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This week in hell: What about the damn dampers?

We are certainly in the (very) early stages of the departure of The Joint Commission’s Plans for Improvement (PFI) process from our midst (Is it possible for a process to have abandonment issues? I suspect we’re going to be feeling something like it for quite some time to come.) and there continues to be much to chew on. This week, I’m going to break it down into a couple of chunks that will hopefully allow us to more easily digest this big mouthful of unpleasantness, but first, a rant (ooooh, big surprise):

 

  • I honestly don’t have a dog in this particular fight beyond my position as an observer of accreditation and regulatory compliance activities in healthcare, but I continue to “bump” up against the practice of TJC revealing substantive (and substantial) changes in forums that are not completely accessible to everyone with a dog in the fight. I don’t know about you, but my boss is generally inclined for me to be busy doing productive work, so I don’t oft (okay, never) get to the annual ASHE conference (and yes, I recognize the educational value, etc., of such gatherings, but, as you all probably know pretty well, that can be a very tough sell). Consequently, I (and perhaps a whole bunch of “yous” out there in the audience) was not present when the discontinuation of the PFI process was announced. I don’t know if there was a Q&A that followed the announcement, so I have no idea if questions were asked and answered, asked and deferred, asked and not answered, etc. I suspect if we all had known what was coming down the pike this year, between adoption of the 2012 Life Safety Code® (LSC) and PFI getting kicked to the curb, we might all have made a little bit of an extra effort to get to ASHE (well, perhaps you would have—I was having way too much fun tripping around Texas). At any rate, at the very least, I would love to see a transcript of the presentation as well as any Q’s and A’s that might have occurred. As an alternative thought, I also believe that something this monumentally important is deserving of a free webinar from TJC that includes a live Q&A (or if not a live Q&A, answers to pre-submitted questions would be okay)—this has the potential to be enormously painful for facilities and safety folks over the next little while (the optimist in me says “little while,” my fear is fairly long while) and, as customers, I think those same facilities and safety folks deserve a little time with the powers that be.
  • So what do we do with the damn dampers? As near as I can tell (with absolutely no empirical data beyond the number of questions I’ve received on the topic), there are a fair number of folks who have taken advantage of the PFI process for managing inaccessible dampers. When the PFI process goes away, does this mean all those dampers have to be brought in to compliance within the 60-day window? I am truly hoping that something specific to this issue is forthcoming before folks start tying up all the mechanical contractors in the US. Perhaps there’s a categorical waiver in the future for this piece of business—I think that would be a nice surprise. One thing I can tell you is that I know of at least one hospital that CMS required to clean up the damper issues identified on the PFI, so I have no reason to think that leniency will be the order of the day.
  • For those of you that reflect the PFI process in either your management plans or your ILSM plans/policies, you should probably pull those out and update the process as a function of no PFI process (I’m still not quite over the initial shock of that). Certainly for many, many years, a fundamental part of the standards-based requirements relative to ILSM was the management of LSC deficiencies that could not be immediately corrected (or corrected immediately, depending on your perspective), which brings us squarely into the realm of the PFI process. At any rate, make sure you make a quick of any policies/processes (hey, maybe even in your work order system) to make sure that you expunge all evidence of the PFI process.
  • As to the discontinuation of the Basic Building Information component of the Statement of Conditions, one of the things that’s “driven” by the information contained therein is the number of survey days, based on the square footage of healthcare occupancies in your facility. I don’t believe that the square footage question is asked during the organizational application process (might be worth checking with the individual in your organization charged with filing the application to verify what may or may not be in the mix), which makes me wonder how they will make the determination if folks don’t update the eBBI information. I suppose they have a basic starting point now, so it probably won’t change that much, but I also think of the SOC as a great means of communicating certain information to the surveyors—existing waivers/equivalencies (which makes me wonder: are we looking at a day when all the existing waivers/equivalencies granted by TJC go away or at least have to be resubmitted to CMS?), locations and square footage of suites, level of sprinkler coverage, and other unique aspects of the building can all be memorialized in the comment section of the SOC. But if the surveyors aren’t going to look at the SOC any more, do we print out the information and provide it to them directly or does this become one more potential sticking point during a survey? I guess a lot of the same information can be included on the life safety drawings, but I know a lot of folks don’t have the wherewithal to manage the drawings themselves so they use an architect or fire protection engineer for updates, etc.

 

All that said, I guess we’ll just have to keep our fingers crossed that some level of sanity is restored to the process, but given the state of the world, I don’t think I’m going to be holding my breath while I wait.

Breaking news: PFIs take a flyer!

Well, I suppose there was a certain element of inevitability to this. First, the expulsion of the most global “FIs” in the Joint Commission arsenal—the Requirement for Improvement (RFI) and the Opportunity for Improvement (OFI)—which left only one FI to be expelled, our good friend and (sometimes) benefactor, the Plan for Improvement (PFI). And that day has come (I don’t think there are any intact FIs kicking around, but I could be mistaken…)!

In what will likely end up being filed under the “no good deed goes unpunished” category (I’m more or less characterizing the adoption of the 2012 Life Safety Code® (LSC) as a good deed, though I will submit to you that, if only coincidentally, there has been an unleashing of a most distressing pile of poop), The Joint Commission has announced that, beginning August 1, 2016, it will eliminate the PFI process as a means of managing LSC deficiencies that cannot be immediately corrected and will take longer than 45 days to resolve. Yes, you did not misread that last sentence: say so long, farewell, auf wiedersehen, good bye (can I get an au revoir or adios?!?) to one of the most beloved characters in all of regulatory nuance. So, in place of the PFI process is an expectation for life safety deficiencies to be corrected within 60 days—unless, of course, you want to pursue a time-limited waiver with the friendly folks at your regional CMS office (don’t that sound like a party?). This information comes to us courtesy of the good folks at the American Society for Healthcare Engineering (ASHE), who provided this to members as an advisory released late yesterday afternoon.

When Jay Kumar, my editorial foil at BLR/HCPro asked me for my initial thoughts, there were several expletives that came to mind (and I suspect they are coursing through your collective craniums as well), but I do know that a fundamental means of having some element of control (even if it was somewhat illusory in nature) in managing conditions in the physical environment has pretty much been ripped from our hands. I guess we could look at this as one more piece of the “becoming more like CMS” movement that has been afoot for quite a few years now. Or maybe, as CMS never really accepted the PFI process as an alternative means of LSC compliance, they finally told TJC to cease and desist. I’m thinking this probably also pretty much quashes any thought that the Building Maintenance Program will ever be anything more than it is now (at this point, I’m not really sure what it is beyond a means of organizing the maintenance of certain life safety building features, not a bad thing, but not quite as compelling as it once was).

The process as outlined in the ASHE Advisory goes a little something like this:

 

  • Deficiencies will need to be corrected within 60 days of being identified unless the CMS regional office approves an extension.
  • All requests for extensions will be handled by CMS regional offices. However, The Joint Commission will allow facilities to submit requests and receive a receipt to show they are in the pipeline waiting for an extension.
  • The Joint Commission will not review open PFI items, and PFIs will not be a part of final reports.

Now before you get overly panicky, apparently we will still be able to use the PFI process as an “internal management process,” so everything’s good—right?

I guess we’re going to have to wait and see how this all unfolds in the field, but I have a sneaking suspicion that, of all the changes we’ve encountered this year, I suspect this one is going to result in the greatest amount of disruption, at least in the short term.

But hey, we work in healthcare—we embrace change! We grab change by the throat, throw it on the ground and kick it ’til it stops moving. We love change!

As plain as the nose on your emergency response plan…

Periodically, the whole concept of adopting plain language codes for emergency response plan activities/activations percolates to the top of somebody’s to-do list (I’d much rather embrace the concept of the to-don’t list, but that’s a discussion for another day). There was a little bit of that (more by inference than anything else) in the CMS follow-up report to the hospital response to Superstorm Sandy. Jeez Louise, that seems like eons ago…

This discussion always seems to engender a lot of back and forth, mostly regarding the balancing act of providing enough information to direct an appropriate response and not providing enough information to cause a panic. I recognize both sides of the argument, but I must say that I haven’t seen a lot of data to support a wholesale change, particularly as it would require a fair amount of education (and yes, I know that just because something requires education, etc., is not enough to forego adopting a new strategy, etc.). But I will also say that, depending on your organizational palette when it comes to emergency notification, all the different codes relative to workplace violence, active shooter, emergency assistance calls, etc., may well benefit from a more succinct announcement.

Recently, the Texas Hospital Association has weighed in with a recommendation to its members to adopt plain language codes, including a sample policy, an implementation timeline, and some examples (you can find that information here). It appears that there’s a move away from the (fairly standard, though not quite universal) Code Red designation for a fire alarm activation to the plainer language (though somehow not quite as sexy) “fire alarm activation.” It does appear that medical emergencies will remain as the (again, fairly standard, not quite universal) Code Blue (I guess that one’s gotten enough play on medically-oriented TV programs to have become part of the vernacular—where are the TV shows about safety in hospitals?!?), but there are some other terms that are worth of consideration. I don’t know that there’s necessarily a groundswell of support, but sometimes Texas can be something of a bellwether, so it may be a good opportunity to look at the possibilities, particularly if you haven’t in a while.

That said, I have two (relatively moderate) concerns. One being we are still waiting on the unveiling of the CMS final rule on all things emergency management; I had thought perhaps that pursuit had become somewhat dormant, but with the adoption of the 2012 edition of NFPA 99 excluding the chapter on emergency management, I think we have to believe that something regulatory this way comes. At any rate, will CMS push for some standardized notification language, particularly as a function of a focus on interoperable communications capabilities? I think that card has been dealt, I guess we’ll have to see how it gets played.

The other concern is the overarching concept of interoperable communication capabilities; I, for one, do not recommend you go about changing anything in terms of notification until you have some talk-time with the local emergency response authorities. They may or may not feel like they have a stake in this discussion, but you want to be absolutely certain that any modifications you might be entertaining will not somehow fly in the face of established protocols, language, etc. Isolationism, particularly when it comes to emergency management, is not likely to be a winning strategy as it usually requires the cooperation of disparate resources. So don’t forget to keep the community folks in the loop—you never know when they might come in handy!

 

Teddy Roosevelt would likely not cotton to these monkeyshines…

Our former president, one Theodore Roosevelt (when are Simon and Alvin going to run for office? I think their time is nigh…) is famous for a number of things, including the introduction of “bully” as a positive adjective (if you want to check out the manuscript that started it all, you can find it here). Unfortunately, the verb bully is very much a presence in today’s society (reaching near pandemic proportions in the various social media forums), including the healthcare industry. Now, I have certainly kvetched once or twice about the lack/loss of civility in general and our good friends in Chicago have taken up the gauntlet, and I think we can all agree: “bullying has no place in healthcare.”

As I reflect on the past 50 or so years (maybe a little more towards the so, but that’s just between us), I can look back on any number of encounters with bullies (only one black eye and that was rather a long time ago), including the 35+ years in healthcare. Bullies come in all shapes, sizes, social position, jobs, etc., and you can’t always tell right away who might rule in (or out) for this least desirable (well, maybe not least, but purty darn close) of personality flaws. Sometimes it’s folks who are in positions of authority/power, sometimes not, sometimes it even comes with a smile (though I’ve noted that those smiles rarely, if ever, reach the eyes), but I think I can safely say that bullying behavior engenders some of the most unpleasant “environments” that we are likely to experience. In the latest Quick Safety publication, Joint Commission offers some insight into the cultural elements that exist/foment when bullying is present in the healthcare environment. And while the Quick Safety publications are not necessarily enforceable as standards, this does tie back to Sentinel Event Alert #40 (Behaviors that undermine a culture of safety), which is aimed at the appropriate management of various forms of disruptive behavior, including bullying. At any rate, the Quick Safety article specifically references some action items that were included in the Sentinel Event Alert:

 

  • Educate all team members on appropriate professional behaviors that are consistent with the organization’s code of conduct
  • Hold all team members accountable for modeling desirable behaviors
  • Develop and implement policies and procedures/processes that address:
    • Bullying
    • Reducing fear of retaliation
    • Responding to patients and families who witness bullying
    • Beginning disciplinary actions (how and when)

 

So, my question to you is: How are things going in this area of concern? I don’t know that I’ve run into anyone who’s been able to completely eliminate bullying (or, as I think about it, anyone who’s been able to demonstrate a reduction in such behaviors—it just seems to be much more of a constant escalation, but that may just be me). I’m hoping that perhaps someone will have some stories to share with the group, even tales of efforts that fell short of the mark. We know it’s out there and I’m thinking that the release of this Quick Safety article may be a harbinger of future survey focus—how would you respond if the question came up during survey? I think it’s a reasonably safe pontification to say that bullying really doesn’t help to get things accomplished (again, recognizing that there are certain mindsets that might disagree, but I suspect those that disagree might be of the bullying persuasion), but I am interested in hearing about your experiences.

Are we there yet? Almost certainly not!

One of the fundamental purposes/charges of any high-reliability organization/program, etc., is to be able to identify improvement opportunities and to act upon those opportunities in a manner that actually results in sustained improvement. In the Boston area, we call that “making things bettah!” So, when it comes to the management of the physical environment, I think we can all agree that sustainable improvement is a good thing and, from an operational perspective, really makes a lot of sense. But it’s not necessarily good sense that drives your performance improvement efforts—it’s also a regulatory requirement.

If you look at the CMS Conditions of Participation, clearly there is an expectation of CMS for the management of the physical environment to be incorporated into the hospital’s QAPI program:

482.41 Condition of Participation: Physical Environment

The hospital must be constructed, arranged, and maintained to ensure the safety of the patient, and to provide facilities for diagnosis and treatment and for special hospital services appropriate to the needs of the community.

Interpretive Guidelines §482.41

This CoP applies to all locations of the hospital, all campuses, all satellites, all provider-based activities, and all inpatient and outpatient locations.

The hospital’s Facility Maintenance and hospital departments or services responsible for the hospital’s buildings and equipment (both facility equipment and patient care equipment) must be incorporated into the hospital’s QAPI program and be in compliance with the QAPI requirements.

Interpretive Guidelines §482.41(a)

The hospital must ensure that the condition of the physical plant and overall hospital environment is developed and maintained in a manner to ensure the safety and well being of patients. This includes ensuring that routine and preventive maintenance and testing activities are performed as necessary, in accordance with Federal and State laws, regulations, and guidelines and manufacturer’s recommendations, by establishing maintenance schedules and conducting ongoing maintenance inspections to identify areas or equipment in need of repair. The routine and preventive maintenance and testing activities should be incorporated into the hospital’s QAPI plan.

So, that sets things up fairly succinctly, but in looping back to what CMS is calling/looking for in terms of the indicated “QAPI requirements,” I think there may be opportunities to open things up a bit beyond merely tracking compliance rates (which, typically, perform up to/within regulatory/organizational expectations) and start to look at what those compliance rates mean in terms of demonstrating/verifying the effective management of the physical environment. For example, to my mind, monitoring fire drill compliance as a straight X number of drills per quarter, etc., really doesn’t make a great deal of sense, unless you are having difficulties meeting the requirement (and I should point out that if you are having difficulties conducting fire drills, that’s not going to play well with too many regulatory surveyors). Where I think the “gold” might be (continuing the fire drill example) is in working on figuring out how to demonstrate that the fire drills are effective in preparing folks to respond appropriately in the event of a fire, which leads us to the next piece of the CMS expectation:

482.21(a)(2) The hospital must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that assess processes of care, hospital service and operations.

 482.21(b)(2) The hospital must use the data collected to–(i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement and changes that will lead to improvement.

If you have indicators that are consistently performing at the 100% level, while someone is still going to be monitoring those programmatic aspects, it’s probably time to retire them from the active reporting structure to your EOC Committee. Now I know folks are usually loathe to focus too much on the negative stuff (nobody wants to get in trouble, etc.), but if I may make the suggestion—as a starting point, look at the stuff that you do pretty well, but not perfectly (and if we have learned nothing else over the past couple of years, it’s those things that are not perfect that can cause the biggest problems during a survey). For example, say you are tracking completion rates for non-urgent work order requests, and you are experiencing a pretty solid 90%-95% closeout rate. Now, I would call that a pretty good rate for the non-urgent stuff (presuming that this sterling completion rate is not getting in the way of completing urgent work order requests), but what about that 5%-10% of things that aren’t being completed? Are there any butt-biters in that grouping (things that later resurface to bite you on the backside)? In the interest of putting our best face forward, I think sometimes we focus too much on what has been done and not so much and what hasn’t been done. And I will tell you, the stuff that doesn’t get done will usually cause more trouble than the stuff that did get done.

So when it comes to performance improvement, while it is nice to reflect on the successes of the past, the key metrics “live” in the journey ahead: recognizing that compliance is a journey and not a destination. We ain’t never gonna be “done” with this little pursuit.

For those of you in the northern hemisphere, please enjoy these first days of summah! For those of you at the other end of the globe, wintah is nice, too!

A clear case of compliance interruptus

Greetings one and all from high above the 2012 Life Safety Code® (LSC) compliance track with a quick update on CMS plans for administering surveys, etc., in the wake of official adoption of the 2012 LSC. I’m climbing out on a limb just a little bit as the latest missive in this regard from The Joint Commission indicates that it will begin surveying to the requirements of the 2012 LSC on July 5 (Happy freakin’ Independence Day), but it appears that CMS has other ideas. In a member alert disseminated late last week, our friends at the American Society for Healthcare Engineering (ASHE) are reporting that a memorandum was issued by CMS to the various and sundry accreditation agencies (TJC, DNV, HFAP, M-O-U-S-E) indicating that hospitals have until November 7, 2016 before this new shiny hammer is wielded during accreditation surveys. Now, I think it was likely that there would be some sort of transition period for this process (the accreditors would have to update their standards manuals, etc., and I don’t think that happens overnight, but maybe there are manual elves that come in under cover of darkness), so I guess that has come to pass and the end date for that transition is November 7 (I guess they didn’t want to wait until the following month’s day of infamy).

As I’ve noted in this space recently, a lot of the basic tenets of compliance are going to pretty much stay the course. We will continue to manage rated barriers (walls, decks, doors); we will continue to manage egress (perhaps a little more simply, but clutter will still be clutter) and so on. There may be some efficiencies to be gained in the practical application of the various fire alarm and fire suppression system inspection, testing, and maintenance processes (I’ll have to do some edumacation on those), but I really think that the devil in all these details is going to come from how the requirements of NFPA 99 Standard for Health Care Facilities are administered and/or otherwise enforced. NFPA 99 has always kind of hovered in the background, but I think is going to be very much a coming out party. At any rate, ASHE has made available a fair number of resources (some readily accessible, some for members) and I would encourage you to do a little digging if you have not already done so. I still think the physical environment is going to figure quite strongly in the survey process, but maybe this is where we get to share the most frequently cited standards lists with the clinical folks.

On a closing, and most somber note, in the wake of events in Orlando this weekend (thoughts and prayers to all the victims, their families, the community at large, and pretty much everybody else), I can’t help but think that there’s got to be a better way. I know the circumstances that can lead up to events like these are extraordinarily polarizing—and I’ve noted that the polarization didn’t waste any time manifesting itself in the halls of social media. I wish that I had some sage bit of advice or encouragement, but nothing is coming right now beyond this old cliché (doesn’t make it any less useful or true)—cherish your loved ones…right now! We will all be better for it.

AAMI: What you gonna do?

By necessity, this is going to be somewhat of a hodgepodge of stuff as there are no new postings to The Joint Commission’s PEP site. Looks like we’ll have to wait for July to see what they have to say about the intricacies of LS.02.01.30, though I suspect that we can anticipate some coverage of hazardous locations (Can’t they come up with a better descriptor? While I absolutely understand that the requirements are driven by the point at which the level of stored combustibles in a space is considered “hazardous,” I find that it can be rather challenging when communicating to the clinical folks as to why they shouldn’t randomly convert patient rooms to storage rooms. The refrain is typically “We don’t have anything hazardous in the room, we just have paper supplies, etc.” to which I respond, “Well, you’ve got an amount of paper supplies, etc., that is considered hazardous by the Authority Having Jurisdiction,” to which I tend to receive a blank look and an “oh.” Told you this was going to be a hodgepodge…

Getting back to our PEPpy discussion; I think we’ll find out a bit about smoke barriers, corridor walls, corridor doors, etc. But then again, with the adoption of the 2012 Life Safety Code®, the scheduled PEP modules may be deferred and perhaps they’ll post something relating to whatever changes will be occurring to the Life Safety chapter of the accreditation manual. I think that’s enough blathering about something that didn’t happen, so let’s talk about something that did happen.

At this point, you (or your organization—why I would think that you would have been involved in this is beyond me…) should be well-ensconced in the practical applications of the National Patient Safety Goal regarding the management of risk associated with clinical alarm systems as a function of the Joint Commission requirements thereof:

  • Leadership establishment of alarm system safety as an organizational priority
  • Identification of the most important alarm signals to manage
  • Establishment of policies and procedures for managing those most important alarm signals
  • Education of staff and licensed independent practitioners about the purpose and proper operation of alarms systems for which they are responsible

Hopefully you’ve got that all going in the right direction. But if you’re falling a little short or if, indeed, you’re not sure about progress, the good folks at the Association for the Advancement of Medical Instrumentation (AAMI) have a webpage devoted to information regarding clinical alarms. Those resources include a downloadable Clinical Alarm Management Compendium (maybe CLAMCOMP would be a good acronym) to assist you in these endeavors. If you haven’t yet checked out the AAMI materials, I would very much encourage you to do so (or encourage you to encourage whoever is managing this process in your organization) is because reference to this webpage is included in the rationale statement for this particular safety goal and the stuff that ends up in the accreditation manual has a tendency to take on an elevated criticality in the hands of some surveyors. We could certainly talk about what is and what isn’t “surveyable” as a function of its appearance in any of the manuals, but if you haven’t referenced the AAMI stuff, you are in a position to have defend why you haven’t used such an august reference in your pursuit of alarm safety. To add a bit of heft to this advice, you might also consider the May 18, 2016 edition of Joint Commission Online, in which there is a link to an article published by the AAMI Foundation entitled “Framework for Alarm Management Maturity.”

This may be much ado about nothing, or more likely, folks are already “down” with this. But on the off chance that somebody out there actually uses this space for information and hasn’t run across this, I think it’s worth a mention. You certainly want to make sure that your alarm management process is maturing in proper fashion.

Before you a-Q’s me, take a look for yourself…

As we await new content on the PEP (aka the newly-popular Joint Commission offering, the Physical Environment Portal), I want to draw your attention to an interesting development on another part of the Joint Commission’s website: the ever-popular (such popularity and minimal polarity…) Frequently Asked Questions page (now re-imagined as Standards Interpretations—really, check it out). And let me tell you, there is a ton of newly configured information to be found. If I were really attentive to such things (I usually am, but in this case I wasn’t expecting such a sweeping re-imagination of this part of the TJC website), I would be able to tell you how much more information there is to be had, but I think I can safely say that, at least in terms of the numbers of entries, the amount has easily doubled in relation to the “old” FAQ page. Some of the material appears to be derived from information that had been previously shared through George Mills’ Clarifications and Expectations column in Joint Commission Perspectives; other bits and pieces seem to be derived from information shared on the PEP. There also seems to be some stuff that hinges on the practical application of the now-expiring CMS categorical waivers (which I guess means there will be some updating of content in the not-too-distant future) and some other stuff that appears to have been developed specifically for this new page. (Dare we call it the Standards Interpretation Portal? We’ll be able to engage in regular SIP-ing!)

At any rate, I’m going to be poring over these entries with great interest and I would recommend that you keep a close eye on the SIP as well. Remember, the interpretations published on the SIP (I really do like that!) are “enforceable” as standards, and there’s no reason to think that TJC surveyors aren’t going to be checking out these materials as well. One interesting note: I don’t recall seeing any official announcement regarding the re-birthing of the FAQs (I won’t claim that I track every utterance from the folks in Chicago), so I may be pre-empting the grand unveiling (if you have a standards question, don’t forget to SIP!).

One item that really caught my fancy (and this was in response to a client question) was the entry regarding oxygen storage, which I know has plagued a number of organizations, particularly as a function of the segregation requirements. My thoughts on this have been that the simplest means of separation is to focus on full and not-full as the segregation metric; most folks do not have sufficient space to be able to reasonably pull off the full/in use/empty trifecta and NFPA 99 really only requires that the full cylinders be separated from everything else. So, if you use the full/not full designations, it’s not only a simpler decision-making process in the moment, it appears to be in keeping with the information shared on the SIP.

I’ll let you be the judge of what’s going to work in your organization, but I do believe that the fewer complications in the mix, the greater the likelihood of compliance.

I recommend you starting SIP-ing right away and maintain your compliance hydration throughout the hot summer months!

 

The answer, my friends, is blowing in your facility

As I think everyone is aware, there has been a lot (okay, perhaps quite a lot) of focus during our pas de deux with the regulatory survey groups running around our hospitals on the various and sundry environmental conditions (temperature, humidity, air pressure relationships) for which there are various and sundry requirements (we’ve discussed those general considerations in the past, but if you need a refresher, feel free to dig through the archives at Hospital Safety Center). But a recent issuance from the CDC really starts to point to some of the ways in which the whole air pressure thing can actually influence the effectiveness of the management of immunocompromised patients as a function of air pressure relationships. There’s also an interesting study done by the folks at Johns Hopkins that speaks to the amount of time the doors to surgical procedural rooms are open during cases. I think we can all agree that keeping the doors shut during cases should probably be on the list of good ideas, but I suppose there can be a lot of coming and going—enough to de-pressurize the room. I’ve always felt that it is important to have some sense of how long it takes to de-pressurize and re-pressurize some of these critical areas; you want to make sure that folks are checking the pressure relationships when you have your greatest chance of success, recognizing that these rooms all “breathe” to one extent or another (and some of them come very close to wheezing…).

At any rate, information like this will likely only increase the attention paid to these areas during our survey encounters, with the added dynamic of this information being representative of the time-honored “smoking gun.” So, certainly acting on the CDC’s recommendation that immunocompromised patients not be placed in negative-pressure environments is something we can implement right away, but you’re probably going to want to come up with some sort of methodology for identifying those patients that rule in for that demographic (I’m thinking that our patients would tend more towards the immunocompromised side of the coin than not). We certainly don’t want to inadvertently put patients at elevated risk for infection, etc., by placing them in an inappropriate environment, so I think my immediate advice would be to look really closely at the information from the University of Pittsburgh Medical Center cases. If the end result looks an awful lot like a risk assessment, then I think you’re in the right place—and your patients will be, too!

 

Everybody here comes from somewhere else…

First off, just wanted to wrap up on the missives coming forth from our compadres at The Joint Commission and ASHE relative to the adoption of the 2012 Life Safety Code® (LSC) by CMS. The word on the street would seem to be rather more positive than not, which is generally a good thing. Check out the statements from TJC and ASHE; also, it is useful to note that the ASHE page includes links to additional materials, including a comparison of the 2000 and 2012 editions of the LSC, so worth checking out.

At this point, it’s tough to say how much fodder there will for future fireside chats. It does appear that the adoption of the 2012, while making things somewhat simpler in terms of the practical designation of sleeping and non-sleeping suites (Don’t you wish they had “bumped” up the allowable square footage of the non-sleeping suites? Wouldn’t that have been nice.), combustible decorations and some of the other areas covered by the previously issued CMS categorical waivers (If you need a refresher, these should do you pretty well: ASHE waiver chart and Joint Commission), isn’t necessarily going to result in a significant change in the numbers and types of findings being generated during Joint Commission surveys. From my careful observation of all the data I can lay hands on, the stuff that they’re finding is still going to be the stuff that they are likely to continue to find as they are the “deficiencies” most likely to occur (going back to the “no perfect buildings” concept—a lovely goal, but pretty much as unattainable as Neverland). I’m not entirely certain what will have to occur to actually bring about a change in EC/LS concerns predominance on the Top 10 list; it’s the stuff I can pretty much always find (and folks usually know when I’m coming, so I’ve pretty much lost the element of surprise on the consulting trail). Now, it may be that the new matrix scoring methodology will reduce the amount of trouble you can get into as the result of existing deficiencies—that’s the piece of this whole thing that interests me the most—but I see no reason to think that those vulnerabilities will somehow eradicate themselves. I suppose there is an analogy relative to the annual review of our hazard vulnerability analysis (HVA)—the vulnerabilities will always exist—what changes (or should change) is our preparedness to appropriately manager those vulnerabilities. Makes me wonder if it would be worth doing an EC/LS HVA kind of thing—perhaps some sage individual has already tackled that—sing out if you have. At any rate, I’ll be keeping a close eye on developments and will share anything I encounter, so please stay tuned.

Hopping over to the bully pulpit for a moment, I just want to rant a bit on what I think should be on the endangered species list—that most uncommon of beasties—the kind and decent person. I know that everyone is nice to folks they know (more or less), but there seems to be a run on a certain indifference to politeness, etc., that, to be honest, makes me see a little read from time to time. But then I think to myself that it is probably just as rude to overreact to someone else’s rudeness, so take some deep cleansing breaths and let it go. Now I would love to hear from folks that they haven’t noticed this shift and that their encounters with folks are graced with tolerance, kindness, etc.; it would do my heart good. Maybe it’s just me…but somehow I’m thinking maybe not.

Please enjoy your week responsibly and we’ll see what mischief we can get into next week.