational perspective, really makes a lot of sense. But it’s not necessarily good sense that drives your performance improvement efforts—it’s also a regulatory requirement.

If you look at the CMS Conditions of Participation, clearly there is an expectation of CMS for the management of the physical environment to be incorporated into the hospital’s QAPI program:

482.41 Condition of Participation: Physical Environment

The hospital must be constructed, arranged, and maintained to ensure the safety of the patient, and to provide facilities for diagnosis and treatment and for special hospital services appropriate to the needs of the community.

Interpretive Guidelines §482.41

This CoP applies to all locations of the hospital, all campuses, all satellites, all provider-based activities, and all inpatient and outpatient locations.

The hospital’s Facility Maintenance and hospital departments or services responsible for the hospital’s buildings and equipment (both facility equipment and patient care equipment) must be incorporated into the hospital’s QAPI program and be in compliance with the QAPI requirements.

Interpretive Guidelines §482.41(a)

The hospital must ensure that the condition of the physical plant and overall hospital environment is developed and maintained in a manner to ensure the safety and well being of patients. This includes ensuring that routine and preventive maintenance and testing activities are performed as necessary, in accordance with Federal and State laws, regulations, and guidelines and manufacturer’s recommendations, by establishing maintenance schedules and conducting ongoing maintenance inspections to identify areas or equipment in need of repair. The routine and preventive maintenance and testing activities should be incorporated into the hospital’s QAPI plan.

So, that sets things up fairly succinctly, but in looping back to what CMS is calling/looking for in terms of the indicated “QAPI requirements,” I think there may be opportunities to open things up a bit beyond merely tracking compliance rates (which, typically, perform up to/within regulatory/organizational expectations) and start to look at what those compliance rates mean in terms of demonstrating/verifying the effective management of the physical environment. For example, to my mind, monitoring fire drill compliance as a straight X number of drills per quarter, etc., really doesn’t make a great deal of sense, unless you are having difficulties meeting the requirement (and I should point out that if you are having difficulties conducting fire drills, that’s not going to play well with too many regulatory surveyors). Where I think the “gold” might be (continuing the fire drill example) is in working on figuring out how to demonstrate that the fire drills are effective in preparing folks to respond appropriately in the event of a fire, which leads us to the next piece of the CMS expectation:

482.21(a)(2) The hospital must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that assess processes of care, hospital service and operations.

 482.21(b)(2) The hospital must use the data collected to–(i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement and changes that will lead to improvement.

If you have indicators that are consistently performing at the 100% level, while someone is still going to be monitoring those programmatic aspects, it’s probably time to retire them from the active reporting structure to your EOC Committee. Now I know folks are usually loathe to focus too much on the negative stuff (nobody wants to get in trouble, etc.), but if I may make the suggestion—as a starting point, look at the stuff that you do pretty well, but not perfectly (and if we have learned nothing else over the past couple of years, it’s those things that are not perfect that can cause the biggest problems during a survey). For example, say you are tracking completion rates for non-urgent work order requests, and you are experiencing a pretty solid 90%-95% closeout rate. Now, I would call that a pretty good rate for the non-urgent stuff (presuming that this sterling completion rate is not getting in the way of completing urgent work order requests), but what about that 5%-10% of things that aren’t being completed? Are there any butt-biters in that grouping (things that later resurface to bite you on the backside)? In the interest of putting our best face forward, I think sometimes we focus too much on what has been done and not so much and what hasn’t been done. And I will tell you, the stuff that doesn’t get done will usually cause more trouble than the stuff that did get done.

So when it comes to performance improvement, while it is nice to reflect on the successes of the past, the key metrics “live” in the journey ahead: recognizing that compliance is a journey and not a destination. We ain’t never gonna be “done” with this little pursuit.

For those of you in the northern hemisphere, please enjoy these first days of summah! For those of you at the other end of the globe, wintah is nice, too!

A clear case of compliance interruptus

Greetings one and all from high above the 2012 Life Safety Code® (LSC) compliance track with a quick update on CMS plans for administering surveys, etc., in the wake of official adoption of the 2012 LSC. I’m climbing out on a limb just a little bit as the latest missive in this regard from The Joint Commission indicates that it will begin surveying to the requirements of the 2012 LSC on July 5 (Happy freakin’ Independence Day), but it appears that CMS has other ideas. In a member alert disseminated late last week, our friends at the American Society for Healthcare Engineering (ASHE) are reporting that a memorandum was issued by CMS to the various and sundry accreditation agencies (TJC, DNV, HFAP, M-O-U-S-E) indicating that hospitals have until November 7, 2016 before this new shiny hammer is wielded during accreditation surveys. Now, I think it was likely that there would be some sort of transition period for this process (the accreditors would have to update their standards manuals, etc., and I don’t think that happens overnight, but maybe there are manual elves that come in under cover of darkness), so I guess that has come to pass and the end date for that transition is November 7 (I guess they didn’t want to wait until the following month’s day of infamy).

As I’ve noted in this space recently, a lot of the basic tenets of compliance are going to pretty much stay the course. We will continue to manage rated barriers (walls, decks, doors); we will continue to manage egress (perhaps a little more simply, but clutter will still be clutter) and so on. There may be some efficiencies to be gained in the practical application of the various fire alarm and fire suppression system inspection, testing, and maintenance processes (I’ll have to do some edumacation on those), but I really think that the devil in all these details is going to come from how the requirements of NFPA 99 Standard for Health Care Facilities are administered and/or otherwise enforced. NFPA 99 has always kind of hovered in the background, but I think is going to be very much a coming out party. At any rate, ASHE has made available a fair number of resources (some readily accessible, some for members) and I would encourage you to do a little digging if you have not already done so. I still think the physical environment is going to figure quite strongly in the survey process, but maybe this is where we get to share the most frequently cited standards lists with the clinical folks.

On a closing, and most somber note, in the wake of events in Orlando this weekend (thoughts and prayers to all the victims, their families, the community at large, and pretty much everybody else), I can’t help but think that there’s got to be a better way. I know the circumstances that can lead up to events like these are extraordinarily polarizing—and I’ve noted that the polarization didn’t waste any time manifesting itself in the halls of social media. I wish that I had some sage bit of advice or encouragement, but nothing is coming right now beyond this old cliché (doesn’t make it any less useful or true)—cherish your loved ones…right now! We will all be better for it.

AAMI: What you gonna do?

By necessity, this is going to be somewhat of a hodgepodge of stuff as there are no new postings to The Joint Commission’s PEP site. Looks like we’ll have to wait for July to see what they have to say about the intricacies of LS.02.01.30, though I suspect that we can anticipate some coverage of hazardous locations (Can’t they come up with a better descriptor? While I absolutely understand that the requirements are driven by the point at which the level of stored combustibles in a space is considered “hazardous,” I find that it can be rather challenging when communicating to the clinical folks as to why they shouldn’t randomly convert patient rooms to storage rooms. The refrain is typically “We don’t have anything hazardous in the room, we just have paper supplies, etc.” to which I respond, “Well, you’ve got an amount of paper supplies, etc., that is considered hazardous by the Authority Having Jurisdiction,” to which I tend to receive a blank look and an “oh.” Told you this was going to be a hodgepodge…

Getting back to our PEPpy discussion; I think we’ll find out a bit about smoke barriers, corridor walls, corridor doors, etc. But then again, with the adoption of the 2012 Life Safety Code®, the scheduled PEP modules may be deferred and perhaps they’ll post something relating to whatever changes will be occurring to the Life Safety chapter of the accreditation manual. I think that’s enough blathering about something that didn’t happen, so let’s talk about something that did happen.

At this point, you (or your organization—why I would think that you would have been involved in this is beyond me…) should be well-ensconced in the practical applications of the National Patient Safety Goal regarding the management of risk associated with clinical alarm systems as a function of the Joint Commission requirements thereof:

  • Leadership establishment of alarm system safety as an organizational priority
  • Identification of the most important alarm signals to manage
  • Establishment of policies and procedures for managing those most important alarm signals
  • Education of staff and licensed independent practitioners about the purpose and proper operation of alarms systems for which they are responsible

Hopefully you’ve got that all going in the right direction. But if you’re falling a little short or if, indeed, you’re not sure about progress, the good folks at the Association for the Advancement of Medical Instrumentation (AAMI) have a webpage devoted to information regarding clinical alarms. Those resources include a downloadable Clinical Alarm Management Compendium (maybe CLAMCOMP would be a good acronym) to assist you in these endeavors. If you haven’t yet checked out the AAMI materials, I would very much encourage you to do so (or encourage you to encourage whoever is managing this process in your organization) is because reference to this webpage is included in the rationale statement for this particular safety goal and the stuff that ends up in the accreditation manual has a tendency to take on an elevated criticality in the hands of some surveyors. We could certainly talk about what is and what isn’t “surveyable” as a function of its appearance in any of the manuals, but if you haven’t referenced the AAMI stuff, you are in a position to have defend why you haven’t used such an august reference in your pursuit of alarm safety. To add a bit of heft to this advice, you might also consider the May 18, 2016 edition of Joint Commission Online, in which there is a link to an article published by the AAMI Foundation entitled “Framework for Alarm Management Maturity.”

This may be much ado about nothing, or more likely, folks are already “down” with this. But on the off chance that somebody out there actually uses this space for information and hasn’t run across this, I think it’s worth a mention. You certainly want to make sure that your alarm management process is maturing in proper fashion.