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From the muddy banks of compliance

Let’s break from form a little bit and start with a question:

How often are you (and by you, I mean your organization) screening contracted staff, including physicians, physician assistants, nurse practitioners, etc.?

A recent TJC survey resulted in a finding under the HR standards because the process was being administered on a biannual cycle. The finding vaguely referenced OSHA guidelines in identifying this deficiency, but the specific regulatory reference point was not provided (though apparently a call to Chicago validated that this was the case). Now, anyone who’s worked with me in real time knows that I have an exhaustive (and, at times, exhausting) curiosity about such matters. The deficiency “concepts” are usually sourced back to a “they;” as in, “they told me I had to do this” “they told me I had to that.” I am always, always, always curious as to who this “they” might be and whether “they” were good enough to provide the applicable chapter and verse. The answer, more often than not, is “no.” Perhaps someday we’ll discuss the whimsical nature of the” Authority Having Jurisdiction” (AHJ) concept, but we’ll save that for another day.

At any rate, I did a little bit of digging around to try and locate a regulatory source on this and in this instance, the source exists; however, the standard is not quite as mandatory as one might first presume (If you’re thinking that this is going to somehow wrap around another risk assessment conversation, you are not far from wrong). So, a wee bit of history:

Back in 1994, the CDC issued their Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Facilities, ( which, among other things, advises a risk-based approach to screening (Appendix C speaks to the screening requirements for all healthcare workers, regardless of who they work for. The guidance would be to include contract folks. The risk level is determined via a risk assessment (Appendix B of the Guidelines is a good start for that). So, for a medium exposure risk environment, CDC recommends annual screening, but for a low exposure risk environment, they recommend screening at time of hire, with no further screening required (unless your exposure risk increases, which should be part of the annual infection control risk assessment).

But, in 1996, OSHA issued a directive that indicates annual screening as the minimum requirement , even for low-risk exposure risks, and even while referencing the CDC guidance: ( with medium risk folks having semi-annual screening and high-risk folks being screened on a quarterly basis. So, friends, how are you managing folks in your environment, particularly the aforementioned contracted staff? Do you own them or is it the responsibility of their contracted employer? Does this stuff give you a headache when you think about it too much? It sure gives me one…occupational hazard, I guess. At any rate, it’s certainly worth checking to see whether a risk assessment for TB exposure has been conducted. The OSHA guidance document clearly indicates that if you haven’t, it’s the responsibility of the surveyor to conduct one for you, and I don’t know that I’d be really keen on having that happen.

In your eyes – the light, the heat … the chemicals?

A couple of weeks ago, a client was asking me about who should be performing the weekly checks of eyewash stations. A clinical surveyor consultant had given them the impression that this should be the responsibility of maintenance staff. Now, I’m not sure if this direction was framed as a “must” or a “would be a good idea,” but what I can tell you is that there is no specific regulatory guidance in any direction on this topic. I do, however, have a fairly succinct opinion on the topic—yeah, I know you’re surprised to hear that!—which I will now share with you.

Certainly we want to establish a process to ensure the checks will be done when they need to be done. I agree that maintenance folks are typically more diligent when it comes to such routine activities than clinical folks often are. However, from an end-user education standpoint, I think it is way more valuable for the folks who may have to use the device in the area to actually practice its operation. If they do have a splash exposure, they would have a moderately increased familiarity with the location, proper operation, etc., of the device. Ideally, the eyewash will never have to be used because all our engineering controls and PPE will prevent that splash (strictly speaking, the eyewash is a last resort for when all our other safeguards have failed or otherwise broken down.

I’m also a believer (not quite like Neil Diamond, maybe more like Smashmouth) that providing for the safety of an organization is a shared responsibility. Sure, we have folks who call ourselves safety professionals help guide the way. But real safety lives at the point of care/point of service, where everyone works. So it’s only appropriate that each one of us take a piece of the action.

Now be thankful…

As we begin 2012, I am curious as to how folks fared with their EC programs last year (2011). Whether it be blessing, curse, reason to give thanks, reason to give up—never! – what worked for you, what didn’t work , and what do you feel comfortable sharing with the rest of the safety community?

From my experiences, I witnessed yet another year in which folks were charged with doing more with less. I have no sense that 2012 will be bringing any wealth of riches to hospital safety programs. Part of the problem is the safety community has once again proven itself as more than adept at finding a way to make things work, make sure folks are safe, and generally make sure the wheels don’t fall off the safety bus. So, to paraphrase that estimable sage, one P. Frampton: I want you to show me the way. The only unique thing about challenges is how we meet them. In the spirit of giving, I exhort you to share your wisdom with this community.

And in exchange? You would have my personal gratitude and my warmest wishes to you and your family for a most joyous New Year. (Hey, I’ve got a budget too…)

I need to know

Another challenge that’s been rearing it’s ugly little head is the requirement for staff and licensed independent practitioners (LIP) to describe or demonstrate actions to be taken in the event of an environment of care incident, as well as knowing how to report an environment of care risk. I will freely admit that this one can be most tricky to pull off).

The tricky piece, at least in my estimation, is that any data that would be gathered during survey would be the result of direct interaction with staff in the care environment. For staff, one strategy would be for them to contact their immediate supervisor to report a risk, or to be able to articulate the use of a work order system to notify facilities, biomedical, safety, and/or environmental services of conditions needing resolution. Alternatively, some hospitals have a single phone number for reporting unsafe conditions. Presumably, staff can also speak to their specific roles in emergency response activations such as fire, security, disaster, etc.

As to the LIPs, this task can be exponentially more difficult as, strictly speaking, the expectations of this group are pretty much the same as the rest of the house. I’m presuming that you have an emergency phone number to report codes and fire events. An LIP who is able to articulate familiarity with those codes and events would be useful toward a finding of compliance. They really ought to be able to articulate past the point of ignoring something and to at least be able to put in motion some sort of reasonably attainable resolution.

Again, I’ve not seen this come up a great deal with the LIPs, though certainly the rest of the cadre of front line staff would be considered targets during a survey. I think the key approach is to very clearly and very simply define what constitutes appropriate responses of staff and practitioners. When The Joint Commission doesn’t specifically define what they mean in a standard, it behooves us to define how compliance works in our organizations.

If they don’t know by now…you must be remarkably emergency-free

Lately, I’ve encountered some consternation relative to emergency management, specifically EM.02.02.07, for communicating in writing to each licensed independent practitioners their role in an emergency and to whom they would report in an emergency.

From my experiences, there are any number of ways to demonstrate compliance with this performance element, and to be honest, I’ve not heard of any Joint Commission surveyors “pushing” on this issue, but it could certainly be a vulnerability. One way folks comply with this standard is through credentialing and/or re-credentialing, making use of a process that is already in place. I’m presuming that you have e-mail access for your medical staff members, in which case a simple summary of their duties/roles in an emergency response activation would suffice. Another thought would be handouts at your regularly scheduled medical staff meetings, though, depending on attendance, this might be a tough one to sell if you have a particularly picky surveyor. Anything along these lines would be quite adequate as a demonstration of compliance with this standard.

By the way, the standard does not specify a frequency, so–at least for the moment—you need only document one communication of this nature. It would certainly be appropriate to inform medical staff of substantive changes in their roles, etc., but that would not be considered a standards-based requirement.

I need to know – the re-rise of glutaraldehyde-based disinfectant

One of the developments of the last few years that pleased me most was the move away from glutaraldehyde-based disinfectants to safer alternatives. But now—and I am at a loss to understand what is prompting this—I am seeing a resurgence in the use of the glutaraldehyde-based disinfectants. As we are more or less familiar, glutaraldehyde is a fairly complicated environmental hazard to manage (not the most complicated, but up there on the list), with requirements regarding monitoring of conditions, ventilation, etc. For the big picture, the following link will do nicely:

So what is pushing us back toward a, oh I don’t know, certainly a more hazardous material? You’ll get absolutely no argument from me when it comes to the importance of properly disinfecting reusable medical devices; the rate of hospital-acquired infections is so much greater than we as safety professionals can live with. I had heard of some instances in which devices like endoscopes were stained following disinfection using OPA-like products, but my understanding was that any discoloring on the surface of devices was residue of proteinaceous materials that weren’t completely removed during the pre-disinfection process. (You can’t really call it staining as these devices are generally impermeable, so if it can’t sink in, it can’t stain.) So, I ask you: What up with this? I want to be able to help folks move in the right direction, and I’m not convinced that moving back toward glutaraldehyde is the right direction. If you folks are privy to something that allows this to make sense, please share. It is, after all, the time of the season. Hope to hear from you soon.

A cup of coffee, a sandwich, and…the boss!

If you’ve not yet procured a copy of the November 2011 issue of The Joint Commission Perspectives, I would encourage you to do so. There is a very interesting article that focuses on a strategy for establishing more effective communication between the folks charged with managing the physical environment (that would be you) and hospital leadership.  Now I think this is a pretty cool idea, but I couldn’t say with any degree of certainty how widespread a success it might be as there are a number of variables involved (and that’s not counting personalities). That said, it’s certainly a strategy worth pursuing, if it doesn’t pursue you first.


A little more conversation – and a little more action too!

By this point, you should be thinking about (or already acted on) setting up conversations with your testing vendors to ensure that your fire protection systems testing, inspection, and maintenance documentation reflects the requirements as outlined in EC.02.03.05, Element of Performance #25. Your vendor (and, as the end game, you) is on the hook to provide the following information:

-          The name of the activity

-          The date of the activity

-          The required frequency of the activity (i.e., quarterly, annually, etc.)

-          The name and contact information, including affiliation of the person who performed the activity

-          The NFPA standard(s) referenced for the activity

-          The results of the activity (usually pass or fail)

I’m sure you’ll remember past discussions regarding testing documentation. If you need a refresher, click here. We know that there continues to be a fair amount of survey vulnerability when it comes to this area—it’s still in the top 10 most frequently cited standards for 2011. Clearly, there are some very specific expectations in play here. The actual content and context of those expectations might still be a wee bit murky, but hey, what are you going to do? Ithink it’s time to make sure that our testing vendors are singing from the same hymnal.

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You gotta serve somebody… ‘cause you’ve got HOSPITAL-ity!

A few weeks ago,  I was reading “the nation’s newspaper” (USA TODAY, of course,) and I noticed an article on the front page (below the fold, but definitely front page) about a chain of boutique hotels that has invested in body language training for staff in order to more efficiently identify client needs–just by looking for non-verbal cues. Now, those of you who have been following this blog for a while may remember that my formative years in healthcare were firmly planted in the environmental services realm, so I’ve had what you might call a front row seat for the transformation of certain elements of healthcare from a purely service-oriented pursuit to one that embraces the concept of hospitality.

As safety professionals (and in recognition that sometimes our roles go way past safety), we’re always on the lookout for new trends and this article struck me as, maybe, just maybe, an indication of things to come in how are patients’ expectations may evolve (the evil part of me wants to say mutate, but we’ll leave that be for the moment) based on their experiences in other hospitality/service settings (Catch phrase idea: “Putting the hospital into hospitality.” feel free to make any use of it you might). Depending on the size and complexity of your organization, any number of you folks have responsibilities for front-line staff, be it support services folks, security officers, etc., the number of customer encounters can be rather extensive. I know from my own practice that those types of encounters can be very powerful indeed when it comes to managing the overall patient experience.

So, the question I have for you this day, boys and girls, is: How do we work toward a more customer-focused hospitality sensibility without completely negating our focus on regulatory compliance (basically enforcement of the rules)? I suspect, and perhaps you can confirm or debunk, that this is going to become an increasingly delicate balancing act. Can we still hold the ideals of safety while enhancing the patient experience? What say you, good readers?