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I’ve got a feeling…

Just a quick drop of the microphone to let you know that our friends in Chicago are presenting a webinar on the SAFER methodology that The Joint Commission will use during hospital surveys starting in January. As we’ve discussed previously, with the removal of standard types (As and Cs and whatever else you can conjure up) and the introduction of the “Survey Analysis for Evaluating Risk (SAFER) matrix to prioritize resources and focus corrective action plans in areas that are in most need of compliance activities and interventions,” it appears that once again we are heading into some white water rapids (certainly Class 4, with intermittent burst of Class 5/6—better wear your life vest). That said, I appears that the webinar (scheduled for November 15) is for a limited audience number, but I do think that it might be useful to listen in to hear what pearls may (or may not) be uttered. You can register here and it also appears that the session will be recorded and made available on the TJC website (as near as I can tell, the webinar is free, so check your local listings).

Ciao for now. Back next week with more fun than you can shake a stick at…

History shows again and again how standards (and EPs) point out the folly of men…

It’s beginning to look like the proofreaders in Chicago must be enduring some late nights watching the Cubs! I don’t know about you folks, but I rely rather heavily on the regular missives from The Joint Commission, collectively known as Joint Commission E-Alerts. The E-Alerts deliver regular packages of yummy goodness to my email box (okay, that may be a little hyperbolic) and yesterday’s missive was no exception. Well, actually, there was an exception—more on that in a moment.

While it did not get top billing in the Alert (which seems kind of odd given what’s been going on this year), the pre-publication changes to the Life Safety chapter of the accreditation manual have been revealed, including comparison tables between what we had in January 2016 and what we can expect in January 2017. Interestingly enough, the comparison tables include the Environment of Care (EC) chapter stuff as well (though the EC chapter did not merit a mention in the E-Alert), so there’s lots of information to consider (which we will be doing over the course of the next little while) and some subtle alterations to the standards/EP language. For example (and this is the first “change” that I noted in reviewing the 112 pages of standards/EPs), the note for EC.02.02.01, EP 9 (the management of risks associated with hazardous gases and vapors) expands the “reach” to specifically include waste anesthetic gas disposal and laboratory rooftop exhaust (yes, I know…very sexy stuff!). It does appear that at least some of the changes (tough to figure out the split between what is truly “new” and what is merely a clarification of existing stuff—check out the note under EC.02.03.05, EP 1 regarding supervisory signal devices because it provides a better sense of what could be included in the mix). Another interesting change occurs under EC.02.03.05 (and this applies to all the testing EPs) is that where previously the requirement was for the completion dates of the testing to be documented, now the requirement actually states that the results of the testing are to be documented in addition to the completion dates. Again, a subtle change in the language and certainly nothing that they haven’t been surveying to. Oh, and one addition to the canon is the annual inspection and testing of door assemblies “by individuals who can demonstrate knowledge and understanding of the operating components of the door being tested. Testing begins with a pre-test visual inspection; testing includes both sides of the opening.” At any rate, I will keep plowing through the comparison table. (Remember in the old days, it would be called a crosswalk. Has the 21st century moved so far ahead that folks don’t know what a crosswalk is anymore?)

The top billing in yesterday’s All Hallows Eve E-Alert (making it an Eve-Alert, I suppose) went to the latest installment in that peppiest of undertakings, the Physical Environment Portal. Where the proofreaders comment comes into play is that the Alert mentions the posting of the information relative to LS.02.01.30, (which happened back in August) but when you click on the link, it takes you to the update page, where the new material is identified as covering LS.02.01.35, so there is updated material, though you couldn’t really tell by the Alert. So, we have general compliance information for the physical environment folks, some kicky advice and information for organizational leadership, and (Bonus! Bonus! Bonus!) information regarding the clinical impact of appropriately maintaining fire suppression systems (there is mention of sprinkler systems, but also portable fire extinguishers). I’d be interested to see if anyone finds the clinical impact information to be of particular use/effectiveness. I don’t know that compliance out in the field (or, more appropriately, noncompliance) is based on how knowledgeable folks are about what to do and what not to do, though perhaps it is the importance of the fire suppression systems and the reasons for having such systems (Can you imagine having to evacuate every time the fire alarm activates? That would be very stinky.) that is getting lost in the translation. I have no reason to think that the number of findings is going to be decreasing in this area (if you’re particularly interested, the comparison table section on LS.02.01.35 begins on p. 80 of that document—any changes that I can see do appear likely to make compliance easier), so I guess we’ll have to keep an eye on the final pages of survey year 2016 and the opening of the 2017 survey season. Be still my beating heart!

I wanna know: Have you ever seen the rain?

In our intermittently continuing series on the (final!) adoption of the 2012 Life Safety Code®, we turn to the one area about which I have still the most concerns—the magic land of NFPA 99. My primary concern is that while NFPA 99 contains lots and lots of references to risk assessments and the processes therein, I’m still not entirely convinced that the CMS oversight of the regulatory compliance process is going to embrace risk assessments to the extent that would allow us to plot our own compliance courses. I guess I will have to warily keep my fingers crossed and keep an eye on what actually occurs during CMS surveys of the physical environment. So, on to this week’s discussion…

When considering the various and sundry requirements relating to the installation and ongoing inspection, testing and maintenance of electrical system components, one of the key elements is the management of risk associated with electrical shock in wet procedure locations. NFPA 99 defines a wet procedure location as “(t)he area in a patient care room where a procedure is performed that is normally subject to wet conditions while patients are present, including standing fluids on the floor or drenching of the work area, either of which condition is intimate to the patient or staff.”

Typically, based on that description, the number of areas that would “rule in” for consideration as wet procedure locations is pretty limited (and depending on the nature, etc., of the procedures being performed maybe even less limited than that). But in the modern age, the starting point for this discussion (and this is specifically provided for under section of the 2012 edition of NFPA 99) is that operating rooms are to be considered wet procedure locations—unless a risk assessment conducted by the healthcare governing body (yow!) determines otherwise (all my yammering over the years about risk assessments is finally paying off—woo hoo!). By the way, there is a specific definition of “governing body”: the person or persons who have overall legal responsibility for the operations of a healthcare facility. This means you’re going to have to get your boss (and your boss’ boss and maybe your boss’ boss’ boss) to play in the sandbox on this particular bit of assessmentry.

Fortunately, our good friends at ASHE have developed a lovely risk assessment tool (this is a beta version) to assist in this regard and they will share the tool with you in exchange for just a few morsels of information (and, I guess, a pledge to provide them with some useful feedback as you try out the tool—they do ask nicely, so I hope you would honor their request if you check this out—and I really think you should). Since I’m pretty certain that we can attribute a fair amount of expertise to any work product emanating from ASHE (even free stuff!), I think we can reasonably work with this tool in the knowledge that we would be able to present it to a surveyor and be able to discuss how we made the necessary determinations relative to wet procedure locations. And speaking of surveys and surveyors, I also don’t think it would be unreasonable to think that this might very well be an imminent topic of conversation once November 5 rolls around and we begin our new compliance journey in earnest. Remember, there is what I will call an institutional tendency to focus on what has changed in the regulations as opposed to what remains the same. And I think that NFPA 99 is going to provide a lot of fodder for the survey process over the next little while. I mean think about it, we’re still getting “dinged” for requirements that are almost two decades old—I think it will be a little while before we get our arms (and staff) around the ins and outs of the new stuff. Batten down the hatches: Looks like some rough weather heading our way!

At any rate, here’s the link to the wet procedure location assessment tool.

Hope everyone has a safe and festively spooky (or spookily festive) All Hallows Eve!

Is you is or is you ain’t a required policy?

Yet another mixed bag this week, mostly from the mailbag, but perhaps some other bags will enter into the conversation. We shall see, we shall see.

First up, we have the announcement of a new Joint Commission portal that deals with resources for preventing workplace violence. The portal includes some real-world examples, some of the information coming from hospitals with whom I have done work in the past (both coasts are covered). There is also invocation of the Occupational Safety & Health Administration (lots of links this week). I know that everyone out there in the listening audience is working very diligently towards minimizing workplace violence risks and perhaps there’s some information of value to be had. If you should happen to uncover something particularly compelling as you wander over to the Workplace Violence Portal, please share it with the group. Bullying behavior is a real culture disruptor and the more we can share ideas that help to manage all the various disruptors, we’ll definitely be in a better place.

And speaking of a better place, I did want to bring to your attention some findings that have been cropping up during Joint Commission surveys of late. The findings relate to being able to demonstrate that you have documented a risk assessment of the areas in which you manage behavioral health patients; particularly those areas of your ED that are perhaps not as absolutely safe as they might otherwise be, in order to have sufficient flexibility to use those rooms for “other” patients. Unless you have a pretty significant volume of behavioral health patients, it’s probably going to be tough to designate and “safe” rooms to be used for behavioral health patients only, so in all likelihood you’re going to have to deal with some level of risk. I suppose it would be appropriate at this juncture to point out that it is nigh on impossible to provide an absolutely risk-free environment; the reality of the situation is that for the management of individuals intent on hurting themselves, the “safety” of the environment on its own is not enough. Just as with any risk, we work to reduce the risk to the extent possible and work to manage what risks remain. That said, if you have not documented an assessment of the physical environment in the areas in which you manage behavioral health patients, it is probably a worthwhile activity to have in your back pocket. I think an excellent starting point would be to check out the most recent edition of the Design Guide for the Built Environment of Behavioral Health Facilities, which is available from the Facilities Guidelines Institute. There’s a ton of information about products, strategies, etc. for managing this at-risk patient population. And please keep in mind that, as you go through the process, you may very well uncover some risks for which you feel that some level of intervention is indicated (this is not a static patient population—they change, you may need to change your environment to keep pace), in which case it is very important to let the clinical folks know that you’ve identified an opportunity and then brainstorm with them to determine how to manage the identified risk(s) until such time as corrective measures can be taken. Staff being able to speak to the proactive management of identified risks is a very powerful strategy for keeping everybody safe. So please keep that in mind, particularly if you haven’t formally looked at this in a bit.

As a closing thought for the week, I know there are a number of folks (could be lots) who purchased those customizable EOC manuals back in the day and ever since have been managing like a billion policies, which, quite frankly, tends to be an enormous pain in the posterior. I’m not entirely certain where all these policies came from, but I can tell you that the list of policies that you are required to have is actually fairly limited:

  • Hazard Communications Plan (OSHA)
  • Bloodborne Pathogens Exposure Control Plan (OSHA)
  • Respiratory Protection Program (OSHA)
  • Emergency Operations Plan (CMS & Accreditation Organizations)
  • Interim Life Safety Measures Policy (CMS & Accreditation Organizations)
  • Radiation Protection Program (State)
  • Safety Management Plan (Accreditation Organizations)
  • Security Management Plan (Accreditation Organizations)
  • Hazardous Materials & Waste Management Plan (Accreditation Organizations)
  • Fire Safety Management Plan (Accreditation Organizations)
  • Medical Equipment Management Plan (Accreditation Organizations)
  • Utility Systems Management Plan (Accreditation Organizations)
  • Security Incident Procedure (Accreditation Organizations)
  • Smoking Policy (Accreditation Organizations)
  • Utility Disruption Response Procedure (Accreditation Organizations)

Now I will freely admit that I kind of stretched things a little bit (you could, for example, make the case that CMS does not specifically require an ILSM policy; you could also make the case that it is past time for the management plans to go the way of <insert defunct thing here> at the very least leaving it up to the individual organizations to determine how useful the management plans might be in real life…). At any rate, there is no requirement to have any policies, etc., beyond the list here (unless, of course, I have left one out). So, no policy for changing a light bulb (regardless of whether it wants to change) or policy for writing policies. You’ll want to have guidelines and procedures, but please don’t fall into the policy “trap”: Keep it simple, smarty!

A toast(er) to all that have gone…

Earlier this week, I received a question regarding the need to do a risk assessment that would allow (or prohibit) the use of toasters in break rooms, etc., due to the open heating element. I should probably mention that this “finding” was not at the hands of The Joint Commission, but rather one of the other acronymic accreditation agencies, but these things do tend to travel across agency boundaries, so it may be a topic of conversation for your “house.” At any rate, the request was aimed more at identifying a format for documenting the risk assessment (an example of which follows), as the surveyor who cited the toasters indicated that a risk assessment supporting continued use of the toasters would be sufficient. Special survey hint: If a surveyor indicates that a risk assessment would be an acceptable strategy for whatever practice or condition might be in question, you should consider that a pretty good indication that there is no specific regulatory guidance in any direction for the subject at hand. Though I will also note that if a surveyor does not “bite” on a risk assessment, it doesn’t mean that there is a specific regulation/statute/etc. that specifies compliance, so even if there appears to be no relief from a risk assessment, a thorough review of what is actually required is always a good idea. Which probably represents a good point to discuss the risk assessment components:

  1. Issue Statement. Basically a recap of what the condition or practice that has been identified as being problematic/a vulnerability, etc.. Using this week’s topic—the use of open element appliances in break rooms, etc. (no reason to confine the discussion to toasters; might as well include toaster oven, grills, and other such appliances)
  2. Regulatory Analysis. Reviewing what is specifically indicated in the regulations: CMS Conditions of Participation; Accreditation Agency standards and performance elements; state and local laws and regulations should definitely be discussed, as well as any other Authorities Having Jurisdiction (AHJ) that might weigh in on the topic. For the open element appliance discussion, I always encourage folks to check with their property insurer (they are a very important, and frequently overlooked, AHJ); they might not tell you that you can or can’t do something (again, based on whether there is an actual regulatory requirement), but they might tell you that if you do X and have a fire, etc., they might elect not to cover damages.
  3. Literature Review. Review any manufacturer recommendations or information from specialty society or trade associations. Staying with our friends the toasters, most of the devices in use in your organization are probably manufactured “For Household Use Only”; you might be hard-pressed in the risk assessment to be able to indicate definitively that the devices are being used in accordance with that level of use (I mean I love toast as much as the next person, but I don’t toast a whole loaf every day…). As a consultative aside, my philosophy has always been to encourage (okay, mandate, but only when I was in a position to make the call) the use of commercial-grade toasters. Yes, they are more expensive, but they are also less likely to self-immolate, which (in my book) is rather a good thing. We definitely don’t need things bursting into flames in our break rooms, etc.
  4. Review of Safety, Quality and Risk Management Data. Check your records. You know you’ve had accidental activations of the fire alarm system (though I do believe that toaster events have faded to a distant second behind microwave popcorn). Is there evidence that your organization is not doing an appropriate job of managing these devices/appliances. I suppose you could take into consideration anecdotal data, but I would be very careful as that can be tricky.
  5. Operational Considerations and Analysis. Discuss how things are being managed now; how often are the appliances being cleaned, serviced, etc. Is that often enough? Is there sufficient smoke detection, suppression, etc.? Do you need to have “official” guidelines for safe toaster use (no sticky, gooey toaster strudels, etc.)? If you’re going to allow something (recognizing that a prohibition is the easiest thing to police from a surveillance perspective), you may find that folks will require a bit of sensible direction to manage the risks effectively.
  6. Organizational Position and Policy Statement/Approval and Adoption. Once you’ve figured out what you want to do, just outline the position you are adopting, make sure that what you’re doing is not in opposition to any existing policy or plan, and then run it through the appropriate committees for final approval and adoption by the organization. In most instances, there is absolutely no reason to establish a specific policy for these things; set it up as a guideline or a protocol or a standard operating procedure (SOP). There are really very few policies that are required by law or regulation. Please don’t feel the need to populate your EOC manuals with a million and one incidental policies (I think this might be a good topic of future conversation).

There are many ways to “skin” a risk assessment and the methodology indicated above may not be suitable for all audiences, but it is a very good way to document the thoughtful analysis of an issue (be it identified during a survey or during your own surveillance activities), particularly when logic does not immediately prevail. (And believe me, logic doesn’t prevail as often as it used to. It makes me sad to think about all the gyrations that have been “committed” because we’ve been forced to deal with something that is “possible” as opposed to “probable” or “actual.” And if you’re thinking that the management of cardboard is somewhere in that equation, you would indeed be correct…) It all goes back to the subtle dynamics between what you “have” to do versus what you “could” do—to a very large extent, at least in terms of the regulations, we get to make our own way in the world. But that world is full of surveyors who are perfectly willing to disagree with any decision we’ve ever made; and they tend not to allow us to do the risk assessment math in our heads (pity, that). This is a pretty straightforward way to get your work on paper. I hope you find it useful.

Ah, the fresh (de)scent of hell…

Two relatively disparate topics of conversation this week; one that I suppose could be characterized as good news, the other not so much…

First, the good news: The Joint Commission is continuing in its review and revision of the various and sundry accreditation programs and has earmarked a number of EC performance elements for the scrap heap, one of which is kind of interesting (and none of which is what I had really hoped for—the management plans, like the monster in some horror flicks, just keep coming back for more). So the requirements that are either redundant or will be left up to the decision of each organization are as follows:


  • The requirement to monitor and report all incidents in which medical equipment is suspected in or attributed to the death, serious injury, or serious illness of any individual. Reason: All required by the Safe Medical Devices Act of 1990.
  • The requirement to have procedures that address how to obtain emergency repair services. Reason: Issue should be left to organization discretion.
  • The requirement to provide emergency access to all locked and occupied spaces. Reason: Should be left to organization discretion.
  • Requirement for staff and LIPs to describe or demonstrate methods for eliminating and minimizing physical risks in the environment of care. Reason: Left to organization discretion.
  • Requirement for staff and LIPs to describe or demonstrate how to report EC risks. Reason: Left to organization discretion.
  • Requirement for semiannual environmental tours in patient care areas. Reason: Left to organization discretion.
  • Requirement for annual environmental tours in non-patient care areas. Reason: Organization discretion.
  • Requirement to use environmental tours to identify environmental deficiencies, et al. Reason: (all together now!) Organization discretion.
  • Requirement for representatives from clinical, administrative, and support services to participate in the analysis of EC data. Reason: You guessed it!
  • Requirement to evaluate changes to determine if they resolved environmental safety issues. Reason: not quite what you might be thinking—It’s because this element is implicit in the requirement for your organization to take action on the identified opportunities to resolve environmental safety issues. But wait: How are we going to identify opportunities if we are wicked discreet about the environmental tours? Hmmm…

So we lose 10 performance elements that will now become “ghost” standards (don’t get any ectoplasm on you…icky!) Clearly the expectation that these elements are going to be present somehow and/or somewhere in your EC program is not going away and, to be honest, I’m not convinced (at least at the moment) that you’ll be able to risk assess your way out of a lot of this stuff. I’m most disappointed (after the management plans—I really, really, really don’t have a whole lot of use for them—they bring no intrinsic value to the process and are naught but an exercise in paperwork) in the removal of the specific requirements for staff to be able to describe or demonstrate methods for eliminating risks and to be able to report EC risks. I suppose you could decide that folks don’t have to know that stuff, but I have spent a lot of time and energy beating the drum for the “spread” of safety to point of care/point of service folks. Safety does not live on a committee; it does not live on a periodic survey process. Safety lives everywhere in your “house” every moment of every day. Somehow removal of those two EP’s makes me a little verklempt…

But not as verklempt as some of the folks in Chicago might be of late. Quick background: Periodically, CMS is charged with notifying Congress as to how the various and sundry accreditation organizations are faring when it comes to surveying to the Conditions of Participation, which is pretty much the fundamental task of the deemed status process. At any rate, the information that CMS shared with those pesky Congresspersons can be found here. Of particular interest to this conversation is the information beginning at the bottom of p. 38 of the document, where you will find a table that outlines the disparity rate between Condition-level findings identified by the accrediting organizations (referred to as AOs in the report) and those found by CMS during validation surveys. While (and I don’t think it’s much of a surprise) CMS does ferret out things that were missed during the regular accreditation survey, of the “big three” accreditors of hospitals (AOA/HFAP, DNV, TJC), only TJC did not improve its disparity score in FY 2014 (as the only accrediting agency for psychiatric and critical access hospitals, it didn’t do real well there, either—see pp. 39-40).

But where things get kind of ugly for us is the table (lucky #13) on p. 44, which lists the types of findings missed most frequently in hospitals by the accreditation organizations as compared to CMS. And the most frequently missed Condition of Participation? Why, it’s our old friend, the Physical Environment! The environment fares somewhat better in psychiatric hospitals (which, to be honest, surprises me a little, but it may be a question of a small sample size; unless, of course, your sample size is HUGE!) and about the same in critical access hospitals. At this point, I think I’ve probably yapped enough for one week, but I would encourage you to check out the analysis of the physical environment findings starting on p. 49. It doesn’t paint a particularly bright picture, particularly if there were any of you folks anticipating a return to the clinical side of things during surveys. All signs point to even more scrutiny (happy, happy, joy, joy!) of the physical environment…imagine that.

Batten down the hatches, mateys—we’re in for quite a blow!

Hortle didn’t hear a portal (with apologies to one T. Geisel)

As I get a little longer in the tooth, I find that I need to create reminders for myself of subjects to cover during our weekly visits. Typically, I will capture an idea as a draft email and return to it as time permits. At any rate, as you are very much aware, there’s been a lot of material in recent weeks that have precluded the need to dig into my archives, but in the interest of keeping my draft emails at a manageable level, as well as making sure that I cover all the discussion points that I wanted to share, over the next little bit (unless something breaks big or bad in the compliance world) I’m going to set the wayback machine for stun and run a few timeless classics (at least I think they’re timeless—please feel free to disagree). Let’s hark back to July to revisit a concept that occupies a lot of my waking time: stewardship and accountability for the management of the physical environment.

As I was lurking about Joint Commission’s Physical Environment Portal (PEP) to see if there were any updates to be found, I stumbled upon a missive in TJC’s leadership blog that I did not recall seeing. This dates back to October 2015 in 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!

As a closing thought, I was rather remiss in my discussion of the final CMS emergency preparedness rule. I neglected to indicate that the new regulations are effective 60 days after publication in the Federal Register (which plunks us into November 2016—you can make a reference to turkeys if you like) and implementation must be completed by November 15, 2017 (again, I will stand by my stand that this is not going to be a very big deal for hospitals—I have yet to find anything that is well and truly new and/or different in what is actually required. As with all things, I suspect that the worm will turn on the interpretive dances of the surveyors).

At any rate, if you don’t have plans for next Tuesday at 1:30 pm EDT, you might want to check out the public call to discuss the new rule, hosted by CMS’ Medicare Learning Network. The call is scheduled to last 90 minutes and you can register here. I will be doing client work that day, but I suspect that there might one or two folks from the editorial world that may tune in, so I am looking forward to finding out what the “skinny” might be on all this stuff. Much ado about nothing or something wicked this way comes? I guess we’ll find out soon enough…

Isolation room occupancy notification? Do tell!

I know there’s been a lot of “official” activity of late occupying my thoughts, but there’s one discussion I’ve been pondering for a bit and, as something of a change of pace, I thought I would kick this one out to you.

One of the struggles I’ve noticed over the years is the intermittent disconnect when it comes to the management of patients that are on one type of precaution or another. Now I recognize that sometimes those precautions are for the benefit/protection of the patient and other times they are for the benefit/protection of everyone else. As near as I can tell, that’s a pretty clear set of considerations. And (also as near as I can tell), the successful management of that set of considerations often hinges on appropriate and timely communications to support staff that precautions are in place so they can plan accordingly.

But I still encounter instances in which the communication of a patient’s precaution status is incomplete and/or not particularly timely, which increases the potential for a gap in protection (again, staff or patients can be at greater risk). For example, staff on the unit removing the precaution sign from the door when the patient has been discharged, but before the folks from Environmental Services have cleaned the room and made it ready for the next patient. Or a patient is transported somewhere for testing and the precaution information is not shared at the outset of the process—sometimes folks don’t find out until after the testing/procedure has been completed. I know in this age of electronic medical records, etc., this type of information is “available”, but just because something is “there” doesn’t necessarily mean that the person at the other end of the process actually “saw” the information.

In noting that the National Patient Safety Goal regarding handoff communication is 10 years old this year (2006 seems like such a long time ago!), I was poking around on the interweb to see what resources, etc., might be available and  couldn’t help but notice that the focus of a lot of the information is for communications between caregivers, so building on the paradigm shift that we are all caregivers, I think it points out the importance of ensuring that everyone along the care continuum receives the information they need to do their job safely. And in doing so, we have to work under the thought that unless we specifically communicate something to the “next step” in the process (and yes, that “step” can be a person), we are responsible for letting that person know what’s going on—every time. Things can change outside of our “field of vision”; maybe there’s someone who’s just returned from vacation or was off for a couple of days and wasn’t here for the patient’s stay up to this point. It is just as important for them to be brought up to date as it would be if the patient were just arriving. Given everything that goes on between the four+ walls of our organizations, I don’t think anyone can afford the luxury of assuming (and I think the risks of the “assume” have been very well-established) that everyone has a complete idea of what’s happening.

And I know that we are by no means perfect when it comes to this stuff—just look at your patient satisfaction scores—a great majority of the improvement opportunities relate to how effectively we communicate with: our patients, our patients’ family members, each other. Humans tend to be a rather social bunch of folks and I don’t think it hurts anyone in the process to make sure that everyone has a clear understanding of what is going on.

On that note, I will leave you with one quote, attributed to Stephen Hawking (I consider him a pretty bright guy): “For millions of years, mankind lived just like the animals. Then something happened which unleashed the power of our imagination. We learned to talk and we learned to listen. Speech has allowed the communication of ideas, enabling human beings to work together to build the impossible. Mankind’s greatest achievements have come about by talking, and its greatest failures by not talking. It doesn’t have to be like this. Our greatest hopes could become reality in the future. With the technology at our disposal, the possibilities are unbounded. All we need to do is make sure we keep talking.”

So let’s follow the Hawk’s lead and keep talking!

Oh, what fresh hell is this?

Much as 2016 has laid waste to the pantheon of pop culture, so has it decimated the status quo in the realm of facilities and safety management. While this year has brought “pleasures” expected (adoption of the 2012 edition of the Life Safety Code®) and unexpected (the demise of the Plan for Improvement process), it appears that the wheels (gears?) that drive this regulatory machine are not yet done churning out new stuff for us to ponder.

As you’ve probably heard by now, last week CMS finally dropped the mike on the federal requirements relating to emergency management and the healthcare world. (Press release can be found here; link to the final rule–the hospital requirements start on p. 584 of this oh so fabulous 651-page document. Monsieur Needle, please meet Monsieur Haystack…zut alors!)

Let’s do a quick run-through of the four primary components:

  • You have to have an emergency preparedness plan that must be reviewed and updated at least annually.
    • The plan must be based on, and include, a documented facility-based and community-based risk assessment, utilizing an all-hazards approach.
    • The plan must include strategies for addressing emergency events identified by the risk assessment, utilizing an all-hazards approach.
    • The plan must address patient population, including, but not limited to, persons at-risk; the type of services the hospital has ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.
    • The plan must include a process for cooperation with the various AHJs’ efforts to maintain an integrated response during a disaster or emergency situation, including documentation of the hospital’s efforts to contact such officials, and when applicable, its participation in collaborative and cooperative planning efforts.
  • Develop emergency preparedness policies and procedures that must be reviewed and updated at least annually. The policies and procedures must address the following:
    • The provision of subsistence needs for staff and patients, whether they evacuate or shelter in place, include, but are not limited to the following:
      • Food, water, medical, and pharmaceutical supplies.
      • Alternate sources of energy to maintain the following:
        • Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions.
        • Emergency lighting.
        • Fire detection, extinguishing, and alarm systems.
        • Sewage and waste disposal.
        • A system to track the location of on-duty staff and sheltered patients in the hospital’s care during an emergency. If on-duty staff and sheltered patients are relocated during the emergency, the hospital must document the specific name and location of the receiving facility or other location.
        • Safe evacuation from the hospital, which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s); and primary and alternate means of communication with external sources of assistance.
        • A means to shelter in place for patients, staff, and volunteers who remain in the facility.
        • A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains the availability of records.
        • The use of volunteers in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated healthcare professionals to address surge needs during an emergency.
        • The development of arrangements with other hospitals and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to hospital patients.
        • The role of the hospital under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials.
      • Develop and maintain an emergency preparedness communication plan that must be reviewed and updated at least annually, which includes names and contact information for the following:
        • Staff
        • Entities providing services under arrangement
        • Patients’ physicians
        • Other hospitals and CAHs
        • Volunteers
      • The communications plan must also include contact information for the following:
        • Federal, state, tribal, regional, and local emergency preparedness staff
        • Other sources of assistance
      • The communications plan must identify primary and alternate means for communicating with the following:
        • Hospital’s staff
        • Federal, state, tribal, regional, and local emergency management agencies
      • The communications plan must provide a method for sharing information and medical documentation for patients under the hospital’s care, as necessary, with other healthcare providers to maintain the continuity of care.
      • The communications plan must provide a means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii).
      • The communications plan must provide a means of providing information about the general condition and location of patients under the facility’s care as permitted under 45 CFR 164.510(b)(4).
      • The communications plan must provide a means of providing information about the hospital’s occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee.
    • Develop and maintain an emergency preparedness training and testing program that is reviewed and updated at least annually.
      • The training program must provide for:
        • Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role
        • Emergency preparedness training at least annually
        • Maintenance of documentation of the training
        • Demonstration of staff knowledge of emergency procedures
      • The testing program must provide for:
        • Participation in a full-scale exercise that is community-based or when a community-based exercise is not accessible, an individual, facility-based. If the hospital experiences an actual natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in a community-based or individual, facility-based full-scale exercise for one year following the onset of the actual event.
      • Conduction of an additional exercise that may include, but is not limited to the following:
        • A second full-scale exercise that is community-based or individual, facility-based
        • A tabletop exercise that includes a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan
      • Analysis of the hospital’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the hospital’s emergency plan, as needed.

To be honest, at first blush, I don’t see anything of particularly dire consequence (feel free to disagree; I’m always up for some civil—or uncivil—discourse) unless you’ve done a less-than-complete job of documenting your communications with the various and sundry AHJs (“The plan must include a process for cooperation with the various AHJs’ efforts to maintain an integrated response during a disaster or emergency situation, including documentation of the hospital’s efforts to contact such officials, and when applicable, its participation in collaborative and cooperative planning efforts.”). In fact, it will be interesting to see if TJC backs off of their caveat that tabletops don’t count towards the annual exercise requirement though, as you can see, the tabletop must include some very specific elements.

There is some additional language relating to provisions for stand-by and emergency power that includes providing for generator locations when you build new or renovate (who wants an emergency generator that could end up under water?); maintaining fuel sources during an emergency; testing components in accordance with requirements, etc., but, again, I’m not seeing a lot of indigestion-inciting language. I suppose it is possible that, at the end of all this (I mean, what’s left to tweak), there will be enough certainty in the regulatory fabric to promote a consistent application of the standards, etc. during surveys. Wouldn’t that be nice…

And to the surprise of absolutely no one…

Last week, the good folks at The Joint Commission announced the list of the five most challenging standards for hospitals surveyed during the first six months of 2016 (for those of you remaining reluctant to subscribe to the email updates, you can find the details for all accreditation programs here. For the purpose of this discussion, the focus will be on the hospital accreditation program—but if you want to talk detail specific to your organization—and you are not a hospital, just drop a line).

While there has been some jockeying for position (the once insurmountable Integrity of Egress is starting to fade a wee bit—kind of like an aging heavyweight champion), I think we can place this little grouping squarely in the realm of the management of the physical environment:


  • 02.06.01—safe environment
  • 02.02.01—reducing the risk of infections associate with medical equipment, devices and supplies
  • 02.05.01—utility systems risks
  • 02.01.20—integrity of egress
  • 02.01.35—provision and maintenance of fire extinguishing systems

I suspect that these will be a topic of conversation at the various and sundry TJC Executive Briefings sessions to be held over the next couple of weeks or so, though it is interesting to note that about while project REFRESH (the survey process’s new makeover) has (more or less) star billing (we covered this a little bit back in May) , they are devoting the afternoon to the physical environment, both as a straight ahead session helmed by George Mills, but also as a function of the management of infection control risks, with a crossover that includes Mr. Mills. I shan’t be a fly on the wall for these sessions (sometimes it’s better to keep one’s head down in the witless protection program), but I know some folks who know some folks, so I’m sure I’ll get at least a little bit of the skinny…

I don’t think we need to discuss the details of the top five; we’ve been rassling with them for a couple of years now and PEP or no PEP (more on the Physical Environment Portal in a moment), I don’t believe that there’s much in the way or surprises lurking within these most challenging of quintuplets (if you have a pleasant or unpleasant surprise to share, please feel free to do so). And therein, I think, lies a bit of a conundrum/enigma/riddle. As near as I can tell, TJC and ASHE have devoted a fair amount of resources to populating the PEP with stuff. LS.02.01.35 has not had its day in the port-ular sunshine yet,  but it’s next on the list for publication…perhaps even this month; not sure about IC.02.02.01, though I believe that there is enough crossover into the physical environment world, that I think it might be even be the most valuable portal upon which they might chortle. And it does not appear to have had a substantial impact on how often these standards are being cited (I still long for the days of the list of the 20 most frequently cited standards—I suspect that that list is well-populated with EC/LS/IC/maybe EM findings). As I look at a lot of the content, I am not entirely certain that there’s a lot of information contained therein that was not very close to common knowledge—meaning, I don’t know that additional education is going to improve thing. Folks know what they’re not supposed to do. And with the elimination of “C” performance elements and the Plans for Improvement process, how difficult is it going to be to find a single

  • penetration
  • door that doesn’t latch
  • sprinkler head with dust or paint on it
  • fire extinguisher that is not quite mounted or inspected correctly
  • soiled utility room that is not demonstrably negative
  • day in which temperature or humidity was out of range
  • day of refrigerator temperature out of range with no documented action
  • missing crash cart check
  • infusion pump with an expired inspection sticker
  • lead apron in your offsite imaging center that dodged its annual fluoroscopy
  • missed eyewash station check
  • mis- or unlabeled spray bottle
  • open junction box


I think you understand what we’re looking at here.

At any rate, I look at this and I think about this (probably more than is of benefit, but what can one do…), even if you have the most robust ownership and accountability at point of care/point of service, I don’t see how it is possible to have a reasonably thorough survey (and I do recognize that there is still some fair variability in the survey “experience”) and not get tapped for a lot of this stuff. This may be the new survey reality. And while I don’t disagree that the management of the physical environment is deserving of focus during the survey process, I think it’s going to generate a lot of angst in the world of the folks charged with managing the many imperfections endemic to spaces occupied by people. I guess we can hope that at some point, the performance elements can be rewritten to push towards a systematic management of the physical environment as a performance improvement approach. The framework is certainly there, but doesn’t necessarily tie across as a function of the survey process (at least no demonstrably so). I guess the best thing for us to do is to focus very closely on the types of deficiencies/imperfections noted above and start to manage them as data, but only to the extent that the data can teach us something we don’t know. I’ve run into a lot of organizations that are rounding, rounding, rounding and collecting scads of information about stuff that is broken, needs correction, etc., but they never seem to get ahead. Often, this is a function of DRIP (Data Rich, Information Poor) at this point, I firmly believe that if we do not focus on making improvements that are aimed at preventing/mitigating these conditions (again, check out that list above—I don’t think there’s anything that should come as a surprise), the process is doomed to failure.

As I tell folks all the time, it is the easiest thing in the world to fix something (and we still need to keep the faith with that strategy), but it is the hardest thing in the world to keep it fixed. But that latter “thing” is exactly where the treasure is buried in this whole big mess. There is never going to be a time when we can round and not find anything—what we want to find is something new, something different. If we are rounding, rounding, rounding and finding the same thing time after time after time, then we are not improving anything. We’re just validating that we’re doing exactly the opposite. And that doesn’t seem like a very useful thing at all…