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Before they make me run…

One topic upon which I’ve not weighed in is the proposed changes to The Joint Commission’s Emergency Management and Leadership standards to more clearly reflect the responsibility of organizational leadership to provide oversight of the Emergency Management function in both critical access hospitals and “regular” hospitals. (Details can be found here:

The proposed changes have been open for comment since late October, but the field review process (which can – and hopefully has/will – include your thoughts and comments, boys and girls) is coming to a close (December 4, 2012 is the cutoff date) and I didn’t want you folks to miss out on the opportunity to shape the future (that’s probably a wee bit hyperbolic, but that’s me).

Now, to be completely honest with you, I hadn’t really looked too closely at the suggested changes, as much because I think there’s likely to be pushback from some folks to “soften” the language in the Leadership chapter regarding the anointing of an individual to be the “emergency manager” (that’s my euphemism). And after what happened in NYC post-Sandy, this could end up being a very interesting conversation.

I can’t honestly say that I disagree empirically with anything they’re proposing;  they still seem convinced that hospital leaders will not take this stuff seriously (unless they are well and truly “on the hook”). I suspect that there’s going to be a lot of up-selling at individual hospitals that the changes mean that someone must be hired specifically to handle emergency management, which will, in turn, cause consternation among those in healthcare who count the beans, which will, in turn, result in TJC having to clarify what they mean.

But again, I don’t think that what they are suggesting is out in left field, or– to any great extent–unreasonable. I’ve been to any number of hospitals where the leadership oversight of the EM program is one “hat” among many, but not every healthcare organization is in the crosshairs of crazy levels of emergencies (part of me can’t escape the thought that Sandy, like Katrina, was an event above and beyond what they could normally expect to experience, based on past history), so there will always be some level of variability. In looking back at the last 18-24 months, we’ve had a lot of catastrophic events directly impacting hospitals. For whatever reason, hospitals had never really taken a direct hit from a tornado until last year; so, does what happened in Joplin last year change how you have to look at things, particularly in tornado country? Absolutely, but that’s how you have to manage risk – focus on what you know has happend/can happen, and then work on the rest of it as time permits.

At any rate, I would encourage any of you folks out there who have not taken advantage of the field review to weigh in and raise the conversation to an ever-more-thoughtful level. You folks, as I like to say, are living the dream– and your stories/challenges are invaluable to this process. Make yourselves heard, lads and lassies, make yourselves heard!

I ain’t missing you (are you sure about that?)

As much as I had hoped for a reduction in findings relative to EC.02.03.05 (maintaining fire safety equipment and fire safety building features), that hope is being dashed on the rocks of reality. And once again, it appears that a lot of it has to do with the quality of the documentation provided to us by our fire alarm and sprinkler testing vendors.

Where this has been cropping up most recently is in the realm of ensuring that each of the applicable devices is tested in absolute accordance with the requirements for frequency. For example (this from a recent survey), if you have your vendors doing 25% of your inventory each quarter (for the devices that need to be tested annually), then you need to make sure that the number of devices tested in the 1st quarter of last year matches up with the number if devices tested in the 1st quarter of this year, or you need to have a very clear understanding of why the numbers don’t match up. Maybe you installed and/or removed devices from service; maybe there are devices that they could get to in one quarter and couldn’t in the subsequent (more on this in a moment).

Ultimately, we need to make sure that each of the devices in our inventory is being tested at the appropriate frequency. A question for those of you who have your fire alarm testing done on a once-a-year schedule: If a device can’t be tested during the regularly-scheduled activity– say, for instance, a patient room is occupied and the smoke detector can’t be tested– how are you making sure that that device doesn’t fall out of the testing loop?

I know it’s just a single device, but if it’s in a place that’s tough to get to, the next thing you know, you’ve got a couple of years passing without that device being tested… and it becomes low-hanging fruit for a diligent surveyor. I’m just saying…

Temper Temper(ature)

In the continuing pursuit of every possible question that could ever be asked about eyewash stations, there’s been some chatter recently (as well as some field encounters) relative to what is involved with the weekly operational testing of emergency eyewash equipment, particularly whether or not you have to verify the temperature of the flushing fluid. The “good” news is that while there is a requirement to periodically verify the temperature of the flushing liquid, that period is one that is some 52 weeks in length, so we can put that down for an annual visitation. Having said that, I’m thinking this might be a fine opportunity to cover the basic goals of the weekly test (I find there is frequently a bit of a gap in terms of front-line staff’s understanding of the reasons behind the testing).

Let’s start with the ANSI standard. The intent of the weekly activation from the ANSI perspective is to ensure that there is a flushing fluid supply at the head of the device and to clear the supply line of any sediment buildup that could interfere with flow (that’s why you do the test with the caps on – if the pressure isn’t sufficient to “pop” the caps, then there may be some blockage). Running the water also helps to minimize any contamination due to stagnant water.

Another common question is, “How long should I run the water?” The answer is “It depends.” I think we’ve discussed this before, but once more unto the breach: You have to consider the amount of water contained in the eyewash itself, and the water which is in all the sections of piping that do not form part of a constant circulation (a “dead leg” in the plumbing, as it were). Since water tends to be stagnant in these sections until a flow is activated, you need to run the device long enough to flush out all the stagnant water. This may take a little bit of figuring, but once you’ve figured out the time period, you should be good to go.

You also want to make sure that the eyewash equipment is completely accessible, the protective caps are in place, and someone hasn’t installed a cabinet over the device close enough to result in a head injury if someone tries to use the eyewash (don’t laugh – I’ve whacked my head more than once trying to fit my noggin into a confined eyewash. Yes, I realize that head trauma probably explains a lot, but that is an entirely different topic of conversation). Ultimately, it’s about making sure that if someone gets some bad stuff in their eyes, they have an appropriate means of responding to that exposure. Hopefully, it’s not something we need to use very often, but if we have the eyewash stations, we have to properly maintain them.

96 Tears – 96 Hours – 96 Response Plans – You’re gonna cry – cry, cry, cry!

I was doing some work at a client facility recently and happened to be on site when these folks were entertaining the representative from their property insurer. While there was lots of discussion about processes for managing fire alarm and sprinkler system impairments (might be worth checking with your property insurer for their definition of an impairment – might be a little more restrictive than you might think, especially if you are using the 4-hour timeframe identified in the Life Safety Code / TJC standards), which I expected, there was a little more attention paid to emergency response plans, particularly in relation to utility systems failures, primarily as a function of business continuity.

The rep was really keen to see the organization’s detailed response plans for the normally-anticipated failures and it prompted the thought that, in these days of the (at least somewhat) monolithic 96-hour assessment/response plan dynamic, whether we’re best served by having really in-depth, specific response plans, or if we’re better off with what amounts to a bullet list of strategies for managing the risks and vulnerabilities inherent in a particular failure event. So my question to you is this: How “deep” do your response plans go? Are we talking lots of details or is it more or less a response framework that requires a little more intuition/familiarity on the part of your incident commander?

I know that the structure and content of response plans have evolved (mutated?) over the past 10 years or so, but I’d be hard pressed to be able to quantify the improvements (I’m certain that there have been improvements – but I can’t say how I “know” this). Or, in the vernacular of this year’s presidential race, if we are better off than we were 10 years ago – how can we “prove” that improvement?

What say you?

How long has this been going on?

We’re rounding the turn and headed for home – no squeeze play at the plate this time…I hope!

EC.02.05.09 – Inspection, testing and maintenance of medical gas and vacuum systems (#16, with 24% of hospitals having been cited)

It seems to me that we’ve discussed this in the past as well, but it appears that, in this survey year, everything bears repeating.

Anything that your medical gas and vacuum testing activities generate as deficiencies/recommendations/hints from Heloise/etc. needs to be accounted for somehow. Maybe your medical air intake is right next to an isolation exhaust, or it’s nothing more than a leaky outlet, or the issue is non-compliant construction (a favorite is the medical gas zone shutoff valve in the PACU with no intervening wall) that can wait until you do a remodel/renovation project. Whatever it is, you need to say, “This is what we’re doing about that, based on our assessment of the involved risks.” And don’t wait to get ahead of the curve on the fixes: As soon as the activity is completed you are on the hook for the fixes, so you need to know what’s on that list even before you get the pretty report. The clock starts ticking upon identification of the condition, so if you have to wait a month or 45 days for the report, you (and more importantly, your patients) are at some level of risk.

The other thing to do is make sure that your vendor is not using this process to drum up work; I can’t tell you how many times I look at multiple years of testing documentation and find the same “deficiency” over and over again – and then find out, well, it’s not really a deficiency at all. You will get slapped during a survey for this – if it’s a critical fix, then fix it, if it’s not a critical fix, then dot the “I’s” and cross the “t’s” and make sure they are accounted for.

Another component of this is obstructed access to zone shutoff valves, as well as making sure that the labeling of valves is accurate (areas served, contents of piping – labels have to be accurate, accurate, accurate). Also, make sure that what you are calling the area of coverage is in some sort of accordance with what the staff calls the area. I can’t tell you how many times that I’ve seen zone valves labeled in accordance with the architectural drawings and find out that front line staff really doesn’t know which areas are served by the valves. Knowledge is very powerful, and certain knowledge is an invaluable commodity during surveys.

EC.02.05.07 – Inspection, testing and maintenance of emergency power systems (#17, with 23% of hospitals having been cited)

Emergency generators and automatic transfer switches have to be tested in accordance with the requirements of EC.02.05.07 – if you need me to tell you what those are at this point, you may be in the wrong line of work. However, I am more than happy to answer any questions you might have regarding this most important subject. 30%, 30 minutes, no closer than 20, no greater than 40 between tests, run it for 4 hours at a minimum 30% load every 36 months – these are a few of my favorite things.

EC.02.03.01 – Management of fire risks (#20, with 19% of hospitals having been cited)

Breathing a sigh of relief, we’re near the end of our little journey through time and (interstitial) space.

This is another of those findings that it becomes a question of how far one must look before one can encounter enough deficiencies to drive an RFI (the answer in this case being 2). The question I have for you is this – how many junction boxes do you have in your facility. 100? 1,000? 10,000? So, the follow-up question is: How many would an individual (say, a Joint Commission Life Safety surveyor) have to look at before they found two that didn’t have a cover? There are so many opportunities to drop the ball on this one – mechanical spaces, comms closets (it’s very rare that I find an open j-box in an electrical closet – but not impossible). You know they’re going to look above the ceiling – and they’re not just looking for penetrations – and cabling on sprinkler piping – and, and…

You need to enlist the efforts of everyone who does work above the ceiling in your facility; they don’t necessarily have to fix it, but if you know where it is, then you have a shot at being able to address it before it gets ID’d during a survey. The proactive approach works unbelievably well for stuff like this.

And on the horizon looms the specter of a return to focus for the prevention of surgical fires – including the participation of physicians. Too many (and my stance is that one surgical fire is too many) surgical fires occur for my (or anyone’s) liking, so it’s time to kick this process into high gear. I know they’re busy, and may not always seem to be the most cooperative bunch on the planet, but this I see as a moral imperative (and it appears that TJC is similarly inclined – so if you won’t do it for me, do it for them). We can do a better job of educating folks about the risks of surgical fires – and so, we must do just that.

One other related thought is to make sure that you are appropriately managing amounts of compressed gas – don’t go over 12 e-cylinders in an unprotected area. And make sure that your gas storage rooms (for amounts greater than 300 cubic feet of gas) are appropriately fire-safe, etc.

This concludes our test of the emergency survey broadcasting system – this was only a test. We now return you to our regular programming, which is already in progress. If you have any questions or concerns about this or any other topic, you know where I am…

And where it’s going, no one knows

Continuing on our recap of survey adventures, we finish out the Top 10:
EC.02.06.01 – Establishment and maintenance of a safe, functional environment (#9, with 32% of hospitals having been cited)
A couple of somewhat disparate conditions are coalescing under this particular standard:

  • Safety and suitability of interior spaces – this apparently is where the unsecured compressed gas cylinders are ending up when they are found during survey. Not necessarily the place I would have picked (I’d run with EC.02.01.01 EP #3 – minimization of safety risk in the environment), but I can see where it would fit;
  • Management of ventilation, temperature and humidity in the care environment – this is one that will cause you so much heartache, it’s not funny. Temperature and humidity logs? You better have ‘em (and yes, I know that they are not specifically required in the regulatory verbiage, but that doesn’t mean a (insert descriptor of your choice) thing. Trust me on this, if on nothing else, ever!) Make sure that you have extremely reliable pressure relationships in every spot where you’ve got clean/soiled environments cheek-to-jowl; clean/sterile; sterile/soiled, etc. The air has got to flow from the good to the bad (euphemistically speaking), if it flows from the bad to the good, you are going to get lit up like a Roman candle during survey, likely resulting in a CMS visit to boot – none of us want that, none of us at all.
  • Finally, and I don’t know that this got a whole lot of play in the official version, but there is a universal opportunity relative to cleanliness in the patient environment. There are some that I’ve seen who do a pretty good job, but I also know that I’ve not encountered anything close to perfect. If you have a surveyor with a mind to find dust, etc. somewhere in the patient environment, it will be found and it will be cited. Tell me the EVS folks aren’t shoveling against the tide sometimes…

EC.02.02.01 – Management of Hazardous Materials Risks (#10, with 29% of hospitals having been cited)
Lots of funky conditions can reside here, to name just a couple:

  • Management of eyewash stations – weekly checks, temperature, obstructions, where they are installed, etc.
  • Labeling secondary containers – if the chemical leaves its home vessel and is placed in another vessel, the second vessel (spray bottle, basin, sink) needs to have the hazard identified, unless the second vessel is absolutely attended until it is used/properly disposed – and even then, I’d do the label;
  • Access to the Hot Lab in Nuclear Medicine – you’ve got to have a policy that makes sense about access, particularly for couriers delivering the materials – and remember, they’re already driving around with the stuff – if they want to swipe the stuff, they’ll just keep driving – so keep an eye on your stuff (George Carlin would want you to). That said, you should track down the July 2012 edition of Perspectives – there’s a lovely article on just this subject – can you say risk assessment? Thought so.

OK, we’ll do one more for this week, breaking into the next 10
EC.02.05.01 – Managing risks associated with Utility Systems (#11, with 28% of hospitals having been cited)

For those of you with older buildings and/or older utility system components, this one may keep you up at night. The sort of overarching way this is popping up during surveys (other than temperature, humidity, and ventilation, about which we’ve already spoken and will, no doubt, speak of again) is the inability of the system (whichever system it might happen to be) to achieve required results. Now, the sticking point here relates very much to what constitutes a “required result”. In case you hadn’t noticed, CMS is pretty much calling the shots when it comes to enforcement and, with increasing frequency, the practice of grandfathering older, lesser-performing systems is going by the wayside. If you (or someone you love) has a utility system that is not performing up to modern standards, then you had best get going on a risk assessment and identify mitigation strategies for appropriately managing the risks associated with the current performance level of the systems (and, perhaps, a plan for how you’re going to get to where you need to be).

The other condition that has been popping up is the identification, in writing, of inspection and maintenance activities (and the appropriate intervals) for all operating components of utility systems on the utility management inventory (which is, of course, populated through an arduous risk assessment process). It’s my understanding that continuous monitoring through the good graces of a building automation system is an acceptable means of compliance with this requirement, but if you don’t have a building automation system, you’d best be prepared to produce, in writing, the activities and intervals as noted above (a computerized work order system might work – but it has to be a pretty robust platform).

And so we’ve reached the end of yet another batch of fun facts and figures – next week, we’ll wrap it all up – until next year!

Wait there’s more – three men in black said don’t report this…

So, we’ll start this week’s coverage with that pesky little Infection Control (IC) finding (yes, I do recall saying that I would make sense of this as a function of the EC/LS continuum):

Managing the risks of infections associated with medical equipment, devices, and supplies (#5 on the list of top-cited standards, with 39% of hospitals having been cited – IC.02.02.01)

This primarily has  to do with the various and sundry methods of disinfection that are used in the healthcare environment, from low-level disinfection (EP 1), which includes the presence of expired product (i.e., spray disinfectant, disinfectant wipes) to ensuring that staff are knowledgeable of how long they have to keep the surface wet in order to disinfect said surface. And that’s not just the folks in EVS, that’s everybody who wipes something down with a disinfectant. If the goal is to disinfect the surface (which is different than cleaning – cleaning doesn’t take as long), then everyone who uses the stuff has to know how long the surface has to stay wet.

The next component is the intermediate- and high-level disinfection and sterilization processes, particularly when it comes to the manual disinfection of medical equipment. We’ll be chatting about this more in the future, but (and I will eventually reiterate – but don’t I always?), if there are folks in your organization who are performing manual disinfection of patient care devices/instruments, most frequently using an OPA product – you need to make sure that the process has been evaluated  as a function of what is actually required by the manufacturer.  This is a very complicated process (with lots of steps to go awry), and perfection is not merely the goal, it must be attained at every step, every time. Perfect, perfect, perfect…did I say perfect? Indeed, I did!

You also have to make sure that you are properly disposing of medical equipment, devices, and supplies – which means it is vewwy vewwy important that everyone understands what constitutes medical waste – how bloody, etc. do things have to be before they go into the red bag.

Finally, this one deals with the storage of medical equipment, devices, and supplies. This could be any number of things, one of which is not particularly negotiable – outdated stuff – no real defense there. But it could also be any one of those bugaboos – storage under the sink, uncovered linen carts, cardboard, non-solid bottom shelves of storage carts, etc. If I’ve said this once, I’ve said it a million times – there are no (nationally promulgated – check your local listings for regulations near you) rules about these. Each of these is a case of self-determination on the basis of a risk assessment – each represents an infection control risk. Our obligation is to identify the most effective means of managing those risks.

So, as you can see, this is all stuff that fits ever so neatly into the EC world – always more to keep an eye on, don’t you know.

LS.02.01.30 – Provision and maintenance of building features to protect individuals from fire and smoke (#7 on the top-cited list, with 36% of hospitals having been cited)

As the list of non-surprise issues continues, we find ourselves facing non-intact smoke barriers (Can you say “penetrations” again? Good!) and door issues. Hopefully, you all are starting to become familiar with the specifics (you’d better be); EP16 – 23 are providing the most compelling fodder for survey findings. Also, findings relative to the protection of hazardous areas – once again, door latching issues, doors that don’t self- or auto-close and latch (maybe because they’ve been wedged open or had a latch taped over), maybe the odd penetration – pretty basic stuff, all in all.

LS.02.01.35 – Fire extinguishing system requirements (#8 on the list, with 35% of hospitals having been cited)

Eighteen-inch storage leads the parade, but other things to keep an eye out for are:

  • Cabling and other materials draped over/attached to sprinkler piping (including the supports) – chances are you’ve got some of this somewhere in your building – it’s up to you to find it before TJC does.
  • Dust and/or other materials (including grease) on sprinkler heads – gunked-up sprinkler heads don’t work nearly as effectively as those that are pristine. By now, you (or your sprinkler contractor) should have a pretty good idea of which heads are susceptible to build-up of ca-ca.
  • Missing escutcheons – if we only knew where the blessed things went. It’s like some sort of black hole or extraterrestrial event – they disappear and we’re on the hook.

And look, we haven’t even quite finished with the top 10 yet , but rest assured…

Where’s the devil? In the details, of course.

So now that we know the numbers, let’s dig in to what continues to make these little darlings such the rage when it comes to the current survey process:

LS.02.01.20 – Integrity of means of egress (#2, with 52% of hospitals having been cited)

Corridor clutter – I don’t care what’s going to happen with the adoption of the 2012 edition of the LSC (whenever it happens – 2014, anyone?), this one is not going away and, let’s admit it, this one is almost impossible to avoid, especially when you bring in the questionable designation of suites (or non-designation as the case may be; we’ll talk more about suites in the coming weeks, but suffice for now,you need to familiarize yourself with EP’s 16 – 22 on this one, and make sure the suites are identified on your life safety drawings).

Another issue that I continue to encounter is the issue of locked egress doors, especially in areas other than behavioral health units (but, please make sure on the behavioral health units that every staff member has a key). You need to become intimately familiar with the requirements under NFPA 101-2000: 18/ and all associated references (it jumps back to Chapter 7 – and best you make the jump as well).  Security hardware vendors will install equipment in a manner that will get you into hot water during a survey if you don’t pay attention. As a final note, I suspect that exit signs and NO exit signs figure in on this one as well. As always, lots of opportunities for deficiencies here, that’s kind of why it sits so very close to the top of the list…

LS.02.01.10 – Design and maintenance of building and fire protection features (#3, with 47% of hospitals having been cited)

Can you say penetrations? I thought you could! Again, no surprises here – penetrations in fire rated walls. Other non-surprises, you might ask? Door issues – closing, latching, unapproved protective plates, gaps between meeting edges of door pairs, undercuts, decorations and coverings on rated doors – again, how far would they have to look to find these in your “house?” Also, apparently, issues with dampers missing from fire walls – you gotta know where your fire walls are and you gotta know where the dampers (or “dampahs,” as we say in Boston) are. You can get into more trouble by not knowing stuff…

EC.02.03.05 – Maintenance and testing of fire safety equipment and fire safety building features (#4, with 40% of hospitals having been cited)

Again (and I’m going to stay on this one until it finally goes away), my most fervent wish is to make this one history. There are 25 Elements of Performance, representing hundreds if not thousands of opportunities for someone to screw up. Miss a couple of smoke detectors because they were in occupied patient rooms and boom: RFI! Not running the weekly fire pump test for at least 10 minutes, boom: RFI! Miss a couple of fire extinguishers one month (or a single extinguisher for a couple of months), boom: RFI! One of your vendors not indicating the NFPA standard on their documentation, boom: RFI! Do I need to continue? I think not. BTW – this is the #1 most frequently cited standards for critical access hospitals.

And an additional BTW – if, by some strange quirk of fate, you don’t have the documentation available for the surveyor at the time of survey, you don’t just get dinged under EC.02.03.05, but also under the Leadership standards (LD.04.01.05, EP #4 for those of you keeping track). You absolutely, positively have to have the documentation readily available at all times! Even if you go the post-survey clarification route and succeed in establishing a score of compliant for EC.02.03.05, the leadership RFI will stay – because you should have had the documentation available!

I think that’s enough for this week, but stay tuned for the next installment of “Survivor: TJC.”

And the beat goes on – La de da de de, la de da de da…

Alright – so anybody come up with any bright ideas about the looming presence of the EC/LS standard in the list of most frequently cited standards during Joint Commission surveys? Keep those cards and letters coming and maybe we’ll make some sense of this whole thing.

One good thing I can report (and we’ll cover the numbers more thoroughly when we discuss the individual standards and potential vulnerabilities) is that there was some improvement in the standards cited towards the top of the charts, but there were definitely some rising tides as well. Continuing through the rest of the 20, we have:

–          At #11, with 28% of hospitals having been cited – EC.02.05.01 – Managing risks associated with Utility Systems

–          At #16, with 24% of hospitals having been cited – EC.02.05.09 – Inspection, testing and maintenance of medical gas and vacuum systems

–          At #17, with 23% of hospitals having been cited – EC.02.05.07 – Inspection, testing and maintenance of emergency power systems

–          And, at #20, with 19% of hospitals having been cited – EC.02.03.01 – Management of fire risks

So, only 40% representation in the 11-20 group, but for my money, this is getting kind of ridiculous when you think about it.

All in all, I think we (in the aggregate) do a pretty decent job of protecting folks in our organizations from the various and sundry risks that we might encounter.  (I believe to my heart that we haven’t quite hit our stride relative to the management of risks associated with workplace violence, but we’re getting there, but that’s the only area in which I generally see significant improvement opportunities.) We do not generally have people perishing from fires in hospitals, and while we may not get everything right every single time (we demand perfection, but the human element frequently intrudes on that demand), I believe that hospital safety/life safety/facilities professionals perform at a very high rate (keep that thought about rates in your mind’s eye – we’ll come back to rate-based management of survey vulnerabilities as we move through the details of the Top 20).

I guess we avoided having to take it on the chin for a whole bunch of years, and now it’s our turn in the barrel. That said, I’m looking for lots of improvement in the next survey year – and I hope I can help you get there.  So, next week, we’ll cover each in greater detail, maybe talk a little strategy – it’s all good. Until then…

We’re number 2! We’re number 2!

As September draws to a close, it’s time for a recap of the survey year according to the information provided at Joint Commission Executive Briefings, held in locations all across this great nation.

One interesting change is that rather than covering the 10 most frequently cited standards during Joint Commission surveys, the scope has expanded to the 20 most frequently cited standards. And the reason for the expansion, you might well ask? As near as I can tell (or so I’ve been told), it’s because the Life Safety and Environment of Care standards have taken over the top 10 to the extent that the Joint needed to adjust to keep some of the clinical issues on the map.

So, by my calculations, 12 of the 20 most frequently cited standards reside pretty squarely in the management of risk in the physical environment (there’s one that may not seem to “fit”, but trust me on this – it’s definitely something we need to have on the radar. More on that in a moment).

Removing the clinical standards, we come up with a tally of:

#2, with 52% of hospitals having been cited – LS.02.01.20 – Integrity of means of egress

#3, with 47% of hospitals having been cited – LS.02.01.10 – Design and maintenance of building and fire protection features

#4, with 40% of hospitals having been cited – EC.02.03.05 – Maintenance and testing of fire safety equipment and fire safety building features

#5, with 39% of hospitals having been cited – IC.02.02.01 – Managing the risks of infections associated with medical equipment, devices, and supplies (this is the sort of an odd one, but you’ll see it fits – I gar-on-tee that)

#7, with 36% of hospitals having been cited – LS.02.01.30 – Provision and maintenance of building features to protect individuals from fire and smoke

#8, with 35% of hospitals having been cited – LS.02.01.35 – Fire extinguishing system requirements

#9, with 32% of hospitals having been cited – EC.02.06.01 – Establishment and maintenance of a safe, functional environment

#10, with 29% of hospitals having been cited – EC.02.02.01 – Management of hazardous materials risks

So, that’s an 80% showing for the EC/LS clan in the top 10. Now, one thing we’re going to have to try and figure out is this:

Are they finding this stuff because they’re looking for it? Or,

Are they looking for this stuff because it’s easy to find?

That’s your discussion point for the week – let’s see what you can come up with and we’ll get to the rest of the Top 20 next week.