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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.

(Fire) Pump it up!

Just a thought relative to a finding from a recent survey – a quick show of hands, if you will. For those of you blessed (cursed?) with having a fire pump (or two, or three, or…), when your folks conduct the weekly churn test, are they documenting the pressures at the pump as required by NFPA 25-1998, 5-

It seems that there are some instances in which the run time for the test is all that is being documented, so if you think you might be among those who aren’t documenting the pump pressures, consider yourself informed. For those of you who don’t have fire pumps, well, one less thing to worry about, which leaves about 999,999 things to worry about. You take one down, pass it around…

It only takes a minute (OK, maybe a minute and a half…)

As we continue to peel back the layers of the (green) onion that is fire alarm and suppression system testing documentation, I bring you this from the survey front: I can’t say that I find this consistently documented, which makes me think this is worth sharing with the group. By the way, for those of you who have not yet bitten the bullet, it may be time to extend your NFPA library beyond the Life Safety Code®. There are way too many pieces of the puzzle that live in the “other” codes for us to refrain for much longer (not that I am in any way endorsing any particular organization or product, but sometimes the way forward becomes impossibly clear…).

And so, turning to the testing of the emergency services notification transmission equipment (the equipment that comes into play when one must summon assistance from local/regional emergency responders), for this particular sequence of events, there is a requirement under NFPA 72, 1999 edition, 7-2.2 that indicates the receipt of the signal at the supervising station within 90 seconds shall be verified.

Now, for those of you who utilize a central monitoring service (and who, hopefully, are documenting each leg of that signal process – fire alarm system to central monitoring service; central monitoring service to the emergency responders) and, I suppose, those of you who ring directly through to the emergency responders – are you counting those precious seconds when you do your quarterly testing? If not, you would have to consider yourself a little bit vulnerable. Word to the wise.

Smoke ‘em if you got ‘em, but be careful where you install them…

Every once in a while, someone will “challenge” me relative to something I “know” is the real deal. Now, just so we’re clear on this, I absolutely encourage the respectful pursuit of knowledge, and it helps keep me on my toes, metaphorically speaking.

The issue in question during this recent survey was regarding the requirements for the placement of smoke detectors vis-à-vis the location. Or, in the vernacular, “Where does it say that it the code?” At this particular facility (as will happen from time to time), I noted that there were several smoke detectors that were located within three feet of air supply/return vents. I fully recognize that moving such devices around can represent a not-insignificant expense, so I was happy to respond to the “nobody’s ever said anything about that before” conversation, but had to admit that I was not certain as to the chapter and verse that governed this particular metric.

So, for the purposes of furthering the knowledge base, I give you NFPA 99 – 1999 edition, which is the edition of record referenced in the 2000 Life Safety Code®:

2-3.5.1*: In spaces served by air-handling systems, detectors shall not be located where airflow prevents operation of the detectors.

Now you may have noticed that there is no specific distance indicated, just a (not particularly useful) thou shalt not. So, how do we figure out where to go with this? Luckily, the little asterisk, points in a very useful direction. And so, to the Appendix!

A-2-3.5.1: Detectors should not be located in a direct airflow nor closer than 3 ft (1 m) from an air supply diffuser or return air opening. Supply or return sources larger than those commonly found in residential and small commercial establishments can require greater clearance to smoke detectors. Similarly, smoke detectors should be located farther away from high velocity air supplies.

Which provides us with a minimum distance of 3 feet (or 36 inches, for those of you inclined to such measures). While there is still a little wiggle room (not necessarily related to the little asterisk) relative to distance from larger and/or high velocity sources (in fact, you could make the interpretive case that supply and/or return sources in hospitals might indeed be larger than those commonly found in residential and small commercial establishments), this gives us the means of drawing a line in the sand beyond which we shouldn’t traverse. As a final thought, for those of you eagerly awaiting the opportunity to embrace the 2012 edition of The Life Safety Code®, the 2010 edition of NFPA 99 provides this little piece of the regulatory pie under

What I did on my summer vacation…

While I was on vacation a few weeks back, I used some of my “leisure” time to read the daily paper, and I came upon an article regarding the sentencing of a woman who had abducted an infant back in 1987 and raised the infant as her own child. One of the things that struck me is how the abduction scenario (or as much as can be discerned from the news account) involved an infant that had been discharged following delivery and had then been readmitted to the hospital a couple of weeks later. I reflected on how “useful” this scenario could be in developing abduction exercises, and I wondered how often folks are testing response in areas other than the mother-baby unit.

So, I ask you dear readers – what “other” areas have you identified as being at risk for potential abductions – inpatient, outpatient, how about in the home when mother and baby have been discharged. How are we educating staff and patients to the very real risks that exist in way too many places (in my humble opinion)? What do you think? How “far” do you take your responsibilities in this regard?

Soul kitchen

In the August 2, 2012 edition of the fabulous HCPro e-newsletter Hospital Safety Connection, the weekly tip discussed the various merits (or not) of whether kitchens ought to be considered hazardous areas. This discussion apparently engendered much debate, though mostly as a function of what would be considered a hazardous area under the Life Safety Code® (LSC).

While I can understand the interpretive aspect of this from an LSC perspective, my opinion has always been that if you were to consider a mental list of the various and sundry safety risks and hazards that one might encounter as a healthcare worker, the kitchen area has the potential for just about all that would be included in that “mental” list (let’s see. Fire? Check. Sharps? Check. Burns? Yup. Slips, trips, falls? Check, check, check. Need I continue? I think not). And if you extend the kitchen environment to the food services folks who deal directly with patients, then there aren’t too many potential risks that would not be in the mix.

So, while the designation of kitchens as a hazardous area may be debatable from a Life Safety Code perspective, from a pure safety/risk management perspective, it would have to be considered a most (potentially) hazardous area. What say you?

How do you handle …

This is a condition/practice I’ve noticed at any number of facilities.

In facilities that have stairwells that go up past the highest occupied floor (generally leading up to some sort of mechanical/penthouse type area), folks have frequently installed a chain across the stairs leading up as a barrier to unauthorized traffic. In one particular, but by no means unique, instance, a “not an exit” sign” was placed on the chain to reinforce that upward travel at that point was for authorized persons only. Now those of you keeping track of the intricacies of NFPA 101 will note that the wording of the sign in question is not in strict compliance with what is required by (a compliant sign would consist of the words “no” and “exit,” with NO written in letters 2 inches high and EXIT written in letters 1 inch high, with the word EXIT being below the word NO.) And interestingly enough, there is a specific performance element in the Joint Commission standards that addresses this (LS.02.01.20 EP #30).

But during a recent survey of the facility in question, the condition noted above generated a finding, though not under EP #30 (it ended up under EP #32, which is sort of the Life Safety Code® general duty clause egress-related bucket), and also included the citation that the chain impedes exiting from the level above. How about them apples!?! [more]

Infant abduction drills

There’s nothing I like more than questions from the studio audience, so this week I thought I’d field a question on one of those risks that never seems to go away completely, as much because there are not very many specific requirements. So, let’s consider abduction drills.

The current situation at this particular organization involves what I think is a pretty good cross-section of activities: campus-wide drills, suspicious person(s) on the unit drills, mother/baby-specific drills, as well as random quizzing of staff throughout the organization on their role(s) in the infant abduction policy (they have to answer 10 questions about the policy), and a monthly operational test of the infant security alarm system. Again, I think that’s a very good start to things. But it does sort of beg the question as to what requirements exist? Well, dear reader, I beg you, please read on.

Strictly speaking, The Joint Commission (TJC) does not have a great deal that could be characterized as requirements in this regard. EC.02.01.01 EP #9 requires hospitals to have written procedures that can be acted upon in the event the hospital experiences any security incident, including abductions of infants of pediatric patients. That’s pretty much all there is in the standards. I’m presuming that you have a written procedure for responding to an infant and/or pediatric abduction incident, so we’re off to a good start. [more]

Mirror, mirror on the wall … is that me?

One of the curious things I encounter on an increasingly regular basis is the Dorian Gray-like (but in reverse) effect of the ID badges of folks who’ve worked at an organization for a rather long time. So long, in fact, that they really don’t look like their ID pictures any more. I know you’ve seen it too.

Now, I’ve always considered the hassle of having folks wear ID badges as being an important component of our security management strategies. As a general consideration, we do have an obligation to ensure that we’re not giving any interlopers a chance of breaching our security (and don’t get me started on those folks who are not nearly as careful about their ID badges as they should be. I know it makes me sound petulant, but we really ask so little of folks in this regard).

So, I ask those of you responsible for the ID process, have you established criteria for an update of photo IDs? Weight loss or gain, hair color changes, the aging process (all potentially contentious topics for discussion)? Or, like the motor vehicle registry folks, do you re-take pictures after a certain amount of time, maybe contingent on how much a person has changed in the ensuing period. Any feedback or discussion would be most appreciated.