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Remember, technology is still a toddler

Or mayhap a preschooler…

When it comes down to the usual arc of things, our reliance on technology often exceeds technology’s “ability” to do everything we would want it to do when we want it done. In this regard, I imagine technology as a really precocious toddler that frequently astounds, but also frustrates more often than we would like (imagine when technology becomes a surly teen!), resulting in various and sundry risks, hazards, etc. Well, this is a landscape that the good folks at ECRI tend to watch very carefully, with the end result being regular recommendations to the folks actually dealing with the ups and downs (hopefully more ups) of technology operations, as well as the bosses. Now I will say that not everything on the ECRI list has a direct impact on the hospital safety world (though one could submit that the pervasiveness of technology provides potential issues for all manner of stuff) as information with which to be familiar. At any rate, this year there are two offerings, one to provide information to the folks occupying the environs of the C-suite, the most interesting/applicable offerings being those related to UV disinfection technology and the application of technology in caring for patients with opioid addiction (that one is less directly tied to safety operations, but this has such wide-ranging implications, it can’t possibly hurt to have a little background info). And then for us non C-suiters, a report on the top Technology Hazards in healthcare for 2017 is also on offer, with infection control and prevention being somewhat of a common thread in the hazards, but clinical alarm safety is also represented. The links provided here will take you to access portals where, for a nominal offering of contact information, you can download these reports.

Now, in looking out my window, it appears that winter has finally put in an appearance on the East Coast (though I guess the rains out in California over the past few days is also representative of a winter weather pattern, albeit less snow-covered) and it reminded me of my past days of having (personal and professional) responsibility for (among any number of things) snow removal. Now, to my way of thinking, there is a certain zen that can be experienced when one is combatting the forces of nature one on one (preferably at night) that is probably one of my favorite OCD moments (and believe me, shoveling snow in the middle of the night brings with it a certain inescapable essence of OCD, but I digress). At any rate, one of the more important aspects of the snow removal game is that of ensuring that any and all nearby fire hydrants are well and truly accessible in the event they are needed in an emergency. Just as there is many a slip twixt cup and lip, any delay in accessing firefighting resources can yield catastrophic results, so, as a community service, I give you this information. Particularly in those areas experiencing a little more snow than usual, this might even be worth sharing with the rest of the folks in your organization. I figure if it helps even one person to be a little safer, then it’s worth the effort to spread the news.

My heart is black and my lips are cold

Crash carts on flame with rock and roll!

I figured I’d start out the newly minted 2017 with a few brief items of interest: a device warning from FDA, some thoughts regarding post-Joint Commission survey activities, and a free webinar that some of you might find of interest.

On December 27, the Food & Drug Administration (FDA) communicated a warning letter to healthcare providers regarding potential safety issues with the use of battery-powered mobile medical carts. The warning is based on FDA’s awareness of reports of “explosion, fires, smoking, or overheating of equipment that required hospital evacuations associated with the batteries in these carts.” Apparently, the culprits are those carts powered by high-capacity lithium and/or lead acid batteries and it also appears that there is a distinct possibility that you might just a few of these rolling around in your facility. Fortunately, the warning (you can see the details here) also contains some recommendations for how to manage these risks as a function of the preventive maintenance (PM) process for the battery-powered mobile medical carts; as well as recommendations for what to do in the event a fire occurs (might be a good time to think about testing your organization’s fire response plan as a function of response to a Class C electrical fire). The warning letter also contains some general recommendations for managing the mobile medical carts. So, if you were wondering whether you were going to have anything interesting to put on the next EOC Committee agenda, this one might just fit the bill. As a final thought on this, I think it very likely that our comrades in the regulatory surveying world might be interested in how we are managing the risks associated with these carts—and if you’re thinking risk assessment, I couldn’t agree more!

Moving on to the post-survey activity front, TJC division, for those about to be surveyed (I salute you!), I have some thoughts/advice for preparing yourselves for a slight, but nevertheless potentially dramatic, shift in what you will need to provide in your Evidence of Standards Compliance—a plan for ongoing compliance. Now I will admit that in some instances, being able to plot a course for future compliance makes a lot of sense; for example, managing pressure relationships in procedural areas. If you get tagged for that during a survey, I think it’s more than appropriate for them to want to know how you’re going to keep an eye on things in the future. But what about the million and one little things that could come up during a survey (and with the elimination of the C elements of performance, I think we all know that it’s going to seem like a million and one findings): doors that don’t latch, barrier penetrations, dusty sprinkler heads, etc. There already exist processes to facilitate compliance; are we going to be allowed to continue to use surveillance rounds as the primary compliance tool or is the survey process going to “push” something even more invasive? It is my sincere hope that this is not going to devolve into a situation in which past sins are held in escrow against future survey results—with compounding (and likely confounding) interest. Sometimes things happen, despite the existence/design/etc. of a reasonably effective process. As I’ve said before (probably too many times), there are no perfect buildings, just as there are no perfect plans. Hopefully perfection will not become the expectation of the process…

As a final note for this week, one of the bubbling under topics that I think might gain some traction the new year is the management of water systems and the potential influence of ASHRAE 188: Legionellosis: Risk Management for Building Water Systems. I know we’ve touched on this occasionally in the past and I think I’ve shared with you the information made available by our good friend at the Centers For Disease Control and Prevention (check it out, if you haven’t yet done so), but in the interest of providing you with some access to a little more expertise than I’m likely to muster on the topic, there is a free webinar on January 19 that might be worth your time. In the live online event, “Following ASHRAE 188 with Limited Time, Money, and Personnel: Pressure for Building Operators and Health Officials,” respected expert Matt Freije will briefly discuss the pressure facing building operators as well as health officials regarding compliance with ASHRAE 188 to minimize Legionella risk, suggest possible ways to reduce the pressure, and then open the conversation to the audience. The 60-minute webcast begins at 1 p.m. EST. It’s free but space is limited; you can register here.

So that’s the scoop for this week. I hope the new year is treating you well. See you next week!

It’s not funny how we don’t talk anymore

A mixed bag of stuff this week (dig, if you will, a picture: sleigh full of regulatory madness), including the Perspectives coverage of the Emergency Management standards. But first, a little musing to usher in the change of the seasons.

The nature of my work/vocation requires me to travel a fair amount—and I am not whining about that—it’s my choice to continue to do so, and I understand that if the travel gods are displeased, there is no point in kvetching, but I digress. One of my favorite travel pastimes is watching fellow travelers as they navigate the various and sundry obstacles that one might encounter as they complete the check-in/TSA gauntlet, etc., after which, they generally “crash” in the gate areas or airline clubs. One of the most fascinating/disturbing trends (and I suspect you’ve probably witnessed this yourselves—perhaps even in your own homes) is groups of people (even families!) staring at their devices…and saying not a word to each other. I can’t help but think that if we can’t (or I guess more appropriately, don’t) converse in our private lives, it’s going to have a not-so-good impact on discourse in the workplace. We are better when we are talking—and even technological isolation is still isolation-y.

Hopping down from the ol’ soapbox, just a quick couple of words on the Emergency Management stuff in Perspectives. Interestingly enough (almost to the point of being strangely enough), it appears that folks responding to emergencies have found that the EM standards facilitate effective response—go figure! While I am certainly glad to hear that, I’m not necessarily surprised, mind you. After all, the basic tenets of small “e” emergency management are what inform the big “E” Joint Commission chapter, so if there’s stuff that doesn’t lend itself to response, recovery, etc., I would hope that it would have been expunged by now. Another area of emphasis in the article is the importance of collaboration with the community and other health providers when you are dealing with a significant emergency (as an aside, the CMS final rule also highlights the importance of that collaboration), which (once again) makes a great deal of sense from a practical standpoint. The article closes out with some links to useful information; I’d encourage you to check them out once the stockings are hung by the chimney with care:

Finally, to close out this epistle, I would encourage you to climb into the wayback machine and revisit those halcyon days of Sentinel Event Alert #37 and the management of emergency power systems, etc. My gut tells me that e-power is going to continue (if not increase) to be a focal point for pretty much any and all regulatory systems and the advice provided in SEA #37 relative to evaluating your e-power capabilities, assessing the reliability of normal power, etc., can only become more timely as our reliance on technology grows at an almost exponential rate. We certainly don’t want to get caught unawares on the e-power front and I’d be willing to bet that there have been some changes in the technology infrastructure in your place that might be significant enough for some analysis. At any rate, some more links to peruse once you’ve laid out the cookie and milk for that right jolly old elf:

Beyond that, I hope that we all get a chance to turn off the technology for a bit over the next couple of weeks (and I mean that in the best possible way—I am no Luddite!) and allow some real-time reflection with our family, friends and, indeed, the world at large.

Here’s hoping that 2017 rings in the return of civil discourse!

Ring out, solstice bells!

And so we turn again to our perusal of the bounty that is the December issue of Perspectives and that most splendid of pursuits, the Clarifications and Expectations column. With the pending changes to the Life Safety (LS) chapter, it appears that we are in for a sequential review of said chapter, starting at the beginning (the process/program for managing LS compliance within your organization) and (at least for now) moving to a deep dive into the ILSM process in January—so stay tuned!

So let’s talk a little bit about the requirements relative to how the physical environment is designed and managed in such a manner as to comply with the Life Safety Code® (LSC). Previously, there were but four performance elements here: assigning someone to manage the process (assessing compliance, completing the eSOC, managing the resolution of deficiencies); maintaining a current eSOC; meeting the completion time frames for PFIs (did you ever think we would get to a point where we could miss those three letters?); and, for deemed status hospitals, maintaining documentation of AHJ inspections. For good or ill (time, as always, will be the final judge), the number of performance elements has grown to six with a slight modification to some of the elements due to the shift away from the eSOC as one of the key LS compliance documents and the evolution (mutation?) of our friend the Plan for Improvement into the Survey-Related PFI. With greater numbers of performance elements, I guess there will be a subsequent increase in confusion, etc. regarding interpretations (yours, mine, theirs) as to what it all means, which leaves us with requirements to:

 

  • Designate resources for assessing life safety compliance (evidence could be letters of assignment, position descriptions, documentation in meeting minutes); the survey process will include an evaluation of the effectiveness of the chosen method(s) for assessing LS compliance

 

  • Performance of a formal LS compliance assessment of your facility—based on time frames determined by your organization (big freaking hint: “best practice” would be at least annually); you can modify/adjust time frames based on the stability of your physical environment (if there’s not a lot going on, you might be able to reduce frequencies, though I haven’t been to too many places that didn’t have some activities that would impact LS compliance (Can you say “network cabling”? Sure you can!). Also, there is mention of the use of certain performance elements sprinkled throughout the LS chapter that will be used for any findings that are not specifically covered by the established performance elements. Clearly, there is a desire to leave no stone unturned and no deficiency unrecorded. Yippee!

 

  • Maintaining current and accurate life safety drawings; we’ve covered this in the past (going back to 2012), but there are still some folks getting tagged for having incomplete, inaccurate or otherwise less-than, life safety drawings. Strictly speaking, the LS drawings are the cornerstone of your entire LS compliance efforts; if they need updating and you have a survey any time in the next 12-18 months, you better start the leveraging process for getting them reviewed/revised. They don’t tell you how to do it, but if they’re not on auto-cad at this point, you better have a wizard for whatever program you are using. All they need to do is find one inconsistency and they can cite it…ugh! Check out the list in Perspectives and make sure that you can account for all of it.

 

  • Process for resolving deficiencies identified during the survey; we know we have 60 days to fix stuff found during the survey (and hopefully they don’t find anything that will take longer than that to resolve—I have this feeling that that process is going to be exceptionally unwieldy—and probably unyielding to boot). The performance element covers the process for requesting a time-limited waiver—that’s got to happen within 30 days of the end of the survey. Also, the process for requesting equivalencies lives here (if folks need a refresher on equivalencies, let me know and I will put that on the list for 2017 topics). Finally, this is also where the official invocation of the ILSM process as a function of the post-survey process is articulated (I think we covered that pretty thoroughly last week, but if you have questions—go for it!).

 

  • Maintaining documentation of any inspections and approvals (read: equivalencies) made by state or local AHJs; you’ve got to have this stuff organized and in a place you can lay your hands on it. Make sure you know how often your AHJs visit and make sure that you have some evidence of their “presence.” I think it also makes sense to keep any inspections from your property insurers handy—they are almost as powerful an AHJ as any in the process and you don’t want to run afoul of them—they can have a significant financial impact if something goes sideways with your building.

 

  • The last one is a little curious to me; I understand why they’re saying it from a global perspective, but it really makes me wonder what prompted specific mention. You can read the details of the language in Perspectives, but my interpretation of this is “don’t try any funny stuff when you’re renovating interior spaces and leave 4-foot corridor widths, etc., when you have clearly done more to the space than ‘updated finishes.’” I think this is the call-to-arms relative to having a good working knowledge of Chapter 43 of the 2012 You need to know what constitutes: repair; renovation; modification; reconstruction; change of use or occupancy classification; addition (as opposed to subtraction). Each of these activities can reach a degree/scope that “tips” the scales relative to the requirements of new versus existing and if you haven’t made that determination (sounds very much like another risk assessment, don’t it?) then you can leave it in the hands of a surveyor to apply the most draconian logic imaginable (I think draconian logic might be oxymoronic—and you can put the accent on either syllable), which will not bode well for survey success.

 

That’s the word from unity for this week; next week, we’ll check up on some Emergency Management doings in the wake of recent flooding, including some updates to the Joint Commission’s Emergency Management Portal (EMP?). Hope your solstice salutations are merry and bright until next time!

Gathering gobs of Grinchiness

As the ol’ Physical Environment Portal remains barren of new goodies (maybe we will awake the morning of December 25 and find crisply wrapped interpretations under the tree—oh, what joy for every girl and boy!), we will turn yet again to the annals of Perspectives to mayhap glean some clarity from that august source of information. I suspect that as the December issue is chock-a-block full of life safety and emergency management goodness, we’ll be chatting about the contents for a couple of sessions. First, the big news (or what I think/suspect is the news that is likely to have the most far-reaching implications for survey year 2017): a survey process change relative to the evaluation of Interim Life Safety Measures. Actually, I should note that, as the changes were effective November 17, 2016, those of you experiencing surveys ‘twixt then and the end of the year will also be subject to this slight alteration.

So, effective 11/17/16 (the 46th anniversary of the recording of Elton John’s landmark live album 11/17/70—coincidence? Probably…), the evaluation of your ILSM process (inclusive of the policy, any risk assessments, etc.) will be expanded to include discussion of how, and to what extent, ILSMs will be implemented when there are LS deficiencies identified during your survey that (presumably) cannot be immediately corrected, based on your ILSM policy. Sounds pretty straightforward, but it does make me wonder how the LS surveyor is going to have enough time to review your documentation, thoroughly survey your facility, and then sit down to review any LS findings and discuss how your ILSM policy/process comes into play. I have to tell you, when I first read this, my thought immediately went to “one more day of LS surveying to endure for any reasonably-sized hospital” and, taking into consideration all the other changes going on, while I hope I am incorrect, it does make me wonder, wonder, wonder. Also, the ILSM(s) to be implemented until the deficiency is resolved will be noted in the final survey report, so it probably behooves you to have a process in place to be able to FIFI (find it, fix it) every LS deficiency as it is encountered—and since everything counts with the abolition of the “C” performance elements, you know what you probably need to do.

At any rate, with the announcement that we can expect full coverage of the ILSM standard, there was also a note that an additional performance element has been added to provide for any additional ILSMs you might want to use that are not specifically addressed in the other performance elements for this standard. I’m not exactly sure how this would play out from a practical standpoint; maybe you could specifically include in your policy a provision for checking exit routes in construction only when the space is occupied, etc. As near as I can remember, the only instance I can think of somebody being cited for having an ILSM in their policy that did not precisely reflect the performance elements in the standard was back when the EP regarding the prohibition of smoking was discontinued from the standard; there were a few persnickety surveyors who cited folks for not having removed that from their policy (persnickety is as persnickety does), but that’s all I can think of.

Next week, we’ll chat a bit about some of the pending changes to the Life Safety chapter wrought by the adoption of the 2012 Life Safety Code®. In a word, riveting!

Now bring me some sticky findings—and bring them right here!

Another hodgepodge of stuff this week. I suppose with the holidays, I could be lazy and break these up into smaller chunks of bloggy goodness—maybe next week, but first some ponderings.

I was penning some thoughts relative to the current state of accreditation and a common theme kept reasserting itself: the recent changes are going to absolutely nothing to help decrease the number of findings in the physical environment and, in fact, are much more likely to increase the number (and probably types) of findings experienced during regulatory inspections. Now, I suppose this is rather an extension of the alignment with CMS (I mean, whoever received a visit from those folks and escaped completely unscathed? Perhaps some, but not a whole bunch, I’d venture to guess) and how that philosophy (scorched earth seems like a particularly apropos descriptor—at least at the moment) aligns with the idea/sense/concept that perfection is a noble goal, but not particularly obtainable on this particular space-spinning blue sphere. I’ve said it before, I’ll (no doubt) say it again: they are going to find “stuff” when they visit you—they have to! But that brings me back to the age-old question of what value does this level of attention to minutia bring to the process. I don’t think there’s anyone among us that believes that we have achieved a level of perfection of heretofore untold proportions—has a lot to do with why we have to show up at work every day, n’est-ce pas? There has got to be a better way to facilitate improvement in the management of the healthcare environment without brandishing the regulatory equivalent of a sharp stick (if not a cattle prod). So, as we wind down the 2016 season, those one-off OFIs have now been converted into a cluster of regulatory middle fingers—ouch! Okay, hopping down from the soapbox.

In the December 2016 issue of Perspectives, there is a fair discussion on how the Interim Life Safety Measures (ILSM) process is going to be utilized (perhaps even evaluated) during the survey process. In the October Perspectives, there was coverage of how a completed project (that involved ILSM implementation) would be reviewed to evaluate the effectiveness of the ILSM process. There was also discussion indicating that construction-related deficiencies would not be cited as specific RFIs but rather as a function of the ILSM performance elements. But the December publication offers yet another nuance to the process—when you have a Life Safety Code® deficiency identified during survey, there will be a resultant “discussion” of the deficiency and an inquiry as to which ILSM will be implemented to protect building occupants until such time as the deficiency (or deficiencies) is corrected. I think the important thing to keep in mind here is that the requirement is to implement your ILSM policy, which would then provide criteria for determining what, if any, of the ILSMs would be implemented. I also think that now would be a really good time to dust off your ILSM policy and run it through a couple of test deficiencies to ensure that your policy supports a reasonable approach to ILSM implementation. Finally (on this subject), in the days when clarification of findings was a worthwhile endeavor, it never “paid” to fix stuff during the survey (fixing a condition was tantamount to admitting that you had messed up), but now that everything gets cited, the simplest ILSM to implement is “none at all because we fixed the condition.” Can somebody give me a “that’s a pain in the posterior”? Amen!

As a final thought (or perhaps thoughts) for the week, I think we have to treat any construction or renovation activities as an invasive procedure, so we need to come up a process akin to the Universal Protocol adopted by the folks in surgery to make sure that everyone is on the same page before the activity starts (and that especially includes contractor staff—I am absolutely convinced that we could do a better job with that process).  As an offshoot of this, I think it might be time to adopt a process for periodically evaluating the construction/renovation management process, much as we evaluate the 6+1 EC/EM functions. I can’t think of a single “normal” process that has more potential for disruption, angst, chaos—you name it—than the construction and renovation process. Some folks are fortunate enough to have in-house resources for the management of these activities, but even then there can be opportunities for improvement–the communications process springs to mind as being frequently flawed.

Until next time, I bid you as much holiday cheer as you can tolerate!

Can we count painful survey findings and new requirements as blessings?

First off, please accept my bestest wishes to you and yours for a most joyous and restful (or as restful as you want it to be) Thanksgiving holiday.

To paraphrase a certain musical ensemble, what a long, strange compliance year it’s been. Hopefully, 2016 will head off into the realm of history with a whimper (I think we’ve experienced enough “bangs” to take us well into 2017 and beyond). And so, a little casserole of safety stuff to tide you over ’til next week. First up, some risk assessment deliciousness, courtesy of NFPA 99.

I had intended to discuss this back a few weeks, but there has been a lot to discuss these past few weeks. At any rate, I was able to get a look at the CMS update portion of the Executive Briefings presentation and it appears that there was some discussion relating to the practical application of how a space is used to determine the risk category for the equipment and/or systems used to support that space. My sense of this is that it’s not so much the space itself as it is, but rather what processes, etc., exist within the space you are evaluating, using the definitions from NFPA 99. So, the methodology focuses on an analysis of facility systems and equipment based on the risks associated with failures of those systems:

Category 1—Facility systems in which failure of such equipment or system is likely to cause major injury or death of patients or caregivers

Category 2—Facility systems in which failure of such equipment or system is likely to cause minor injury to patients or caregivers

Category 3—Facility systems in which failure of such equipment is not likely to cause injury to patients or caregivers

Category 4—Facility systems in which failure of such equipment would have no impact on patient care.

 

So, moving to the definitions in NFPA 99, you sort the above concepts based on how the space is used:

  • Facility systems and equipment for critical care rooms would be Category 1
  • Facility systems and equipment for general care rooms would be Category 2
  • Facility systems and equipment for basic care rooms would be Category 3
  • Facility systems and equipment for support rooms would be Category 4

Each of the chapters in NFPA 99 (gas and vacuum systems, gas equipment, electrical systems, HVAC, etc.) have provisions for the different categories, as applicable, so it appears that the expectation (at least as it was presented at Exec Briefings) is that the organization of the facilities systems and equipment would reflect this methodology. To be honest, I think this may be more of an issue with re-packaging how things are equipped and maintained; maybe including the category designation on work orders, etc. I don’t know that this is going to extend to TJC’s activities, though with the bad marks it received on its CMS report card, it seems unlikely that TJC will become more reasonable…time, as they say, will tell.

Another potential complication for survey year 2017 (I’m pretty confident of this, but not yet certain about the timeline for implementation) is a broadening of the Evidence of Standards Compliance (ESC) process to include at least two more considerations. At the moment, the ESC process requires a response to the following categories: Who (is responsible for the correction); What (was done to correct the deficiency); When (the corrective action was completed); How (the corrective action was implemented and will be sustained), and Measure of Success (for those pesky “C” performance elements—to which we will bid a hearty “adieu” on January 1, 2017). I think we’re all pretty familiar with that part of the process (I can’t imagine that anyone’s had a survey with no findings in the physical environment, though I suppose the infamous “bell” curve might dictate otherwise), but there is indication that with the removal of the Measure of Success category, we will have two additional elements to document within the framework/context of the corrective action: Leadership Involvement and Preventive Analysis. At the moment, it appears that the sequence will look something like this:

Who:

Leadership Involvement:

What:

When:

How:

Preventive Analysis:

I think being able to account for leadership involvement is a pretty straightforward response (I think probably the best way to frame this would be to identify the boss of whoever the “who” would be; and perhaps that boss’ boss, depending on the circumstance), but I suspect that the Preventive Analysis portion of the response could get quite complicated. As near as I can tell, it would be an amalgam of the root cause that resulted in the finding and the strategy for preventing future deficiencies, although minimizing the risk of recurrence might be a more useful viewpoint—as I like to tell folks, it’s the easiest thing in the world to fix something and the among the most difficult things to keep that something fixed. Hopefully, this will end up being no more than a little more water under the bridge, but I guess as long as findings in the physical environment remain a focus, the sustainment of corrective actions will be part of the conversation.

And on that note, I bid you a Thanksgiving to eclipse all yet experienced: gobble, gobble!

The song changes and yet remains the same…

There was a time when The Joint Commission actually seemed to be encouraging folks to fully engage with the clarification process in all its bountiful goodness. And I certainly hope that folks have been using that process to ensure that they don’t (or didn’t) have to “fix” processes, etc., that might not have been absolutely perfect in execution, but were not, by any stretch of the imagination, broken. But now, it appears that the bounty is going to be somewhat less bountiful as TJC has announced changes to the process, effective January 1, 2017. Please forgive my conspiracy theorist take on this, but it does seem that the new order in the accreditation world appears to lend itself to survey reports that will be increasing in the number of findings, rather than a reduction—and I am shocked! Okay, perhaps “shocked” is a tad hyperbolic. BTW, in a new Advocacy Alert to members, it appears that ASHE has come to the same conclusion, so it’s not just me…hoorah!

And so, the changes:

 

  • Any required documents that are not available at the time of survey will no longer be eligible for the clarification process (basically, the vendor ate my homework). It is important for everyone to have a very clear understanding of what TJC means by “required documents”—there is a list on your organization’s Joint Commission extranet site. My advice, if you have not already done so, is to immediately coordinate the download of that list with your organization’s survey coordinator (or whoever holds the keys to accessing that information—it may even be you!) and start formulating a process for making sure that those documents are maintained in as current a fashion as possible. And make sure your vendors are very, very clear on how much time they have to provide you with the documentation, as well as letting you know ASAP whether you have any deficiencies/discrepancies to manage—that 60-day correction window can close awfully quickly!
  • While I never really liked to employ this strategy, there were times when you could use clerical errors in the survey document to have things removed from the survey report. Areas that were misidentified on the report (non-existent to your facility; not apropos to the cited finding, for example, identification of a rated door or wall where there is none, etc.) or perhaps the location of the finding was so vague as to be impossible to identify—these have all been used successfully, but (apparently) no more. Now whether this means that there will be more in-depth discussions with the survey team as they prepare the report is unknown at this time, but even if one slips by (and I can tell you, the survey reports in general are much more exact—and exacting—in their description of the deficiencies and their locations), it won’t be enough to remove it from the report (though it could make your ESC submittal a bit more challenging if you can’t tell what it is or where it is).
  • The other piece of this is, with the removal of “C” Elements of Performance, you can no longer go the audit route to demonstrate that you were in substantial compliance at the time of survey. So now, effectively, everything is being measured against “perfection” (son of a…); miss one month’s check on a single fire extinguisher and—boom—finding! One rated door that doesn’t latch? Boom—finding! One sprinkler head with dust or a missing escutcheon? Boom—finding! And, as we touched on last week, it’s not just your primary location (aka, “the hospital”) that’s in play—you have got to be able to account for all those pesky little care sites, even the ones for which you are not specifically providing services. Say, for example, the landlord at one of your off-sites is responsible for doing the fire extinguisher checks; if something is missed (and hey, what’s then likelihood of that happening…), then you are vulnerable for a finding. So, unless you are prepared to be absolutely, positively perfect, you’d best be making sure that your organization’s leadership understands that the new survey reality is not likely to be very pretty.

I would like nothing better than to tell you that with the leadership change in Washington there will be a loosening of the regulatory death grip that is today’s reality, but somehow I don’t think that’s gonna happen…

Pauline’s Preposterously Perilous Permutations

Or, for the less aged folks, we could use Penelope Pitstop’s Preposterously Perilous Permutations…

I’ve recently had the opportunity to review some fourth quarter (2016) Joint Commission survey reports and I have to tell you that I’m not seeing indication of the rosiest of futures when it comes to the physical environment. (I keep trying to convince myself that it is merely because of my perspective that things seem to be weighted so heavily in the direction of the physical environment—it is, after all, my “beat.”) That being said, there does seem to be a trend in “where” the findings are being found, so to speak. And that, my friends, is in the outpatient setting, particularly physician office practices.

The story kind of starts with the “reveal” of TJC’s prepublication of the 2017 EC and LS chapters. I suspect that we will continue to discuss the various and sundry permutations of peril that will befall us as we move through the process, but this week I wanted to focus on a corner of the Life Safety chapter that doesn’t necessarily get a lot of attention: the Ambulatory Health Care Occupancy standards and performance elements.

Contained within the Ambulatory Health Care Occupancy section are some notes, one of which appears to be very much like business as usual when it comes to determining what rules in and what rules out when it comes to ambulatory surgery services, and so we have something to the effect that the ambulatory-related standards apply to care locations where four or more patients (at the same time) are provided either anesthesia or outpatient services that render those patients incapable of being able to save themselves in an emergency (I’m paraphrasing a bit here—our friends in Chicago are very attentive to verbatim quotes of their content—you’d think that the Cubs win might put them in a better frame of mind, but that’s too much risk. Maybe they’re sore winners…).

So, we got that one, yes? Pretty straightforward, very much in keeping with how we’ve been managing our outpatient environments, etc.

But then we move on to the second note, and the slope gets a bunch more slippery (and again, I paraphrase): if you use TJC accreditation for deemed status purposes, the ambulatory LS standards apply to outpatient surgical departments in hospitals—regardless of how many patients are rendered incapable (so that’s one patient all the way up to however many patients you can render incapable of self-preservation…ouch!). Now, I guess we could have some fairly lengthy discussion about exactly what constitutes “outpatient surgical departments in hospitals.” Does that mean physically within the four walls of the hospital? Does it mean operated under the hospital’s license or CMS Certification Number (CCN)? At the moment, I’m tending to lean towards the latter, just because it would be so much more messy.) It will be interesting to see how this whole thing rolls out into survey reality; it is entirely possible that folks are already having these discussions with their TJC account reps as planning for the 2017 survey season begins in earnest, if anyone has some indication on how, for instance, office-based surgical procedures are being accounted for in the process. Can you imagine having an LS surveyor heading out to all those physician offices in which surgical procedures are occurring? It’s about half past Halloween, but that’s a pretty scary thought. Sooooo, you might want to start evaluating your offsite locations for compliance with the LS.03.01.XX standards and performance elements.

Some other potential vulnerabilities relate to the management of high-level disinfection activities in these same office environments. I’m seeing a lot of the same types of findings that were once associated with areas like ultrasound, cardiology, etc., basically locations in which instruments and equipment are being manually disinfected. Lately I’ve seen findings relating to eyewash stations (check those disinfectant products to make sure that if you have a corrosive product, you’ve got a properly ANSI-configured eyewash station and if you have one, make sure it’s being checked on a weekly basis), management of disinfectant temperature, ensuring there is sufficient ventilation, making sure secondary containers are properly labeled (including biohazard labels), using PPE in accordance with the disinfectant product’s Instructions for Use, etc. The real “danger” here is that this appears to be becoming a mix that results in significant survey impact relative to the physical environment, infection control, even surgical services. These are findings that can “squirt” (small pun intended) in many different directions, causing a big freaking mess, particularly when it comes down to clinical surveyors conducting the outpatient portion of the survey. You might want to make sure you’ve got a very robust means of communications from the outpatient sites to ensure that you can nip these types of findings in the bud. But you also probably want to do a little focus education with the folks out in the hinterlands to ensure that PPE is available and used, products are being used properly, etc. I know it becomes “one more thing” to do, but I think we have to come to grips with the reality that the surveyors are becoming very adept at generating lots and lots of findings in the physical environment; they understand that there are locations in almost any healthcare organization that are not “attended” quite as robustly and that if they pick at certain common vulnerabilities, they will be rewarded with findings. We need to take that away from them, toot sweet!

Keep documenting those risk assessments: the Conditions of Participation and other regulatory rapscallia still do not tell us how to appropriately maintain a safe environment, so we have to be diligent in plotting our own course(s). We get to decide how we do this, but we do have to actually make those decisions—and make them in a manner that provides evidence of the process. I know it probably seems like a lot of drudge work, but it’s pretty much what we have to do.

As a closing note, I’d like to thank all the veterans for their service, pride and dignity—we are all the better for it!

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…