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How long can this go on?

Recently I received a question regarding the use of the risk assessment process to determine whether an environmental condition was being appropriately managed. During survey, these folks were cited for not actively monitoring temperature and humidity in a sterile storage supply room adjacent to the OB surgical procedure room (this is one location that I’ve seen cropping up in recent surveys—please remember to keep an eye on sterile storage locations). The physical layout of the space, including the HVAC equipment, basically provides the “same” environment for the procedure room (where they had been monitoring humidity and temperature), so the question became whether the risk assessment process could be used to indicate that if the temp and  humidity in the procedure room had been fine, then the sterile storage room would be fine as well.

Now if we’d been having this discussion prior to the survey finding, we might have had a little bit of leverage, but I still think it would be a tough sell, both during survey or as part of the clarification process, because up to this point, there was no performance data to support that determination (which doesn’t mean it isn’t the case, just means there’s no supporting data—a very important and useful thing to have). My advice, especially since they’d taken the hit during survey, was to collect data for 12 months (this particular facility is located in an area that has four seasons—if you’re looking at a similar situation, but you only have, say, two seasons, you might be able to get away with fewer than 12 months of data) and then make the determination that monitoring only need be occurring in one location in this space. As an additional protective measure, I also suggested they might consider submitting data to the folks at the Joint Commission Standards Interpretation Group and query whether the consistency of data supports the monitoring conditions in the entire suite and not having to monitor in each space. Surveyors are more frequently arriving with past survey results, so it’s important to make sure you are appropriate and consistently managing past findings—you don’t want to be in a position in which previously noted conditions have not been corrected.

It was the worst of times, it was the worst of times—or perhaps not

It appears that we are soon to be basking in the presence of an interesting confluence. It appears that CMS is looking very closely at requiring hospitals to conduct four-hour generator tests every year. Don’t know that that is a particularly surprising development given the focus on the reliability of emergency power, though I’m not sure how much the brain trust for NFPA 110 was consulted in this regard. At any rate, you will definitely want to take a look at the Federal Register for December 27, 2013 for the proposed rules (the emergency generator piece can be found on pages 79173-4, but the whole proposed rule has to do with hospitals and emergency preparedness; I suspect we’ll be chatting about this stuff for a while). Go to the Federal Register webpage where you can download the PDF of the proposed rule (and get yourself some snacks, it’s 120 pages long). The comment period ends on February 25, so you might want to get in on the action, the options for commenting are on the webpage.

Moving on to the other piece of this lovely regulatory (governmental?) maelstrom, we have the EPA, which is enacting fairly significant requirements for emergency generator emissions (you can find a story on this topic from Health Facilities Management magazine). You can find more information about the specifics of the emissions requirements at the EPA website.

It appears that we will be looking at additional generator testing with stricter emissions requirements—sounds like way too much fun!


It’s the most wonderful time of the year (for many safety folks)

As one year draws to a close (sometimes it takes until the end of January to be able to “close out” December), for many safety professionals, it’s time to start working on the annual evaluation of Environment of Care program. Hopefully, in reviewing performance over the last 12 months, you’ve made some improvements, but you’re hopefully also identifying the improvement opportunities that await your program in 2014.

The annual evaluation process is one to which I give a lot of thought over the year, as I look at how folks are administering the process. And I think my best advice is to think about the evaluation process as a way to tell the story of your program—unless you’re just “setting out” on the safety journey, you have a wealth of history (triumphs, frustrations, maybe one or two non-starters—remember, there are no failures as long as you learn something from them) and all-too-often, I see folks focusing only what has happened in the last 12 months without placing those 12 months into some sort of historical context. Use the evaluation of the scope, objectives, performance, and effectiveness to reflect the journey/story that has resulted in your program being where it is. I’m sure you’ve all experienced instances in which, when looking at the last 12 months, the picture you’re holding is somehow incomplete. You know you’re better/different than what you’re looking at, but how do you clarify that picture, particularly when you’ll be communicating that picture to your EoC team and probably organizational leadership?

I think if you focus on the (hi)story (I don’t think I could go back further than a couple of years—maybe five, but that would be at the very most) of your program, you’ll be able to  frame things in such a way as to really crystallize the journey. You are where you are for a reason and sometimes 12 months of activity/performance isn’t enough to provide a true appreciation for where you’ve been, where you are now, and where you are going.

A new year and a period of transition

Those of you in the audience paying close attention to the content of the blog may well have noticed a heretofore gap in “fresh” materials, so I wanted to take a moment to comment on that, to offer my wishes for this brave new year, and to update you on what’s been going on in my sphere of influence.

So, first things first: I have absolute confidence that 2014 will be an improvement over 2013—or, at the very least I will remain hopeful until proven otherwise (it’s how I roll!) And so, I offer this aspiration for your professional existence: I hope 2014 kicks serious keister!

I’m back in the swing of things (though if you know someone who is in need of a gently used EC/LS/EM consultant, please point them in my direction) and you can expect at least weekly updates in these pages, as well as (hopefully—yes, I am full of…hope! Shame on those who thought I was full of something else) an updated version of the Hospital Safety Director’s Handbook (the update will include a new title, but we’ll save that for later) to be published later this year. There been a boatload of changes in the healthcare safety landscape since the last edition was published; if you have anything you’d like to see included, now would be a very excellent time to weigh in.

And how might one weigh in? I’m glad you asked! I’ve set up an email account to handle professional communications, so if you have questions, comments, concerns, suggestions, thoughts, curses, etc., I can be reached at It has been one of the great pleasures of my existence to have gotten to know you folks over the past 10 years and I have every intention of continuing that relationship—and this community—for the foreseeable future. On that note, I’m going to close things out for the moment, but in the words of my esteemed ancestor, Dugout Doug, I shall return!

When two tribes go to war: EVS to the rescue!

A while back we discussed the two tribes that inhabit the healthcare world—the finders and the fixers. During that discussion, I advised the development of a more robust participation on the part of the finders, so the fixers can focus on the fixing, as opposed to having to go out and find stuff to fix (during safety rounds, etc.) This week I’d like to focus on a very important group in the finder tribe: the environmental services staff (EVS).

Generally speaking, at least in my experience, once they have completed a cleaning task, the EVS folks are charged with performing a visual inspection of the area that has been cleaned. Sort of like reviewing the answers to a test before you turn in the test paper—dotting the “I’s” and crossing the “t’s” as it were. So the thought I had (though it may be as much question as thought…here’s where you folks come into the picture) is to find out whether your EVS folks are checking for what might loosely be termed “maintenance issues” when they go about their cleaning rounds. I guess my overarching thought on this is that when (or maybe if…I’ll let you be the judge of that) a room is ready for occupancy (which I suppose kind of limits this to rooms cleaned after patient discharge), the room should be as “ready” as possible. This includes making sure that the place is not only clean, but the various and sundry component systems are also in good working order: TV works, lights work, toilet flushes, faucet doesn’t leak, ceiling tiles are clean and present, cubicle curtains are all hooked up, etc. It seems to me that it would be a pretty fair customer satisfier not to have to worry about whether stuff works, but that may just be me (I know I would like that…). So, what do you folks think?

New webcast provides training on OSHA HazCom revisions, GHS updates

OSHA requires hospitals to have completed training by December 1, 2013 on its revised Hazard Communication Standard for all staff who come into contact with hazardous chemicals. On Wednesday, January 8, 2014, HCPro is presenting a webcast to help you understand the changes and train staff on the GHS updates. In this 90-minute program, expert speakers Marge McFarlane and Paul Penn will explain what staff need to know to be safe and to implement the GHS changes. In addition, McFarlane and Penn will participate in a live question-and-answer session.

You can find more information and register for the webcast here.


If you don’t have pictures, you don’t have —!

As you are all no doubt familiar, sometimes those educational topics surrounding safety can come across as a bit dry and that dryness all too frequently ends up being the focal point of safety presentations. Now, one of the fun little quirky things that you run into when flying is that every time you get on a plane, you have to go through orientation (if only we as healthcare safety professionals could “capture” an audience as frequently as the airlines do) and sometime those orientations are very much less than compelling. And so, I thought that you might find the following offerings from NPR and The Telegraph of some interest, entertainment, and perhaps some inspiration. As I like to say during my consulting visits, this stuff doesn’t have to be torture. At any rate, I hope you enjoy these, and maybe you’ve got some homegrown footage you’d want to share (or perhaps already have shared); there’s no reason we can’t all partake of such splendor.

And who drills the drillers?

Another email question asked whether there were any specific Joint Commission education requirements for the folks who conduct quarterly fire drills. The short answer to that question is no, TJC does not require any specific education for the folks conducting the fire drills. But you know that I rarely rest upon the short answer, so I would certainly think that from a practical standpoint, it might not be a bad idea to have a little education package gathered together for that purpose. Ultimately, there is a responsibility to ensure that folks are competent in whatever they’re doing and you would certainly want to make sure that any folks assessing the competencies of others (which is nominally what you’re doing when you conduct fire drills) are themselves competent in that process. Again, not a bad idea to have something, but it’s not specifically required. I would suggest including some accounting of the process in your Fire Safety Management annual evaluation. Is anybody else working on this type of thing? I suppose there are lots of points in which staff interactions are evaluated for compliance—how do you make sure the folks doing the oversight have got the goods? I, for one, would be interested to hear any stories about this.

Searching so long…

I don’t hear too many stories like this anymore, but I can tell you, as a former manager of security services at a hospital, this is one that really gives me pause.

In September, at a hospital out in San Francisco, a patient disappeared from her room, after which a search ensued with no result. The awful thing is that the patient was found in a locked stairwell about two weeks later by an engineering staff member doing rounds. You can find the San Francisco Examiner story that caught my eye (as well as several related stories).

Now I’m sure the investigation will yield some indication of what happened, but I’m also thinking that the whole story may never be revealed. Was that stairwell inspected prior to the point when the engineering staff person made their rounds? How was the search conducted? Was there a conscious decision to limit the search to unsecured areas? At what point do you suspend the search?

I’m certainly not going to Monday-morning quarterback such an awful circumstance, but the question I ask myself is this: can you stop looking when you’ve not found the person you’re looking for? Again, it’s my understanding that the stairwell in question was secured, but how many times have you encountered a security system that was absolutely impregnable—my experience has been that the human element is all too frequently the means of defeating the certain security measure. So has this particular tragedy caused anyone to look at, or even rethink, their search protocols? Are there areas you might not consider as being accessible that might warrant at least inclusion in a comprehensive search grid? I’d be interested in what you all think about this one.

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…