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After all these years, it’s true: Your mother doesn’t work here

Over the years, once or twice I’ve ventured into staff areas as I’ve toured various facilities—sometimes you find some things that are a little disconcerting (electric grills, various electric food-preparation appliances), but sometimes you find things that can bring a little levity to the moment. One of the time-honored postings is a variation on that old saw “Pick up your mess, your mother doesn’t work here.” While I know that is not always a factual statement (my mom worked at the same hospital as I did for rather a while, though she was not particularly keen on cleaning up messes in either place), I think there is a grain of something that is instructive in how we need to move forward in the management of the physical environment. It all ties back to the finder/fixer dynamic that can work so very efficiently when you get enough participation, with a little bit of incident command tossed in for good measure. Ideally, the level of response to any condition would be in direct proportion to the resources needed to resolve that condition, with the thought being that whoever first identifies the condition is thus “in command” of mustering those resources. So, a paper towel or a plastic bag or some other debris on the floor becomes the point of contact relative to that response. My personal philosophy in this regard (and I apologize if I’ve spouted off on this in the not-distant-enough past) is that if I encounter a condition that I can resolve by my own actions, then that is my obligation. I am no big fan of leaving things for others to do, and I know that tendency exists to one degree or another in most people (I know better than to think everyone is so inclined), but the question I keep asking myself is: How do we get folks to act on it? Someone’s walking along with a cafeteria tray and a napkin blows off the tray—there are thems that will stop and pick up the napkin and there are thems that do not. I guess the overarching question is whether or not it is foolish to think that we can get batter at this, but doggone it, don’t you think we should be able to? Oi!

On a completely unrelated note, word came down from Mount TJC last week that a new module has been uploaded to the Environment of Care portal dealing with that even more time-honored undertaking, the integrity of egress. In looking over the materials (and I encourage you to do so as well—it won’t take very long), the focus appears to be corridor clutter and the locking of doors in the path of egress. Now, the example given on the portal page indicates that it is an example of improved compliance for EP 1 (locked egress doors) and EP 13 (corridor clutter), but the example seems to be a rather odd confluence of discussion points. Both topics are addressed, for sure, but I’m not entirely certain how instructive this is, particularly the piece about locked doors. Maybe you folks see things differently; I’d love to get your feedback.

That said, one thing I noticed was missing (can you really notice something missing?) was no coverage of findings related to Exit and NO Exit signs—maybe some sense of how you can evaluate your facility in this regard. It seems to me that I’ve encountered a slew of findings relating to egress signage (more not having NO Exit signs than not having enough exit signs), including concerns with non-compliant signs (for example, the 2000 Life Safety Code® has very specific instructions relative to NO Exit signs: “7.10.8.1 No Exit. Any door, passage, or stairway that is neither an exit nor a way of exit access and that is located or arranged so that it is likely to be mistaken for an exit shall be identified by a sign that reads as follows: NO EXIT Such sign shall have the word NO in letters 2 in. (5 cm) high with a stroke width of 3/8 in. (1 cm) and the word EXIT in letters 1 in. (2.5 cm) high, with the word EXIT below the word NO.” ). It just seems to me that there could be a little more information to help organizations better prepare their facilities for inspection, but also (and in my mind, this is rather more important) provide a safer care environment. Maybe I need to adjust my expectations on this process…

If you set things up correctly…they will still find stuff!

Those of you who are frequent readers of this little space are probably getting tired of me harping on this subject. And while I will admit that I find the whole thing a tad disconcerting, I guess this gives me something to write about (the toughest thing about doing the blog is coming up with stuff I think you folks would find of interest). And so, there is an extraordinary likelihood that you will have multiple EC/LS findings during your next triennial Joint Commission visit—and I’m not entirely convinced that there’s a whole lot you can do to prevent that from happening (you are not powerless in the process, but more in that in a moment).

Look at this way: Do you really think that you can have a regulatory surveyor run through your place for two or three days and at the end “admit” that they couldn’t find any deficiencies? I’ve worked in healthcare long enough to remember when a “no finding” survey was possible, but the odds are definitely stacked against the healthcare professionals when it comes to this “game.” And what amazes me even more than that is when folks are surprised when it happens! Think about, CMS has been taking free kicks on TJC’s noggin for almost 10 years at this point—because they weren’t finding enough issues during the triennial survey process. BTW, I’m not saying that there’s a quota system in place; although there are certainly instances in which surveyors over-interpret standards and performance elements, I can honestly say that I don’t find too many findings that were not (more or less) legitimate. But we’re really and truly not talking about big-ticket scary, immediate jeopardy kind of conditions. We are definitely talking mostly about the minutiae of the safety world—the imperfections, if you will—the slings and arrows of outrageous fortune that one must endure when one allows humans to enter one’s hallowed halls. People mess stuff up. They usually don’t mean to (though there are some mistakes, and I think you can probably think of some examples in your own halls), but as one is wont to say, feces occurs. And there’s a whole segment of each healthcare organization charged with cleaning up that feces—wherever and however it occurs.

So what it all comes down to is this: you have to know what’s going on in your building and you have to know where you stand as a function of compliance, with the subset of that being that you have to have a robust process for identifying conditions soon enough and far enough “upstream” to be able to manage them appropriately. We’ve discussed the finder/fixer dynamic in the past (here’s a refresher), so I won’t belabor that point, but we need to use that process to generate compliance data. Strictly speaking, you really, really, really need to acquaint yourselves with the “C” Elements of Performance; compliance is determined as a rate and if you can demonstrate that your historical compliance rate is 90% or better, then you are in compliance with that standard/EP. But if you’re not using the surveillance process, the finder/fixer process, the tracer process, the work order process, the above the ceiling permitting process, ad nauseum, to generate data that can be used to determine compliance, then you are potentially looking at a very long survey process. Again, it goes back to my opening salvo; they are going to find “stuff” and if you are paying good attention to what goes on in your organization, then they shouldn’t be able to find anything that you don’t already know about.

The management of the physical environment is, at its heart, a performance improvement undertaking. As a support process for hardwiring ongoing sustained improvement, a process for the proactive risk assessment of conditions in the physical environment is essential. As an example, the next assessment would use the slate of findings from your most recent surveillance rounds to extrapolate the identification of additional risks in the physical environment. For all intents and purposes, it is impossible to provide a physical environment that is completely risk free, so the key focus becomes one of identification of risks, prioritizing the resolution of those risks that can be resolved (immediate and long-term), and to develop strategies for managing those risks that are going to require resource planning and allocation over an extended period of time. The goal of the process is to ensure that the organization can articulate the appropriate management of these risks and to be able to provide data (occurrence reporting, etc.) to support the determination of that level of safety. By establishing a feedback loop for the management of risk, it allows the organization to fully integrate past actions into the improvement continuum. If you think of the improvement continuum as a football field (it is, after all, the season for such metaphors) or indeed any game “environment,” you need to know where you are in order to figure out where you need to go/be. The scrutiny of the physical environment has never been greater and there’s no reason to think that that is going to change any time soon. Your “power” is in preparing for the survey by being prepared to make full use of the post-survey clarification process—yup, they found a couple of doors that didn’t close and latch, a fire extinguisher that missed a monthly inspection or two, and on and on. Anticipate what they’ll find based on what you see every time you “look” (again, it’s nothing “new” to you—or shouldn’t be) and start figuring out where you are on the grid. That way, they can find what they want (which they will; no point in fighting it anymore) and you can say, thanks for pointing that out, but I know that my compliance rate for doors/fire extinguishers/etc. is 90%, 91%, 92%, etc. We want them to work very hard to find stuff, but find stuff they will (that’s a little Yoda-esque). We just have to know what do “aftah.”

Reducing the length of stay: Not yours, but somebody who visits but once in a three-year cycle…

One of the most interesting parts of my job is helping folks through the actual Joint Commission survey process. Even as a somewhat distant observer, I can’t help but think that the average survey (in my experience) is about a day longer than it needs to be. Now, I recognize that some of that on-site time is dedicated to entering findings into the computer, so I get that. But there are certain parts of the process, like, oh I don’t know, the EC/EM interview session, that could be significantly reduced, if not dispensed with entirely. Seriously, once you’ve completed the survey of the actual environment, how much more information might you need to determine whether an organization has its act together?

At any rate, I suppose this rant is apropos of not very much, but the thought does occur to me from time to time. So I ask you: is there anybody out there who feels the length of the survey was just right or, heaven forbid, not long enough? As I’ve always maintained, TJC (or, for that matter any regulatory survey type—including consultants) tend to look their best when you see them in the rear view mirror as you drive off into the future. I know the process is intended to be helpful on some level, but somehow, the disruption never seems to result in a payoff worth the experience. But hey, that may just be me…

Any thoughts you’d like to share would be most appreciated.

The final countdown

One of the things I’ve noticed in my journey through the highways and byways of healthcare is that we do an awful lot of education. The one compelling example that springs to mind is the challenges we’ve had over the last decade involves the appropriate storage/management of compressed gas cylinders. For years we struggled with getting folks to place the cylinders in an appropriate stand or rack; in some instances, we had to share folks some of those lovely videos of what can happen when an unrestrained cylinders becomes violently “active” (something like this one).

Now, I am happy to report that  it appears that we eventually got folks to come to grips with this (though I still periodically run into pockets of resistance), but now we have a new “foe” in the management of compressed gas cylinders—segregating full and not full cylinders. Now I know that we’ve discussed this in the past, but the thought that I have circling what’s left of my brain is this: recognizing how long it took to get folks to play nice, (so to speak) with appropriately securing those pesky e-cylinders, is there a way we can gain compliance in a more accelerated fashion?

To that end, I would ask you to think about how we did the cylinder restraint education and to come up with a way (or perhaps you already have, in which case, please share) to evaluate the education process. Again, we do a ton of education and yet we still have staff (and others; can’t forget some of those lovely contractors) who do stuff that we don’t want them to do. I harbor no illusion that we can completely eliminate undesirable behaviors, but I think we should be able to improve our “situation” to the point that perhaps only five of the most frequently cited standards reside in the physical environment. Do I hear four? Three? Two? One? What do you think?

Cue the drum roll: Ladies and gentlemen, I give you the Portal of Perception!

Not so very long ago, The Joint Commission and ASHE announced the creation of an information resource to assist with all those pesky EC/LS findings that have been reproducing like proverbial rabbits (here’s coverage of that announcement  and coverage of those rapidly reproducing findings).

Well, since that announcement, the elves have been very busy cobbling together bits and pieces of this and that, with the end result being a rather interesting blend of stuff (please note that I did not employ the more severe descriptor—stuff and nonsense), with titles like “Is Your Hospital’s Air Ventilation System Putting Your Patients At Risk?” (this one’s in the Leadership module, so I guess they’re asking the question of organizational leadership). I truly hope that your response to that particular query would be “absolutely not,” but I’ve also been working this part of the street long enough to know (absolutely, if you will allow me a brief moment of hyperbole) that there are few absolutes when it comes to the management of the physical environment.

Which leads me to the follow-up thought: Recognizing that there is always the potential for the performance of air ventilation systems to drift a little out of expected ranges, at what point does the performance of air ventilation systems actually put patients at risk? And perhaps most importantly, have you identified those “points” in the performance “curve” that result in conditions that could legitimately cause harm to our patients? And please know that I understand (in perhaps a very basic sense, but I think I can call it an understanding) how properly designed and maintained HVAC systems contribute to the reduction of HAIs, etc. But with any fluid situation, there is an ebb and a flow to conditions, etc., that, again, may veer into the “red” zone from a compliance standpoint. But let me ask you—particularly those of you who have experienced out-of-range conditions/values—have those conditions resulted in a discernible impact on your infection control rates, especially those relating to surgical site infections?

BTW, I’m asking because I really don’t know what you folks are experiencing. And, for those of you that have identified shortcomings on the mechanical side of things, are your Infection Control folks keeping a close (or closer) eye on where those shortcomings might manifest themselves as a function of impact to patients? From the information posted in the Portal (I think I’m going to capitalize), remedying compliance issues in this regard is a simple four-step process (You can find the example of improved compliance there). Who knew it would be so easy? (I could have had a V8!) I don’t think anyone in the field is looking at this as a simple, or easy, task.

At any rate, despite the best efforts of the Portal, until we have buildings (and staff) that are a little closer to perfect, I think we’re going to continue to see a lot of EC/LS findings during survey. Ohboyohboyohboyohboyohboy!

Also, as I think about it, please be sure to check out the Clarifications and Expectations column in the September issue of Joint Commission Perspectives; there are some interesting points to be gleaned, the particulars of which we will cover in a wee bit, so watch this space!

Same as it ever was… same as it ever was… same as it ever was…

As the back-to-school sales reach their penultimate conclusion, I look back on the year so far and am amazed at how quickly we’ve blown through fully two-thirds of 2015—yow! For a while it seemed like winter was never going to release us from its icy grasp and now we’re looking forward to its return, so I guess we have naught to do but look forward towards the onslaught of 2016. I hope, for all our sakes, it is a kinder and gentler new year.

But before the past little while takes on the rosy hue of nostalgia (as it almost always does), our friends in Chicago have provided an excellent opportunity to reflect on the “sins” of the past by revealing the most frequently cited standards during the first six months of 2015. And to almost no one’s surprise, four out of the top five most frequently cited standards (at the moment, the “reveal” is only for the top five—I guess we’ll find out about the rest of the top 10 at some point) are smack dab in the middle of the management of the physical environment, with the top three most frequently cited standards for hospitals being EC.02.06.01 (#1 with 59% of hospitals surveyed being cited), IC.02.02.01 (#2 and 54%) and EC.02.05.01 (#3 and 53%; looks like a real fight for that #2 spot), all of which reflect elements tying together the management of the physical environment with the control and prevention of infection (not everything cited is in the physical environment/infection control bucket, but from what I can gather, rather a fair amount is related to just that).

At this point (and I full recognize that this is a rather reiterative statement), I’m going to crawl out on a limb and say that the single greatest survey vulnerability for any (and every) healthcare organization is the management of the surgical/procedural/support environments. The hegemony of this aspect of the survey (and regulatory compliance) process comes very close to defying understanding. At this point, there’s no real surprise that this is an (if not the, and I would argue “the” is the word) area of intense survey scrutiny, so what’s the deal?!? Forty percent of the hospitals surveyed from January to June appear to have done okay on this, or is that number really a red herring? It would not surprise me that 100% of the hospitals surveyed ran afoul of one of the top three. Anybody out there surveyed so far this year that managed to escape, relatively, scott-free on this?

I’ve certainly done a lot of yammering in this regard over the past few months (years?) and it appears that I am raging against the dying of the light to minimal effect. I have a lot of ideas about this, but I guess I’m putting it out there: has anybody really got this under control? I think we all have a stake in this thing and the sooner we can get our hands on an effective process for managing this, the better. I will admit that it is entirely possible that, particularly given the age of a lot of hospital infrastructure components, this is not going to go away until they stop focusing as much on it. At this point, I haven’t run into too many folks that have been cited under the big three for whom infection rates are anything other than what would normally be expected—though perhaps infection control rates are higher than they “should/can” be—I guess we could be in the midst of a paradigm shift on this. I don’t want to have to wait to find out.

Letting the days go by…

Try not to breathe

I know that we’ve visited (and revisited) this topic once or twice over the last little while, but it continues to be (at least in my mind’s eye), the most significant vulnerability for every healthcare organization that uses The Joint Commission (TJC) for accreditation services: the management of temperature, humidity, and air pressure relationships (THAPR—How’s that for an acronym? It’s pronounced “thapper” or, if you’re from Boston, “thappah”) in the care environment. Folks continue to be cited for issues in this regard; other folks are jumping on board (a little late, but better than never) but are in the closing section of their survey window; and others still have not quite grasped the importance of having a stranglehold (if you will) on those areas for which there are THAPR requirements. Those of you who’ve accompanied me in the blogosphere for a while know that I do not do a lot of product marketing (even my own product), but I will encourage you once again: if you do not have a copy of ASHRAE 170—2008 Standard for Ventilation of Health Care Facilities, you are not in possession of what may be (at least at the moment) the single most important slab of information in the physical environment pantheon (yes, we will always have a place in our hearts for the 2000 edition of NFPA 101 Life Safety Code®; probably for too long, based on the ever-so-slow-to-adopt new things track for the 2012 edition).

While I’m not suggesting that you memorize ASHRAE 170 (it is fairly brief and those of you with eidetic memories probably won’t be able to keep yourselves from doing so), I am suggesting that you need to go to the table on pages 9-11 and start identifying the areas in your organization that have specific requirements and start figuring out where you stand in relation to those requirements, and perhaps more importantly, come to some sort of sense as to how reliably your systems can support those requirements. And you really need to go through the entire table; TJC certainly is. Just last week, I heard of pressurization issues in lab and pharmacy areas (labs are to be under negative pressure; pharmacies under positive) that added up to condition-level survey results.

Make sure you know where you have sterile storage in your organization; sterile storage areas are to be under positive pressure and should be monitored for temperature and humidity. But the reality of the situation is that you have sterile supplies in locations throughout your organization, so you have to define what does and what does not represent sterile storage (my best advice is to coordinate with your infection control and surgical folks on this one—it’s beginning to look a lot like a risk assessment—everywhere you go!). That way, you have a solid foundation for determining what needs to be managed from an environmental standpoint; it’s the only thing that will keep you out of the hottest water during survey.

Two final thoughts before signing off for this week; make sure that routine bronchoscopies are being performed under negative pressure (urgent or emergency bronchoscopies may not have quick enough access to the appropriate environment, so make sure that folks know what protective measures need to be considered to protect themselves and the patient when they’re aerosolizing potential bugs). There are still instances in which this is being cited during survey, so I think my best advice is to go and check with your respiratory therapy folks, as well as the folks in surgery, critical care, infection control, etc., and ask the question: Are bronchoscopy procedures being performed, and if so, where are they being performed? Then you can start walking it back to a point where you can be assured that they are being done in an appropriate environment.

The last thing is a brief reminder that the process for the survey of the physical environment (again, as it is currently being administered) involves all of the survey team – when it comes down to this are of concern, there is no more “clinical” versus “non-clinical”; everything that occurs within the four walls of your organization are patient care activities, direct or indirect (you may have noticed TJC has been splitting its performance elements using that very same language). Coordination of the various hospital services, etc., has never been more heavily scrutinized and never been found more wanting during survey. There is a paradigm shift afoot, my friends, and we need to get on the good foot.

Leave it better than you found it!

This past week (and this coming week as well), I’ve been on vacation in Maine (code name: A Beautiful Place by the Sea), which affords me the luxury of observing a lot of human behaviors, some interesting, some not so much. Some winning, and others that just grate.

There’s been a movement to reduce the amount of “invasive” plant species that have, in some instances, overtaken the natural landscape (and no, I’m pretty sure that this reduction is going to extend to tourists, though I bet there are moments…). So something of a reclamation project is underway, the result of which will (ideally) be a sustainable and less intrusive beautification. Where things go a little awry is in the areas somewhat off the more deliberately beauteous locales and offers what appears to be too many opportunities for the dark underside of human behavior to hold sway. Each morning, I make a circuit of the area and have noted beer and soda cans tossed into bushes, dirty diapers tossed under those same bushes and all matter of detritus left behind, presumably because the effort to properly dispose of these items was greater than what could be tolerated in the moment. My walk, at least partially, includes collecting some trash (I will admit that I’ve avoided the dirty diapers—I will have to prepare better in the future) along the way, but I have a pretty good sense of where the waste receptacles are along the way, so it’s not like I have to lug the stuff for miles.

At this point, you’re probably asking yourself: What does this have to do with healthcare safety and the myriad related conditions and practices that I might encounter during the workday? Well, the thought that keeps returning to the front of my head goes back to the age-old task of trying to “capture” these conditions at the point at which they occur, or at least when they are identified (yes, it’s another “see something, say something” tale). When we encounter unsafe conditions during rounds—damaged walls, unattended spills, etc.—we “know” that these things did not happen by themselves, so what prevented the originator of the condition from at least saying, “Oh poop, I need to tell somebody about that hole in the wall/spill on the floor so it can be remedied.” Not a particularly difficult thing conceptually, but human behavior-wise, it seems like it is an impossible task. I suppose you could look at it as job security (hahaha!), but having to manage all these little “dings” keeps us away from paying attention to the big and bigger dings that we know are out there. I suspect that I’m probably not supposed to be thinking about this stuff so much when on vacation, but I guess that’s part of my brain that never really shuts off. And don’t get me started about people who leave shopping carts out in the middle of the parking lot at the grocery store (yes, that’s me pushing a line of carts either to the cart corral or back to the store—it is a most consistent manifestation of my OCD). Hope your August is proving to be most splendid!

I’m-a gonna raise a fuss and I’m-a gonna raise a holler!

Sometimes, particularly during the summer, it can be a challenge to come up with compelling—hopefully your definition of compelling and my definition of compelling match up pretty well—material for the blog, so I will periodically go back through e-mails I’ve received, etc. to see if there’s anything worth sharing with folks. I was trolling through my inbox for missives from our friends in Chicago that I might have missed when they originally arrived (so, I guess this would be a review of missed missives) and I noticed an item from back in June that I had not previously brought to your attention that highlighted some of the resources available in the area of emergency management. Strangely enough, the resources are available as part of the The Joint Commission’s (TJC) portal program, thus the Emergency Management Portal.

There’s a fair amount of interesting information (and I think we all recognize the value of being familiar with any information TJC sees fit to present to the world at large), with click-through links for topics such as air disaster, violence/security/active shooter, hurricane, tornado, water crisis (industrial incident), and winter storm. The June notice deals with some topics relating to crisis management guidance and senior leadership (if you’ve noticed a trend towards elevating accountability/involvement of senior leadership in the physical environment/emergency management realm, I wouldn’t disabuse you of that notion) will take you to those details. Other than the leadership stuff, it doesn’t appear that there’s been a ton of updating since the beginning of 2014, but one item highlighted on the portal home page is a link to a blog on John Maurer’s (he’s one of the folks in TJC’s Engineering Department) Q & A during the November 2013 JCR Annual Ambulatory Care Conference. While the content is “aimed” at ambulatory care, there is a certain “timeless” quality to the questions and even if you are not currently responsible for any ambulatory sites, if you intend to stay in healthcare, it is more than likely that you’ll be getting in to the care and feeding of some ambulatory sites before too long. At any rate, I always enjoy Mr. Maurer’s work and if you’ve not encountered him, I think you will too. If you want to bypass the portal, you can link directly to the Q & A. It shouldn’t take too long to go through the blog, but I think you’ll find it to have been time well spent.

Underneath the accreditation manual last night!

And just when you thought you’d opened up all the presents under the tree, you see one way in the back and it’s another one from our friends at The Joint Commission (TJC)…but not just then, our friends at the American Society of Healthcare Engineering (ASHE) are also joining in this festive holiday season! Who needs the colds of December when such a bounty is available now!

TJC and ASHE have joined forces to create a portal to assist healthcare organizations in managing those pesky Environment of Care (EC)/Life Safety (LS) findings that have been (literally and figuratively) sweeping the nation. The stated purpose of the portal is to provide information to reduce findings of non-compliance with the eight EC/LS top findings (not sure if they’ll be coming up with a portal to address the IC findings under IC.02.02.01). They’ve broken things down to eight individual modules, one each for EC.02.05.01, LS.02.01.20, EC.02.06.01, EC.02.03.05, LS.02.01.10, LS.02.01.30, LS.02.01.35, and EC.02.02.01. These modules are being rolled out between now and October/November 2016, so this is going to be a gift that keeps on giving. We may have to rewrite the 12 Days of Christmas…

One thing that’s available right now is a Fireside Chat, featuring George Mills from TJC and Dale Woodin from ASHE (you’ll see the “screen” on the right hand side of the linked page noted above). The video takes about 20 minutes to watch, but it gives you a glimpse of the thought process behind the portal, the mission of the portal, a discussion of the portal itself, and ultimately, what the expectations are of organizations. It sounds like the portal is going to feature information that gets down to the EP level (I don’t know that there will be too many surprises for what EPs get the attention, particularly if you’ve been following this space) and, hopefully, will provide some practical (and I mean practical in a sustainable way) compliance solutions. I’m really interested to see what the sum and substance of the modules will be; I don’t know that there are that many “secrets” left, though I’m hoping that there’s a lot of good discussion about managing compliance data. I have yet to find a “perfect” building from a physical environment standpoint (buildings are never more perfect than the moment before you let the first person in), so it will be interesting to see how much focus is on recognizing those imperfections and “managing” them as a function of the all-important “high-reliability” benchmark. One last note, Messrs. Mills and Woodin indicate that all of the modules will be available throughout the rollout period (I’m glad they’re doing that, but it makes me wonder why they wouldn’t), though they don’t speak to the time beyond the end of the rollout. Maybe by then it won’t be necessary, but I’m thinking it would be nice if they could keep this going for at least the following (2017) year; that way, we’ll have gotten through an almost complete accreditation survey cycle.

At any rate, definitely check out the portal—and be sure to set aside some time for the Fireside Chat (sounds like the Chat will be a regular feature of the portal)—it’s definitely worth more than the 20 minutes it will take. And I don’t know that I wouldn’t make a point of sharing it with your boss (and maybe your boss’s boss); the greater the understanding of what is at stake, the greater the likelihood of appropriate levels of support when you have to go to the mat to make improvements in the physical environment.