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Alien invasion: Take me to your (Emergency Management) leader!

It’s been a fairly busy year when it comes to updates of standards and such (short of the anticipated adoption of the 2012 Life Safety Code®…as Tom Petty once noted, the waiting is the hardest part, but I digress) and this week we’ll take a look at the new requirements relative to leadership and oversight of the Emergency Management (EM) function. I’m still not entirely certain what we’re gaining by this, unless as a means of ensuring that organizational leadership is inclined to provide sufficient resources to the task of being appropriately prepared for emergencies, but I’m sure it will all be made clear in the fullness of time.

So, we start with LD.04.01.05 which (in EP 5) mandates hospital leaders to identify an individual (and it does say “individual,” not the usual “individual(s)”—sounds like only one person’s going to be on the hook for this) to be accountable for matters of EM that are not within the responsibilities of the incident commander role. This includes such processes as staff implementation of the four phases of EM (mitigation, preparedness, response, and recovery); staff implementation of EM across the six critical areas (communications, resources and assets, safety and security, staff roles and responsibilities, utilities, and patient clinical and support activities); collaboration across clinical and operational areas relative to EM; and collaboration with the community relative to EM stuff. I think that’s pretty straightforward and, to be honest, I can’t say that I’ve run into any organizations that have not taken things to this level.

Next up we have LD.04.04.01. EP 25, which ties hospital senior leadership in as the drivers of EM improvements across the organization, including prioritization of improvement opportunities, as well as a specific review of EM planning reviews (a review of the review, if you will) and a review of the emergency response plan (exercises and real events) evaluations. So this speaks to a very specific communications process from the “boots on the ground” EM resources up to senior leadership. This one is very doable and even “done-able” if you’ve been including consideration of EM program evaluations as a function of your annual evaluation of the Environment of Care Management program. Lots of folks are doing this, so this one’s not so much of a stretch.

Finally, we have EM.03.01.03, EPs 13 and 15, which basically establish the requirement to have a specific process for the evaluation of EM exercises and actual response activities. You’re doing this, I am quite certain, but what you might not be succinctly documenting is the multidisciplinary aspect of the evaluation process (don’t forget to include those licensed independent practitioners—we want them at the table). It goes on to the process for reporting the results of the exercise/event evaluations to the EOC committee. Again, I’m pretty confident that this is in place for many (probably most, maybe even all) folks.

That’s the scoop on this. The changes are effective January 1, 2014 and I don’t think this is going to present much of a problem for folks, though please feel free to disagree (if you are so inclined). Certainly what’s being required fits into the framework of processes and activities that are already in place, so less fraught with peril than other changes that could have been made. (I’m still waiting for the influx exercise requirement to be changed to an evacuation exercise requirement. I think we do influx pretty well; evacuation, that’s a whole other kettle of fish.)

Well, while I don’t think that you’d have to include alien invasion on your HVA, if such a thing were to occur, at least we’ll know who to take them to when they ask…

What time is it? It’s JCST (Joint Commission Standard Time)!

In the June 2013 edition of The Joint Commission’s Perspectives, George Mills covers the thorny topic of the Environment of Care management plans. Within his dissertation, he makes note that he doesn’t recommend inclusion of the Joint Commission standards and Elements of Performance (EP) in the management plans (see p. 6 of the article “Environment of Care Management Plans” for the skinny). The reasons include the caution not to “merely” restate the EPs and standards (I’ve seen management plans that consist of nothing but a reiteration of the standards and performance elements, verbatim, with no supporting description of the organization’s strategies for complying with each of the required elements—not a good thing at all), as well as to avoid the “tedious” task of making sure that minor changes to the standards (which happen periodically, but I don’t know that I’d get to the point where I’d call it tedious to review the standards from year to year) don’t trip you up during a survey. He finishes with the statement that surveyors know the standards and EPs, so they don’t need to be repeated in the management plans.

Now I don’t necessarily disagree with any of those statements, but I don’t know that there isn’t a benefit to indicating the specific performance elements as a function of the management plans, if only to ensure that it is very clear to everyone (internal reviewer, regulatory surveyor, etc.) how your organization manages compliance with each of those elements and standards. My personal experience (and those of folks with whom I have worked with on their management plans) has been that the easier it is for the surveyor to tie a standard or an EP to a specific portion of your management plan, the greater the likelihood that they will “tick” that element off and move on to other things. To be honest, when I’m looking at management plans, I tend to focus as much on what has changed recently as anything—it provides evidence that the folks charged with managing the EC program are making sure that they’re staying on top of changes  to the standards.

As a further enticement to you folks who’ve not yet added Perspectives to your monthly reading list, p. 8 of the June issue also includes a rubric for evaluating the “quality” (my interpretation) of your management plans. It’s an interesting exercise that you might even consider covering as a group exercise with your EC committee. One of the most important aspects of this whole magillah is for your committee to have a comprehensive sense of how risk is managed in the physical environment—from the identification of opportunities through the strategies developed to make good on those opportunities through the monitoring and evaluation of performance relative to those opportunities. While there will always be content experts in the mix, it is of critical importance to a highly performing committee for the committee as a whole to be able to speak to what’s going on. If you can get to that point, you have really got something powerful upon which to sustain your program.

Take this leaking boat (with apologies to The Swell Season)

As I was cruising through the updated State Operations Manual from CMS, I happened upon something that I can honestly say I’d not really “seen” before. And so, I direct you to the following paragraph from the guidance provided to surveyors conducting CMS surveys:

“Determine whether the hospital maintains the ABHR [alcohol-based hand rub] dispensers in accordance with the manufacturer’s guidelines, or, if there are no manufacturer’s guidelines, that the hospital has adopted policies and procedures to ensure that the dispensers neither leak nor the contents spill.”

“(T)he dispensers neither  leak nor the contents spill.” Now I don’t know about you, but from my experiences, that (as they say) is a pretty tall order and I can’t say that I’ve run into a whole lot of folks who’ve had unbridled success in this regard. I’ve seen more paint, wood, just about any surface you could name, pretty much ruined by alcohol-based hand sanitizer, so I’m thinking that the whole no leak or spill thing has a ways to go.

What are your experiences with this? Anyone have any success stories they’d like to share with the class? The floor is open and we eagerly await your contribution.

This just in: Absolutely nothing

While we are on the subject of the CMS, you may be interested to know that an update of the State Operations Manual (which is basically the foundation resource for the conduction of CMS surveys) was unveiled on June 7. You can find the transmittal here.

The good news is that there are no changes to the content relative to the survey of the physical environment, including the Life Safety Code® (LSC) requirements. The bad news is that there are no changes to the content relative to the survey of the physical environment, including the LSC requirements. So, no green light on the 2012 edition of the LSC—and the peasants don’t rejoice.

I can’t think of anything that’s more keenly anticipated than the 2012 LSC, at least in healthcare safety circles (and hopefully circle doesn’t become a pejorative term—that would be most unfortunate). Like children on the eve of a birthday, we wait, and wait, and wait…

You may want to smoke during surveys

I could have sworn that I had covered this last year, but I can find no indication that I ever got past the title of this little piece of detritus, so I guess better late than never.

One of the more interestingly painful survey findings that I’ve come across hinge on the use of a household item that previously had caused little angst in survey circles—I speak of the mighty tissue paper! There has been any number of survey dings resulting from tissue paper either being blown or sucked in the wrong direction, based on whether a space is supposed to be positive or negative. And this lovely little finding has generated a fair amount of survey distress as it usually (I can’t say all, but I don’t know of this coming up in a survey in which the following did not occur) drives a follow-up visit from CMS as a Condition-level finding under Physical Environment/Infection Control.

The primary “requirements” in this regard reside under A-Tag 0726 and can be found below. Now I’m thinking that tissue paper might not be the most efficacious measure of pressure relationships, which (sort of—give me a little leeway here) begs the question of whether you should be prepared to “smoke” the doorway/window/etc. for which the tissue paper might not be as sensitive to the subtleties of pressures. I think it’s a reasonable thing to plan for—as much because there can be a whole lot at stake.  So, I’ll ask you to review the materials below and be prepared to discuss…


(Rev. 37, Issued: 10-17-08; Effective/Implementation Date: 10-17-08)

§482.41(c)(4) – There must be proper ventilation, light, and temperature controls in pharmaceutical, food preparation, and other appropriate areas.

Interpretive Guidelines §482.41(c)(4)

There must be proper ventilation in at least the following areas:

• Areas using ethylene oxide, nitrous oxide, glutaraldehydes, xylene, pentamidine, or other potentially hazardous substances;

• Locations where oxygen is transferred from one container to another;

• Isolation rooms and reverse isolation rooms (both must be in compliance with Federal and State laws, regulations, and guidelines such as OSHA, CDC, NIH, etc.);

• Pharmaceutical preparation areas (hoods, cabinets, etc.); and

• Laboratory locations.


There must be adequate lighting in all the patient care areas, and food and medication preparation areas.

Temperature, humidity and airflow in the operating rooms must be maintained within acceptable standards to inhibit bacterial growth and prevent infection, and promote patient comfort. Excessive humidity in the operating room is conducive to bacterial growth and compromises the integrity of wrapped sterile instruments and supplies. Each operating room should have separate temperature control. Acceptable standards such as from the Association of Operating Room Nurses (AORN) or the American Institute of Architects (AIA) should be incorporated into hospital policy.

The hospital must ensure that an appropriate number of refrigerators and/or heating devices are provided and ensure that food and pharmaceuticals are stored properly and in accordance with nationally accepted guidelines (food) and manufacturer’s recommendations (pharmaceuticals).

Survey Procedures §482.41(c)(4)

• Verify that all food and medication preparation areas are well lighted.

• Verify that the hospital is in compliance with ventilation requirements for patients with contagious airborne diseases, such as tuberculosis, patients receiving treatments with hazardous chemical, surgical areas, and other areas where hazardous materials are stored.

• Verify that food products are stored under appropriate conditions (e.g., time, temperature, packaging, location) based on a nationally-accepted source such as the United States Department of Agriculture, the Food and Drug Administration, or other nationally-recognized standard.

• Verify that pharmaceuticals are stored at temperatures recommended by the product manufacturer.

• Verify that each operating room has temperature and humidity control mechanisms.

• Review temperature and humidity tracking log(s) to ensure that appropriate temperature and humidity levels are maintained.


Kind of vague, yes indeedy do! Purposefully vague—all in the eye of the beholder. Lots of verification and ensuring work, if you ask me, but this should give you a sense of some of the things about which you might consider focusing a little extra attention.

Time has come today (or perhaps time won’t let me…)

Last week, we started the discussion regarding findings relative to the inspection, testing, and maintenance of medical gas systems, which reminds me that I kind of skirted exactly how those findings were manifesting themselves.

The most common variant is for organizations that have established a less-frequent-than-annual schedule for the med gas system components, particularly the outlets (as they are usually the most numerous of the system components). Folks are doing half or a third or a quarter of their outlets on an annual basis, and they have not specifically identified the time frame in the Utility Systems Management Plan (USMP; feel free to give your USMP a quick check to see if you’ve defined the time frame(s) for the med gas system components and that your practice accurately reflects what is in the management plan, which is the other most common way this standard generates findings). Make sure you identify the time frame for the testing, etc., and make sure that what the management plan says accurately reflects the process (I know there’s a certain inescapable logic to this, but I’ve seen folks get tagged for this, so please just take a moment to make sure…).

How do we determine those time frames? Well, once again we can ping back through to EC.02.05.01, this time stopping at EP 4, which requires the identification (in writing—but of course) of inspection, testing, and maintenance intervals “based on criteria such as manufacturers’ recommendations, risk levels, or hospital experience.” I think that pretty much captures the gamut of possible criteria, but I’ll throw the question out to the studio audience: Anyone using anything other than those criteria? If so, please share. This would be required for all the utility systems on the inventory, so the next question becomes: What’s on your inventory and how did you populate that inventory?

Jumping back a wee bit further to EC.02.05.01, EP 2, it appears that we would choose between an inventory that contains all operating components of utility systems or we would establish the inventory based on “risks for infection, occupant needs, and systems critical to patient care (including all life-support systems).” Now, I’m not at all certain what you folks might doing individually (I suspect it will have at least something to do with the complexity of your systems and the component elements), but I’m going to guess we have a mix of both strategies of inventory creation. So the task then becomes one of fitting the medical gas system, in total or in pieces, into that decision, then considering the criteria noted under EP 4 to wrap things up in the form of a lovely little risk assessment. Then update the USMP to reflect whatever it is you’ve determined and you should be good to go.

A word of caution/advice: Once you’ve done the risk assessment, picked the maintenance strategy, determined the frequency, and updated the USMP, please remember that is always a wise move to periodically evaluate the decision you made relative to, well, basically anything in your USMP/inventory thing. And a fine spot to do that (if you prefer to call it an opportunity, you’ll get no grief from me) is the annual evaluation process. It comes down to a simple question: Have the maintenance strategies, frequencies, and activities provided reliable performance in support of patient care activities? And while the answer is also pretty simple (yes or no, maybe with a periodic instance of “don’t know” thrown in for good measure), it might be useful to develop a measurement that will tell you when the process is not working well. Could be something like “unscheduled disruptions resulting from preventable conditions” (which might indicate you need to increase your frequencies) or delays in care and/or treatment as the result of unscheduled disruptions (I am a very big fan of EC measurements that tie performance in the care environment back to the bedside—powerful stuff), things like that.

We always want to try and base our risk decisions on data, but sometimes you have to pick a course based on that rapidly vanishing commodity—common sense. When that occurs, I’d want to have some means of “telling” whether the decision was a good one, fold that into (or through) the annual evaluation process, and then move on to the next challenge (and there will surely be another challenge…any minute now). Hope you found this discussion helpful. I will again solicit any feedback that might be percolating out there—I love to know what you all are doing with this stuff, and so does the rest of the class.

I’m feeling a little (medical) gassy…

One Joint Commission survey finding I’ve noticed cropping up in a couple of instances has to do with the routine inspection, testing, and maintenance of critical components of medical gas and vacuum systems. I thought it might be useful to chat a bit about this, particularly as the standard/performance element language is among the more open-ended in terms of what may or may not be required.

EC.02.05.09, EP 1 indicates that the hospital must, in time frames defined by the hospital, inspect, test, and maintain critical components of piped medical gas systems, which include master signal panels, area alarms, automatic pressure switches, shutoff valves, flexible connectors, and outlets. These activities must be documented. So, we’ve got a couple of things going on—“time frames defined by the hospital” and “critical components of piped medical gas systems”—but not a whole lot of indication as to what the heck these are supposed to mean. Or is there something  that would lead us on a path towards conduction of a (you may have guessed this) risk assessment (did you guess, huh, did you? I bet you did…)?

Actually, as a starting point, EC.02.05.09 has a note that gives us a little something to grow on: See also EC.02.05.01, EP 3. Moving on (or back in the standards to EC.02.05.01, we see that EP 3 requires us to identify, in writing, inspection and maintenance activities for all operating components of utility systems on the inventory. Okay, so we have to have written procedures/protocols/ something that we can use to demonstrate compliance; BTW, there are a number of different approaches to maintenance that are allowable—predictive maintenance, reliability-centered maintenance, interval-based maintenance, or metered maintenance are all in the mix—and you can choose whichever of the strategies is appropriate to whatever you are maintaining. Pretty cool, yes?

So we establish what activities are going to be identified and what maintenance approach(es) we are going to be using, which gets us closer to the time frame, but perhaps not quite all the way there. And there is still the matter of how we might define “critical components of piped medical gas systems.” Stay tuned for our next installment…see you next week!

Take an ‘M’ down, pass it around—now you’ve got SDS

In case you missed it, OSHA’s Hazard Communications Standard has been revised to align with the United Nations Globally Harmonized System of Classification and Labeling of Chemicals (GHS) and the first important “to do” date is rapidly approaching (you’ve got a little less than six months—December 1, 2013 is the target). Lots of information can be found here, including an OSHA FactSheet on the topic.

The expectation before us regarding the December deadline is to provide education to our staff on the new label elements and the Safety Data Sheet (SDS) format. Ultimately, this process will result in a much more standardized “look” for the hazard information folks will access to determine how best to manage the risks in their workplace.  The training must include information on the standardized format, including the information contained in the various sections as well as how the information on the product label(s) relates to the SDS.

As a gentle reminder as you embark on this education journey, always remember that OSHA requires you to present information to staff in a manner and language that your employees can understand (this likely represents different types of challenges for each of you). The OSHA page above has links to educational information in English and Spanish, but some of you may have to come up with materials in other languages. I believe that this will be beneficial in the long run, but it represents change, so there will be barriers to be managed. Funny how change erects all sorts of interesting challenges.

As a final note (for the moment) in this regard, the “other” things on the to-do list are to continue to update safety data sheets as new ones become available; continue to provide education on the new label elements; and (this is an important one) update your hazard communications program if new hazards are identified. I’m hoping that any changes to your HazComm plan will be minimal, but you definitely want to start thinking about those updates (June 1, 2016 will be here before you know it).

Jeannie needs a shooter (well, an active shooter response plan…)

The time has come, the Walrus said, to talk of many things…and so today’s tusk (excuse me, task) is to find out where all you good folks out there in radio land are relative to developing active shooter plans for your organizations (either as ground zero, in response to an event in the community, or a combination of both). While there are certainly a majority of communities that have not experienced the horror of an active shooter occurrence, I think that the time where we could “risk assess” our way out of needing to have a response plan for such events has pretty much gone by the wayside.

So, how are you folks working through this? I would think that you’d be interfacing with local (and perhaps regional) law enforcement folks in coming up with a comprehensive response plan. How’s that been going? Any lessons learned you’d be inclined to share with this community? Have you encountered any internal staffing issues as you develop operational plans (depending on your facility layout, you may have a whole bunch of doors to be secured in the event of a lockdown)? Are you going to identify and educate door “monitors” ahead of time or do you think that Just in Time education is going to prove sufficiently effective?

My hope is that no one else is going to get the chance to find out how effective their response plan is, but my fear is that hope is going to take a back seat to reality before too long. But I will remain optimistic until proven otherwise.

Do you have to be so negative/positive?

Time for a little update from the field during survey year 2013. If there’s one topic (or topical set, if you will) that’s causing much angst in the survey world, it’s the focus being paid to areas that have specific environmental performance requirements (e.g., air pressures, temperature, humidity). Last year there seemed to be a little bit of a “run” on issues relating to low humidity, but with the issuance of the CMS categorical waiver, I think the low humidity problems are going to fade into the sunset. But that still leaves us with high humidity conditions and those pesky pressure relationships—I can pretty much guarantee that, for the foreseeable future, Joint Commission surveyors are going to be scrutinizing your logs, field testing your pressure relationships and all manner of mischief when it comes to this stuff. So, I would advise you to start doing the same. Check those logs going back to last year’s rather toasty environs. Did you experience out-of-range values in your procedure rooms? If so, were there any documented actions in response to those out-of-range values? Clearly, if there was no documented response, you are potentially looking at a finding during survey, but if you can demonstrate that you have a well-controlled process now, then maybe you can convince the survey team that past performance doesn’t indicate current or future results and you can negotiate a more favorable settlement. Remember, this is an area that can drive a condition-level finding for CMS in no time flat. You need to have an effective process in place or you will definitely suffer the slings and arrows of outrageous survey fortune—and I don’t think any of us wants that. I know I wouldn’t like it…