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Well, hello there, Mr. Vendor Man: Can we see your papers?

Reaching into the old e-mailbag, a question was raised regarding who “owns” the process for credentialing and what survey vulnerabilities might be lurking in the process. Now I can start by saying that there are no specific requirements as to a credentialing process for vendors; the overarching expectation is that vendors are like any other risk—something to be managed appropriately. Certainly, if you have equipment vendors scrubbing out and assisting in the OR, then that has a more far-reaching implication than a vendor who is responsible for managing copy machines. I suppose if you had to stretch things a bit, whoever is responsible in the organization for managing contracts would certainly be in a leadership position for stuff like this, but that responsibility can be more or less genericized as a function of “services will be provided in accordance with all applicable standards and regulations, including CMS, Joint Commission, state, etc. This would include consideration of such things as competence of the vendors (as an example, I will invoke Clinical Engineering relative to oversight of the contract services provided by external vendors—how do you make sure that contract equipment services personnel are adequately competent, etc.?). I don’t know that you could ever really trace it back to one or two folks in terms of ownership of the process—an organization of any complexity, etc. is going to have many, many contracts for various and sundry services, so there would almost have to be some division of responsibility (I say almost because I suppose you could maybe find the person with worst case of OCD in the organization and hand the responsibility to them—you’ll sleep at night—but he or she probably never will again) that ultimately ties back to senior leadership.

All that said, survey preparation comes down to knowing that the organization is effectively managing contract service vendors (and I’m using that term at its most expansive definition—everybody that provides services that is not directly employed by the hospital would have to be considered in the mix). You could certainly distill this group down to those which would be considered most critical (if that sounds like a risk assessment, you would be correct) and then identify a strategy for monitoring and periodic evaluation of performance. It’s all about having an effective process; generally speaking, TJC generally “leans” on this only when they’ve identified a clear and present failure mode; so if the vendors are adequately competent and behave themselves while under your roof, you should be okay—but you have to have some sense of whether than is indeed the case.

BTW: I had no intention of sexism in the headline; I was going to do the split Mr./Ms. Vendor Person,  but, I don’t know, Mr. Vendor Man seems a little more rock and roll…

Calling all cords

During a recent Joint Commission survey, a question was raised regarding the “length” of nurse call cords (it appears that the surveyor indicated that the end of the cord should be an inch above the finished floor). The Facility Guidelines Institute requires that the call be within reach of a patient on the floor, but there is no specific distance indicated. Now, my personal rule of thumb has always been to try and “hit” a point that is about 3 inches off the finished floor (about the height of your average piece of cove base); this allows access to someone who’s on the floor, but provides enough clearance for mopping the floor (and believe me, those cords can pick up a lot of built-up detergent if you don’t leave enough room). However, if your EVS folks are using microfiber mops, which are a little less poofy (that’s kind of a technical term), then you might be able to have the end of the cord a little closer to the floor. Ultimately this, like countless other topics of conversation we’ve featured here, becomes the function of appropriately managing the involved risks—fallen folks being able to summon help and not having to grab a fistful of sticky call cord to get that help. Of course, if staff are wrapping the cords around the grab bars in the bathroom, that, as they say, is a whole other thing…and not a good one. Oh, and by the way, don’t forget that the cords themselves also represent a cleaning/disinfection challenge—they ain’t so easy to clean—and they really should be done on a pretty regular basis.

And yet another Top 10 list…

Recently, ECRI unveiled its list of the Top 10 Healthcare Technology Hazards (here’s an article discussing this topic). And strangely enough, there is at least a couple that I think you will find oh-so-very familiar. Hopefully, you’re already working on the hazards that fall under your jurisdiction (which will vary from organization to organization), but I think it’s never a bad idea to take a look at what the think tanks are identifying (best believe that your favorite regulatory agency—insert name here—is keeping close tabs on groups like ECRI) and plan accordingly. I’m just going to list the hazards as indicated by ECRI, but if anyone out there in radio land has an interest in more in-depth discussion, please let me know and we can do just that. That said, I think these are pretty straightforward.

1)      Alarm hazards

2)     Infusion pump medication errors

3)     CT radiation exposures in pediatric patients

4)     Data integrity failures in EHRs and other health IT systems

5)     Occupational radiation hazards in hybrid ORs

6)     Inadequate reprocessing of endoscopes and surgical instruments

7)     Neglecting change management for network devices and systems

8)     Risks to pediatric patients from “adult” technologies

9)     Robotic surgery complications due to insufficient training

10)   Retained devices and unretrieved fragments

Train staff on revised HazComm standard with new DVD

OSHA’s revised Hazard Communication standard requires hospitals and other healthcare facilities to have trained staff on the new Globally Harmonized System (GHS) by December 2013. The intent is to make the identification of hazardous chemicals much quicker and easier, and to make it faster to find recommended first aid procedures in the event of worker exposure.

HCPro will offer several staff training solutions to help facilities, including Hazard Communication Training: Implementing the GHS, a new DVD that will be available in December. This video will help you:

  • Meet OSHA requirements for training employees on the Hazard Communication standard
  • Train staff to understand the revised Hazard Communication standard
  • Improve hazardous chemical safety in your facility
  • Learn the new pictograms issued by OSHA

Chemical manufacturers aren’t required to comply with the new regulations until June 1, 2015. That means there will be close to a two-year gap during which employees will need to understand the traditional material safety data sheets (MSDS) as well as the new safety data sheets (SDS).

Visit the HCPro Marketplace for more information and to order.

What is a Life Safety Code® deficiency?

One of the time-honored pursuits, mostly as a function of what you can and cannot manage through the plan for improvement (PFI) process, is what exactly constitutes a Life Safety Code® (LSC) deficiency. Just so you know, I used the “exactly” descriptor for a reason—because the definition, while pretty clear (at least to my mind—feel free to disagree) is a fair distance from exact, but read on and maybe it will become a little more clear.

The “secret” to all of this can be found on pp. 24-25 of the 2000 edition of the LSC. Contained on these two pages are the “documents or portions thereof” that “are referenced within this (Life Safety) Code as mandatory requirements and shall be considered part of the requirements of this (Life Safety) Code.” Thus, these requirements include some of the items you’d probably expect to be there: NFPA 10 Standard for Portable Fire Extinguishers, NFPA 13 Standard for the Installation of Sprinkler Systems, NFPA 70 National Electrical Code, NFPA 99 Standard for Health Care Facilities; and maybe some that you wouldn’t necessarily include in the mix, but make sense when you think about it: NFPA 30 Flammable and Combustible Liquids Code, NFPA 241 Standard for Safeguarding Construction, Alteration, and Demolition Operations. Not that I usually get into product endorsements, but I think even a casual glance at the list of required elements would point you towards having a subscription to all the NFPA codes—and that’s not getting into the other publications cited as required (ANSI, ASME, UL) because they all have a share in the mandated references. Oh yes, and the final “other” publication mentioned is Webster’s Third New International Dictionary of the English Language, Unabridged; you could probably get into a lot of trouble with that…

Therefore, an LSC deficiency is really any condition or practice that is not compliant with any of the referenced codes (is your head spinning yet?), so you can probably craft a PFI for just about any safety-related hazard. In this world of ever-shrinking operational budgets, the PFI process may become an everyday tool as opposed to the once in a blue moon process it has sometimes been in the past. Remember, if the deficiency can be resolved within 45 days, then you can use your work order system. But if you can’t resolve the deficiency within 45 days (and budget constraints are no doubt going to have a greater impact on that in the future), then the PFI could become your new BFF.

In-house fire alarm testing documentation must include the required elements

When it comes to the Life Safety document review, there is still a fair amount of survey risk exposure and (no surprise) a fair amount of survey findings. EC.02.03.05 is the 6th most frequently cited standard; 44% of the hospitals surveyed in the first six months of 2013 were cited under this standard!

Some of the findings have related to irregularities in the testing process. You have to make sure that your device inventory numbers match up; if you had 50 pull stations last year and 55 pull stations this year in the testing documentation, you had better know why and it better be because you added some pull stations, otherwise it could get ugly. But one thing I’ve seen in a couple of recent surveys (both TJC and in my own practice) is the documentation of fire alarm and sprinkler system testing and maintenance that is performed by in-house staff. A typical one is the weekly fire pump test—pretty much everyone does that one in house. Now, there’s nothing wrong with that, but you have to make sure that the documentation of in-house activities is in compliance with EP 25, which requires the inclusion of the following information:


  • Name of the activity
  • Date of the activity
  • Required frequency of the activity
  • Name and contact information, including affiliation, of the person who performed the activity
  • NFPA standard(s) referenced for the activity
  • Results of the activity

In my experience, most folks have the first three pretty well in hand, but sometimes those last three get lost a bit in the shuffle. It might be worth a review of your in-house documentation to make sure you have all the required elements in place.

Pictograms of matchstick men

In our ongoing series (okay, perhaps that’s a rather ambitious descriptor, but there’s been more than one) relative to the upcoming implementation of the changes to OSHA’s Hazard Communication standard, you might find the information regarding the required pictograms helpful in getting your organization’s folks up to speed on what things are going to look like in the future.

The use of the pictograms is not mandated until June 2015, but I think this will improve the communicability of the hazards of products used by staff in the field. Check out the new graphics here.

Spread out! A Stooges primer on cylinder storage

One group of findings that I have seen with increasing frequency in survey reports are those relating to the segregation of stored compressed gas cylinders. Now I think we can agree that the general concept of enforcing the appropriate segregation of cylinders makes some sense. We certainly would not want to put folks in a position where they would have to hunt around for a full cylinder in an emergency—or worse, grab a nearly empty cylinder when responding to an emergency (and yes, I understand everyone’s belief that grabbing a not full cylinder would never happen “in their house,” but I also know that there is a great belief that nothing could ever get into the MRI magnet field, etc. and I know that sometimes the human element doesn’t work exactly as you would prefer).

I’ve seen many different strategies: “full” and “empty” signs on the storage racks or on the walls above the storage racks; racks painted different color (red for the empties, green for the fulls), etc. There is no specifically prescribed method for ensuring appropriate segregation, but I can tell you one thing: if you have locations for full and empty storage in close physical proximity, it is inevitable (in my experience, natch) that the separation will become blurred and you’ll end up with in use or empty cylinders (more on that in a moment) stored in your full rack. I think the strategy that gives you the best shot at compliance is having the storage racks in completely separate spaces (if the room is big enough for separation, that may work, but I’m really talking one room for the fulls and another room for the empties).

One sticking point in this whole magillah is: how do we manage the cylinders that are not full, but not yet empty? Oxygen ain’t cheap and nobody wants to be in the position of returning partially filled cylinders to their vendors—it’s kind of wasteful. So when you come right down to it, we’ve really got three “classes” of cylinders to manage: full cylinders, in-use cylinders, and empty cylinders. But somehow the code doesn’t necessarily capture the in-use cylinders as a specific concept (NFPA 99-1999 4- (b)(2) says: “if stored within the same enclosure, empty cylinders shall be segregated from full cylinders. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly.” (By the way, I think this particular code reference tacitly supports having the full and empty cylinders in separate rooms) But our friends from Chicago (aka The Joint Commission) provide us with a little more specificity; in the December 2012 issue of Perspectives, we find the following passage “(r)acked full cylinders must be segregated from those that have been opened or used (see NFPA 99-1999 4- There should be no confusion for health care personnel who need a cylinder for patient care about which cylinder to select. If empty and full cylinders are comingled in the same rack without clearly separating the two groups, staff might accidentally retrieve a partially full or empty cylinder rather than a full cylinder.”

So, the acid test, so to speak, is keeping the full cylinders separate from “those that have been opened or used). To that point, I think the way to move forward on this is to establish a policy (you might consider a little risk assessment at the front end) that clearly indicates compliance as a function of the full cylinders being in their own location and once a cylinder is used, moves to a location separate from where the full cylinders are stored. That way you can start to measure compliance with your policy as a function of a compliance rate; you collect data during hazard surveillance and safety rounds (maybe even during fire drills). Once you start tracking your compliance rate, even if there happens to be a misplaced cylinder during a survey, you can use the historical compliance data to support clarification of the finding. This is one of those compliance shortfalls that can come up during survey that can almost always be clarified—as long as you know what your compliance rate is over time. Think of it this way, for every cylinder you might find in the wrong spot (or even not properly secured), there was (I hope!) way, way more that are being appropriately managed—that’s the compliance number that you want to track. It will help get you out of survey trouble!

You lift me up!?!

As I wander around the countryside visiting hospitals of all shapes and sizes, there are a few common challenges that seem to give just about everyone fits. And probably among the most common of commonalities is the challenge of managing patient lifting and all the inherent risks of that frequently occurring occurrence (that would be a FOO for you in acronym-land).

At any rate, while catching up on some conversations on one of the safety listservs (this particular listserv focuses on colleges and universities, but there are some healthcare folks in the mix as well) and I found reference to a very interesting article on patient lifting.

The most useful thing about the article (and it’s pretty gosh-darn useful) is that it includes a link to a protocol that can be used (very quickly so it seems) to effectively forecast the patient care and financial impact of patient lifting changes. Now I know from my past experiences that it can be really tough to “sell” the C-suite on avoided future expenses based on a little technology investment in the now. I’m not sure where you all are in relation to this as a focus item, but on the off chance that it might be helpful…

Steak tips, turkey tips, and compliance tips—such a deal!

I’m not entirely certain what to make of this, but I always try to share anything I come across that might prove useful to you folks in the field. Back in July (yes, I know we are now edging towards the wintry portion of our year—we’ve had a lot of stuff to discuss), in one of the regular editions of Joint Commission Online, there was a list of compliance tips for the most frequently cited Life Safety standards.

Nothing wrong with that, as a going concern, but where I kind of got bogged down when I looked at the tips is that they weren’t necessarily in reference to stuff I’ve seen most in the field. All code compliance tidbits, to be sure, but again, not necessarily the type of stuff with which I’ve seen folks struggle.

As an example, the first tip deals with the required clear width of doors to sleeping rooms, egress doors, and doors to diagnostic treatment areas (existing construction must have at least 32 inches of clear width; new construction must have at least 41½ inches of clear width). Now I can think of a few instances in which I’ve encountered doors that were a might on the narrow side, but I’m also thinking door width is driving this particular standard (LS.02.01.20—egress requirements) to be among the most cited in all of survey land? I don’t know, which is why I’m not sure what to make of this. At any rate, make of it what you will—just make sure you grill those tips to your liking.