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The final countdown

One of the things I’ve noticed in my journey through the highways and byways of healthcare is that we do an awful lot of education. The one compelling example that springs to mind is the challenges we’ve had over the last decade involves the appropriate storage/management of compressed gas cylinders. For years we struggled with getting folks to place the cylinders in an appropriate stand or rack; in some instances, we had to share folks some of those lovely videos of what can happen when an unrestrained cylinders becomes violently “active” (something like this one).

Now, I am happy to report that  it appears that we eventually got folks to come to grips with this (though I still periodically run into pockets of resistance), but now we have a new “foe” in the management of compressed gas cylinders—segregating full and not full cylinders. Now I know that we’ve discussed this in the past, but the thought that I have circling what’s left of my brain is this: recognizing how long it took to get folks to play nice, (so to speak) with appropriately securing those pesky e-cylinders, is there a way we can gain compliance in a more accelerated fashion?

To that end, I would ask you to think about how we did the cylinder restraint education and to come up with a way (or perhaps you already have, in which case, please share) to evaluate the education process. Again, we do a ton of education and yet we still have staff (and others; can’t forget some of those lovely contractors) who do stuff that we don’t want them to do. I harbor no illusion that we can completely eliminate undesirable behaviors, but I think we should be able to improve our “situation” to the point that perhaps only five of the most frequently cited standards reside in the physical environment. Do I hear four? Three? Two? One? What do you think?

Cue the drum roll: Ladies and gentlemen, I give you the Portal of Perception!

Not so very long ago, The Joint Commission and ASHE announced the creation of an information resource to assist with all those pesky EC/LS findings that have been reproducing like proverbial rabbits (here’s coverage of that announcement  and coverage of those rapidly reproducing findings).

Well, since that announcement, the elves have been very busy cobbling together bits and pieces of this and that, with the end result being a rather interesting blend of stuff (please note that I did not employ the more severe descriptor—stuff and nonsense), with titles like “Is Your Hospital’s Air Ventilation System Putting Your Patients At Risk?” (this one’s in the Leadership module, so I guess they’re asking the question of organizational leadership). I truly hope that your response to that particular query would be “absolutely not,” but I’ve also been working this part of the street long enough to know (absolutely, if you will allow me a brief moment of hyperbole) that there are few absolutes when it comes to the management of the physical environment.

Which leads me to the follow-up thought: Recognizing that there is always the potential for the performance of air ventilation systems to drift a little out of expected ranges, at what point does the performance of air ventilation systems actually put patients at risk? And perhaps most importantly, have you identified those “points” in the performance “curve” that result in conditions that could legitimately cause harm to our patients? And please know that I understand (in perhaps a very basic sense, but I think I can call it an understanding) how properly designed and maintained HVAC systems contribute to the reduction of HAIs, etc. But with any fluid situation, there is an ebb and a flow to conditions, etc., that, again, may veer into the “red” zone from a compliance standpoint. But let me ask you—particularly those of you who have experienced out-of-range conditions/values—have those conditions resulted in a discernible impact on your infection control rates, especially those relating to surgical site infections?

BTW, I’m asking because I really don’t know what you folks are experiencing. And, for those of you that have identified shortcomings on the mechanical side of things, are your Infection Control folks keeping a close (or closer) eye on where those shortcomings might manifest themselves as a function of impact to patients? From the information posted in the Portal (I think I’m going to capitalize), remedying compliance issues in this regard is a simple four-step process (You can find the example of improved compliance there). Who knew it would be so easy? (I could have had a V8!) I don’t think anyone in the field is looking at this as a simple, or easy, task.

At any rate, despite the best efforts of the Portal, until we have buildings (and staff) that are a little closer to perfect, I think we’re going to continue to see a lot of EC/LS findings during survey. Ohboyohboyohboyohboyohboy!

Also, as I think about it, please be sure to check out the Clarifications and Expectations column in the September issue of Joint Commission Perspectives; there are some interesting points to be gleaned, the particulars of which we will cover in a wee bit, so watch this space!

Same as it ever was… same as it ever was… same as it ever was…

As the back-to-school sales reach their penultimate conclusion, I look back on the year so far and am amazed at how quickly we’ve blown through fully two-thirds of 2015—yow! For a while it seemed like winter was never going to release us from its icy grasp and now we’re looking forward to its return, so I guess we have naught to do but look forward towards the onslaught of 2016. I hope, for all our sakes, it is a kinder and gentler new year.

But before the past little while takes on the rosy hue of nostalgia (as it almost always does), our friends in Chicago have provided an excellent opportunity to reflect on the “sins” of the past by revealing the most frequently cited standards during the first six months of 2015. And to almost no one’s surprise, four out of the top five most frequently cited standards (at the moment, the “reveal” is only for the top five—I guess we’ll find out about the rest of the top 10 at some point) are smack dab in the middle of the management of the physical environment, with the top three most frequently cited standards for hospitals being EC.02.06.01 (#1 with 59% of hospitals surveyed being cited), IC.02.02.01 (#2 and 54%) and EC.02.05.01 (#3 and 53%; looks like a real fight for that #2 spot), all of which reflect elements tying together the management of the physical environment with the control and prevention of infection (not everything cited is in the physical environment/infection control bucket, but from what I can gather, rather a fair amount is related to just that).

At this point (and I full recognize that this is a rather reiterative statement), I’m going to crawl out on a limb and say that the single greatest survey vulnerability for any (and every) healthcare organization is the management of the surgical/procedural/support environments. The hegemony of this aspect of the survey (and regulatory compliance) process comes very close to defying understanding. At this point, there’s no real surprise that this is an (if not the, and I would argue “the” is the word) area of intense survey scrutiny, so what’s the deal?!? Forty percent of the hospitals surveyed from January to June appear to have done okay on this, or is that number really a red herring? It would not surprise me that 100% of the hospitals surveyed ran afoul of one of the top three. Anybody out there surveyed so far this year that managed to escape, relatively, scott-free on this?

I’ve certainly done a lot of yammering in this regard over the past few months (years?) and it appears that I am raging against the dying of the light to minimal effect. I have a lot of ideas about this, but I guess I’m putting it out there: has anybody really got this under control? I think we all have a stake in this thing and the sooner we can get our hands on an effective process for managing this, the better. I will admit that it is entirely possible that, particularly given the age of a lot of hospital infrastructure components, this is not going to go away until they stop focusing as much on it. At this point, I haven’t run into too many folks that have been cited under the big three for whom infection rates are anything other than what would normally be expected—though perhaps infection control rates are higher than they “should/can” be—I guess we could be in the midst of a paradigm shift on this. I don’t want to have to wait to find out.

Letting the days go by…

Try not to breathe

I know that we’ve visited (and revisited) this topic once or twice over the last little while, but it continues to be (at least in my mind’s eye), the most significant vulnerability for every healthcare organization that uses The Joint Commission (TJC) for accreditation services: the management of temperature, humidity, and air pressure relationships (THAPR—How’s that for an acronym? It’s pronounced “thapper” or, if you’re from Boston, “thappah”) in the care environment. Folks continue to be cited for issues in this regard; other folks are jumping on board (a little late, but better than never) but are in the closing section of their survey window; and others still have not quite grasped the importance of having a stranglehold (if you will) on those areas for which there are THAPR requirements. Those of you who’ve accompanied me in the blogosphere for a while know that I do not do a lot of product marketing (even my own product), but I will encourage you once again: if you do not have a copy of ASHRAE 170—2008 Standard for Ventilation of Health Care Facilities, you are not in possession of what may be (at least at the moment) the single most important slab of information in the physical environment pantheon (yes, we will always have a place in our hearts for the 2000 edition of NFPA 101 Life Safety Code®; probably for too long, based on the ever-so-slow-to-adopt new things track for the 2012 edition).

While I’m not suggesting that you memorize ASHRAE 170 (it is fairly brief and those of you with eidetic memories probably won’t be able to keep yourselves from doing so), I am suggesting that you need to go to the table on pages 9-11 and start identifying the areas in your organization that have specific requirements and start figuring out where you stand in relation to those requirements, and perhaps more importantly, come to some sort of sense as to how reliably your systems can support those requirements. And you really need to go through the entire table; TJC certainly is. Just last week, I heard of pressurization issues in lab and pharmacy areas (labs are to be under negative pressure; pharmacies under positive) that added up to condition-level survey results.

Make sure you know where you have sterile storage in your organization; sterile storage areas are to be under positive pressure and should be monitored for temperature and humidity. But the reality of the situation is that you have sterile supplies in locations throughout your organization, so you have to define what does and what does not represent sterile storage (my best advice is to coordinate with your infection control and surgical folks on this one—it’s beginning to look a lot like a risk assessment—everywhere you go!). That way, you have a solid foundation for determining what needs to be managed from an environmental standpoint; it’s the only thing that will keep you out of the hottest water during survey.

Two final thoughts before signing off for this week; make sure that routine bronchoscopies are being performed under negative pressure (urgent or emergency bronchoscopies may not have quick enough access to the appropriate environment, so make sure that folks know what protective measures need to be considered to protect themselves and the patient when they’re aerosolizing potential bugs). There are still instances in which this is being cited during survey, so I think my best advice is to go and check with your respiratory therapy folks, as well as the folks in surgery, critical care, infection control, etc., and ask the question: Are bronchoscopy procedures being performed, and if so, where are they being performed? Then you can start walking it back to a point where you can be assured that they are being done in an appropriate environment.

The last thing is a brief reminder that the process for the survey of the physical environment (again, as it is currently being administered) involves all of the survey team – when it comes down to this are of concern, there is no more “clinical” versus “non-clinical”; everything that occurs within the four walls of your organization are patient care activities, direct or indirect (you may have noticed TJC has been splitting its performance elements using that very same language). Coordination of the various hospital services, etc., has never been more heavily scrutinized and never been found more wanting during survey. There is a paradigm shift afoot, my friends, and we need to get on the good foot.

Leave it better than you found it!

This past week (and this coming week as well), I’ve been on vacation in Maine (code name: A Beautiful Place by the Sea), which affords me the luxury of observing a lot of human behaviors, some interesting, some not so much. Some winning, and others that just grate.

There’s been a movement to reduce the amount of “invasive” plant species that have, in some instances, overtaken the natural landscape (and no, I’m pretty sure that this reduction is going to extend to tourists, though I bet there are moments…). So something of a reclamation project is underway, the result of which will (ideally) be a sustainable and less intrusive beautification. Where things go a little awry is in the areas somewhat off the more deliberately beauteous locales and offers what appears to be too many opportunities for the dark underside of human behavior to hold sway. Each morning, I make a circuit of the area and have noted beer and soda cans tossed into bushes, dirty diapers tossed under those same bushes and all matter of detritus left behind, presumably because the effort to properly dispose of these items was greater than what could be tolerated in the moment. My walk, at least partially, includes collecting some trash (I will admit that I’ve avoided the dirty diapers—I will have to prepare better in the future) along the way, but I have a pretty good sense of where the waste receptacles are along the way, so it’s not like I have to lug the stuff for miles.

At this point, you’re probably asking yourself: What does this have to do with healthcare safety and the myriad related conditions and practices that I might encounter during the workday? Well, the thought that keeps returning to the front of my head goes back to the age-old task of trying to “capture” these conditions at the point at which they occur, or at least when they are identified (yes, it’s another “see something, say something” tale). When we encounter unsafe conditions during rounds—damaged walls, unattended spills, etc.—we “know” that these things did not happen by themselves, so what prevented the originator of the condition from at least saying, “Oh poop, I need to tell somebody about that hole in the wall/spill on the floor so it can be remedied.” Not a particularly difficult thing conceptually, but human behavior-wise, it seems like it is an impossible task. I suppose you could look at it as job security (hahaha!), but having to manage all these little “dings” keeps us away from paying attention to the big and bigger dings that we know are out there. I suspect that I’m probably not supposed to be thinking about this stuff so much when on vacation, but I guess that’s part of my brain that never really shuts off. And don’t get me started about people who leave shopping carts out in the middle of the parking lot at the grocery store (yes, that’s me pushing a line of carts either to the cart corral or back to the store—it is a most consistent manifestation of my OCD). Hope your August is proving to be most splendid!

I’m-a gonna raise a fuss and I’m-a gonna raise a holler!

Sometimes, particularly during the summer, it can be a challenge to come up with compelling—hopefully your definition of compelling and my definition of compelling match up pretty well—material for the blog, so I will periodically go back through e-mails I’ve received, etc. to see if there’s anything worth sharing with folks. I was trolling through my inbox for missives from our friends in Chicago that I might have missed when they originally arrived (so, I guess this would be a review of missed missives) and I noticed an item from back in June that I had not previously brought to your attention that highlighted some of the resources available in the area of emergency management. Strangely enough, the resources are available as part of the The Joint Commission’s (TJC) portal program, thus the Emergency Management Portal.

There’s a fair amount of interesting information (and I think we all recognize the value of being familiar with any information TJC sees fit to present to the world at large), with click-through links for topics such as air disaster, violence/security/active shooter, hurricane, tornado, water crisis (industrial incident), and winter storm. The June notice deals with some topics relating to crisis management guidance and senior leadership (if you’ve noticed a trend towards elevating accountability/involvement of senior leadership in the physical environment/emergency management realm, I wouldn’t disabuse you of that notion) will take you to those details. Other than the leadership stuff, it doesn’t appear that there’s been a ton of updating since the beginning of 2014, but one item highlighted on the portal home page is a link to a blog on John Maurer’s (he’s one of the folks in TJC’s Engineering Department) Q & A during the November 2013 JCR Annual Ambulatory Care Conference. While the content is “aimed” at ambulatory care, there is a certain “timeless” quality to the questions and even if you are not currently responsible for any ambulatory sites, if you intend to stay in healthcare, it is more than likely that you’ll be getting in to the care and feeding of some ambulatory sites before too long. At any rate, I always enjoy Mr. Maurer’s work and if you’ve not encountered him, I think you will too. If you want to bypass the portal, you can link directly to the Q & A. It shouldn’t take too long to go through the blog, but I think you’ll find it to have been time well spent.

Underneath the accreditation manual last night!

And just when you thought you’d opened up all the presents under the tree, you see one way in the back and it’s another one from our friends at The Joint Commission (TJC)…but not just then, our friends at the American Society of Healthcare Engineering (ASHE) are also joining in this festive holiday season! Who needs the colds of December when such a bounty is available now!

TJC and ASHE have joined forces to create a portal to assist healthcare organizations in managing those pesky Environment of Care (EC)/Life Safety (LS) findings that have been (literally and figuratively) sweeping the nation. The stated purpose of the portal is to provide information to reduce findings of non-compliance with the eight EC/LS top findings (not sure if they’ll be coming up with a portal to address the IC findings under IC.02.02.01). They’ve broken things down to eight individual modules, one each for EC.02.05.01, LS.02.01.20, EC.02.06.01, EC.02.03.05, LS.02.01.10, LS.02.01.30, LS.02.01.35, and EC.02.02.01. These modules are being rolled out between now and October/November 2016, so this is going to be a gift that keeps on giving. We may have to rewrite the 12 Days of Christmas…

One thing that’s available right now is a Fireside Chat, featuring George Mills from TJC and Dale Woodin from ASHE (you’ll see the “screen” on the right hand side of the linked page noted above). The video takes about 20 minutes to watch, but it gives you a glimpse of the thought process behind the portal, the mission of the portal, a discussion of the portal itself, and ultimately, what the expectations are of organizations. It sounds like the portal is going to feature information that gets down to the EP level (I don’t know that there will be too many surprises for what EPs get the attention, particularly if you’ve been following this space) and, hopefully, will provide some practical (and I mean practical in a sustainable way) compliance solutions. I’m really interested to see what the sum and substance of the modules will be; I don’t know that there are that many “secrets” left, though I’m hoping that there’s a lot of good discussion about managing compliance data. I have yet to find a “perfect” building from a physical environment standpoint (buildings are never more perfect than the moment before you let the first person in), so it will be interesting to see how much focus is on recognizing those imperfections and “managing” them as a function of the all-important “high-reliability” benchmark. One last note, Messrs. Mills and Woodin indicate that all of the modules will be available throughout the rollout period (I’m glad they’re doing that, but it makes me wonder why they wouldn’t), though they don’t speak to the time beyond the end of the rollout. Maybe by then it won’t be necessary, but I’m thinking it would be nice if they could keep this going for at least the following (2017) year; that way, we’ll have gotten through an almost complete accreditation survey cycle.

At any rate, definitely check out the portal—and be sure to set aside some time for the Fireside Chat (sounds like the Chat will be a regular feature of the portal)—it’s definitely worth more than the 20 minutes it will take. And I don’t know that I wouldn’t make a point of sharing it with your boss (and maybe your boss’s boss); the greater the understanding of what is at stake, the greater the likelihood of appropriate levels of support when you have to go to the mat to make improvements in the physical environment.

I saw Mommy kissing the senior engineer…

Late last week, The Joint Commission provided information regarding the mid-term edition of this year’s Survey Activity Guide (SAG—and no, I will not make any gratuitous remarks about that particular acronymic confluence…), which includes “new description for Facility Orientation-Life Safety Surveyor and minor revisions to Environment of Care Session and Life Safety Building Tour for hospitals and critical access hospitals.”

While the minor revisions to the Environment of Care session and Life Safety building tour are indeed just that (with one exception that you already know about—more in a moment), it appears that Santa Mills has left us a nice little package under the Christmas in July tree: a new Life Safety and Environment of Care Document List and Review Tool (just think, kids—now you can survey like a real surveyor!). While I jest a wee bit (jester that I am), I do think that this is a pretty useful thing for the good folks in Chicago to be sharing. I think you’ll find the tool may give you a sense of “what” they’re looking for in terms of documentation; it also contains a nifty little typographical error. Let’s see who has the eagle eyes out there in radioland…

The one change that is a little more than minor (if only for its far-reaching consequences in surveys the past 18 months) is the instruction for surveyors to assess operating rooms for proper pressure relationships. I guess highlighting it in the new SAG means that there were some surveyors who weren’t checking the ORs for proper pressure (or perhaps some hospitals who were surprised that it happened—hey, that’s not in the book!?!). At this point, it seems hard to imagine anyone in the industry that isn’t expecting this, but I suppose stranger things have happened. As I’ve said probably too many times, they are getting a lot of mileage out of this, so best to be on one’s toes in the management of the procedural environment.

Also, one other item: they’ll be requesting a list of all the locations in your organization in which high-level disinfection and sterilization are in use, so you’d best be keeping an eye on OPA usage out in the hinterlands of your organization. You wouldn’t want a pesky surveyor finding one of your clinic sites using OPA without your knowledge (and appropriate environmental management—air pressure, eyewash stations—I think you know the drill on this stuff).

At any rate, this link will take you to the download page, if you’ve not already opened the “present.”

Happy survey prep!

Oh no, Mr. Bill!

I always view with great interest the weekly missives coming from The Joint Commission’s various house organs, particularly when there’s stuff regarding the management of the physical environment. And one of the more potentially curious/scary “relationships” is that between the good folks in Chicago and the (I shan’t editorialize) folks at the Occupational Safety & Health Administration. They’ve had a nodding acquaintance over the years, but there is evidence in some quarters (I’ve seen a decided uptick in survey findings relating to hazardous materials and waste inventories—as we’ve noted before, a list of your Safety Data Sheets is not going to be enough on its own to satisfy a finding of compliance with the Hazard Communications standard), that concerns relative to occupational health and safety are becoming a target area during Joint Commission surveys.

At any rate, last week, buried in last Wednesday’s action-packed edition of Joint Commission Online, there was an item highlighting the OSHA updates of key hazards for investigators to focus on during healthcare inspections.

Now I can’t imagine that the list of key hazards would come as a surprise to anyone in the field (in case you were wondering, they are: musculoskeletal disorders (MSD) related to patient or resident handling; bloodborne pathogens; workplace violence; tuberculosis; and slips, trips and falls—surprise!), as these are pretty typically the most frequently experienced occupational risks in our industry. What remains to be seen, and what I suspect we need to be keeping in mind as the wars for accreditation supremacy continue, is whether this OSHA guidance translates across to TJC survey methods and practices (I don’t think TJC is as “beholden” to OSHA as they are to CMS, but who knows what the future may hold). That said, I don’t think it would be unwise or in any way inappropriate to shine as much “light” as possible on your organization’s efforts to manage these occupational risks. I’m guessing your most frequently experienced occupational illness and injury tallies are going to include at least two or three of the big five (I suspect that TB may be the least frequent for hospitals, though if you count unprotected/unanticipated exposures, the numbers might be a little higher). Perhaps (if you have not already done so) some performance indicators relating to the management of these risks (successful or unsuccessful) might be a worthwhile consideration as we continue through the EC/safety evaluation cycle (I know some of you are doing your evaluations based on the fiscal year cycle, of which many are wrapping as we speak). And remember, there’s no rule that says you can’t develop and implement new indicators mid-cycle. Take a good look at the numbers you have and figure out whether your organization is where it needs to be from a performance standpoint. If the numbers are good—it might behoove you to ask the question or whether that level of performance is the result of good design or good fortune (there’s nothing wrong with good fortune, though it does tend to be less reliable than good design). As with so many of our critical processes, the more we can hardwire compliance/good practice, the easier our jobs can be. Perhaps that’s an overly optimistic thought, but as I gaze out over Boston Harbor this morning, optimism doesn’t seem to be misplaced—optimism is good to have when flying!

Perhaps one isn’t the loneliest number after all…

This past week, my travels brought (or, more appropriately, returned) me to the environs of the New English, where I got to work a little out of my normal scope of practice: a health center setting. Now typically, as business occupancy settings, health center environments (I thought) tend to be a little less complicated than hospitals and ambulatory surgery centers, etc., but I learned last week that even business occupancies can experience the “bliss” of competing jurisdictions—oh, what fun!

So, typically using Chapter 38 (new) or 39 (existing) from NFPA 101 as my baseline expectation for compliance, we started the document review (this particular organization is looking at embarking upon Joint Commission accreditation). A couple of tweaky things in the fire alarm testing documentation, but nothing of great concern; some tweaks relative to some utility systems testing, but again, nothing major. Then we started looking at the documentation of fire inspection reports and I ran into a somewhat unanticipated condition: the local fire inspector was using the state fire code (in this case, Massachusetts), which is based primarily on NFPA 1 Fire Code. I will freely admit that my familiarity with NFPA 1 as a specific document is rather limited, but I was able to make use of NFPA’s free access to important codes and standards through its online portal. Interestingly enough, there are a lot of common threads between 1 and 101, but for those of you with business occupancies separate from your main campus, it might behoove you to acquaint yourself with some of the basics, particularly if your state fire code is based on NFPA 1 (if I was good, I’d figure out which states those were—maybe another time).

Anyhoo, where things got kind of interesting was that the regional authority having jurisdiction for this particular organization was the state Department of Public Safety (DPS), who it appears are using NFPA 101 as their consensus standard for life safety. This organization is in what I will call a reclaimed warehouse (circa early 1900s), where things like egress may have been considered, but not to the degree in present day. The basement level is more than one-half story below the level of exit discharge (actually, the stairwell goes two levels below the level of exit discharge), so the DPS inspector told them they have to install a gate in each of two stairwells to prevent folks from heading down past the level of discharge. I think you’re probably familiar with that condition. Well, when the local inspector saw the gates, he cited the organization for obstructing egress (I looked at the area where the gates were installed and they were well out of the way of the egress route, but close enough to prompt departure from the stairwell). Now, I did look in NFPA 1 and cross-referenced it to the state fire code (there are certain elements of NFPA 1 that the state code does not adopt, but this wasn’t one of them) and the allowance (actually, I guess it is really a requirement) for the gates in the stairwells is clearly indicated in this particular situation. I encouraged the plant ops director to try and figure out a solution in coordination with the local guy when he returns for his re-inspection. I suspect (hope) that this was just an interpretation based on a partial familiarity with the code in question (that’s never happened before, has it?) and that all will end well. I’ll keep you posted if I hear anything.