Time for a little update from the field during survey year 2013. If there’s one topic (or topical set, if you will) that’s causing much angst in the survey world, it’s the focus being paid to areas that have specific environmental performance requirements (e.g., air pressures, temperature, humidity). Last year there seemed to be a little bit of a “run” on issues relating to low humidity, but with the issuance of the CMS categorical waiver, I think the low humidity problems are going to fade into the sunset. But that still leaves us with high humidity conditions and those pesky pressure relationships—I can pretty much guarantee that, for the foreseeable future, Joint Commission surveyors are going to be scrutinizing your logs, field testing your pressure relationships and all manner of mischief when it comes to this stuff. So, I would advise you to start doing the same. Check those logs going back to last year’s rather toasty environs. Did you experience out-of-range values in your procedure rooms? If so, were there any documented actions in response to those out-of-range values? Clearly, if there was no documented response, you are potentially looking at a finding during survey, but if you can demonstrate that you have a well-controlled process now, then maybe you can convince the survey team that past performance doesn’t indicate current or future results and you can negotiate a more favorable settlement. Remember, this is an area that can drive a condition-level finding for CMS in no time flat. You need to have an effective process in place or you will definitely suffer the slings and arrows of outrageous survey fortune—and I don’t think any of us wants that. I know I wouldn’t like it…
All things being equal, I suspect that folks are wrestling with the very expansive elements of the Sentinel Event Alert regarding the management of medical device alarms (Sentinel Event Alert #50). I think the important thing to do is to first document a risk assessment that takes into account the various clinical alarm systems, identifying those that might legitimately be considered critical and use that as the starting point. I think it would behoove you to involve the folks in clinical engineering as they probably have performance data that would be very useful (equipment that they find during preventive maintenance activities that perhaps are not appropriately configured for audibility, etc.), it would also be important to include any potential occurrence reporting data that might indicate that there have been issues involving audibility of clinical alarms, etc. To be honest, I am not so sure that any one organization’s approach will be sufficiently universal to be used across the board beyond a simple “these are the specific risks involved with the clinical alarms you’ll be using” (in recognition that this may vary based on clinical location/service) and “these are the specific strategies we are using to appropriately eliminate/mitigate those risks.” I know that may sound like an overly simple approach, but if you do a good job on the risk assessment groundwork, you will have everything you need to manage the education process. As a further enticement, the Sentinel Event Alert web page noted above also includes links to a couple of podcasts that discuss the Alert in pretty fair detail. I don’t know that I’d recommend listening to it on the treadmill, but it’s probably a good way to combine work and exercise…
Good news for those of you who might be struggling a bit with low humidity levels (below 35%) in your surgical procedure areas. CMS issued a categorical waiver based on the recent changes to the FGI Guidelines for the Design and Construction of Health Care Facilities (including the recently updated ASHRAE 170 standard) that allows for relative humidity (RH) values in surgical procedure areas down to a 20% level. Could this be an example of science triumphing over bureaucracy? Only time will tell.
As always, there are some caveats involved: the waiver does not apply if more stringent humidity levels are required under state or local law or regulation or if the reduction of the RH would negatively affect ventilation system performance (which means you need to “know” where you stand relative to state/local requirements as well as the design specifications for your HVAC equipment—and if that sounds like a risk assessment, quack quack!).
Also, the waiver does not specifically establish an upper limit for RH in these areas; it does, however, strongly recommend that an upper level of 60% be maintained based on ASHRAE keeping that upper limit. So I guess those of you in more swampy areas of the world are going to have to keep on keeping on with that. Make sure you’ve got your response to out-of-range values process in good working order.
Administratively, while you will not have to apply in advance for the waiver or wait until you’ve been cited (which is always a fun thing), you must document that you’ve decided to use the waiver. Also, be prepared to notify the survey team assessing Life Safety Code® compliance at the opening conference of the survey that you have decided to use the waiver. Failure to provide documentation of your prior decision to use the waiver could result in a citation.
I guess this is just one more step on the road to the adoption of the most contemporary of codes and regulations. Can you say 2012 edition of NFPA 101? Sure you can! And hopefully, we’ll all be able to say that before too very long…
Recently, a client sent me a question regarding assessing his surgical procedure rooms as wet locations. This was primarily as a function of the changes to NFPA 99, which brings the concept of wet locations and surgery back into the mix (the 2012 edition of NFPA 99 defines wet procedure locations as the “area in a patient care room where a procedure is performed that is normally subject to wet conditions while a patient is present, including standing fluids on the floor or drenching of the work area, either of which condition is intimate to the patient or staff,” NFPA 99 – 2012: 3.3.184). Previously, operating rooms were not considered wet locations as a rule, but now it appears that the pendulum has swung in the other direction.
To that end, the American Society of Healthcare Engineering (ASHE) issued an advocacy statement last year recommending that organizations form a risk assessment group to develop a process for evaluating surgical procedure rooms to determine which of these areas, if any, might legitimately be considered wet locations. Now based on the definition from NFPA 99, you could probably rule out a lot of procedure areas (rooms designated for eye surgery, neurosurgery, ENT surgery, etc.), but in other areas it may require some observations of the procedures being performed to determine the extent of standing fluids, etc. Once you’ve determined that you have wet locations, then you would need to move to provide appropriate protection (GFCI protection, isolated power, etc.). And there are other considerations as well, based on the activities in the space, the “state” of the equipment used in the space, etc. There can be any number of contributing factors that could increase the risk to staff and patients in wet locations; Appendix B of the 2005 edition of NFPA 99 speaks of such things as line-powered equipment that is within reach; a damaged line cord, attachment plugs, or exposed metal presenting a risk of direct exposure to a conductor; damaged equipment with “live” metal, exposed metal that has become ungrounded, a person making contact with a live metal surface, etc.
As with so many things, the key process is the almighty risk assessment, so if you’ve not yet wrestled with this bear, you might find it useful to start the process (in full disclosure, the ASHE advocacy statement came out last year—and if you don’t think certain three-letter regulatory agencies are not familiar with this bit of news, I would encourage you to think otherwise). Sometimes codes change for good reasons, sometimes maybe not so much, but we have an obligation to provide the safest possible environments for patients and staff and this looks like something that can be at least determined fairly simply (fixing this if you have issues is likely to be much less simple).
Now there may be some folks out there who are thinking that there are certain topics to which I have administered beatings akin to the deceased equine, but sometimes there are other folks who appear to share at least some of my “wacky” perspectives on how to manage safety in the healthcare environment.
So, I encourage you to contact the individual in your organization responsible for coordinating Joint Commission accreditation and ask them to share with you the February 2013 issue of Joint Commission Perspectives. And, if you turn to p. 9, you will find the latest column penned by George Mills entitled “Safety Champions—Making Health Care Safety Everyone’s Business.” And to this, I say hallelujah! Those of you who’ve been with me since we started this little space (it’s been years and years, I tell you, years and years) will recognize this as a common theme (I think I’ve twisted it every which way, over time, but you should recognize the basic form) and still one that I believe holds a key to compliance success ( I refrain from referring to it as “the” key, because the education “key” is pretty gosh-darn important as well).
And, interestingly enough, Mr. Mills’ column in the March 2013 issue of Perspectives focused on, wait for it…
Can I get an A(ssess)MEN(ts)! Stay tuned: You know I’ll have something to add to that conversation…
An interesting topic came across my desk relative to a January 2013 survey, and it pertains to the use of your HVA process as a means of driving staff education initiatives.
During the Emergency Management interview session during this particular survey, the surveyor wanted to know about the organization’s hazard vulnerability analysis (HVA) process and how it worked. So, that’s pretty normal—there are lots of ways to administer the HVA process—I prefer the consensus route, but that’s me.
But then the follow-up question was “How do you use the HVA to educate staff and their actions to take?” Now, when I first looked at that, I was thinking that the HVA process is designed more as a means of prioritizing response activities, resource allocations, and communications to local, regional, and other emergency response agencies, etc., but staff education? Not really sure about that…
But the more I considered the more I thought to myself, if you’re going to look at vulnerability as a true function of preparedness, then you would have to include the education of staff to their roles and responsibilities during an emergency as a critical metric in evaluating that level of preparedness. The HVA not only should tell you where you are now, but also give you a sense of where you need to take things to make improvements and from those improvements, presumably there will be some element of staff education. A question I like to ask of folks is: “What is the emergency that you are most likely to experience for which you are least prepared?” Improvement does not usually reside in things you already do well/frequently. It’s generally the stuff that you don’t get to practice as often that can be problematic during real-life events. One example is the management of volunteer practitioners—this can be a fairly involved process. But if you haven’t practiced it during an exercise, there may be complexities that will get in the way of being able to appropriately respond during the emergency. Which is why I recommend if you haven’t practiced running a couple of folks through the volunteer process, what better time than during an exercise?
One of things that continuously comes up on my pondering list is how to enlist the eyes, ears, noses, and fingers of frontline staff in the pursuit of the early identification of risks in the physical environment. Unless one of the facilities maintenance folks happens to be in the right place at the right time, in all likelihood, an aberrant condition is going to manifest itself to somebody working out at the point of care/point of service. And my firm belief is that the organizations that manage environmental risks most effectively (including the “risks” associated with unannounced regulatory survey visits) are the organizations that have most effectively harnessed these hundreds, if not thousands, of agents in the field 24/7.
So, my latest take on this is that we can subdivide the totality of every (and, really, any) organization into two main constituencies—finders and fixers. The key is to get the finders mobilized, so the fixers (who, truth be told, in most organizers are currently finder-fixers) can focus on actually repairing/replacing stuff. I’m at a loss to explain why this can be such a difficult undertaking, so I’ll ask you, dear reader: What do you think? Or if you’ve found a way to really mobilize the “finders” in your organization, how did you make it happen? Did you have to guilt them into it, did you establish a “bounty” system for reporting conditions, etc.? I am firmly convinced that if we can enlist these folks in the identification of hazards, we can really move towards a process for ensuring constant readiness.
If I might beg your indulgence, I just wanted to take a moment to recognize the herculean efforts of the Boston hospital community during last week’s bombing at the Boston Marathon. All too often, when disaster strikes, hospitals don’t receive many kudos—I guess the expectation is that hospitals are always ready for the worst (true, that).
Over the last decade or so as a consultant, I have had the opportunity to work with many of the folks who were charged with coordinating response and, to be honest, the level and nature of response from the hospitals in Boston was no great surprise to me. While Marathon Monday is certainly a “big” date on the preparedness calendar for Boston hospitals, I’ve seen a lot of the work behind the scenes and can only be impressed by the commitment to preparedness on the part of so many.
But in saying that, I also recognize that, by and large (or at least the ones I’ve visited), I believe that hospitals in the United States are extraordinarily well-prepared to handle emergencies of virtually every stripe. That’s not to say that every response effort is absolutely perfect—but these folks learn from those “opportunities” and continue to improve their organizations’ ability to respond to emergencies.
I hope to have the opportunity to work with more of you folks in the future, but in closing, please join me in a tip of the cap to the hospital folks in Boston. I am extremely proud to have worked with some of you and proud of the efforts by all concerned!
Postscript: I penned the above prior to the successful law enforcement resolution to the bombing in Boston. It sounds like it’s going to be a while before we find out anything of use regarding the planning, etc., of this catastrophic event, but I think it’s certainly worth tipping the cap once again to the awesomely coordinated efforts of all levels of the law enforcement community. I’m sure there will be ample Monday-morning quarterbacking relative to just about any decision/strategy involved in bringing this incident to a (sort of) close, but all I know is that it was a sizable measure of comfort when flying back home to Boston last Friday evening to know that the matter was in hand and Boston had resumed some semblance of normalcy. It was good to be home!
Every once in a while I like to take questions from the studio audience and today I’d like to address the question of where one has to have copies of their Safety Data Sheets (in the interest of history, I’m going to resist using the “old” term Material Safety Data Sheets) in each department.
So, the short answer is “no,” there is no specific requirement to have copies of the SDS in each department. But there is some contextual stuff that requires a bit of diligence, so I think a quick review of the language in the Hazard Communications Standard may be useful (the section of the Standard dealing with SDS is 1910.1200(g) – we’re just looking at the portion that discusses how employers are expected to manage them):
1910.1200(g)(8) The employer shall maintain in the workplace copies of the required safety data sheets for each hazardous chemical, and shall ensure that they are readily accessible during each work shift to employees when they are in their work area(s). (Electronic access and other alternatives to maintaining paper copies of the safety data sheets are permitted as long as no barriers to immediate employee access in each workplace are created by such options.)
1910.1200(g)(9) Where employees must travel between workplaces during a workshift, i.e., their work is carried out at more than one geographical location, the material safety data sheets may be kept at the primary workplace facility. In this situation, the employer shall ensure that employees can immediately obtain the required information in an emergency.
1910.1200(g)(10) Safety data sheets may be kept in any form, including operating procedures, and may be designed to cover groups of hazardous chemicals in a work area where it may be more appropriate to address the hazards of a process rather than individual hazardous chemicals. However, the employer shall ensure that in all cases the required information is provided for each hazardous chemical, and is readily accessible during each work shift to employees when they are in their work area(s).
So, basically it all really boils down to that last statement. You need to have SDS information for each hazardous chemical and that information has to be readily accessible to employees when they are in their work area(s). As I think we’ve discussed in the past (but if we haven’t, we’re going to, starting now), the Hazard Communication Standard is a performance standard (much like many of the Joint Commission standards). The HazComm Standard does not specify much in the way of compliance strategies, but rather focuses on establishing certain expectations and then each organization has to figure out how to meet those expectations from an operational standpoint. You can go about this pretty much any way that you want—as long as you can effectively provide access to SDS information for employees. If you can effectively provide access without having copies of SDS at the department level, then that’s what you can do. And if you can’t, then you have to come up with a strategy that does—which for the department-level access means copies of the SDS in the department. And to keep things on a front and center kind of standing, I might suggest that the effectiveness of the process for providing access to SDS information would make a very good performance measure upon which to evaluate the effectiveness of your Hazardous Materials and Waste Management program. Test the process—see if folks can retrieve the information they need without too much difficulty. If it’s a web-based program, ask them to show you how they work the process. Fax on demand? Same thing—have staff show you the process works. That way you “know” that you have an effective process.
I know we’ve (at least sort of) talked about this before (for those of you who might need some thought refreshment in that count or if you’re new to the conversation, see this previous post), but there are still some findings being generated during Joint Commission surveys this year, so I figured it might be worthwhile revisiting one aspect of the whole nuclear medicine security issue.
Let me preface things by noting that I don’t believe that there have been too many instances (a number that approaches zero) in which nuclear medicine deliveries to hospitals have been diverted or otherwise redirected for nefarious purposes. That said, there are certain provisions in the regulations regarding radiation safety and controls programs in healthcare that require couriers delivering nuclear materials to your hot lab (presuming you have one) to be escorted when they are in the hot lab. Unfortunately, if you are interested in finding out what the deal might be for you, the first point to keep in mind is that some states (a handful or so) administer their radiation control programs in accordance with the Nuclear Regulatory Commission (NRC) statutes which do require the escort into the hot lab. But (and isn’t there always a “but”?), there are a great many other states that have an “agreement” with the NRC that allows them to pretty much make their own way (to see where your state figures into the equation, this would be a good place to start) in this regard.
Now the good survey folks from our friends at TJC know about the requirement for escorting the couriers, but they are not necessarily conversant with the requirements for the agreement states—and some of the agreement states do not specifically require the escorting of the couriers into the hot lab. So you need to know (yes, another in the long list of things you need to “know”) what the requirements are in your state, so if it does come up in survey (and it is coming up with increasing frequency), you will know where you stand from a compliance standpoint. As a further thought on this coming up as a survey finding, I suspect that you would need to be prepared to show the surveyor(s) the regulatory evidence that you don’t have to do the escort thing, and, if that is not sufficient evidence in the moment (and we’ll discuss how that might happen in a moment), then you will probably need to make full use of the post-survey clarification process.
Now, the reason I suspect that the state regs might not be enough revolves around the general concept of best practices, etc., which are becoming increasingly similar to actual regulations (or so it seems—it might just be my overactive imagination. I think not, but I’m prepared to admit that there is a possibility). To that end, I suggest (and if you’ve been paying any attention over the years I’ve been scribbling this blog, you probably have a good idea where I’m going now—and I certainly wouldn’t want to disappoint) that you conduct a (ta-da!) risk assessment to demonstrate that the levels of security in place are of sufficient robust-ity (I know that’s not a real word, but shouldn’t it oughta be?) that an unescorted courier results in minimal, if any, risk to your organization.
As I look back at this little screed, I’m glad that I did not promise (or otherwise imply) that I was going to be brief. At any rate, make sure you understand the security requirements in your state and make sure that you are poised and ready to educate any surveyors (real or imagined) that might push on your process.