An interesting development on the survey front this year; it may be merely a blip on the compliance radar screen (I know of two instances in which this happened for sure—but if you folks know of more, please share), but if this signals a sea change in how The Joint Commission is administering surveys, you’d best have your ducks in a row.
So, I’ve heard tell of two instances in which the survey team arrived at an organization with the results of the previous triennial survey clutched in their paws, with the intent being to validate that the actions submitted as part of the Evidence of Standards Compliance (ESC) process did indeed remedy the cited deficiency. Now I think we can agree that the degree to which we can fix something and keep it fixed over the course of 36 or so months can be a bit of a, how shall we say, crap shoot. As we’ve noted in one fashion or another, lo these many years, fixing is easy—keeping it fixed is way difficult.
And so dear friends, those of you in the survey bucket for 2013 should dig out those survey results from last time, review the ESC submittal and make sure that what was accepted by TJC as a means of demonstrating compliance with the standards is indeed the condition/practice that is in place now. And the reason this is so very, very important, just to complete the thought, is that there is a pesky little standard in the APR chapter of your beloved Accreditation Manual (APR stands for Accreditation Participation Requirements, and the standard in question is APR.01.02.01) that requires “(t)he hospital provides accurate information throughout the accreditation process.” So if a surveyor gets to thinking that there may have been some less than forthcoming aspect of your action plans, etc., you could be looking at a Preliminary Denial of Accreditation, a most unpleasant state of affairs, I assure you. So let’s give those “old” findings at least one more ride around the track and make sure that we’ve dotted all the “i’s” and crossed all the “t’s.”
In case you’ve not heard (I don’t see as much info on the various list servs I monitor when it comes to the timing of the unannounced survey process), there have been some instances this year when unannounced Joint Commission surveys have been occurring months earlier than anticipated (nobody has gone outside of their official “window,” which opens 18 months prior to the anniversary date of your last triennial survey).
Certainly during 2012, there were some folks who went six weeks or so early, but we’re talking four or five months early. There was some indication that the incredibly reliable nasty weather in the Midwest and Northeast over the last little while has resulted in some schedule juggling by the folks in Chicago (and doing as much traveling as I do, I can well understand the impact of stinky weather). As has become an increasingly familiar mantra, you can’t predict future survey activities/results based on past experiences, but I figured it might be worth sharing the possibility. You all are supremely prepared for your survey I’m sure, but I figured I’d share that bit of info.
One other survey process wrinkle of some note is the tale of an organization that was anticipating a five-day onsite survey and ended up having a four-day survey—with additional surveyors on the team to compress the five days of activities into four days. So, for those of you with five-day surveys who have blocked off Mondays in hopes of maybe blocking out the entire week, there may be a little surprise in store. This has only happened once that I know of, but if anyone out there has a story to share on that front, I’m sure we would all be very interested to hear.
At any rate, as I type this, I am looking out at a very gray day at the airport in Chicago with a forecast of snow. I guess we’re not quite a week into spring, so this must just be a period of transition. Hopefully we transition pretty darn quickly. I do wonder “where those birdies is” (with apologies to Mr. Nash)…
Another perpetually sticky wicket in the survey process (and we’ve discussed this, oh, once or twice before) is the timeliness of documentation from maintenance and testing vendors and the expectations of how that process has to be managed. During an ASHE-sponsored webinar last fall, George Mills posited the scenario in which there is a delay (delay times can vary, but you probably have a pretty good idea of how long you have to wait for reports to come back from your vendors) in receiving a report for fire alarm testing in which a handful of devices failed during routine testing. If you don’t receive the failure information immediately upon its identification by the vendor, what you are saying, in effect, is that it’s okay for me not to “know” (there’s that word again) how reliable my fire alarm system is for a month while I’m waiting for the report. If any of you think that it is indeed “okay” not to know might want to think about another line of work. From an empirical standpoint, a failed fire alarm device puts the building occupants (patients, staff—you know, those folks) at a greater risk, which is never, never, never a good idea. And what if you don’t get the report for six weeks, the failed devices haven’t been replaced, and now you’re looking at the possibility for having to manage the deficiency with a PFI, ILSM assessment—the whole magillah. Truthfully, you have better things to do with your time.
Mr. Mills’ suggestion (and I think it’s a good one, having made the suggestion at least once or twice in the past) is to ensure (either contractually or otherwise) that any deficiencies identified are in your possession before they “complete” their work. You can set it up so they let you know at the end of each testing day (that would be my preference) or at the end of the engagement. But you have got to have that information in your possession as soon as it can be made available to you. The occupants of your building depend on each and every element of your systems—fire alarm, fire extinguishment, medical gas and vacuum, emergency power—you know that list by heart and it’s your responsibility that they are managed appropriately.
For our next topic of conversation regarding George Mills’ address to the folks in ASHE last year, we take up the ever-vexing task of managing penetrations. Now, there’s certainly been a lot of ire pointed towards the folks who run cabling in healthcare—IT, cabling contractors, etc. But this represents something of a sea change in the public face of this problem—while there certainly any number of “perps” when it comes to making holes in rated barriers, there is a very clear sense that appropriate management of the process results in the buck stopping at a single destination: the desk of the facilities management professional.
So, a quick show of hands: How many folks are using an above the ceiling work permitting process? That many? That’s a pretty good number. But how are you administering that process? Have you told the entire organization about the process? Maybe established a bounty for finding folks working in the ceiling without a permit? You have tens of thousands, if not hundreds of thousands, of square feet in which mischief can occur above the ceiling. If you establish the condition that anyone (and that means folks employed by the hospital—everyone is equal in the eyes of a penetrated rated barrier) working above ceiling must display a permit on the ladder or lift—and get folks to call in when someone is working without a permit, then you can start to manage the process. By the way, I’m a great believer in rewarding folks who drop a dime for this and don’t be cheap; at least buy ’em lunch somewhere nice. And if you find you’re spending too much money feeding your dime-droppers, then that means that your permit process is not working very effectively!
When you find someone working above the ceiling without a permit, throw the bum out! Nothing draws attention to a process like a good swift kick in the pocketbook. If someone does not want to work by our rules, then they can work elsewhere, pure and simple. Then they can explain to their boss why they couldn’t finish a job, as opposed to you having to explain to your boss why you’re getting an RFI for rated barrier penetrations. I know which scenario I’d prefer…
One last thought: As for “existing” penetrations, Mr. Mills clearly indicated the expectation that facilities will undertake an above-the-ceiling inspection at least once per year to catch any deficiencies that were not captured by the normal process. Then you either fix them properly or manage them as a PFI (with applicable ILSM assessment—please don’t forget that piece of the puzzle). It’s really just that simple.
Continuing our coverage of George Mills’ address to the ASHE folks last fall, we turn to what was described as an area with a “lot of problems”: The management of suites.
So, before we get started on this one, I’d like you to make a mental list of all the areas in your organization that have been designated as suites (if you’re not sure what a “suite” is, please e-mail me on the side at the address listed below and I will try to help you to get acquainted with this most useful of life safety concepts). Now that you have that mental list appropriately populated, take out your life safety drawings and check to see how many of those suites are specifically identified (this means the perimeter boundaries of the suite, as well as the square footage of the suite). If you have suites that you have mentally designated, but haven’t gone through the process of having them identified on your life safety drawings, in all likelihood you are looking at RFIs for anything from corridor storage to non-latching corridor doors (suites can have stuff and patient rooms doors that don’t latch – benefit!).
In some ways, this very much comes under the category of things that you have to “know”; it is not nearly enough to “think” that something is compliant. If you expect to successfully navigate the survey process, you have to translate the “think” to the “know.” As a facilities management professional, it is incumbent upon you to have absolute knowledge of where your facility “lies” on the compliance chart. By all means, use your vendors and service folks to gain that knowledge, but be assured of one thing: They won’t be the ones in the “hot seat” come survey time—and you’d better know how to cool off that seat.
If you’re reading this, then in all likelihood you’re a regular subscriber to this august publication (august in February—what kind of crazy talk is that, but I digress). In which case, I’m sure you read with some interest the article a couple of weeks ago in which one Mr. George Mills (of the Joint Commission Mills) called out facilities professionals for something akin to dereliction of duty (okay, that might be a wee bit hyperbolic, but this topic, and Mr. Mills stance on said topic, are as serious as all get out), based on the continued frequency of findings in the EC/LS part of the survey process.
At any rate, back in October 2012, Mr. Mills addressed a group of facility managers during a webinar sponsored by ASHE. During the webinar, there was much discussion of the persistence of EC/LS findings during surveys, including attribution of many of those findings to what was characterized as a “lack of management.” I think we can agree that, as characterizations go, that is a very strongly worded characterization indeed. So what types of things are resulting in this level of unhappiness in Chicago? Stay tuned and we’ll find out (by the way, be prepared not to be surprised about much, or even any, of the sticking points during surveys. If you’ve been following this space for any period of time, you are already intimately familiar with the foibles and follies of the modern-day survey process.
I’m reasonably certain that we’ve dealt with this before, but there’s been a wee bit of a bump in survey findings relative to the practical assessment of PFI’s as a function of Interim Life Safety Measures.
It’s really quite simple, when you come right down to it. The Joint Commission standards require us to assess for Interim Life Safety Measures, based on the criteria in our policy, any Life Safety Code® (LSC) deficiencies that cannot be immediately corrected (BTW – it’s a good idea to define immediately in your policy – the standard holds no specific definition, so it’s a bit of self-determination – but don’t go crazy trying to define immediately as something much more than the end of the shift/end of the day). Okay, that’s a pretty solid LSC deficiency that we can’t fix right away.
So, the next question in this little chain is this – what is the defining characteristic of a PFI? Why, it’s a Life Safety Code deficiency that is going to take some time to resolve (something very much less than immediately)! So, as a simple quid pro quo arrangement (or equation, if you like), we have:
PFI = ILSM Assessment
Where you have the first, you must also have the second, otherwise you could find yourself staring down the barrel of a Situational Decision and potential Joint Commission re-survey. Is there anyone in the studio and broadcast audience that has any desire to endure that fate?
I didn’t think so – so, make sure you have ILSM assessments for each of your PFI’s and you will avoid this particular world of hurt. You should go check right now…
Another contractor-related “impression” that’s surfaced lately (and this is not just in hospitals – this can be in your own backyard) is that fascinating phenomenon of the contractors that show up not exactly when you were expecting them and before you got a chance to let your neighbors know that there will be a project going on.
Admittedly, this (hopefully) doesn’t happen too often in healthcare (it better not, at any rate), but I still run across instances when clinical and other staff in areas adjacent to construction/renovation projects feel that they haven’t received much in the way of effective communication prior to the onset of the crash, bang, boom.
Now I know sometimes this is a little bit of the “it’s easier to get forgiveness than it is to get permission” concept (and yes, I also understand that that is a frequent mantra when it comes to taped-over door latches, door wedges, and other sins upon the life safety components of the building), but it’s not like the work isn’t going to happen, so the bestest thing you can do is to reach out to the neighbors to enlist their advocacy on your behalf. Face it, there’s going to be commotion that’s going to reach the eyes/ears/noses of everyone in adjacent spaces – including patients (the reason we are here, n’est-ce pas?)
If we can get the folks managing care to act as advocates for our sawing and drilling and dropping stuff and (quietly) swearing and playing the radio, etc., then (as with so many things) patients might not feel as inclined to provide negative feedback (no guarantees, but it certainly increases the chances of heading a complaint off at the pass).
One of the truisms of modern healthcare is that we cannot communicate enough, but if we keep everyone in the loop, the likelihood of a successful, complaint-free project increases quite a bit (I was tempted to use the exponential qualifier here, but you don’t need me to go all hyperbolic on you at this late date). So, start talkin’!
In recent months, I’ve encountered a couple of instances in which some contractors doing various and sundry projects for hospitals did something (what follows is merely my opinion) incredibly boneheaded – namely leaving roof access doors unsecured and unmonitored.
I’ve also encountered some instances in which contractors had gone to lunch (yes – they really were out to lunch!) and left their “work” unattended on a patient care unit (thankfully not a behavioral health unit, but still) – electrical closets open/unsecured, open ceilings, the whole gamut.
Now, one of my favorite observations is that the human race has an enormous capacity for doing stupid stuff (insert whatever relevant current event you think might be apropos evidence of such a sweeping generalization). And while we generally have pretty good controls over the folks who are working for us (that still doesn’t mean nothing will happen, but that measure of control can really pay dividends over time), but—and this seems to be on the increase—when we bring in folks from the outside (nominally because we are a wee bit under-resourced on the home front), we have to relinquish at least some of that control.
So I ask: When it comes to orienting contractor staff, on what topics do you focus? Do you make a general “don’t do anything stupid” statement as well as more specific concerns? I sometimes think that contractors forget about the complexities of providing a safe environment for patients. I honestly don’t think it’s a lack of capacity on anyone’s part, but in the heat of the battle, so to speak, and we’re charging towards a project completion date, etc., sometimes…
Anyone out there want to share any interesting examples of close calls / near misses, or even a sense of what you’ve done/learned to keep things on an even keel during construction/renovation projects involving external contractors? I know I’m not alone on this one – how about a little sharing?
One of the realities of modern healthcare has been the shift (not everywhere, but in a lot of places) from inpatient volume to outpatient volume, with the result being a number of facilities that close and re-open patient care units based on demand. Now, certainly an organization has to be able to allocate resources appropriately, so consolidation, etc. is a very viable strategy.
But there are some states that can get a bit testy when it comes to the discussion of licensed beds, etc. and pushing the focus back on hospitals to be able to quickly (there’s no hard and fast number; what’s your state say?) restore those rooms/bed positions to service in the event of an increase in census.
Recently, I chatted with an organization that was facing a real challenge because some of the vacated patient units had been converted to other uses (offices, etc.); they are maintaining all the systems that are needed to return these spaces to patient care (just covering over the utilities in the headwall, etc. with a removable panel), so they’re good on that count. But where things have kind of squirted out the sides of the bag is the management of all the patient room furniture that has been displaced – can’t leave all that stuff in the corridors, etc.
So, this organization is looking at establishing a relationship with a medical furnishings vendor who can provide them with patient room furnishings within 48 hours (that’s the state mandate in this particular instance). This is after investigating the potential for off-site warehousing of the furniture now in service, etc., but it was decided that to do so with be extremely labor/resource intensive and since it’s been a while since they’ve actually had to flex back up, they’ve decided to try and work this through an external source.
So I thought that was pretty cool, but then the question became – how would CMS / TJC look at the farming out of the furniture component of their flex plan?
My first thought was they generally wouldn’t have much to say about stuff concerning licensed beds, etc. (beyond the application process), but then I was thinking that this could be an important component of your Emergency Operations Plan, particularly as a function of having to manage an influx of patients in an emergency. In which case, you’d need to be able to evaluate this process as a function (potentially) of your 96-hour plan, etc. I guess ultimately everything relates to everything else and any substantive changes you might make from an operational standpoint can come under scrutiny during survey. Is anybody out there in the listening audience faced with anything similar—maybe seasonal ebb and flow?