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What is the most dangerous place in your organization?

If you asked a dog the question in the title above, would it say, “Woof”? (Though some might say kitchen…I sometimes do.)

I’ve been encountering a fair number of roof-related opportunities and I wanted to give the topic an airing. I’m not entirely certain what prompted my thinking about rooftops (it’s way beyond Christmas), but I can say that I’ve encountered a bit of a run on unsecured roof hatches/access doors in hospitals (and hotels, too—I suppose I spend as much time in hotels as I do in hospitals—a certain inescapable logic coming into play on that count).

I will admit that I’m no fan of hatches from a practical standpoint (being rather stout and not particularly tall in the physique department), but I’m kind of surprised at the number I’ve encountered that are not secured (and I’m not talking about something that’s sort of secured, though I’ve seen some not-particularly-well-secured hatches as well). I know it’s important for Facilities/Plant Ops staff to have access to roofs, as well as emergency responders, but leaving these types of locations without any security seems way beyond a reasonable strategy. We’re certainly no stranger to the stories of patients wandering off (and I suppose you can’t always predict who might be prone to wandering) and I don’t know that I would want to hang my hat on the “remote” likelihood of someone “stumbling” on to an unsecured roof hatch, so I would ask you to please be attentive to the hatches and “batten them down” if they should have any level of uncontrolled access.

But just so we’re clear, it goes beyond hatches. It is of critical importance that you have a very hardened perimeter for all your roof areas. I don’t know how many times I’ve found propped, unattended doors because someone didn’t feel comfortable “trusting” a vendor (e.g., window washers) with the key to the access door. And I think it is a very well-established truism that doors for which folks do not have keys tend to get propped (I bet we could distill that into some sort of mathematical equation) and the likelihood of the propping is in proportion (I’m guessing inverse, but maybe not) to the risks of leaving that door unsecured. It may even be worth considering having roof access doors and hatches on your “Elvis” list (i.e., that list of critical things to check when you know you’ve got surveyors in the building—oxygen cylinders, corridor clutter, etc.). It’s all part of making absolutely sure that no one is inadvertently put at risk (I don’t believe that folks would purposefully leave a roof door unsecured and unattended—and I hope there’s no one out there to challenge that belief with a real life example).

Finally, don’t forget about fall protection for the folks you allow on the roof, particularly if you have minimal or no parapets. Interestingly enough, our good friends at the Occupational Safety & Health Administration have a few choice thoughts regarding fall protection; you can start that journey here. Even if it’s somebody working for a contractor, if you have a fall, your organization is likely to be mentioned as prominently as the contractor—and if you ask me, that’s no way to get on the front page of the local newspaper. So, the secret word for the week is “protection”: protection of patients, protection of staff, protection of contractors—it’s all part of the mix.

Next up (unless my calendar is lying to me), we should have another fabulous edition of Portal Chortling, with perhaps a side of Fireside Chat. Stay tuned!

The physics of compliance: If you have no friction, you likely have no traction

Or those wheels are going to be slipping all over the place…

This week’s offering is a little bit towards the random musings category, so hang on tight!

Friction vs. traction: I think that just about everyone in the safety community has experienced some level of pushback when they’ve tried to enact some change of process/expectation/behaviors to enhance the safety of their organization. And in so doing, you’ve discovered that the healthcare culture really does embrace change—it grabs change by the throat, throws it on the ground, and kicks it until it stops moving. This usually comes down to the classic “I’ve worked here for umpty-ump years and it’s never been a problem before,” etc., and while it doesn’t always seem so helpful in the moment, it does give you something in the way of useful feedback—they’ve actually noticed what you’re trying to do. For example, I can recall a time when the thought of physicians actually wearing ID badges seemed like a fantasy. And yet, as we speak, it is actually happening in a whole bunch of places (maybe not as much as we would like, but you’ve got to start somewhere). Now admittedly, a lot of the move towards the use of ID badges comes down to the proliferation of access control technology, the end result is that compliance became more convenient (in the ongoing battle between convenience and compliance, all too often convenience kicks compliance’s tailbone).

I would ask you to think about those stubborn deficiencies/behaviors that are perennially on your “needs attention” list and look at whether compliance is sufficiently convenient or has the operationalization of a compliance activity, say, the segregation of full and not full compressed gas cylinders, resulted in a process so complicated that it does not encourage compliance. In this case, I would say that more than 50% of the instances in which I find partially full or empty cylinders in the rack designated for full cylinders is because the racks for the “not full” cylinders were jammed with empties or partials and the only place left to safely store (remember, we’ve been nagging folks for about a decade on the proper storage of cylinders) the partial or empty cylinder is in the full rack. Perhaps the question that needs to be asked is whether there is enough space for the partial/empty cylinders; you can usually control the number of full cylinders being provided, but the number of partial/empties can ebb and flow over the course of a shift, a day, even over a week. I know it’s tough to get folks to own up to having put a cylinder in the wrong place (or damaged a wall, but that’s for another day), but I am fascinated by the action that results in someone doing something that they know they are not supposed to do. By the way, this is based on my firm belief that we’ve done enough education on this subject—and I would like to believe that the education that we’ve provided is sufficiently effective to at least get the message across. In looking at the misfiled cylinder as a failure mode—what happened in the process to result in the cylinder being in the wrong place. I can’t imagine that it’s being done purposely (it happens way too often—if it’s purposeful, we might just as well give up), but there has to be something we can discern from these instances/practices that we can use to encourage compliance—make it more convenient, as it were. So, don’t be afraid of a little friction as you pull these stubborn compliance issues apart. If things go too smoothly, there’s probably a workaround lurking somewhere in the background. Remember, it’s taking the path of “least resistance,” not “no resistance.”

The other random musing for the week is for those of you that may be in the middle of your post-survey process; be very judicious when you are creating your corrective actions plans. All too often, I see folks that have way overcommitted on their corrective action plans. Look very carefully at what the standard or performance element is actually requiring you to do and try to pick the route to compliance that work best operationally (meaning choose strategies that encourage compliance without overwhelming the participants—this is an analogue of the eternal question of how to eat an elephant). Don’t commit to daily activities if you can get where you need to be by doing it weekly; don’t commit to weekly if you can get where you need to be by doing it every other week; and so on. Also, I would advise trying to stay away from activities that don’t make sense—operationally, logically, etc. I tend to say that logic doesn’t always prevail, but I reserve that for direct dealings with regulatory surveyors. Once the surveyors are on their way, take the compliance results as data to make improvements—and focus on determining how you’ll measure those improvements. It puts you in a much better position to avoid those findings in the future (and at some point, the regulatory folks are no doubt going to get ugly when it comes to repeat offenses). As with so many things in the safety and compliance realm: this is a journey, not a destination. And on that quasi-Zen note, I bid you a safe week!

A most mortal portal: Yes, Virginia, you need to have an inventory of your devices…all of ’em

And so, the flying fickle finger of compliance finally points portally (via The Joint Commission’s Physical Environment Portal) in the direction of that most troublesome of standards, EC.02.03.05, and we return once again to the fireside of our intrepid duo, Messrs. George Mills of The Joint Commission and Dale Woodin of ASHE. There are two videos, one for the facilities audience and one for leadership (does anyone else find it fascinating that the duo dons neckwear for the leadership video?).

While I don’t want to engage in revealing any spoilers, in the video, EC.02.03.05 is described as being “most prescriptive” and “frustrating” and also notes that Mr. Mills has taken some pains to “tear apart” the standard in past “Clarifications and Expectations” columns in Joint Commission Perspectives. Yet, yet, yet, approximately 40% of hospitals continue to get cited for deficiencies relative to the myriad components represented in this standard. I personally would love to see how this actually breaks down in terms of which of the 20+ performance elements are the most problematic (I can’t imagine that there are some that “float” to the top more than any others), but the video does seem to indicate what the “problems” are:


  1. You have to have an inventory, by location, of each device class, meaning smoke detectors, heat detectors, pull stations, HVAC shutdown devices, water flows, tamper switches, fire extinguishers, etc. It seems to me that back in the day, there was a reluctance on the part of our Chicagoan friends to actually say the words that would indicate the need for an inventory. But it all comes down (or back—I think I’ve beaten this particular breathless equine once or twice in the past) to knowing that you inspected, tested, maintained, each device in the fire alarm system. So if you (or your vendor’s documentation) do not specifically indicate that each device was demonstrably inspected, tested, maintained, then (buzzer sound): you lose!
  2. The documentation has to be available “upon request”, so really, if you can’t produce the current documentation PDQ, then (buzzer sound): you lose! You can only get credit for those inspection, testing and maintenance activities for which you have available documentation—if you didn’t document it, you didn’t do it. Period. End of story.

Now I certainly recognize that a combination of findings under EC.02.03.05 would drive a finding under the Leadership standards (to be exact, LD.04.01.05 EP 4), based on past survey reports. But apparently there is indeed a magic number of EC.02.03.05 EP findings that will result in the Leadership finding—three or more EPs out of compliance, then (bell rings): you win a discussion with your boss as to how you allowed (and I’m using that term in its most pejorative sense) such a thing to happen. At that point, for example, it is way too late to admit that the fire alarm and sprinkler testing vendors have not given you very useful reports (and something tells me that that particular conversation is not as rare as it ought to be). From watching the video (and in providing a neckwear-enhanced video specifically for your organization’ s leaders and Mr. Mills indicates he had to edumacate his bosses too—we are not alone), there is a very clear expectation that you, the facility/safety professional, will make the effort to proactive communicate with your boss, particularly if you are experiencing service issues, etc., in getting these activities under control. You can certainly make the case that the protection of the entire organization can be compromised if your fire alarm and sprinkler systems are not appropriately maintained, so, really, any infrastructure concerns should be communicated in a timely fashion to the leadership of each organization to ensure that appropriate resources are allocated on an ongoing basis to make sure everything stays on an even keel.

At any rate, our duo takes great pains to point out that none of this stuff is new (the “seed” documents from NFPA 72, 25 and the like having been penned way back in the 20th century), but I do feel that the methodology for surveying has evolved/mutated over time. I mean, if it were really that simple, wouldn’t this go away? They also point out that ASHE has a fair amount of information to assist you in your compliance efforts (ASHE Focus on Compliance: you can be especially warm for their forms) and there’s even a PowerPoint presentation that The Joint Commission uses at the EC Base Camp presentations (you can link to the presentation on the left hand side of the portal page), which gives it the power of the Quadruple P—Portal PowerPoint Presentation! Ultimately, you’ve got to keep a really close eye on this stuff, aside from product expiration dates, the management of the various and sundry elements of EC.02.03.05 is among the most voluminous in sheer numbers—that’s a lot of spheres to keep up in the air—and you only have to drop a couple to earn that lovely chat with your boss. I am absolutely convinced we can make it happen, so let’s see what we can do to retire EC.02.03.05 from the top 10. (Or 20…wouldn’t that be a fine thing?)

So many FSAs, so little time…and all we get is MBW

Flexible Spending Account, Federal Student Aid, Food Services of America, Focused Standards Assessment.

So, I am forced to pick one. While I’m sure the lot of them is most estimable in many ways, I suppose the choice is clear: the freaking Focused Standards Assessment (kind of makes it an FFSA, or a double-F S A…what the…).

Just to refresh things a bit, the FSA is a requirement of the accreditation process in which a healthcare organization (I’m thinking that if you weren’t in healthcare, you probably would be choosing one of the other FSAs) reviews its compliance with a selected batch of Joint Commission accreditation requirements. The selections include elements from the National Patient Safety Goals, some direct and indirect impact standards and performance elements, high-risk areas, as well as the RFIs from your last survey—and I know you’ve continued to “work” those Measures of Success from your last survey. Ostensibly, this is very much an “open book” test, if you will—a test you get to grade for yourself and one for which there is no requirement to share the results with the teacher (in this case, The Joint Commission—I really don’t understand why folks submit their results to TJC, but some do—I guess some things are just beyond my ken…).

The overarching intent is to establish a process that enhances an organization’s continuous survey readiness activities (of course, as I see various and sundry survey results, I can’t help but think that the effectiveness of this process would be tough to quantify). I guess it’s somewhat less invasive than the DNV annual consultative visits, though you could certainly bring in consultants to fulfill the role of surveyor for this process if some fresh eyes are what your organization needs to keep things moving on the accreditation front.

I will freely admit to getting hung up a bit on the efficacy of this as a process; much like the required management plans (an exercise in compliance), this process doesn’t necessarily bring a lot of value to the table. Unless you actually conduct a thorough evaluation of the organization’s compliance with the 45 Environment of Care performance elements, 13 Emergency Management performance elements, 23 Life Safety performance elements (15 for healthcare occupancies, eight for ambulatory healthcare occupancies)—and who really has the time for all that—then does the process have any value beyond MBW (more busy work)? I throw the question out to you folks—the process is required by TJC, so I don’t want anyone to get in trouble for sharing—but if anyone has made good use of this process, I would be very interested in hearing all about it.

This is my last piece on the FSA process for the moment, unless folks are clamoring for something in particular. I had intended to list the EPs individually, but I think my best advice is for you to check them out for yourself. That said, I have a quick and dirty checklist of the required elements (minus the EP numbers, but those are kind of etched into my brain at this point). If you want a copy, just email me at

Brother, can you spare any change…

In the interest of time and space (it’s about time, it’s about space, it’s about two men in the strangest place…), I’m going to chunk the EM and LS risk areas that are now specifically included in the Focused Standards Assessment (FSA) process (previously, the risk areas were only in the EC chapter). Next week, I want to take one more chunk of your time to discuss now the FSA process (particularly as a function of what EPs the folks in Chicago have identified as being of critical importance/status). But for the moment, here are the add-ons for 2016:

Emergency Management


  • participation of organizational leadership, including medical staff, in emergency planning activities (you need to have a clear documentation trail)
  • your HVA; (interesting that they’ve decided to include this one—they must have found enough folks that have let the HVA process languish)
  • your documented EM inventory (I think it’s important to have a very clear definition of what this means for your organization)
  • participation of leadership, including medical staff, in development of the emergency operations plan (again, documentation trail is important)
  • the written EOP itself (not sure about this addition—on the face of it, it doesn’t necessarily make a lot of sense from a practical standpoint)
  • the annual review of the HVA (my advice is to package an analysis of the HVA with the review of the EOP and inventory)
  • annual review of the objectives and scope of the EOP
  • annual review of the inventory
  • reviewing activations of the EOP to ensure you have enough activations of the right type (important to define an influx exercise, as well as, a scenario for an event without community support)
  • identification of deficiencies and opportunities during those activations—this means don’t try to “sell” a surveyor an exercise in which nothing went awry—if the exercise is correctly administered, there will always, always, always be deficiencies and/or opportunities. If you don’t come up with any improvements, the you have, for all intents and purposes, wasted your time… (Perhaps a little harsh, but I think you hear what I’m saying)

Life Safety


  • Maintenance of documentation of any inspections and approvals made by state or local fire control agencies (I think you could make a case for having this information attached to the presentation of waivers, particularly if you have specific approvals from state or local AHJs that could be represented as waivers)
  • Door locking arrangements (be on the lookout for thumb latches and deadbolts on egress doors—there is much frowning when these arrangements are encountered during survey)
  • Protection of hazardous areas (I think this extends beyond making sure that the hazardous areas you’ve identified are properly maintained into the realm of patient spaces that are converted to combustible storage. I think at this point, we’ve all see some evidence of this. Be on the lookout!)
  • Appropriate protection of your fire alarm control panel (for want of a smoke detector…)
  • Appropriate availability of K-type fire extinguishers (this includes appropriate signage—that’s been a fairly frequent flyer in surveys of late)
  • Appropriate fire separations between healthcare and ambulatory healthcare occupancies (a simple thing to keep an eye on—or is it? You tell me…)
  • Protection of hazardous areas in ambulatory healthcare occupancies (same as above)
  • Protection of fire alarm control panels in ambulatory occupancies (same as above)


I would imagine that a fair amount of thought goes into deciding what to include in the FSA (and, in the aggregate, the number of EPs they want assessed in this process has gotten decidedly chunkier—I guess sometimes more is more), so next week we’ll chat a bit about what it all means.

Plus ça change, plus c’est la même chose: Vive Le Joint Commission!

I apologize for not having gotten to this sooner, but sometimes the wind comes out of nowhere and you find yourself heading in a rather unexpected direction (I’ve never spent so much time in Texas!).

With the advent of each new year, our three-lettered friends in Chicago unveil the changes to the accreditation standards for the upcoming cycle. Most of the changes in the EC/LS/EM world (with a couple of fairly notable exceptions—more on those in a moment) have to do with a shift in focus for the Focused Standards Assessment (FSA) process as a function of the various specific risk areas (I will freely admit that this is a wee bit convoluted, but should not necessarily come as a surprise). At any rate, as part of the accreditation process, each organization is supposed to evaluate its compliance based on specific areas of concern/risk identified by The Joint Commission. Thus for 2016, some of the risks to be evaluated have gone away (at least for the moment) and other have been added to the mix:

Please remember: These are not going away entirely, they just don’t have to be included in your organization’s FSA process!

So, we bid adieu to specific analysis of the safety, hazardous materials, medical equipment, and utility systems management plans (leaving security and fire safety in the mix) and we say bonjour to the identification of safety and security risks (as you may have noted, I’m not indicating the specific standard and EP numbers—our friends get a little protective of their content, but if you really need to check out the numbers, please see your organization’s accreditation manual).

We say goodbye to implementing our hazardous material and waste spill/exposure procedures, the monitoring of gases and vapors, and proper routine storage and prompt disposal of trash; and say hello to the hazardous materials and waste inventory, the actual written hazmat and waste spill/exposure procedures, minimization of hazmat risks, ensuring that you have proper permits, licenses, etc., for hazardous materials, and labeling of hazardous materials.

We say howdy to a focused look at fire drills, including the critiques.

We greet a focus on the testing documentation relating to duct detectors, electromechanical releasing devices, heat detectors, manual fire alarm boxes and smoke detectors, as well as the documentation relating to fire dampers.

We say auf wiedersehen to focusing on the selection, etc., of medical equipment, the written inventory of medical equipment, SMDA reporting, inspection, testing and maintenance of non-high risk medical equipment, and performance testing of all sterilizers.

We say guten tag to the written utility components inventory, written frequencies for maintenance, inspection and testing of utility system components, written procedures for utility system disruptions, and minimization of pathogenic, biological agents in aerosolizing water systems.

We say konichiwa to a focus on the provision of safe and suitable interior spaces for patients and the maintenance of ventilation, temperature and humidity in all those other pesky areas (e.g., soiled utility rooms, clean utility rooms, etc.).

We say hola to a focus on whether or not staff (including LIPs) are familiar with their roles and responsibilities relative to the environment of care (I predict that this is one is going to start showing up on the top 10 list soon unless there is a dramatic shift in survey focus).

And we say “Hey-diddly-ho, good neighbor” to the use of hazard surveillance rounds to identify environmental deficiencies, hazards, and unsafe hazards, as well as ensuring that you have a good mix of participants in your EC Committee activities, particularly the analysis of data—clinical, administrative, and support services have to be represented.

Now, there are three standards changes that went into effect on January 1, 2016: one a shift to a different spot in the standards, one a fairly clarifying clarification, and one about which I am not quite sure what to make, though I somehow fear the worst…

The requirement for the results of staff dosimetry monitoring (CT, PET, nuclear medicine) to be reviewed at least quarterly shift from Safety to Hazardous Materials. The EP number remains the same (and I can give you 17 reasons for that…), but it’s only a shift in where it would be scored (another important reason for making sure that you have a solid relationship between your EOC Committee and your Radiation Safety Committee—I’m a great believer in having compliance information in a location where surveyors are more likely to encounter it: EOC Committee minutes).

The requirement for managing the risks associated with smoking activities was clarified to indicate that the risks have to be managed regardless of the smoking types (e-cigarettes and personal vaporizers are officially in the mix); I’m presuming that this is helpful to folks who have perhaps faced some resistance in this area.

And finally (we’ll cover the EM and LS changes next time—nothing particularly scary, but a little too voluminous for this rather dauntingly wordy blog post), the requirements based around the inspection, testing and maintenance of non-high-risk utility system equipment components has gone from a “C” Element of Performance (EP) to an “A” EP (they did remove the Method of Success requirement for a deficient finding in this area—I suspect that was as much for their own sanity as anything else. Plus, it never really made a great deal of sense to figure out how to monitor something over four months’ time that frequently occurs every six or 12 months). My sense is that they are making the change to increase the “cite-ability” of managing utility systems equipment; now they only need to find one instance of noncompliance for a finding. I don’t know that I’ve seen a ton of findings in this area, but I can’t honestly say that I’ve been doing a close count of the OFI section of the reports, so it may be that they’re seeing a trend with the non-high-risk utility equipment that makes them think we’re not doing as good a job managing as we should, but that is wholly and completely conjecture on my part. I will, of course, be keeping a close eye on this one; I have a sneaking suspicion that the focus on utility systems equipment is going to continue into the immediate future and this might just become another pressure point.

As a closing thought relative to the FSA and risk area discussion, I think we can reasonably intuit that (particularly since the FSA process, represents a process for self-reporting) the expectation is for folks to be looking very carefully at the requirements contained within the above-noted areas and that your compliance plans relative to those requirements will be well in hand come survey. For some reason, this shift “smells” like an approach that’s going to be that much more focused on organizational leadership when there are gaps (and ask anyone who’s had a bumpy survey these past couple of years—leadership gets dragged into the fray on a regular basis). The fact of the matter is that they will find something deficient in your facility—if they don’t, they didn’t look hard enough. It’s about having processes in place to recognize and manage those deficiencies appropriately (and yes, I recognize that I am running the risk of repeating myself). This is big-time crazy focus on this stuff—and we need to be continuously improving how we go about doing it (whatever “it” might be).

Back next week to cover the EM/LS stuff. Arrivederci for now!

This American Hospital: HAIs resulting from exposure to lead

As I think I’ve mentioned in the past, I listen to a fair amount of public radio when I’m in the car, and this past Saturday, I stumbled (I’ve found that my errands don’t always coincide with the start and end of programs—thank the gods of radio for podcasts and other forms of re-broadcast) into the middle of a story that I found quite compelling. The program itself is called This American Life and emanates from WBEZ in Chicago; the nominal purpose of the program is to provide a forum for the airing of stories about (natch!) This American Life, which allows it to cover a lot of ground. I always find the stories pretty interesting/compelling, etc., but this past weekend’s episode really got me thinking about the ongoing struggles faced by hospitals as they try to balance security, workplace violence management, the management of behavioral health patients, education of staff in being able to effectively manage crisis situations, etc. Basically, the whole gamut of issues relating to the continuing disenfranchisement of the behavioral health patient community. There are some places that do pretty well with this, but I think the opportunities to do better far outweigh the improvements made so far (that’s as close to editorializing as I’m going to do for the moment).

As I think about it, while Joint Commission compliance is probably THE hot button item when it comes to the management of risks and conditions in the physical environment, I truly believe that, at least for the folks who are typically responsible for managing the physical environment, this topic is by far the more complicated—very much in line with the prevention of healthcare-acquired infections—and, interestingly enough, there can be a crossover, but more on that in a moment.

The story deals with a “delusional” (my quotes) patient who, in the course of his stay in a hospital (you can find out a lot of the details by listening to the episode, which can be found here) encountered a situation in which he did indeed contract an HAI because of an exposure to lead, namely a bullet fired by a police officer in this patient’s hospital room. Now (trying not to sound too old), back in my days of operational responsibility, I have overseen dealings with behavioral health patients, on-duty police officers discharging their weapons in the ED, folks injured as a result of physical encounters with patients, etc. But I have to tell you (and at least some of this is the power of the storytelling in conjunction with the story being told), the sequence outlined in the episode is about as harrowing as you could imagine: not very good decisions are made and sustained; family members are perhaps not embraced as a source of useful information (I’m trying to avoid more editorializing—but tell me the story doesn’t ring some bells with you, particularly  if you’ve had operational responsibility for security), staff are perhaps not as well-prepared as they might otherwise be—a real cluster of ugliness.

I know things are never as cut and dried as they seem to be in the aftermath; you might find the “official” response from the hospital a little curious (I did as well, but I understood the forces in play—sounds like there might still be some lingering litigation), but this type of confluence of events is all too easy to imagine. I think it’s definitely in the best interests for the safety/security community to advocate for the management of these types of patients based on the underlying causes (mental illness, behavioral health issues) and not just a panicked response to the symptoms. Yes, we will always have that quotient of patients who are just [insert epithet of your choice here]. But safe care can’t be sacrificed in the rush—safe for the patients, safe for the staff.

I’m happy, hope you’re happy too…

A couple of weeks ago, HCPro’s Accreditation Insider featured an article that addressed a study published by the American Journal of Infection Control on compliance by nurses with the many and varied requirements of the Bloodborne Pathogens standard.

I guess I’m of two minds about the study; it is a somewhat smallish sample size (116 nurses were studied), though presumably statistically valid (not being wicked up on the whole statistical analysis thang, I wouldn’t even presume to presume, but I’m thinking that it would hardly have been worth publishing if it were not of some note). I think in my heart of hearts that (at this point) I would have hoped for better compliance numbers but again I’m not certain that I was particularly surprised that gloves aren’t worn all the time, hands are not washed as often as is necessary (e.g., after taking care of patients, after taking off gloves), and face shields are not worn as often as would be advisable given the risks (no big surprise on the face shields—it is a struggle, struggle, struggle—not just for the potential of an exposure to blood or other potentially infectious materials (OPIM to those among you that are acronymically inclined), but also for potential chemical exposures. (Everybody wants a freaking eyewash station “in case”, but nobody wants to use appropriate PPE to ensure that “case” doesn’t occur—jeepers!)

I haven’t had a chance to actually read the study (yes, I know—shame!), but the article in Accreditation Insider doesn’t really get into what the compliance barriers might have been (I honestly don’t know if the study gets into some of the causative factors), which I think would have been instructive. Apparently, the study concludes with a recommendation for stricter enforcement of compliance policies and to address problem areas with better monitoring and staff education. Now, those are fine things indeed, but kind of begs the question as to what constitutes better monitoring and staff education. I will go on the record here (I don’t think I have previously, but if I have, mea maxima culpa) as no particular fan of computer-based learning. I “get” that it is more convenient for folks to do and thus, generally results in better “compliance” when it comes down to numbers of folks completing the required “modules,” etc. And I also “get” that it is compliant from a regulatory standpoint (BTW, just because I “get” something doesn’t necessarily mean that I am convinced that such claims are valid). What I don’t find as I travel the highways and byways of healthcare facilities is evidence that this process results in an enhancement of staff competence and knowledge. I don’t necessarily think of myself as a Luddite (in fact, I’m pretty okay with a lot of technology), but I don’t know that convenience is the yardstick by which we should be measuring the effectiveness of education. Rant over…

Before I hop along, I do have one favor to ask (and it sort of relates to the above). I understand that, from a sterile processing perspective, it is important to do some sort of enzymatic pre-treatment of soiled instruments so the OPIM doesn’t get all caked and hardened on the surface of said instruments. The favor (or question) is this: Has anyone identified a product that will appropriately pre-treat instruments but not require emergency eyewash equipment? If you have a risk assessment of that determination, that would be very cool. I’m running into another uptick in the proliferation of eyewash stations—I’m a great believer in having them when they are appropriate, but I’m no fan of eyewash stations “in case” (that sounds somewhat familiar…where have I seen that before?). Any feedback would be most appreciated.

Happy Mardi Gras for those of you disposed towards that kind of celebratory activity…

More portal chortlings—under the god(s) of compliance

I guess one could say that it took them a wee bit to get around to the topic of the requirements (and survey vulnerabilities) relating to the built healthcare environment, but they’re really going full bore on EC.02.06.01, particularly as a function of making sure that the responsibility of organizational leadership is recognized as a (if not the) critical component of compliance. I know we’ve already covered the latest fireside chats from Messrs. Mills and Woodin, but if you have not already done so, I would encourage you to do two things (and part of me is a little anxious as this smacks a bit of endorsement, but I think this is important):


  • Include a viewing of the fireside chats at your EOC Committee meetings; I don’t know that I would do all of them at once, but they are certainly brief enough to do one a month. I think it’s crazy important for everyone on the Committee to review the contents of the videos and while I know that you could just furnish the links to the Committee members and have them view on their own, I suspect that there might be some very valuable discussions to be had if you watch it as a group (heck, you could even make some popcorn—multigrain, no butter, perhaps a light dusting of sea salt), with maybe 10 minutes of discussions. While there is not much in the way of epiphanies in the content of the videos (I think everyone kind of recognizes what needs to happen), again, I think you could have a pretty good discussion regarding some of the concepts covered and the practical application of those concepts in your organization. You might even invite folks from procedural environments that are not typically members of the Committee. This is a huge focus of the survey process at the moment and the closer we can get to an intimate understanding of the dynamics, the better off we’ll all be.
  • Share the video with your boss (and if you can do it, your boss’s boss); the fact of the matter is that findings in this area could very well (it’s almost a likelihood) result in a finding under the Leadership standards, which ostensibly ties this up (and back) to the governing board of your organization. I don’t think that you’ll have a very easy time of managing the built healthcare environment without the knowledge and support of your organization’s leaders. We can no longer act as though this stuff is the responsibility of a few folks in the “trenches”; the management of the physical environment extends from point of care/point of service all the way to the top of the organization. It’s all about stewardship and everyone’s role in that pursuit.

Now I’m sure some folks are getting tired of me harping on this dynamic, but until we start managing the physical environment in a proactive, risk-aware manner, the Top 10 is going to continue to be EC Corner—and I don’t think any of us want that.

To assist in providing information to leaders, the latest update to this part of the portal is a downloadable file of the contents of the videos and the posted materials (not quite a transcript). Hopefully you have a leadership team that’s on board with this stuff, but if not, you’ve got to keep hammering on it. Visit this link to get a refresher on the materials.



If anyone has some success stories in this regard, I (for one) would love to hear about them. We are a community of safety professionals; the success of one can be the success of all, so let’s make it happen!


Does closing rooms due to environmental conditions always make the best sense?

Every once in a while, someone asks me a question about why (or as is more the case here, “how”) a certain approach or response “becomes” the standard of practice, etc. For instance, a lot of times, I will find Interim Life Safety Measures policies that always seem to drive implementation, almost in direct opposition to the level of risk engendered by the deficiency (one caveat: I think you really have to tend towards over-implementing for construction and renovation activities, if only because you can have so little actual control over contractor behaviors. You need think only of the number of truly successful above the ceiling work permit processes—almost makes Powerball sound like a sure thing, but I digress). Anyways, to bring this back to today’s topic, I am reasonably certain (I was going to say “know,” but since I haven’t been everywhere) that many, many folks (very close to all) have intermittent struggles with the management of environmental conditions in surgical procedure areas. If we can use the number and type of Joint Commission findings as any indicator, the struggles continue.

I think we can operate under the assumption that there are very few surgical procedure areas that are perfectly configured every moment of every day (I don’t think that’s a stretch, but please let me know if you have found perfection in this regard). But what I see all the time are policies for which the response to out-of-range values (once you’re done with the call tree) is to make the decision to continue with cases or to close the rooms until the conditions can be resolved. Now I know there are instances in which you need to be a little more careful; I can see the risks of continuing with an invasive surgical procedure if your air pressure relationships are bit squirrelly. But what about the actual risks associated with out-of-range temperature and/or humidity? I mean, if you have an upper humidity limit of 60% (which I think is fairly common), a condition of 60.1% RH is an out-of-range value, but I don’t see where it would necessitate closing the room, delaying cases, etc.

I did a little poking around to figure out the genesis of the “closing the room” dynamic and I have been unable to make anything close to a real determination of where this started. Anecdotally, I got some indication that CMS was the perpetrator, but I’ve heard the same thing about CMS and the general prohibition of cardboard, so I think this may very well reside in that vast wasteland of healthcare compliance mythology (and no Mythbusters to tackle these pressing issues—bugger!). At any rate, I’m wondering if anyone out there has really analyzed the increasing/decreasing risk factors relative to out-of-range (low and/or high) humidity or temperature conditions. I can’t help but thinking that we can do better in this regard, so if someone has something to share (perhaps this would be a very good improvement project for 2016). There’s got to be a point where the risk of the environmental condition(s) actually outweighs the risk of delaying treatment/procedures, etc. Maybe it’s time to figure out exactly where those tipping points live…