If you’re reading this, then in all likelihood you’re a regular subscriber to this august publication (august in February—what kind of crazy talk is that, but I digress). In which case, I’m sure you read with some interest the article a couple of weeks ago in which one Mr. George Mills (of the Joint Commission Mills) called out facilities professionals for something akin to dereliction of duty (okay, that might be a wee bit hyperbolic, but this topic, and Mr. Mills stance on said topic, are as serious as all get out), based on the continued frequency of findings in the EC/LS part of the survey process.
At any rate, back in October 2012, Mr. Mills addressed a group of facility managers during a webinar sponsored by ASHE. During the webinar, there was much discussion of the persistence of EC/LS findings during surveys, including attribution of many of those findings to what was characterized as a “lack of management.” I think we can agree that, as characterizations go, that is a very strongly worded characterization indeed. So what types of things are resulting in this level of unhappiness in Chicago? Stay tuned and we’ll find out (by the way, be prepared not to be surprised about much, or even any, of the sticking points during surveys. If you’ve been following this space for any period of time, you are already intimately familiar with the foibles and follies of the modern-day survey process.
I’m reasonably certain that we’ve dealt with this before, but there’s been a wee bit of a bump in survey findings relative to the practical assessment of PFI’s as a function of Interim Life Safety Measures.
It’s really quite simple, when you come right down to it. The Joint Commission standards require us to assess for Interim Life Safety Measures, based on the criteria in our policy, any Life Safety Code® (LSC) deficiencies that cannot be immediately corrected (BTW – it’s a good idea to define immediately in your policy – the standard holds no specific definition, so it’s a bit of self-determination – but don’t go crazy trying to define immediately as something much more than the end of the shift/end of the day). Okay, that’s a pretty solid LSC deficiency that we can’t fix right away.
So, the next question in this little chain is this – what is the defining characteristic of a PFI? Why, it’s a Life Safety Code deficiency that is going to take some time to resolve (something very much less than immediately)! So, as a simple quid pro quo arrangement (or equation, if you like), we have:
PFI = ILSM Assessment
Where you have the first, you must also have the second, otherwise you could find yourself staring down the barrel of a Situational Decision and potential Joint Commission re-survey. Is there anyone in the studio and broadcast audience that has any desire to endure that fate?
I didn’t think so – so, make sure you have ILSM assessments for each of your PFI’s and you will avoid this particular world of hurt. You should go check right now…
Another contractor-related “impression” that’s surfaced lately (and this is not just in hospitals – this can be in your own backyard) is that fascinating phenomenon of the contractors that show up not exactly when you were expecting them and before you got a chance to let your neighbors know that there will be a project going on.
Admittedly, this (hopefully) doesn’t happen too often in healthcare (it better not, at any rate), but I still run across instances when clinical and other staff in areas adjacent to construction/renovation projects feel that they haven’t received much in the way of effective communication prior to the onset of the crash, bang, boom.
Now I know sometimes this is a little bit of the “it’s easier to get forgiveness than it is to get permission” concept (and yes, I also understand that that is a frequent mantra when it comes to taped-over door latches, door wedges, and other sins upon the life safety components of the building), but it’s not like the work isn’t going to happen, so the bestest thing you can do is to reach out to the neighbors to enlist their advocacy on your behalf. Face it, there’s going to be commotion that’s going to reach the eyes/ears/noses of everyone in adjacent spaces – including patients (the reason we are here, n’est-ce pas?)
If we can get the folks managing care to act as advocates for our sawing and drilling and dropping stuff and (quietly) swearing and playing the radio, etc., then (as with so many things) patients might not feel as inclined to provide negative feedback (no guarantees, but it certainly increases the chances of heading a complaint off at the pass).
One of the truisms of modern healthcare is that we cannot communicate enough, but if we keep everyone in the loop, the likelihood of a successful, complaint-free project increases quite a bit (I was tempted to use the exponential qualifier here, but you don’t need me to go all hyperbolic on you at this late date). So, start talkin’!
In recent months, I’ve encountered a couple of instances in which some contractors doing various and sundry projects for hospitals did something (what follows is merely my opinion) incredibly boneheaded – namely leaving roof access doors unsecured and unmonitored.
I’ve also encountered some instances in which contractors had gone to lunch (yes – they really were out to lunch!) and left their “work” unattended on a patient care unit (thankfully not a behavioral health unit, but still) – electrical closets open/unsecured, open ceilings, the whole gamut.
Now, one of my favorite observations is that the human race has an enormous capacity for doing stupid stuff (insert whatever relevant current event you think might be apropos evidence of such a sweeping generalization). And while we generally have pretty good controls over the folks who are working for us (that still doesn’t mean nothing will happen, but that measure of control can really pay dividends over time), but—and this seems to be on the increase—when we bring in folks from the outside (nominally because we are a wee bit under-resourced on the home front), we have to relinquish at least some of that control.
So I ask: When it comes to orienting contractor staff, on what topics do you focus? Do you make a general “don’t do anything stupid” statement as well as more specific concerns? I sometimes think that contractors forget about the complexities of providing a safe environment for patients. I honestly don’t think it’s a lack of capacity on anyone’s part, but in the heat of the battle, so to speak, and we’re charging towards a project completion date, etc., sometimes…
Anyone out there want to share any interesting examples of close calls / near misses, or even a sense of what you’ve done/learned to keep things on an even keel during construction/renovation projects involving external contractors? I know I’m not alone on this one – how about a little sharing?
One of the realities of modern healthcare has been the shift (not everywhere, but in a lot of places) from inpatient volume to outpatient volume, with the result being a number of facilities that close and re-open patient care units based on demand. Now, certainly an organization has to be able to allocate resources appropriately, so consolidation, etc. is a very viable strategy.
But there are some states that can get a bit testy when it comes to the discussion of licensed beds, etc. and pushing the focus back on hospitals to be able to quickly (there’s no hard and fast number; what’s your state say?) restore those rooms/bed positions to service in the event of an increase in census.
Recently, I chatted with an organization that was facing a real challenge because some of the vacated patient units had been converted to other uses (offices, etc.); they are maintaining all the systems that are needed to return these spaces to patient care (just covering over the utilities in the headwall, etc. with a removable panel), so they’re good on that count. But where things have kind of squirted out the sides of the bag is the management of all the patient room furniture that has been displaced – can’t leave all that stuff in the corridors, etc.
So, this organization is looking at establishing a relationship with a medical furnishings vendor who can provide them with patient room furnishings within 48 hours (that’s the state mandate in this particular instance). This is after investigating the potential for off-site warehousing of the furniture now in service, etc., but it was decided that to do so with be extremely labor/resource intensive and since it’s been a while since they’ve actually had to flex back up, they’ve decided to try and work this through an external source.
So I thought that was pretty cool, but then the question became – how would CMS / TJC look at the farming out of the furniture component of their flex plan?
My first thought was they generally wouldn’t have much to say about stuff concerning licensed beds, etc. (beyond the application process), but then I was thinking that this could be an important component of your Emergency Operations Plan, particularly as a function of having to manage an influx of patients in an emergency. In which case, you’d need to be able to evaluate this process as a function (potentially) of your 96-hour plan, etc. I guess ultimately everything relates to everything else and any substantive changes you might make from an operational standpoint can come under scrutiny during survey. Is anybody out there in the listening audience faced with anything similar—maybe seasonal ebb and flow?
Just a quick little list of recent survey findings – not necessarily having anything to do with the Top 20 most frequently cited standards. That said, I do think that this provides ample indication that the survey process is intent on identifying any EC/LS/EM deficiency that could be lurking in the furthest (farthest?) regions of your facility. So, how about:
Have you included (those of you who have them) lightning protection systems in your Utility Management inventory – or completed a risk assessment that indicates inclusion in the inventory is not appropriate?
Do you still maintain (at least) one hard copy of your organization’s Material Safety Data Sheets? If not, what’s your backup and how do you know it’s effective?
What about those rooftop exhausts for isolation rooms—have they been labeled? The biohazard symbol on your rooftop exhausts (or any isolation exhausts) makes quite a statement – and never goes out of style.
What about those flexible and rigid endoscopes? Have you included them in your medical equipment inventory or completed a risk assessment that indicates inclusion in the inventory is not appropriate?
How about those electrical receptacles in locations within 6 feet of sinks and other water sources—are they on GFCI protection? Could be the outlet, could be at the panel, but you need to know, ‘cause if you don’t…
Those of you who are performing manual disinfection of patient care devices / instruments, most frequently using an OPA product: Have you evaluated the process as a function of what is actually required by the manufacturer? This is a very complicated process (with lots of steps to go awry) and perfection is not merely the goal, it must be attained at every step, every time. Perfect, perfect, perfect…
What about those open floor plan areas (frequently ED’s, ICU’s, PACU’s, OR’s) where staff have all manner of equipment and stuff parked outside the rooms (hopefully not obstructing access to the zone shutoff valves) – have you officially designated those areas as suites, and updated the life safety drawings to reflect that designation? If you haven’t, that’s a survey slam dunk for an RFI – better get on it!
I know we’ve spoken of this in the past (or at least I think we have), you have to pay very close attention to the ins and outs of LS.02.01.30 EP #2, which has to deal with combustible storage areas greater than 50 square feet in area. (Storage room = door that self or auto-closes and latches.) And if there’s a “former” patient room (including procedure rooms in the OR, etc.) that’s been converted to storage (particularly if the conversion occurred after March, 2003), then you are looking at the requirements for “new” healthcare, which means sprinklers, one-hour walls, with a 45 minute fire-rated door. I know folks are trying to minimize corridor clutter, but you get right into a whole ‘nother pickle if you don’t watch for these kinds of transformations.
Anything ring any bells for anyone? Might be worth a little mental checklist to make sure you’ve got these areas covered.
There has been a little increase in findings relative to various items (utility system components, security cameras, evacuation devices) being located in egress stairwells. NFPA 101-2000 Life Safety Code 220.127.116.11.1 (e) gets pretty specific about what you can have in terms of penetrations into and openings through an exit enclosure assembly:
(1) Electrical conduit serving the stairway
(2) Required exit doors
(3) Ductwork and equipment necessary for independent stair pressurization
(4) Water or steam piping necessary for the heating or cooling of the exit enclosure
(5) Sprinkler piping
This means, strictly speaking, that things like security cameras, water lines, phone/radio system repeaters, electrical conduit that does not serve the stairwell, etc. are pretty much off the table, particularly if they have been installed after March, 2003 (the official dividing line between new and existing construction).
There is an exception for existing penetrations as long as they are appropriately protected (firestopping, etc.), but if you’ve got newer than ’03 stuff in your egress stairwells, you may have some work ahead to square things away (I’d start with a conversation with either your state AHJ or maybe the engineers at TJC).
In reviewing “stuff” from the past few months (September and October were pretty busy on the regulatory front), I wanted to mention (in case this hadn’t crossed your path) the Government Accountability Office’s (GAO) report on the security of radioactive materials in hospitals as a function of the Nuclear Regulatory Commission’s (NRC) existing requirements. The GAO found the NRC requirements to be somewhat lacking, based on a sample of 26 hospitals and medical facilities.
According to the highlights of the report (you can find the whole megillah at: www.gao.gov/products/GAO-12-925), the NRC did not agree or disagree with the findings of the report, feeling that existing security requirements are adequate. Some of the security lapses found during the GAO survey were such items as unsecured medical equipment containing radioactive material, unescorted access to radiological sources, even (darn it!) numerical keypad lock combinations inscribed on door frames.
Now I will tell you that this is all stuff I’ve encountered periodically during my consulting life (a boss of mine once told me “you can’t mandate intelligence”; then Ron White distilled that into “you can’t fix stupid”) and I will also tell you that sometimes all you can do is shake your head about this stuff. That said, I have no reason to think that the good folks at The Joint Commission (or indeed anybody else with a horse in the regulatory survey derby) are not abundantly aware of this report and it’s contents. So what follows is purely consultative in nature:
Read the report, look at the recommendations, perform a gap analysis at your facility, identify any improvement opportunities, present the risk assessment to your EOC committee and move forward. You may want to consider identifying the necessity for recurring review (which, natch, you should be doing as a function of your annual evaluation of the security management program), if you think you might lose track of this, but I think this should cover things quite nicely.
For those of you go-getters who’ve already run this race – what kind of stuff did you find? Any suggestions for the rest of the classes? Inquiring minds want to know!
One of the interesting dynamics that can come into play relative to code compliance is the concept of getting permission for this, that, or the other thing, from our old friend the Authority Having Jurisdiction (AHJ).
For instance, there are probably a number of you who work in facilities of a certain vintage that indicated the installation of “occupant hoses”—you know, those canvas-y things that used to be coiled up in lovely cabinets. And many, if not most, of you who had such hoses were able to get the permission of the local fire folks to remove them. I mean, really—you’re not going to use them, your staff is not going to use them, and the fire department sure isn’t going to use them, so it’s not a difficult thing to imagine. In some instances, you may have to wait until your facility is fully sprinkled, but generally you can get the locals to sign off on it.
Likewise, you may have a fire pump that, for whatever reason, can’t undergo the annual test at a flow of 150% of the rating for the fire pump. Or you may have a medical gas system component that is not quite up to code, but is allowed by the AHJ as long as you agree to correct the condition when you renovate the applicable space. A common condition is the placement of medical gas zone shutoff valves in the same space as the outlets being controlled—no intervening wall to separate the valve from the outlet (I see this a lot in PACU’s of a certain vintage) and the condition poses no significant risk to occupants, etc. These are both examples of conditions that you wouldn’t have to fix as long as you had the permission of the AHJ.
So, you might ask, what’s the point of this? Well, an interesting phenomenon has been popping up periodically this survey year and it revolves around reliance on the permission of the local AHJ to defer correction of certain items like those noted above. And the sticking point is this – if you have not, upon receipt of this “permission” from the AHJ, then submitted that permission to TJC as a request for a traditional equivalency (you can submit the request on-line through the e-SOC portal – I think you’re going to find you’re using this portal more and more frequently in the future).
To be honest, the process of submitting equivalency requests with TJC has long been in the mix, but it appears that it is becoming a focus in survey year 2012. So, if you’ve been given permission from your AHJ for whatever little condition it might be, you better make sure you’ve submitted the equivalency request to TJC. I have no reason to think that these requests wouldn’t be approved, so long as they are reasonable (i.e.,not indicative of a significant risk). After all, I think one of the key elements in the relationships we have with the folks in Chicago is to let them know what’s going on in an open and forthright manner. I suspect it’s what we would all want if the roles were reversed.
This is a question for those of you who have fire pumps; more specifically, those of you who have fire pumps with automatic transfer switches: How are you documenting that the transfer switch for your fire pump is being tested on a monthly basis in accordance with regulatory standards?
In any number of organizations, one of the automatic transfer switches (ATS) that can get lost in the shuffle is the ATS for the fire pump, as it is frequently located with the fire pump, not with the rest of the transfer switches on the docket for monthly testing. I’ve encountered any number of organizations that have “missed” the monthly testing for the fire pump ATS for just that reason, so I think we can safely say ensuring compliance with the monthly testing requirement calls for a little more forethought and planning. And remember, as an “A” performance element, if you miss a single monthly testing of the fire pump automatic transfer switch, that “earns” you a Direct Impact Requirement For Improvement, something that neither you nor I want to have happen. Well, at least me – I hope you don’t want one of those – they’re wicked icky, so to speak.
At any rate, I’ve seen this one popping up in recent surveys, so if this is not a topic to which you’ve given much thought, it might not be a bad idea to do a little checking. You might find the answers to be more surprising than you’d prefer.