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If you remember nothing else: Nothing happens in isolation…

With the (presumed) onset of regulatory surveys including a more thorough review of survey results past, I would imagine that everyone out there in the listening/reading audience can name at least a couple (if not more) instances of non-compliance that were (for want of a better term) “missed” during survey. Just to use a simple example (which we touched upon back in the wilds of winter), your most recent surveyor may have stopped looking for improperly labeled breakers (spares in the on position; breakers in the on position not labeled, etc.). But the question becomes: How many more are out there…and how carefully did someone look post-survey? Certainly, whatever was identified would have been corrected as part of the plan of correction—you can’t be telling regulators that you did something that you didn’t do, now can you? But what about other potential findings? Now, I recognize that using this particular example is (hopefully) a wee bit hyperbolic in that (again, hopefully), the low risk findings are going to get a mulligan if there are recurrences. If you have really crappy luck, you could have an exit sign burn out every time you have a survey or something similar (can anyone say “improperly segregated compressed gas cylinder”?) but I would think that the little stuff is not going to drive a seriously negative survey result, with perhaps one exception.

The exceptional item (or items) are those in which the management of the care environment crosses into the realm of infection control and prevention: damaged/non-intact surfaces, stained ceiling tiles, etc. The reason for my concern with this stuff is it is really hard to manifest a solid process for managing these incidental conditions without hard-wired participation of point-of-care/point-of-service folks. I don’t know, I’m just having a hard time wrapping my head around taking issue with findings/conditions similar to those found in previous surveys. Now, if we’re talking widespread versus isolated, I can see widespread issues maybe pushing a survey in the wrong direction, but I still think the severity has to come in to play to some degree, as well as the (ever-present) potential for recurrence. To my mind, the stuff that gets broken/damaged tends to be because those are the things that suffer the most “abuse” (and I use that in the most general of meanings). It’s like the fire doors near the loading dock—tell me they don’t have a significantly greater potential for damage, during a survey or not.

At any rate, I think the important thing is to work diligently to ensure that those isolated findings are not the tip of a widespread iceberg. I don’t think we can just stop with what was cited anymore.

Next week, we’ll spend a little time with the “new” expectations relating to the management of workplace violence; I’m still trying to figure out if there’s anything that is truly “new” (I tend to think no, but you never know what might be hiding in the nuances), but we should at least start the discussion of where things seem to be going.

Hope you had a safe and festive Independence Day!

In your eyes: The light, the heat, the flushing fluid…

As is often the case (it probably says more about me than anything else, but what can one do?), it seems that there are always conversations to have about the practical nature of the risks of occupational exposure to injurious chemicals and how eyewash stations figure in the greater reality that is healthcare. In general, we know that eyewash stations are only “required” when there is a risk of occupational exposure to injurious chemicals (here’s a reasonable reinforcement of that interpretation), but somehow, everywhere I go there are eyewash stations in areas for which there is no risk of occupational exposure, etc. It’s possible that there might have been in the past, but the organization was able to make good use of the hierarchy of controls to reduce the risk of occupational exposure by either eliminating the hazard or substituting the product with something that is not injurious. That is not always going to be the case, but it occurs to me that rather than just talk about eyewash stations as a going concern, let’s look at what you can do to either remove ones you have or forego having to ever install an eyewash station in the first place. Which reminds me, if you are building new or renovating existing space, make sure the architects/designers with whom you are working understand when eyewash stations are actually required. I’m finding a lot of eyewash stations in new construction that don’t belong—soiled utility rooms, etc. It’s probably worth asking them for a list of locations where eyewash stations are earmarked for installation; it might save you some aggravation in the future.

At any rate, in the previous passage, I noted the “good use” of the hierarchy of controls, so I thought that this might be a good opportunity to walk through that general concept. Fortunately, this is a topic about which the good folks at NIOSH have given some thought. What follows is rather along the lines of a (very basic) primer, but there’s lots of good content available through the CDC/NIOSH portal.

Hierarchy of controls

  • Elimination: Remove the hazard
  • Substitution: Replace the hazard
  • Engineering Controls: Isolate people from the hazard
  • Administrative Controls: Change the way people work
  • PPE: Protect the worker with personal protective equipment

You may notice that eyewash stations don’t really figure in to the hierarchy, primarily because the role of eyewash stations is in the event of an emergency as the result of a failure of the above-noted controls to prevent the exposure (again, it’s kind of basic, but nonetheless true for its simplicity). I don’t know that there’s necessarily a right or wrong answer for any of this (which has a lot to do with why this is such a perennial consideration in the safety field), but I do know that using the hierarchy to work through how you manage risks of occupational exposure makes a great deal of sense (well, at least it does to me). Please look over the available information and let me know what you think.

I wish each of you and your families a most safe and festive Independence Day (the year is half over—who’d a thunk?!?). See you next week!

They blew the horns…and the walls came down!

Continuing our intermittent discussion about returning to normalcy on the facilities operations front, I’ve been reflecting on the monumental amount of facility modifications that have occurred over the last 15-18 months and what those modifications might portend for the future. I’ve seen all matter of materials used to facilitate containment of patient care units and I was wondering, now that there is lessening need for a lot of these temporary structures, if folks have been thinking about how they would “do it again next time” as they deconstruct the temporary walls. In some instances, I’m sure we’ve had loads of fun removing tape residue from various surfaces (where would we be without tape!?!) and perhaps gone back to review those pesky ILSMs that sprouted up over time. I’m still not sure how ILSM assessment will “play” with the 1135 waivers: Are they required, are they not, are they in the “eye of the beholder”?

At any rate, I’m hoping that somewhere in the hive mind of your organization there is a clear picture of what modifications were made on the fly, which prompted me to do a little poking around on the interwebs regarding the practical application of temporary barriers and I ran across this, which (if you’ve not seen it) I think you’ll find useful as a thought provoker (provocateur?).

Clearly, we are all about wanting to do things better and I think the questions/concerns/considerations raised in the article are definitely worthy of conversation as we plan for the next event. The “good” thing about temporary containment is we don’t have to wait for the next pandemic to get familiar with the modular concept. There are likely going to be construction and renovation projects coming your way and what better “test market” for containment?

So, that’s it for this week. I continue to hope that the true onset of summer will provide some level of opportunity for down time. The older I get, the more I appreciate the “beauty” of time off—even if it’s time off for home projects. Just to be able to focus on stuff that’s not related to “work” is pretty awesome—try it—you’ll like it!

Wishing you wellness and safety!

Every once in a while…

…I make good on the promise of brevity. Let’s see if this is one of those weeks.

As we continue to wind down from the various and sundry modifications that were made to the physical environment to provide appropriate care for patients (and appropriate levels of safety for staff) during the pandemic, it might be a good point to ascertain whether any of the persisting conditions/practices are representative of Life Safety Code® (LSC) or other compliance issues. I am very hopeful that folks are going to be able to “take some time off” this summer (working on the thought that last year, not so much), so my thought is to add (at least) one last go-round before the solstice is upon us—that way, if any regulatory f(r)iends show up over the next few months, you will have a defensible position for any lingering programmatic elements that could raise questions.

To aid in that endeavor, you might consider this article from Healthcare Facilities Management that provides some guidance on just that. There remains the whole notion that we have 60 days after the suspension of the Public Health Emergency (which was renewed in April) to “return to normal,” but it also can tie into whether your organization is still responding to the emergency. If your incident command structure has been discontinued, you may want to really start preparing for bridging any compliance gaps that may still be in place. As you know (by now), I tend to be a proponent for the risk assessment process and any time the future of compliance is uncertain, risk assessments are our best strategy for demonstrating compliance.

One other item for this week. I would encourage you to check out the capabilities of Smart911; while this may not be entirely work-related as a suggestion, from a peace of mind standpoint, ensuring that emergency responders have access to as much pertinent information (and you can decide what is, and what is not, pertinent—hmmm, could be another risk assessment). The more information responders have at their disposal (including your whereabouts if you’re notifying them on a mobile phone), there more quickly and effectively they can respond to the emergency. With all the issues of privacy, etc., there are certain entities that would be more effective in their response, and I think Smart911 makes a lot of sense to be included in trusted sources (hopefully that is not a fleeting thought). Check ’em out and see for yourself. If you’re not comfortable with the process, I get it, but reach out to your local emergency folks to see how they feel about it before you elect not to participate.

Just about a week left of spring 2021. I hope this finds you well and perhaps just a wee bit less anxious about your existence. Until next time…

Bye bye, business occupancy?

To my fairly certain knowledge, I’ve tried to stay away from anything that might approximate “click bait,” though I will freely admit that this week’s “headline” bumps up against it as a general concept. That said, I do think that the current shifting of survey focuses is such that it may be more sensible in the long run to modify the ways in which we “use” business occupancies as a survey preparation methodology.

What prompted the thought (beyond all the hubbub regarding the new section of the Joint Commission’s Life Safety chapter that deals specifically with business occupancies) is the whole notion of the slow envelopment of the “healthcare facility” descriptor as the go-to term for all care locations, be they inpatient or outpatient in nature/design. It does appear that a day could come in which the business occupancy designation means little or nothing from a compliance standpoint—I shudder to think. When you think about it, the “sharp edge” that separated care locations by occupancy classifications has become rather more blurred than not, some of which is the result of there not being clearly defined expectations/standards. Clearly, the business occupancy section of the LS chapter is a step towards a codification of those expectations—and what that means going forward.

If you look at the overview section of the LS chapter in the online manual, there is a note that the first two standards in the chapter (dealing with general expectations, including the management of life safety drawings, and the practical application of Interim Life Safety Measures) apply to all occupancy types. Truth be told that “note” has been sitting there for a while now, but with the creation of the business occupancy section of the LS chapter, I think we can probably intuit that the “general” requirements are going to be more of a focal point during survey. Past experiences tell us that this stuff won’t all get chased right out of the box, but I think one of the pressure points is going to be what you have for life safety drawings for your outpatient locations. Hopefully, that thought will prove to be most incorrect, but I get this feeling…

Another element in the outpatient setting is the practical application of all things relating to infection control; much as is the case with the physical environment in general, the currently drawn lines are not sharply defined, so it becomes the charge for each organization to define the lines of compliance. A good recent example is this article in Health Facilities Management magazine. I’ll let you read this on your own, but it does speak to a fair level of due diligence in determining what is actually required by code and what is the best strategy for your organization. High-level disinfection, sterilization, management of instruments, etc., is likely to continue as a significant survey touch point—and they’re going to kick those tires fairly exuberantly. You need to have a solid foundation for what constitutes compliance for your organization to present as bulletproof a façade as possible, so if you’ve got any of these IC-related processes “living” in your outpatient settings (and odds are that you do), it’s time to start kicking those tires before the folks with the pointy shoes show up…

Hope you all are well and staying safe through this current transition. While I am optimistic about the future, my personal observations during my travels the past couple of weeks is that hand hygiene numbers are starting to tail off a bit. I guess there are some folks that will only wash their hands if they think it’s a matter of life and death…

Stop making sense: Normalizing abnormality…

A brief foray this week, though I hope that is very much in keeping with you all being able to grab a few moments for yourselves over the holiday weekend. It was rather dreary up here in the land of the New English, but the rain is much needed, so if there was a bit of dampening of the spirits, it should take the edge off any fire risks up this way. I would be happy to share with the more parched regions of the country, but it appears that rain (like many other things) is rather more capricious than not…

First up: If you have not had the opportunity to get back to the grind that is the hunt for expiring/expired product, please remember that a ton of products were purchased about a year ago and it does seem like I’ve been running into a bunch of stuff that is reaching the end of its (sometimes not so) useful life. Wipes and sanitizer proliferated quite extensively last spring into early summer, so make sure someone in your organization is worrying about that one.

Next up, the only EC-related item in the June edition of Perspectives (and it is a little bit of a stretch) deals with the Sentinel Event Alert on infusion pump safety. It seems somehow that improvements to medical equipment technology manage to create more challenges for the folks in clinical engineering. The more a device can do, the more stuff that can go wrong. This is not to say that these are in any way a problem in and of themselves, but it seems like there are always gaps in the education process when these things roll out, so best of luck on that front. Medication safety is clearly going to be a focus moving forward and if we have learned nothing over the last little while is that everything ties across the physical environment eventually.

As a closing reiteration (we did touch upon this a couple of weeks ago), just a reminder to try and capture as much of the last year as you can. Many (if not most) of the lessons learned are pretty hard-wired into our response protocols, etc., but it’s also important to take stock of what didn’t work particularly well so we can avoid repeats in the future. One of the consistent challenges I’ve noted over the years is when an organization learns of a process, etc., that has worked really well at another organization and adopts that process lock, stock, and barrel. And a lot of times, that “perfect” process involved a fair amount of stumbling around to get to the point of perfection—and for some reason, folks don’t always share the missteps. It reminds me of that oft-told aphorism regarding doom and repeating history, but let us leave doom to others…

Hope you all are well and making the most of the moment!

If there weren’t challenges…

…it really wouldn’t be an event that requires emergency response.

Somehow over the last little while, the fundamental nature of what constitutes an emergency and, even more importantly, what an appropriate response looks like, appears to have morphed over time. Now we seem to embrace the expectation that whatever happens, hospitals are going to be right on top of things (in a way that, frankly, doesn’t seem to apply to them that would sit in judgment, but that might be something of an editorial comment). But really, can you imagine what would have happened a year ago when pretty much everybody else was working from home, suspending normal operations, etc. (in full recognition that healthcare facilities don’t have the option of opting out of such things)? Now a lot of folks (and no, I’m not going to name names—if you don’t know, then it’s probably just as well) are playing catch-up and generating a wee bit of chaos as they get back to it. Happy happy, joy joy!

At any rate, I do hope that all the surveyors out there kicking the EM tires are paying close attention to some of the information contained in the CMS updates to the emergency preparedness requirements, including:

  • It’s OK for your response process to be the same for multiple risks/hazards
  • Your HVA/program must address each type of hazard, but your policies and procedures can indeed be consolidated (can you imagine how many binders you would need?!?)
  • It is not the job of the surveyor to analyze the appropriateness of the identified risks; their job is to make sure that your program (including policies and procedures) align with your risk assessments (speaking of your risk assessments, they must be demonstrably facility-based/community-based and they must include staffing considerations; emerging infectious disease planning must be in the mix—no surprise there)
  • It is OK (and certainly much more effective) to have each organization’s EM person “show” the requested elements as opposed to surveyor “browsing” of the plan, etc. (the CMS guidance encourages the use of crosswalks to more quickly/readily identify where the component pieces “live”)
  • It is also OK to have your documentation in whatever format makes sense: hard copy, electronic, etc.

I think these are fairly representative of a common-sense approach to surveying compliance with the EM standards; I guess we’ll see how things unfold in the field…

Just a few odds and ends to wrap things up:

  • They encourage the use of the ASPR-TRACIE checklists; lots of good stuff there and well worth poking around and discovering.
  • Emergency power—you have to have what is required by the Life Safety Code® (LSC)/COP for your facility; but please remember that any additional emergency power considerations must be maintained in accordance with the LSC (and, by extension, NFPA 110 et al). I think some folks have this sense that anything not required by the LSC/110 combo can be maintained in whatever fashion they like. This seems to be drawing a line in the sand that they’re not buying it (again, I guess we’ll see what happens in the field—maybe anything that is not LSC-related isn’t offered up for scrutiny); also, they do not allow extension cords to directly connected to generators; generator must interface with facility through transfer system.
  • Functional exercises, mock disaster drills and workshops can be used to count towards the activation requirements (by the way, long-term care facilities are on the hook for annual education; everyone else can go with biannual).
  • Inpatient facilities need to have two years of documentation present; outpatient facilities have to have four years available.
  • Emergency plans are expected to evolve (mutate?) over the course of a long-term event (and I think we know a little something about that…), your plan should include provisions for monitoring guidance from public health.
  • Your plan must include provisions for tracking staff when electronic payroll systems, etc., not available—for example, power outages, etc. consider check-in procedures for on-duty and off-duty staff.
  • Your plan must include a process for communicating with the various AHJS (and, boy howdy, aren’t there an awful lot of those kicking around); as well as provisions for surge planning. As for staffing, while the use of volunteers is optional, there is an expectation that you will have a process for managing them. Over the years, I’ve run into any number of folks that were not at all inclined to deal with volunteer practitioners, but I think the days when that was a reasonable decision point are rapidly fading into the distance.
  • Your plan must also include a process for evacuating patients that refuse to do so; I figure there must be some empirical information that drove the inclusion of this in the guidance. I’m presuming that you have a process already for dealing with recalcitrant individuals, including patients, so I don’t know that this breaks any ground.

Now that I’ve finished typing this, I really don’t see a lot that I would considering troubling or, indeed, troublesome. I would imagine that a lot of this stuff has become rather more hard-wired than not over the past 15 months or so, if it were not already. I think there were a lot of common lessons learned, though the “equation” for “solving” the challenges is probably unique to every organization (unless you’re part of a system in which the facilities are virtually identical). From a compliance standpoint, I think you folks should be OK, but please reach out if you feel otherwise.

So, with June bearing down on us, I trust that you all continue to be well and are staying safe. See you next week!

Take me to your leaders…

I believe that we’ll be able to wrap up the emergency management stuff next week—though I have one or two ideas percolating that I might move to the front of the queue, but certainly before May gives way to June (unless something really interesting pops up out of nowhere…).

With our friends from Chicago returning to the playing field, there was some discussion of a modification to the session with organizational leadership, primarily involving moving the session to the opening of the survey and to have that session focus on leadership’s involvement with response to the pandemic over the last little while. The exact rationale for this strategy (which has since, more or less, gone away) kind of escapes me because I really don’t think the last 12-15 months could have been successfully navigated without some level of interest/action/participation, etc., on the part of hospital leadership teams pretty much everywhere on the globe. That said, I do suspect that the level of interest in all things emergency preparedness have probably not been as widely appreciated as they are right now (soon we will chat about making the most of this moment—but that’s for another day).

At any rate, with the unveiling of the new guidance (I don’t know that there’s necessarily anything “new” that’s going to come out of any of this, but I guess we’ll have to see, but this seems more like a recapitulation or codification than it does a significant change), there continues to be a concerted aim towards clarifying the necessity of organizational leadership participating in the emergency preparedness activities as a baseline expectation (an expectation I think we’ve all shared, yes?). Again, from a practical standpoint, your hospital, in all likelihood, would not have endured the last little while without the active participation/interest/whatever you care to call it from your leadership group. If someone managed to do so (and that doesn’t mean in spite of their participation), I’m keen to hear that story. But in the infinite wisdom of the regulatory monarchy, the following topics of conversation could be raised during any survey event in which leaders are queried about their EM roles:

  • How did the organization encourage collaborations with the available coalitions (local/regional/state: remembering that community partners are defined by each organization)?
  • How did the organization prepare for and manage staffing?
  • How did the organization prepare for and manage evacuation (including planning for the evacuation of patients that do not wish to be evacuated)?
  • How did the organization ensure that communications are collaborative and align with the methods/structures, etc., of the AHJs in the mix?
  • How did the organization promote participation in exercises and engage in the after action report process?
  • How did the organization ensure ongoing preparedness in the face of changes/shifts in community or other partners?
  • How did the organization identify what services would be provided under what circumstances?
  • How did the organization align continuity of operations and business continuity (we’ve had plenty of opportunity to look at this, I would think)?
  • How did the organization effectively manage the delegation of authority, including succession planning considerations?

In almost any other point in modern history, it might have proven to be somewhat burdensome to bring leaders up to speed in advance of a survey, but I can’t imagine that there are too many leadership groups out there that wouldn’t have more than enough practical experience (even if they never completed IS-100 and IS-200). Going forward, I think it’s going to be really helpful to keep the last year in everyone’s heads as a function of how we manage preparedness. It’s not just about regulatory compliance—it’s ensuring that providing care in a safe setting continues to be the number one priority of emergency response.

Hope you all are healthy and staying safe. Somehow I get the sense that we’re not quite done with this (though I would be more than happy to be proven incorrect in that sense), but we will prevail! See you next week!

You better? You bet!

It would seem that while the rest of the world has been busy responding to a pandemic, the folks behind the scenes have been working on identifying the lessons learned and memorializing them in an update to Appendix Z. At first glance, it seemed that this was more a codification of past updates, but as a I looked through the thing in its entirety, it does seem like the changes are more significant/substantive than I thought. That said, I do think that much of the updated material is aimed at helping surveyors to understand what is (and what is not) actually required and that, as with everything in our world, customization of approaches, etc., is not only desirable, but is really the only way to “roll” when it comes to appropriately preparing to respond to an(y) emergency. I suppose one could make the case that, after all of this hoo-hah of the past year-plus, if we’ve not managed to improve our preparedness, then what exactly have we been doing?

Part of the dynamic I keep coming back to with all this is if it were “business as usual,” then it wouldn’t be an emergency. And one of the defining aspects of an emergency is that it tends to push the normal limits of an organization. I remember the hue and cry that went out immediately following Superstorm Sandy’s trek up the East Coast regarding the level of hospital preparedness—because people struggled at the outset. But when the final report from CMS was issued, it turned out that hospitals generally did what they had to do to keep patients and staff safe.

As we look back at the past 18 months or so, I suspect that each organization within the sound of my voice is better prepared than previously for managing the impact of a long-term pandemic event. I also suspect that there have been any number of improvement opportunities identified and I am hopeful that, among other things, your organizational leadership has gained a greater appreciation for emergency preparedness as a proactive undertaking (recognizing that response is typically characterized by reactivity). The truth of the matter is this: while emergency preparedness does not, in and of itself, generate revenue. Effective emergency preparedness allows an organization to continue generating revenue while the feces is striking the rapidly rotating blades—and that makes all the difference in the world.

I suspect that this is going to take a couple of sessions to work through some of the subtleties of the updates, so I would encourage you to start chipping away at this as wander through the very merry month of May. There is a lot of material to digest and while I don’t see anything that’s making me crazy from a survey prep standpoint, I’ll let you be the judge of how that shakes out—at least for the moment.

Before I close out this week’s chat, I did want to tip you to one resource that I think will be really helpful. One of the more painful aspects of the Emergency Preparedness Final Rule has been that the official document that is Appendix Z is designed to include the requirements for all provider types, which makes an already complex set of rules that much more confusing. But someone (bless them, whoever they are) worked to peel out the requirements for each provider type, so if you’re not a “regular” hospital or you have operational responsibilities for more than one provider type, you can find the specifics for each here. There are other resources as well, but just having the requirements by provider type is (at least to me) crazy wonderful—and I hope you think so too.

Next week, we’ll chat about some of the ways in which organizational leaders are going to be looped into this on an ongoing basis—if that doesn’t sound like fun…

Risk assessments: Don’t leave home without one!

An interesting phenomenon I’ve been encountering of late relates to the whole notion of having to do environmental risk assessments in locations that are not specifically designated for the management of behavioral health patients. At this point, I don’t know of any healthcare organizations that would be able to say that they would not be managing behavioral health patients, even if they don’t have inpatient bed capacity, though I suppose you might be able to set up a transfer policy with another local organization that does have inpatient capacity. But those beds are typically in fairly sort supply and might well end up with having to “hold” a behavioral health patient for a prolonged period of time. Maybe you can manage that continuum in your ED, but what if you had a surge of, hmmm, let’s say infectious patients. Is there a possibility that a behavioral health patient could end up on an inpatient unit? And could you say absolutely in either direction without having a risk assessment in your back pocket?

So you could make the case that moving the environmental concerns relating to behavioral health patients from the Environment of Care standards to the National Patient Safety Goals section of the accreditation program has clarified (to a degree) the expectations relative to the management of at-risk patients, but that clarity brings with it some mandates. The mandate comes in three pieces (so to speak): a thoughtful evaluation of the environment; a plan; and available resources to guide staff when you have to put at-risk patients in an environment that is not designated for managing that type of patient.

To my eyes and ears, a thoughtful evaluation of the environment sounds an awful lot like a risk assessment; the FAQ goes on to describe some examples of resources that could be provided to staff, including the use of an on-site psych professional to complete the environmental risk assessment if staff are not sufficiently competent to do so. Which means that, if you do use in-house staff, you might be pushed to identify how you know that the folks doing the evaluation of the space immediately before a patient is placed are competent to do so. Though I suppose that also means you might have to demonstrate how you evaluated the on-site psych person… ah, it never really ends, does it?

At any rate, if you have not done a quick (but thoughtful—gotta be thoughtful!) risk assessment of your non-BH patient spaces, it’s almost certainly worth your time to do so. To my mind, the best risk assessment of all is the one they don’t ask for because the effectiveness of the process is in evidence. But sometimes we don’t get credit for “doing the math in your head,” so the possession of the risk assessment is your best bet.

Thanks for tuning in. Please be well and continue to stay safe. Until next time…