I’m sure you’ve all had a chance to look over the April 2014 issue of Perspectives, in which EC and LS findings combined to take seven of the top 10 most frequently cited standards during 2013, with issues relating to the integrity of egress taking the top spot.
At this point, I don’t think there are any surprises lurking within those most frequently occurring survey vulnerabilities (if someone out there in the audience has encountered a survey finding that was surprising, I would be most interested in hearing about it). The individual positions in the Top 10 may shift around a bit, but I think that it’s pretty clear that, at the very least, the focus of the TJC survey process has remained fairly constant these past couple of years.
Generally speaking, my sense about the TJC survey cycle is that specific focus items tend to occur in groups of threes (based on the triennial survey cycle, with the assumption being that during each three year period, every hospital would be surveyed—and yes, I do know what happens when you assume…) and I think that 2013 may well represent the end of the first go-round of the intensive life safety survey process (I really believe that 2009-2010 were sort of beta-testing years). So the question I have for you good citizens of the safety world: Has anyone been surveyed yet this year? With follow-up questions of:
- Did you feel you were better prepared to manage the survey process this time?
- Was the survey process different this time?
- More of the same?
- More difficult?
- Less difficult?
I’m hoping to get a good sense of whether the tidal wave of EC/LS findings has indeed crested, so anyone interested in sharing would have my gratitude. Please feel free to respond to the group at large by leaving a comment here or if you prefer a little more stealthy approach, please e-mail me at firstname.lastname@example.org or email@example.com.
Actually, the news is even bigger than that: it appears that the CMS machine is churning inexorably towards adoption of the 2012 edition of NFPA 101, Life Safety Code. While the last year or so has seen plenty of tidbits (in the form of waivers) tossed our way, the day we’ve been waiting for is finally upon us. There will be plenty of opportunities for in-depth analysis (minimally, TJC is going to have to reconfigure the accreditation manuals to reflect the changes; just when I had memorized the standard and EP numbers…drat!), but I think the main focus for folks is to weigh in on how this is all going to shake out over the next 12 to 18 months.
Fortunately, the powers that be are allowing a two-month comment period that is scheduled to end on June 16, 2014 (everything should be finalized for CMS in about a nine to 12-month timeframe following the close of the comment period). The proposed rule is available for viewing, at which point you can download the proposed rule in its entirety (and it is, as one might suspect, a pretty entire entirety, which is not so very far from decomposing composers, but I digress). There is much information to digest, and again, we’ll have some time to watch how this whole thing comes to fruition. But once again, it’s important to do the reading ahead of time. Confab with your engineering colleagues at the local, state, regional, and national levels; this may very well be the most sweeping change we’re likely to see in the practical application of the Life Safety Code in our hospitals and other healthcare facilities. Make sure everyone with a voice can be heard in the discussion!
I’m still trying to get my head around the driving forces behind the pending CMS rules regarding all things emergency management. I don’t think I will ever understand why the requirements are quite as complex as they appear to be. My take has always been that the requirements could be distilled down to having a NIMS-compliant incident command structure, establishing a process for credentialing practitioners during an emergency, and a standard set of requirements for conducting exercises—everything that you need to be able to do, I think, fits very nicely into those couple of items. Would your actual plan be a complicated undertaking? Absolutely. The all-hazards approach has to be both flexible and comprehensive, so the mere physics of such an undertaking would tend away from small dense structures to larger, more fluid structure. But I’d not convinced that the overarching requirements need to be quite so (insert adjective here).
I also have a hard time thinking that hospitals and other healthcare organizations don’t take emergency management concerns seriously. As I pen this on the eve of the first anniversary of the Boston Marathon bombing, I continue to reflect on how well the hospitals in the Boston area responded to that horrific event. Were the lessons learned? Opportunities identified? You betcha! But when it comes down to getting the job done in real life/time, last April was a sterling example of how well hospitals plan and cooperate and respond to emergencies. No CEO wants their hospital to be on the front page of the local paper/web page because their organization dropped the ball during an emergency. That kind of publicity, no one needs.
So now we’re faced with another set of requirements—not particularly dissimilar from what we already have—and another set of interpretations by yet another set of authorities having jurisdiction. And the question I have yet to find a really good answer for is this: how is this going to make hospitals better prepared to respond to an emergency? If anyone has figured that one out, please share!
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.