A couple of weeks ago, there was a news item that caught my eye on a couple of levels. I’m sure many, if not most, of you “lived” through the initial onslaught of the hand sanitizer installation wars, and it appears that we may be in for another round of “a chicken in every pot and a dispenser every 6 inches.”
It would seem that the Columbia University School of Nursing and the World Health Organization have determined that about 20% of hospitals don’t have access to hand sanitizer at “every point of care,” thus missing the boat on opportunities to prevent healthcare-acquired infections (see the story here).
Now I can tell you from my experience that I have visited very few hospitals over the past few years in which I could not find expired containers of hand sanitizer hither and thither throughout the healthcare landscape. I think I can recall but a single instance in which I could find a hospital in which there was no expired hand sanitizer. To me, this means one of two things—either people aren’t using the sanitizer because the dispensers aren’t in the “right” location or people just aren’t using the product. (There is something of a third dynamic—hand sanitizer dispensers installed at hand washing sinks—I like to think folks are washing their hands at that point as opposed to using the sanitizer. Call me optimistic!)
The other component that may be impacting the distribution of hand sanitizer dispensers is that pesky Life Safety Code®. The safety folks know that there are limits to how much of this stuff we can have “hanging” around, which, to me, means we need to maximize the utilization of the dispensers that are already in place. If that doesn’t sound like an education opportunity…
I certainly won’t quibble with the notion that we are not doing a particularly spectacular job of managing healthcare-acquired infections, which kind of leads to the other piece of the Columbia/WHO study: not enough focus (resources and financing) on hand hygiene education. I suspect that hand hygiene education is probably covered pretty thoroughly in the orientation process and perhaps touched upon in ongoing annual education programs, but I don’t know that there’s a whole lot of focus on evaluating the effectiveness of hand hygiene education as a going concern. And, as a further thought, I think we need to find a way beyond just asking folks questions about hand hygiene. I think they know what responses are being sought. Maybe we need more black-light auditing of hands in the workplace, I’m not sure. Anybody out there have an evaluation process of which you are particularly proud?
On March 4, 2014, The Joint Commission unveiled the new EC prepublication standards, which have been created at the behest of CMS (oh boy, oh boy, oh boy!). The new standards are based on a Survey and Certification letter (S&C 14-07- Hospitals) issued in December 2013 (you can find the details of that little puppy here).
In the Survey & Certification letter, CMS is basically allowing for medical and/or utility systems equipment to “adjust its maintenance, inspection, and testing frequency and activities for facility and medical equipment from what is recommended by the manufacturer, based on a risk-based assessment by qualified personnel.” There are the usual caveats invoking the Conditions of Participation and other federal or state laws; the example given is that all imaging/radiologic equipment must be maintained per manufacturer’s recommendations (I could be fresh and say that this means that the radiological equipment lobby might be more influential than the hospital lobby, but I guess I just did). Likewise, medical laser devices must be maintained in accordance with manufacturer’s recommendations. The third category of exclusions is “new equipment without a sufficient amount of maintenance history has been acquired.” The whole ball of wax concludes with the statement that “hospitals electing to adjust facility or medical equipment maintenance must develop policies and procedures and maintain documentation supporting their Alternate Equipment Management (AEM) program. They must adhere strictly to the AEM activities and/or frequencies they establish.
Apart from the birth of a kicky new acronym, the new Joint Commission standards pretty much reflect the requirements from the S&C letter, with the inclusion of a pretty nifty clarifying note regarding what can constitute an equipment history: records provided by hospital contractors; information made public by nationally recognized sources; and records of the hospital’s experience over time. I should mention at this point that the new standards apply equally to hospitals and critical access hospitals.
I think the one thing that gives me the most pause (I’m sure there will be other pauses as these start to show up during survey) is the whole concept of the “qualified” personnel doing the risk assessment. Methinks that this will end up driving some sort of accounting/definition of qualified to be determined by each hospital. I guess the questions I have for you folks are:
- How far into the AEM world have you drifted?
- How solidly crafted are your policies and procedures in this regard?
- How well do you think you’ll endure the “qualified personnel” component of the requirement?
I think this is a topic worthy of some discussion. I invite you all to weigh in.
One thing for your to-do list (if it’s not already on your done list) is to take a few moments (okay, maybe a couple more than a few moments) to look over the proposed changes to the way CMS is going to be requiring hospitals to undertake emergency management activities.
You can get the skinny here. The caveat in all this is that you only have until the end of this month to provide feedback on the requirements. Forgive me for being a doom and gloom kind of guy, but something tells me that this is not going to be merely a kind of realignment of resources, etc. I think there is a fair amount of potential for this to cause a lot of heartburn for facilities/safety folks.
Fortunately, the webpage lays out pretty nicely, with click-through links and such, which allows pretty slick navigation of the requirements. I don’t think I’m going to surprise anyone by saying that while there are some consistent concepts, etc., between the proposed requirements and the Joint Commission’s Emergency Management chapter, the two don’t necessarily dovetail seamlessly. For example, it kind of looks like there will be a mandated tabletop exercise (which is defined as 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”). In the Training and Testing section of the proposed rule, there are some click-through resources aimed primarily at assisting smaller facilities—those of you in smaller facilities like critical access hospitals and such—may want to pay very close attention to how this is going to impact your organizations. It sounds nice on paper, but only you folks know how workable these “solutions” might be.
Again, there are common elements—risk assessments, community involvement, emergency plans that reflect reality, etc.—but you and I both know that it doesn’t take a great deal of variable language to create almost insurmountable compliance challenges (note the “almost”; failure, as always, not an option on this wagon train). At this point, it’s impossible to say how much influence can be brought to bear on what’s going to come out of this magillah (and I know it can be very unhappy to weigh in and have one’s thoughts ignored), but I think it is most important to speak up when the opportunity is presented. This will take you to the comment page:
ASHE offered the following suggestions to those who are considering making their own comments:
The comments most likely to affect regulatory decisions are ones that are constructive and clear. Comments should be supported by sound reasoning, scientific evidence, or real-world examples of how your hospital or facility will be affected. Copying and pasting comments or information submitted by others decreases the effectiveness of both your comment and the comment of the original submitter. The best comments explain, in your own words, the positive or negative effects of the proposed rule on your facility and others like it. Remember that public comments are not votes—a single well-written public comment can pull more weight than thousands of form letters.
You may also find value in checking with your state hospital associations. I don’t think we can ever underestimate the impact on daily operations when the feds make changes of this nature and intensity and it’s getting towards the 11th hour. Make those comments count!
Now I don’t think that there’s any here among us who would be inclined to disagree with that as a going concern. The question I have is how might these requirements come into play when CMS adopts the 2012 edition of the Life Safety Code®? We know that CMS is looking very carefully at all things relating to emergency management/preparedness, including a fair amount of focus on the subject of emergency power. I think we can safely intuit that the broad-ish concept of grandfathering is fast becoming extinct. Thus, the question becomes (or perhaps this is really representative of two questions) what could be done now (and perhaps mandated to be done now) to reduce any existing EPSS installations that could be considered at risk (I’m presuming that you’ve all completed your risk assessments in this regard—if you haven’t, I think it would be a wicked swell idea to be jumping on that bandwagon ASAP)? The second prong being, what due diligence has been brought to bear in relation to any pending installations? I’m pretty certain that I would not want to have a brand spanking new generator get flooded out during the next deluge. At any rate, I am interested in finding out more about what you folks have been up to in this regard. I can’t imagine any endeavors in this realm having an inexpensive price tag, so I’m thinking about how folks might have had to, or will have to, sell these “ideas” to organizational leadership.
Touching back on the proposed CMS rule regarding emergency preparedness and hospitals, within the torrent of verbiage, the Federal Register information refers to a hospital evacuation decision guide that’s available through the AHRQ website (just so you know, there is a fairly gloomy caution that the information may be out of date, etc. I’m extremely glad that CMS is using potentially outdated information to promulgate new requirements. Perhaps that’s a wee bit too ironic…). In looking over the materials, I don’t know that the contents are so woefully out of date as to be useless. On the contrary, I think there’s a lot of helpful stuff; while there have been some evacuation-worthy events since June 2011 when this information was last vetted for currency, I’m thinking that the historical precedents in place at the time (Katrina, etc.) would drive a refinement of planning and preparedness as opposed to a wholesale revamping of concepts relating to evacuation of hospitals in response to emergencies.
Have folks out there been using this information? If so, has it been of particular use? Inquiring minds want to know!
I recently signed up for e-mail update relative to The Joint Commission’s leadership blog and what to my wondering eyes should appear but a missive relative to avoiding RFIs in your next survey by focusing on processes relating to…wait for it…the Environment of Care and Life Safety! I don’t know that there’s a whole bunch contained in the blog that we have not discussed at various points over the years (perhaps we are members of a secret society!), but it’s always nice to hear what the folks in Chicago are thinking about. If you’re interested (and I suspect you might very well be) you can find it here.
I’d be curious as to your thoughts in this regard. Maybe there’s something to be gleaned from an operational standpoint that is escaping my notice; it is never a bad thing to learn something new from someone’s perspective.
During a recent CMS survey, one hospital in the Northeast was cited during the inspection of the physical environment for a vent on the roof of the laboratory that was labeled “caution.” The problem—not enough information. As these folks were preparing their response, they asked me what the correct wording would be. And the answer (and I realize I haven’t used this one in a while)? It depends.
Strictly speaking, as a function of the Hazard Communication Standard, the nature of the risk of which one is being cautioned should be identified. In the case of the lab vent, it could be signage indicating that the exhaust is a biohazard or a poison, etc. When you think about it (or even if you don’t), a sign that just says “caution” doesn’t really tell enough of the story—at least in terms of how persons on the roof should be managing the risks. Many, if perhaps not most, OSHA surveyors would accept the biohazard symbol on the vent; or, alternatively, you could also include identification of rooftop hazards in your roof access protocol (I’m sure you have one of those). It sounds like there will probably have to be some follow-up discussion with the inspector to either ask him for some guidance (I’m guessing there may get some generic instruction, but not much in the way of specifics) or at least run by him what the plan of correction will entail. It would be most stinky to have your corrective action plan kicked back because they don’t like how you’ve worded the signage, etc. Fixing identified issues is one thing, but when it gets into the gray area of how you would effectively manage risk is a little bit more tenuous—way better to err on the side of caution.
In reflecting on the healthcare safety news items of the last 12 months, the one that gives me the most pause is the situation involving missing patient at a hospital in San Francisco last fall, solely because it seems to have been so preventable (and yes, I recognize that hindsight is 20/20), even if I also recognize it could potentially have happened at any medium- to large-sized facility.
I guess the answer to the rhetorical question is that the only thing you can do is learn from what happened and make the necessary improvements to ensure that the chances of recurrence are pretty close to zero (this is in recognition that perfection is often a nice objective, but very tough to pull off). It does appear that a number of failure modes were identified (and shared—that’s a good thing—see the story) and I’m sure there have been changes to procedures that reflect what was learned.
How often do patients go “missing”? I don’t know that we’d ever be able to gain a full sense of how many folks are unattended for any length of time. Patients go out for air (smoky air, maybe), or just want to stretch their legs inside. It’s a very slippery slope to try and control every patient’s every waking moment, at least the ones who are mobile (from a risk management perspective, we probably focus more on the movements of the less mobile patients—falls are a big deal too). I don’t think you can, from a practical standpoint, query every patient you might encounter during rounds, though I suppose you could invoke the customer service “Can I help you find something?” to ease that type of encounter. Ah well, I guess this is likely to remain an issue of some complexity, but if anyone out there in the blogosphere would care to share their thoughts and ideas in this forum, I think there would be a great deal of interest.
Howdy, folks! I just wanted to share with you a recent development relative the changes to the emergency generator testing requirements proposed by CMS. I’m not sure how many of you folks are familiar with Dan Chisholm of MGI Consulting, Inc. Dan provides emergency power consulting services to healthcare and mission critical organizations, as well as being a member of the NFPA 110 and NFPA 99 electrical section Technical Committees.
At any rate, Dan responded to the CMS request for feedback relative to the proposed changes, which, in turn, resulted in CMS requesting from him information regarding estimated costs for performing generator tests while operating on emergency power. So, to assist in helping CMS make as informed a decision as possible in this matter (and I think it is in our collective best interests to ensure that they make a well-informed decision), Dan is asking for assistance in gathering this performance data.
When I saw this request, I offered to share the request with you folks out in the blogosphere: I would appreciate anything you folks could do to be of assistance. I recognize that isn’t necessarily within everyone’s “wheelhouse,” but if this isn’t yours, I would appreciate it if shared it with the folks in your organization who oversee the emergency power supply systems. The goal is to supply CMS with as much factual information regarding costs and environmental impact before the comment period closes on February 25.
Please email the following information to firstname.lastname@example.org with “CMS EPSS Data” in the subject line:
1. The total kW load supplied by all generators during a normal monthly test when all ATSs are transferred to the emergency position.
2. The total facility square footage, excluding parking garages, supplied with emergency power.
3. Type of facility: Acute, CAH, or LTC
4. Diesel or natural gas powered generators
Recently I received a question regarding the use of the risk assessment process to determine whether an environmental condition was being appropriately managed. During survey, these folks were cited for not actively monitoring temperature and humidity in a sterile storage supply room adjacent to the OB surgical procedure room (this is one location that I’ve seen cropping up in recent surveys—please remember to keep an eye on sterile storage locations). The physical layout of the space, including the HVAC equipment, basically provides the “same” environment for the procedure room (where they had been monitoring humidity and temperature), so the question became whether the risk assessment process could be used to indicate that if the temp and humidity in the procedure room had been fine, then the sterile storage room would be fine as well.
Now if we’d been having this discussion prior to the survey finding, we might have had a little bit of leverage, but I still think it would be a tough sell, both during survey or as part of the clarification process, because up to this point, there was no performance data to support that determination (which doesn’t mean it isn’t the case, just means there’s no supporting data—a very important and useful thing to have). My advice, especially since they’d taken the hit during survey, was to collect data for 12 months (this particular facility is located in an area that has four seasons—if you’re looking at a similar situation, but you only have, say, two seasons, you might be able to get away with fewer than 12 months of data) and then make the determination that monitoring only need be occurring in one location in this space. As an additional protective measure, I also suggested they might consider submitting data to the folks at the Joint Commission Standards Interpretation Group and query whether the consistency of data supports the monitoring conditions in the entire suite and not having to monitor in each space. Surveyors are more frequently arriving with past survey results, so it’s important to make sure you are appropriate and consistently managing past findings—you don’t want to be in a position in which previously noted conditions have not been corrected.