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Catch a waiver and you’re sitting on top of the world

Lots going on in the regulatory landscape lately—much of it potentially very beneficial to you folks out there in radioland.

On August 30, the folks at CMS issued a whole new set of waivers for consideration including such party-ready favorites as:

  • Medical gas master alarms
  • Openings in exit enclosures
  • Emergency generators and standby power systems
  • Doors (just doors, not The Doors)
  • Suites
  • Extinguishing requirements
  • Clean waste and patient record recycling containers
  • Clarification of the process for adopting the March 9, 2012 waivers

We’ll be discussing some of the ins and outs of the whole waiver scene in coming weeks, but I didn’t want to let too much time go by without letting you folks kick this around. Which reminds me: If anyone has any particular questions on any of the above-noted topics, please feel free to weigh in as we go through them. Not sure that we’ll be doing one per week (maybe two per week—depends on how long-winded I get), but I’d love to include any thoughts or concerns you folks might have.

Finally, if you want to start the required reading in this regard, an excellent starting point would be with the ASHE folks (if you’ve not already tapped into that resource).

Do you want to know a secret?

Apropos of nothing, on the face of it, I wanted to share with you a cautionary tale relative to the importance of accurate (and complete) communications, particularly in those perilous moments when you have a less than satisfied customer. As you might guess, I travel by air a fair amount of the time (and no, this isn’t a beef about delays. I count myself pretty fortunate in that regard. Delays are an inevitable function of any commute, doesn’t matter what mode, but I digress) and, without getting into too much detail, a process that had always worked in the past suddenly did not “go” the way I expected/had experienced literally tens, if not hundreds, of times in the past.

The initial encounter with the airline folks did not yield much in the way of satisfaction; in fact, I don’t think I would be hyperbolic in describing the handling of that interaction as bordering on indifferent. I try to keep an even keel in such matters, but I will tell you that I was a wee bit frustrated. I also knew that there was a process for airing my concerns, so I elected to save it for another day.

At this point (and yes there is a point to all this and I’m almost there), I had a pretty good idea of what was going on (clearly, at least in my mind, it was a systems issue and one part of the system wasn’t communicating very effectively with another part of the system), so I contacted customer service and explained my plight. The person I spoke with was very empathetic and offered a solution that she guaranteed would resolve the issue; I came away with a very positive feeling, but guess what? The solution didn’t work. There were a few more back and forths with a few more ideas/solutions, but nothing that really addressed what I was convinced was the issue.  The customer service folks promised to investigate and let me know.

Well, it turns out that it was a systems issue and at least some folks at the airline knew of its existence and had been working on it for a couple of weeks. They weren’t sure when the issue would be resolved, but I was okay with that—because I now knew what was going on. The “problem,” as I now see it, is that the folks who knew there was a problem and what the “symptoms” of the problem were, didn’t let everyone in the customer service process know what was going on. There is nothing more effective in answering someone’s questions than being able to speak directly to the issue—even if the resolution is not immediate.

How many times in our work lives have we been less than proactive in providing everyone in the process a complete picture of what’s going on? Inevitably, one can look back and figure out exactly when full disclosure fell by the wayside and frequently results in hard feelings, etc. It all kind of dovetails back to the mantra of “if you see something, say something,” though in this case, it’s more along the lines of “if you know something, say something.” While one may not intend to be secretive, sometimes it’s tough to defend “compartmentalization” or whatever euphemism you might adopt.  When it comes to safety, the more everyone knows, the more effectively risk can be managed.

I get (EVS) week at the knees…

Those of you who’ve followed this space for a while know that my first “life” in healthcare was working in various positions in what we now call Environmental Services (used to be Housekeeping and/or Building Services where I “grew up” in healthcare). So, in the spirit of “once a housekeeper, always a housekeeper,” I entreat you to join me in recognizing some of the folks in the trenches as we celebrate Environmental Services and Housekeeping Week from September 8-14. My stance has been that it is nigh on impossible to appropriately prevent infection if the environment is not properly maintained—and that process goal is frequently in the hands of the EVS folks. As with any frontline position, there are challenges galore (it takes a lot of diligence and pride to have to clean up after folks—I did it for a long time and truth be told, I still pick up stuff off the floor, etc.), so I think it an excellent opportunity to let these folks know how important they are in the management of the physical environment. And I will add my own thanks to the folks who wash the floors, clean the toilets, pick up the trash, and a myriad other tasks that, if left undone, would result in a much less tidy experience for our patients and our colleagues. Hip, hip, hooray!

Prioritize this…

During a recent survey, an interesting question was posed to the folks in Facilities, a question more than interesting enough to bring to your attention. The folks were asked to produce a policy that describes how they prioritize corrective maintenance work orders and they, in turn, asked me if I had such a thing. In my infinitely pithy response protocol, I indicated that I was not in the habit of collecting materials that are not required by regulatory standard. Now, I’m still not sure what the context of the question might have been (I will be visiting with these folks in the not too distant future and I plan on asking about the contextual applications of such a request), but it did give me cause to ponder the broader implications of the question.

I feel quite confident that developing a simple ranking scheme would be something that you could implement without having to go the whole policy route (I am personally no big fan of policies—they tend to be more complicated than they need to be and it’s frequently tougher to follow a policy 100% of the time, which is pretty much where the expectation bar is set during survey). I think something along the lines of:

Priority 1 – Immediate Threat to Health/Safety

Priority 2 – Direct Impact on Patient Care

Priority 3 – Indirect Impact on Patient Care

Priority 4 – No patient care impact

Priority 5 – Routine repairs

would work pretty well under most, if perhaps not all, circumstances. The circumstance I can “see” that might not quite lend itself to a specific hierarchy is when you have to run things on a “first come, first served” basis. Now I recognize that since our workforces are incredibly nimble (unlike regulatory agencies and the like), we can re-prioritize things based on their impact on important processes, so the question I keep coming back to is how can a policy ever truly reflect the complexities of such a process without somehow ending up with an “out of compliance with your policy” situation? This process works (or I guess in some instances, doesn’t) because of the competence of the staff involved with the process. I don’t see where a policy gets you that, but what do I know?

If only it were a tankless job…

And yet another story from the survey wars, this time regarding the number of oxygen cylinders that are allowed in a smoke compartment. As was the case regarding the eyewash station risk assessment discussion, this one comes from a Focused Standards Assessment (FSA) survey that I did not personally attend, so if you feel the grain of salt is once again needed, I will wait for you to fetch said salt before I start. Ready? Okay.

Anyway, in this particular survey, the FSA surveyor informed the organization that it could only have 12 oxygen cylinders in a smoke compartment, in this case, the ED. But wait, you say, what’s wrong with that? Read on, read on! Further discussion ensued in which the surveyor indicated that the 12 oxygen cylinders included the cylinders that were on, for example, the stretchers in the individual bays in the ED (this particular ED is designated as a suite of rooms). Now this kind of (okay, very much so) flies in the face of the whole “in use” versus “storage” concept where you can have “storage” of no more than 12 cylinders in a smoke compartment, but you can also have a number of cylinders that are considered “in use.” You will find a most excellent examples of how this works (and please try not to focus on the irony of this information source) in the December 2012 issue of Perspectives; on the right hand column of p. 10, George Mills describes a situation that uncannily resembles the condition that the FSA surveyor indicated was not compliant. And says that it’s okay, because the cylinders on the stretchers would be considered “in use.” If that don’t beat all…

I guess this ultimately goes back to the importance of “knowing” where you stand in terms of compliance. “Knowing” that the oxygen cylinders are considered in use and thus, within allowances, then you can respectfully (perhaps even silently) disagree with the surveyor and go back to more important things. And I suppose if you wanted to be fresh, you could suggest the surveyor sign up for a subscription to Perspectives. Unfortunately, they don’t have those little cards that fall out and can be mailed in as a gag…

What’s the frequency, Kenneth?

In our continuing coverage of stories from the survey beat, I have an interesting one to share with you regarding my most favorite of subjects: risk assessments. During a recent FSA survey (what’s that, you ask? Why, that’s the nifty replacement for the “old” PPR process—yet another kicky acronym, in this case standing for Focus Standards Assessment), a hospital was informed by the surveyor that it was required to conduct an annual risk assessment regarding emergency eyewash stations. Now I will admit that I got this information secondhand, so you may invoke the traditional grain of salt. But it does raise an interesting question in regards to the risk assessment process: Is it a one-and-done or is there an obligation to revisit things from time to time?

Now, purely from a contrarian standpoint, I would argue against a “scheduled” risk assessment on some specific recurring basis, unless, of course, there is a concern that the management of the risk (in question) as an operational consideration is not as easily assured as might otherwise serve the purpose of safety. If we take the eyewash equipment as an example, as it deals primarily with response to a chemical exposure, I would consider this topic as being a function of the Hazardous Communications standard, which is, by definition, a performance standard. So as long as we are appropriately managing the involved risks, we should be okay. And I know that we are monitoring the management of those risks as a function of safety rounds and the review of occupational injury reports, etc. If you look at a lot of the requirements relating to monitoring, a theme emerges—that we need to adjust to changes in the process if we are to properly manage the risks. If someone introduces a new chemical product into the workplace, then yes, we need to assess how that change is going to impact occupational safety. But again, if we are monitoring the EC program effectively, this is a process that “lives” in the program and really doesn’t benefit from a specific recurrence schedule. We do the risk assessment to identify strategies to manage risks and then we monitor to ensure that the risks are appropriately managed. And if they aren’t being appropriately managed…then it’s time to get out the risk assessment again.

Abduction drills as emergency response exercises

One of the survey stories I hear from time to time deals with the efficacy (or the perceived efficacy as a function of Joint Commission surveyors) of using an infant abduction exercise as an emergency management exercise, with the “opinion” usually being that you “can’t” use them. My sense of that has always been that, if you think about it, there are few more disruptive events in any healthcare organization than an abduction event. So while an abduction exercise is not expressly mentioned in the standards, neither is an abduction exercise specifically excluded from the mix.

I believe (and this belief was borne out during a recent survey) is that as long as you plan, execute, monitor, and evaluate an abduction exercise at/to the same degree as you would any other emergency response activity, then there is no real reason why you couldn’t “count” an abduction exercise towards your annual allotment (and yes, I do recognize that an abduction exercise is not an influx exercise, but it could be part of an escalating scenario or as a means of practicing with the local community).

Standing up your incident command structure in response to the abduction exercise—yes, you would definitely want to do that. You also want to make sure that you evaluate the six critical function areas: communications; resources and assets, safety & security; utility systems, staff roles & responsibilities, and patient care and support activities should all be considered in the critique of the organization’s response. For any improvement opportunities that cannot be immediately implemented, make sure you identify any interim measures to bridge those opportunity gaps until they can be finalized. Opportunities and strengths should be communicated to the EC Committee and (ultimately) senior leadership. Basically, it’s the process you should already be using for your “regular” exercises and “real” emergency response plan implementations. If you keep these requirements in mind when, then you can feel confident that you have met the required elements. Bring on the survey!

Hey, how about that new app(liance focus during TJC surveys)?

I don’t know that it represents a significant focus change or if it’s just one of those blips that one might encounter when you hear about survey results, but there is a little groundswell relative to the management of appliances (basically everything that is not clinical equipment, which it appears could extend to utility systems equipment, but there’s no clear sense of that just yet).

I think we can agree than the healthcare environment is chock-a-block full of all manner of devices and appliances from toasters and microwave ovens to refrigerators; from desk lamps to radios and who knows what else. So in that great expanse of possibilities, there have been at least two recent surveys in which the process for managing these types of appliances/devices have come under come scrutiny, resulting in some RFIs for folks.

Now, there are no specific standards or EPs that speak to the management of these appliances/devices, but it appears that where opportunities in this realm are being funneled is our old friend EC.02.01.01, generally a “there was no policy or risk assessment in place to indicate how the risks associated with…” (quotes are mine as I am paraphrasing the general concept). Not that long ago we talked about how far one might need to go when it comes to the ever-present specter of the risk assessment process, and I guess the short answer is: Here’s another instance to flex the ol’ risk assessment muscles.

And so I ask of you: How are you guys managing these pesky appliances? Incoming functional safety inspection (you turn it on and presto, it works) with periodic visual inspections during surveillance rounds? Regularly scheduled preventive maintenance (PM) activities? Re-inspection when something gets busted and is repaired? Inquiring minds (as they are wont to do) await your input!

Thela Hun Ginjeet (and a great big dose of humidity)

Not to belabor or otherwise abuse the deceased equine, I wanted to share with you a potential solution for those of you who might be struggling with high humidity levels in your surgical procedure areas. Let me first say that I’m not an engineer, so I can’t necessarily speak to the science/mechanics of this strategy, but my friends in a nationwide hospital system have employed this with some success. As they say on TV (and radio, and just about anywhere there’s a legal disclaimer), actual results may vary. Consult your (insert professional here) if conditions persist…

And so we have this: Set the discharge temperature of the air handler(s) feeding your ORs (or any other spots where you are having challenges with humidity) to a lower setpoint, to where the reheat coils come on and dry the air. The colder supply air temps from the air handler should trigger the reheat coils to come on, and potentially dry some of that moist air.

Just to give you some geographical context, the folks who appear to be having some luck with this strategy for managing humidity are in those quintessentially arid locations such as Florida, the Carolinas, and Mississippi (when these folks get a new sweater for Christmas, it’s not necessarily something they’d wear). So in the interest of sharing (which generally equates with caring), I figured I’d throw this out there for consideration.

Any folks out there in radioland who’ve tried this and had successes (or not), let me know in the comments. I don’t think this one’s going away any time soon as a survey hot topic, so anything we can do to help each other makes a lot of sense to me, but that might just be me…

Alien invasion: Take me to your (Emergency Management) leader!

It’s been a fairly busy year when it comes to updates of standards and such (short of the anticipated adoption of the 2012 Life Safety Code®…as Tom Petty once noted, the waiting is the hardest part, but I digress) and this week we’ll take a look at the new requirements relative to leadership and oversight of the Emergency Management (EM) function. I’m still not entirely certain what we’re gaining by this, unless as a means of ensuring that organizational leadership is inclined to provide sufficient resources to the task of being appropriately prepared for emergencies, but I’m sure it will all be made clear in the fullness of time.

So, we start with LD.04.01.05 which (in EP 5) mandates hospital leaders to identify an individual (and it does say “individual,” not the usual “individual(s)”—sounds like only one person’s going to be on the hook for this) to be accountable for matters of EM that are not within the responsibilities of the incident commander role. This includes such processes as staff implementation of the four phases of EM (mitigation, preparedness, response, and recovery); staff implementation of EM across the six critical areas (communications, resources and assets, safety and security, staff roles and responsibilities, utilities, and patient clinical and support activities); collaboration across clinical and operational areas relative to EM; and collaboration with the community relative to EM stuff. I think that’s pretty straightforward and, to be honest, I can’t say that I’ve run into any organizations that have not taken things to this level.

Next up we have LD.04.04.01. EP 25, which ties hospital senior leadership in as the drivers of EM improvements across the organization, including prioritization of improvement opportunities, as well as a specific review of EM planning reviews (a review of the review, if you will) and a review of the emergency response plan (exercises and real events) evaluations. So this speaks to a very specific communications process from the “boots on the ground” EM resources up to senior leadership. This one is very doable and even “done-able” if you’ve been including consideration of EM program evaluations as a function of your annual evaluation of the Environment of Care Management program. Lots of folks are doing this, so this one’s not so much of a stretch.

Finally, we have EM.03.01.03, EPs 13 and 15, which basically establish the requirement to have a specific process for the evaluation of EM exercises and actual response activities. You’re doing this, I am quite certain, but what you might not be succinctly documenting is the multidisciplinary aspect of the evaluation process (don’t forget to include those licensed independent practitioners—we want them at the table). It goes on to the process for reporting the results of the exercise/event evaluations to the EOC committee. Again, I’m pretty confident that this is in place for many (probably most, maybe even all) folks.

That’s the scoop on this. The changes are effective January 1, 2014 and I don’t think this is going to present much of a problem for folks, though please feel free to disagree (if you are so inclined). Certainly what’s being required fits into the framework of processes and activities that are already in place, so less fraught with peril than other changes that could have been made. (I’m still waiting for the influx exercise requirement to be changed to an evacuation exercise requirement. I think we do influx pretty well; evacuation, that’s a whole other kettle of fish.)

Well, while I don’t think that you’d have to include alien invasion on your HVA, if such a thing were to occur, at least we’ll know who to take them to when they ask…