At The Joint Commission’s Executive Briefings conference in September, another question that I found of some interest/horror (and please remember—that’s horror with a small “h”) continued the charge into the realms of environmental compliance.
Q: What areas need to be monitored for humidity and temperature? Does this include ICU patient rooms?
A: There are multiple areas in a hospital that require humidity and temperatures be monitored. Recovery rooms, Critical Intensive Care, and procedure rooms all require 30% to 60 % humidity and temperatures ranging from 70-75 degrees Fahrenheit. Other areas can have the same humidity levels but varied temps like the newborn nursery suite, which should have temperatures from 72-78 degrees Fahrenheit and Endoscopy would have temperatures from 68-73 degrees Fahrenheit. A very good reference is the AIA Guidelines for Design and Construction of Hospitals and Healthcare Facilities.
So I’ll ask you: How many folks out there are monitoring your Intensive Care Unit rooms for temperature and humidity? By the way, apparently the “faculty” in this instance were not quite familiar with the categorical waiver relating to humidity levels down to 20%. Actually, I suppose invocation of the American Institute of Architects Guidelines might be an indication that they were using an older edition of the Guidelines, since we all know that they’re the Facilities Guidelines Institute (FGI) Guidelines now.
I think minimally we can take this as further indication of an expansion of survey scrutiny into other areas of the hospital when it comes to the management of environmental conditions. I still think the best thing you can do is to get a copy of the 2010 FGI Guidelines, turn to the section at the end of this mighty tome that deals with the ventilation standards, start making a list, and check it twice.
We’ll cover the remaining questions and answers over the next little while; nothing quite as raucous as these first two, but nonetheless instructive.
This is another plucked from the oblivion of the mailbag…
Back towards the end of September, I received an email from an acquaintance out in California who had attended The Joint Commission’s Executive Briefings conference, which included a session on CMS compliance, presented (or so it would seem) jointly by TJC and Joint Commission Resources. In their never-ending pursuit of encouraging customer participation, the audience (or learners as they are identified on the slide sheet) got to submit some questions to the faculty (who shall remain nameless … primarily because I don’t have that information), for which responses were prepared and shared with the group (there were 6 questions asked, based on the document I’ve seen).
At any rate, there are two questions asked for which the responses were somewhat illuminating, albeit in a rather frightening way:
Q. Does temperature and humidity need to be done/recorded daily in procedural areas even if they are closed (i.e., operating room closed on a Sunday or holiday)?
A. Indoor air quality testing that includes directional air flow, humidity, and temperatures should be done daily when in use, however, it is only recommended monthly when the rooms are not in use. So if the rooms are closed they need not be tested unless they are closed for more than one month, but tested when they are put back in use.
The question I have for the studio audience is this (and it’s not like we’ve had this conversation before in various permutations): Where in the regulations does it require daily performance of “indoor air quality testing that includes (which by extension can be interpreted as “not limited to”) directional air flow, humidity and temperatures”? Now it may very well be that this is an extension of the whole magillah regarding the maintenance and testing of critical utility systems components in accordance with manufacturer recommendations (and I don’t have nearly enough knowledge of the OEM guidance on the various and sundry HVAC systems there are out in TV land to be able to speak to that piece of it). Maybe this is destined to show up on TJC’s FAQ page (I see we’re getting a little acronym-heavy here, so I will try to refrain from further acronymization), but this one seems a little beyond the pale. My advice for the moment is that you really ought to look at this as a risk assessment and make the determination of frequencies, etc. for this kind of stuff. Which brings me to the other question of note, but let’s leave that for next time…
Season’s Greetings to you all and please accept my very best wishes for a safe and fulfilling New Year.
And speaking of the holiday season (please excuse my tardiness on this one—probably should have come up with this before Halloween came and went—oh well…), I was wondering how folks had been coming to grips with the allowances contained within the CMS Categorical Waiver on combustible decorations, now that we are in the midst of our third end-of-the-year-holiday-timey-wimey period since the waiver was issued back in March 2012.
I can anecdotally speak to a fair amount of reluctance on the part of safety and facilities folks in running too far with the decoration waivers (or, to be a wee bit more precise, running too far in terms of communicating the changes to frontline staff; to a degree, I share the horror of what might happen, but I also believe that there is a therapeutic value in making the place look festive during the holidays, but I digress).
So has anybody come up with some creative decorating ideas or are you still embracing your inner Scrooge? You know me, I’m always curious about such things…
As the flu season commences, the specter of Ebola Virus Disease (EVD) and its “presentation” of flu-like symptoms is certainly going to make this a most challenging flu season. While (as this item goes to press) we’ve not seen any of the exposure cases that occurred in the United States result in significant harm to folks (the story in Africa remains less optimistic), it seems that it may be a while before we see an operational end to needing to be prepared to handle Ebola patients in our hospitals. But in recognition that preparedness in general is inextricably woven into the fabric of day-to-day operations in healthcare, right off the mark we can see that this may engender some unexpected dynamics as we move through the process.
And, strangely enough, The Joint Commission has taken an interest in how well hospital are prepared to respond to this latest of potential pandemics. Certainly, the concept of having respond to a pandemic has figured in the preparation activities of hospitals across the country over the past few years and there’s been a lot of focus in preparations for the typical (and atypical) flu season. And, when The Joint Commission takes an interest in a timely condition in the healthcare landscape, it increases the likelihood that questions might be raised during the current survey season.
Fortunately, TJC has made available its thoughts on how best to prepare for the management of Ebola patients and I think that you can very safely assume that this information will guide surveyors as they apply their own knowledge and experience to the conversation. Minimally, I think that we can expect some “coverage” of the topic in the Emergency Management interview session; the function of establishing your incident command structure in the event of a case of EVD showing up in your ED; whether you have sufficient access to resources to respond appropriately over the long haul, etc.
Historically, there’s been a fair amount of variability from flu season to flu season—hopefully we’ll be able to put all that experience to work to manage this year’s course of treatment. As a final thought, if you’ve not had the opportunity to check out the latest words from the Centers for Disease Control and Prevention (CDC) on the subject, I would direct your attention to recent CDC info on management of patients and PPE.
I suppose, if nothing else, the past few weeks of our encounter with Ebola demonstrates something along the best laid plans of mice and men: it’s up to us to make sure that those plans do not go far astray (with apologies to Robert Burns).
There’s been a fair amount of discussion in the trenches about the changing dynamics relative to the maintenance of medical equipment and utility systems equipment in the face of all the changes in Joint Commission standards, invocation of CMS as the supreme authority, etc. And while I’m absolutely convinced that this is a conversation that is likely to evolve/mutate over time (the topic of relocatable power taps springs to mind as an example of some fairly rapid-cycle change in approach), I figure we can at least start the conversation and see what happens.
From a compliance standpoint, I think the critical dynamic is how much, if any, of your medical equipment and/or utility systems equipment inventory is being maintained through the application of an alternative maintenance strategy, which effectively means any maintenance strategy that is not in strict adherence to what is recommended by the original equipment manufacturer (OEM). I know a lot of folks are using a database system for managing preventative maintenance activities, but I will admit to not being sufficiently familiar with each system’s capabilities, so I may go somewhat far afield in this portion of the program. Please feel free to issue an e-dope slap if I get things going sideways.
If you are fortunate enough to have a system that is (or is capable of) keeping track of the inventory as a function of whether it is being maintained under an alternative maintenance strategy, then that becomes the basis of any discussion in this regard during a survey. Once you’ve done that initial “sort” (if it is applicable; if you’re maintaining everything in accordance with the OEM, then you really only need to state that in the applicable management plan), then I would recommend a second sort for each category (you could call one category OEM and the other AEMS—Alternative Equipment Maintenance Strategy) to determine what high-risk equipment resides in each of those categories, if any. Ideally (at least from a strict compliance approach), you are not managing any high-risk equipment through an alternative strategy; that will make things potentially less contentious during survey. If you do find that you have some high-risk equipment in the AEMS bucket, then you’re probably going to have to move those processes into the OEM bucket—hopefully a minimally disruptive task.
I guess the other piece of this that could end up being a pain in the butt is if folks had elected not to include all of the medical and/or utility system equipment components, in which case you’re going to have to “capture” anything you might have left out of the inventory to start with. As an editorial aside, every time I think about this whole thing, the more peeved I become because while I understand what they’re getting at from the larger perspective of ensuring safety and operational reliability, I can’t escape the thought that the focus on this whole thing is completely in inversion to the performance of this process over time. In general, we are not hurting people through our medical equipment/utility systems, but it is what it is, I guess. Still, I can’t help but think they must have better things to do than worry about this stuff.
At any rate, the next step depends on whether you’re managing any of this equipment through an alternative maintenance strategy/system. If that is the case, you need to go through the list of equipment being managed in this fashion and provide support the determination whether it is safe to permit medical equipment to be maintained in an alternate manner, based on criteria that includes:
- How the equipment is used, including the seriousness and prevalence of harm during normal use
- Likely consequences of equipment failure or malfunction, including seriousness of an prevalence of harm
- Availability of alternative or back-up equipment in the event the equipment fails or malfunctions
- Incident history of identical or similar equipment
- Maintenance requirements of the equipment
The other piece of this is that the above analysis has to be performed by a “qualified individual(s)” (and, as with the responsibility for maintaining the SOC, there is no specific direction in regards to what constitutes a qualified individual–I would recommend making that determination and running it through the EOC Committee for their knowledge/approval. At the end of the day, the complexities all grow out of the use of alternative maintenance strategies for medical/utility systems equipment, with the end game being (as is noted under both EC.02.04.01 and EC.02.05.01) “the strategies of an AEM program must not reduce the safety of equipment and must be based on accepted standards of practice” (they specifically cite AAMI/ANSI EQ56: 2013 Recommended Practice for a Medical Equipment Management Program).
Unfortunately, I think this is mostly going to be grunt work unless you’ve never gone down the AEM road (which would make little or no sense; I don’t think anyone has enough resources to absolutely manage every piece of medical and/or utility system equipment in accordance with OEM). It’s getting everything into the correct categories and moving on from there.
As the trees turn over their colors, it (sometimes) gives me time to go back over stuff we’ve covered out here in the blogosphere, with the intent of trying to capture some things of note that I think are worth mentioning, even if they are not quite “hot off the presses.”
One of the interesting shifts is the subtle redefining of several of the compliance time frames invoked throughout the standards and performance elements. Not all of the definitions changed, but in the interest of full disclosure, I think we should include the lot of them:
- Every 36 months/every three years = 36 months from the date of the last event, plus or minus 45 days
- Annually/every 12 months/once a year/every year = one year from the date of the last event, plus or minus 30 days
- Every six months = six months from the date of the last event, plus or minus 20 days
- Quarterly/every quarter = every three months, plus or minus 10 days
- Monthly/30-day intervals/every month = 12 times per year, once per month
- Every week = once per week
A particularly curious impact of this shift is the abandonment of the time-honored “not less than 20 days and not more than 40 days” intervals for emergency power testing activities. Now we have “at least monthly” for those very same activities, which probably means that you may want to consider scheduling your generator tests earlier in the month so if you have to postpone/delay the testing of your generator(s) to work around patient care activities, etc. You don’t want to run out of “month.” It will be interesting to see how this translates into the survey process.
The other thing that I’m “watching” is how that definition of quarterly is going to dovetail with how you would conduct fire drills. Is there going to be yet another “counting” vulnerability? I know the Conditions of Participation indicate that fire drills are to be conducted at “unexpected times under varying conditions,” which somehow seems to fly in the face of an every three months plus or minus 10 days. Maybe that’s a big enough window to keep things unexpected; I guess we’ll see how things unfold.
One of my favorite pastimes when I’m driving (and I do get to drive a fair amount) is to listen to the public radio station in whatever area I might be traveling. And if the travel deities are truly smiling on me, I get to listen to a revolving set of programs collectively known as Public Radio Remix. My “description” of Public Radio Remix (if you’re curious about any and all manner of things, please check it out) is something akin to driving cross-country late at night where radio stations fade in and out and you end up experiencing a fairly wide swath of the human condition (bear with me—I do have some relevant content to share).
One of my favorite shows on Public Radio Remix is one called 99% Invisible, which started out as a project of a public radio station in San Francisco (KALW) and the American Institute of Architects (AIA). Now, I know you folks would probably recognize the AIA as you’ve been taken to task over the years relative to compliance with the AIA’s Guidelines for the Design and Construction of Health Care Facilities (I’m pretty sure the folks at The Joint Commission have a copy or two of the Guidelines on their shelves), so this is where I kind of tie this back around to our normal avenue of discussion.
At any rate, recently I was driving to the airport early in the morning and I “bumped” into the episode that revolved primarily around the design, etc., of fire escapes, but went on to cover a lot of elements of egress. I will tell you that I had my safety geek “on” for the drive to the airport that morning. The episode is a wee bit less than 20 minutes in length, but if you have a spare 20 minutes (Okay, I think this is interesting enough to recommend you use one of your non-spare 20 minutes), I think you’ll find this a pretty cool story.
I must warn you that you might find yourself “trapped” in the 99% Invisible experience (there are many very interesting stories in addition to this one), so I will ask you to please enjoy responsibly.
In preparation for our journey into the restrooms of your mind (sorry—organization), you might consider a couple of things. Practicing this during surveillance rounds is probably a good thing; increasing folks’ familiarity with the potential expectations of the process is a good thing. But in practicing, you can also consider identifying an organizational standard for responding to restroom call signals, that way you can build at least a little flexibility into the process, maybe enough to push back a little during survey if you can allow for some variability.
Another restroom-related finding has had to do with the restrooms in waiting areas in clinic settings (ostensible restrooms that can be used by either patients or non-patient who may be in the waiting area). There is a requirement for a nurse call to be installed in patient restrooms, but there is no requirement for a nurse call to be installed in a public restroom. So what are these restrooms in waiting areas? I would submit to you that, in general, restrooms in waiting areas ought to be considered public restrooms and thus not required to have nurse calls. Are there potential exceptions to this? Of course there are—and that’s where the risk assessment comes into play. Perhaps you have a clinic setting in which the patient population being served is sufficiently at risk to warrant some extra protections. Look at whether there were any instances of unattended patients getting into distress, etc. (attended versus unattended is a very interesting parameter for looking at this stuff). Also, look at what the patients are being seen for; maybe cardiac patients are at a sufficiently high enough risk point to warrant a little extra.
At the end of the process, you should have a very good sense of what you need to have from a risk perspective. That way if you have a surveyor who cites you for not having a nurse call in a waiting area restroom, you can point to the risk assessment process (and ongoing monitoring of occurrences, etc.) as evidence that you are appropriately managing the associated risks—even without the nurse call. In the absence of specifically indicated requirements, our responsibility is to appropriately manage the identified/applicable risks—and how we do that is an organizational decision. The risk assessment process allows us the means of making those decisions defensible.
One of the more common questions that I receive during my travels is “When do you need to do a risk assessment?” I wish that there were a simple response to this, but (as I have learned ad nauseam) there are few things in this safety life that are as simple as I’d like them to be. But I can give you an example of something that you might be inclined to look at as a function of your risk assessment process: restrooms (oh boy oh boy oh boy)!
While I can’t honestly characterize this as a trend (I suspect that, at the moment, this is the provenance of a handful or so of surveyors), there seems to be an increasing amount of attentions paid to restrooms—both public and patient—during surveys. These attentions have included nurse call alarms (or lack thereof), the ability of staff to be able to “enter” restrooms to assist someone in distress, the length of the nurse call cords, etc. Now you might not think that there was a whole heck of a lot of trouble that could result from this type of scrutiny, but I can tell you that things can get a little squirrelly during survey (mostly the rescuing someone from the restroom) if you don’t have your arms around these spaces.
For example (and I think we’ve talked about this as a general observation a while back), there are some surveyors that will almost delight in locking themselves in a restroom, activating the nurse call system and wait to see how long it takes for staff to respond to–and enter!—the restroom (there is a Joint Commission performance element that requires hospitals to be able to access locked, occupied spaces; this would be one of those). Although there is no specific standards-based timeframe for response in these situations, the tacit expectation is that staff will be ready to respond, including emergency entry into the restroom, upon their arrival on the scene. This means that they would either immediately possess the means of entering the restroom or would have an immediate means at their disposal. This, of course, would be subject to the type of lock on the restroom door, etc., but for the purposes of this situation, we must assume that the patient is unable to unlock the door on their own. So, this becomes both a patient safety risk and a potential survey risk.
Stay tuned for some thoughts on how best to manage these types of situations.
We’ve been observing Fire Prevention Week (Fire Safety Week’s “real” name) since 1920, when President Woodrow Wilson issued a proclamation establishing National Fire Prevention Day, and was expanded to a week in 1922. If you’re interested in the “story” of Fire Prevention Week, please check out the National Fire Protection Association (NFPA) website—it even includes mention of Mrs. O’Leary’s cow.
While there is much to applaud in the healthcare industry relative to our maintaining our facilities in fire-safe shape, there are still improvement opportunities in this regard. And one of the most compelling of those opportunities resides in the area of surgical fire prevention. According to the Association of periOperative Registered Nurses (AORN) in the October 2014 issue of AORN Journal, 550 million to 650 million surgical fires still occur annually in procedural environments where the risks of fire reach their zenith.
As we’ve seen from past experiences, AORN is certainly considered a source of expert information and guidance and I think the surgical environments would be well-served to start looking at the three strategies for strengthening their fire safety programs:
– Bring together a multidisciplinary team of fire safety stakeholders
- Think about fire safety in the context of high reliability to tackle the systematic and non-systematic causes for surgical fires
– Make fire prevention part of daily discussion
I don’t want to steal all the thunder, so my consultative advice is to seek out a copy of the article (you can try here and make preventing surgical fires part of your Fire Prevention Week).