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One of your sprinkler heads is loaded: Can you find it before they do?

And now, to the recap of the 10 most frequently cited standards during all of 2018 (in hospitals; other programs are a little more varied), as chosen by somebody other than you (or me): the survey troops at TJC.

The top 10 are as follows:

  • EC 02.01.35—The hospital provides and maintains systems for extinguishing fires (88.9% noncompliance percentage).
  • EC 02.05.01—The hospital manages risks associated with its utility systems (78.7%).
  • EC 02.06.01—The hospital establishes and maintains a safe, functional environment (73.9%).
  • LS 02.01.30—The hospital provides and maintains building features to protect individuals from the hazards of fire and smoke (72.9%).
  • IC 02.02.01—The hospital reduces the risk of infections associated with medical equipment, devices, and supplies (70.9%)
  • LS 02.01.10—Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat (70.7%).
  • LS 02.01.20—The hospital maintains the integrity of the means of egress (67.4%).
  • EC 02.05.05—The hospital inspects, tests, and maintains utility systems (64.7%).
  • EC 02.02.01—The hospital manages risks related to hazardous materials and waste (62.3%).
  • EC 02.05.09—The hospital inspects, tests, and maintains medical gas and vacuum systems (62.1%).

The ongoing hegemony of the top 10’s EOC-centric focus (and I still consider IC.02.02.01 the point upon which infection control and the physical environment intersect—sometimes with spectacular results) leaves little to the imagination (both ours and the surveyors). While you can still get into some significant trouble with certain processes, etc. (more on that next week—I figure if they can have a Top 10 list, then so can I…), the reason that these particular standards continue to jockey for position is because they represent the kinds of conditions (to some degree, I hesitate to call them deficiencies) that you can find literally any (and every) day in your organization. Just think about LS.02.01.35 for a moment: How far would you have to go before you found schmutz on a sprinkler head, something within 18 inches of a sprinkler head, a missing escutcheon (or an escutcheon with a gap), or even something (likely network cabling) lying atop, wire-tied to, somehow “touching” sprinkler piping or supports? I’m going to intuit that you probably won’t have to range too far afield to find something that fits in that category. The only thing I can say is whoever was surveying the “other” 11.1 % of the hospitals in 2018 must not have felt like poking around too much.

At any rate, I don’t know that there is a lot to glean from the 2018 results (same as it ever was…), but if someone out there has a question or concern that they’d like to share, I’m all ears!

Wagering on a sewer thing: How are you managing wastes during an emergency?

Burn, bury, or dump it—apparently there is madness in the method—and your plan needs to reflect the methodologies.

I recognize that, particularly with newly introduced requirements, guidelines, etc., the rarified elements that we collectively (if not quite lovingly) refer to as “surveyor interpretation” are at their most diverse, maddening, arbitrary, capricious, and on and on and on. That said, there is one element relating to the recent CMS update relative to emergency preparedness that I touched upon in the blog a couple of weeks ago , but did not devote a lot of discussion time to it. And that element relates to waste management during an emergency response.

During CMS surveys as recent as March 2019, there has been much discussion about the particulars of how folks are poised to manage the various and sundry waste products generated by/through normal hospital operations, particularly during a prolonged emergency response condition. And while I can’t say I saw this coming (at least not in the first wave of scrutiny), it does appear that the CMSers (or at least some of ’em) are looking for fairly detailed planning in this regard: collection, holding/storage, short-term disposal, long-term disposal, pharmaceutical wastes, chemical wastes, etc. , inclusive of second and third-level backup plans. I suppose, like with just about anything and everything you could name, there is always the potential for external disruption that constricts the ability to remove waste materials from our campuses. And, while I think we tend to focus our preparatory activities on sustaining normal operations, it would seem that there might be some vulnerability relating getting rid of the stuffs that are the result of those normal operations.

At this point, I’m not entirely certain if the focus is more to the consultative than the compliance-related approach—the topic was discussed during survey, but no report has been issued as of this writing (if I hear more, I will certainly let you know), so it’s anybody’s guess. But I do know that these things tend to spread pretty quickly in the field, so it certainly wouldn’t hurt to kick the tires of your waste processes during your next emergency response exercise.

Immediate Jeopardy: How much do you want to wager?

With best wishes to Alex Trebek!

Over the last couple of weeks, the folks at the Centers for Medicare & Medicaid Services (we know them by the cleverly acronymic CMS) have been busy generating lots of guidance for the folks in the field, healthcare organizations and surveyors alike. One of these missives covers the revision of Appendix Q of the State Operations Manual to provide guidance to surveyors and, (by extension) folks charged with compliance at the organizational level, for identifying Immediate Jeopardy (IJ) conditions during surveys. For those of you that have not had the dubious fortune of encountering an IJ in your organization (and I dearly hope that trend continues), it is difficult to describe the impact this can have on an organization. Short of shutting the place down, I cannot think of a more—oh I don’t know, words really seem to fall short in describing the sheer awfulness of an IJ finding.

But as they say, forewarned is forearmed (more on that delightful turn of phrase here). So let’s chat a bit about how one gets to an IJ.

The pieces that comprise an Immediate Jeopardy finding go a little something like this (the entire notification can be found here):

“To cite immediate jeopardy, surveyors determine that (1) noncompliance (2) caused or created a likelihood that serious injury, harm, impairment or death to one or more recipients would occur or recur; and (3) immediate action is necessary to prevent the occurrence or recurrence of serious injury, harm, impairment or death to one or more recipients.”

I think you could probably imagine any number of scenarios that might fit that particular bill; by the way, one of the revisions to this guidance was a change to (2). In the revision, the term “likelihood” replaced “potential.” While I do think “likelihood” is a somewhat higher bar to meet than “potential,” I still see a lot of room for surveyor interpretation. Hopefully, the administration of this judgment call will be more judicious than not. Time will tell…

Fortunately, we do have the opportunity to get a “leg up” on the process by visiting the CMS surveyor training page and working through the education materials provided there (the education is open to providers, so don’t be scared off by the link). I have not yet partaken of the education (it’s on my to-do list) and I will surely provide an update in this space once I have done so.

Keeping an eye on things: Managing behavioral health patients

What, again?!?

Recently, our friends in Chicago added a new FAQ to the canon, this time reflecting on the use of video monitoring/electronic sitters for patients at high risk for suicide (you can find the details here). For those of you paying attention over the years—and I think that’s everybody within the sound of my “voice”—the situational requirements are based on a clear invocation of the “it depends” metric. I think it is pretty clear (and pretty much the standard “problem” relative to the management of behavioral health patients at serious risk for suicide) that providing sufficient flexibility of staffing to be able to provide 1:1 observation of these patients is where folks are looking for that flexibility in technological monitoring and the FAQ pretty much puts a big stop on that front. I think the quote that comes into focus for this aspect is, “The use of video monitoring or ‘electronic-sitters’ would not be acceptable in this situation because staff would not be immediately available to intervene.” So, as a general practice, a 1:1 observation means that somebody (a human somebody) is “immediately available to intervene,” which means all the time, at any time.

At this point in the discussion, I think the important piece of this is (and is likely to remain so) the clinical assessment of the patient, inclusive of the identification of the risk level for suicide. I don’t think that the “reality” of having to deal with way more of these patients than we would prefer is going to change any time soon, and with it, the complete unpredictability of that patient volume as a function of staffing (full moons notwithstanding).

The FAQ goes on to discuss the use of video monitoring in those instances in which it is not safe for staff to be physically located in the patient’s room, but the use of video monitoring has to result in the same level of observation, immediacy of response, etc. It also indicates that video monitoring for patients that are not at high risk for suicide is at the discretion of the organization, indicating that there are no “leading practices” in this regard. I guess that means that you’re really going to have to make your own way if you chose the video monitoring route, which should include (as also noted in the FAQ) provisions for reassessment of the patient(s). Interesting times, my friends, interesting times…

As a final (and almost completely unrelated) note, I wanted to bring to your attention some discussion over at the Motor & Generator Institute (MGI) relating to recent CMS guidance regarding expected temperatures in the care environment during normal power outages and how, if you have a long-term care facility in your mix, a risk assessment might not be enough. You can find the details here and the folks at MGI are encouraging feedback, so I think it might be worth checking out and weighing in.

 

It’s been a long time: Revisiting an EOC perennial

Setting the wayback machine for the dark ages of safety (well, 2011 or so), we come to the last time we covered the monitoring of temperature and/or humidity in surgical spaces, etc. (if you want to revisit those halcyon days, you can head here). The funny thing about this most ancient of history is that, since then, while there have been changes in applicable codes and references, the “new” stuff comes up a little short when it comes to providing guidance relating to monitoring temperature and humidity, particularly as a function of frequency (I suppose we could call it the frequency function if we were being excessively alliterative). The baseline response (catty though it may be) is that you should be monitoring conditions on as frequent a basis as is required to ensure appropriate conditions, given due consideration of the systems you have in place, any manufacturers’ recommendations (which are also not particularly helpful in determining monitoring frequencies), and regulatory guidance (ASHRAE 170; state mechanical code) as applicable.

Ultimately, this all comes down (back?) to the requirements as outlined in the Conditions of Participation, which gives us:

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

So, you might well ask, what are those “other appropriate areas”? For that information, we need to head over to the State Operations Manual/Interpretive Guidelines, which is where the skeleton of the Conditions of Participation is fleshed out into the survey process.  And what do we find there? Take a look:

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.);
  • Laboratory locations; and
  • Anesthetizing locations. According to NFPA 99, anesthetizing locations are “any area of a facility that has been designated to be used for the administration of nonflammable inhalation anesthetic agents in the course of examination or treatment, including the use of such agents for relative analgesia.” NFPA 99 defines relative analgesia as “A state of sedation and partial block of pain perception produced in a patient by the inhalation of concentrations of nitrous oxide insufficient to produce loss of consciousness (conscious sedation).” (Note that this definition is applicable only for Life Safety Code® purposes and does not supersede other guidance we have issued for other purposes concerning anesthesia and analgesia.)

Interesting to note that the list here does not quite match up with the totality of issues for which The Joint Commission is citing folks (clean and soiled utility rooms being first and foremost, though I know that it is merely an extrapolation of the ASHRAE 170 requirements). Also interesting to note that, sterile supply and processing is not specifically mentioned, but (again), I think we can see where the importance of maintaining those spaces drives out of ASHRAE 170.

But what’s the endgame when it comes down to the survey process? The general unhelpfulness of the answer will not surprise you:

  • Review monitoring records for temperature to ensure that appropriate levels are maintained
  • Review humidity maintenance records for anesthetizing locations to ensure, if monitoring determined humidity levels were not within acceptable parameters, that corrective actions were performed in a timely manner to achieve acceptable levels

So (still!) if you follow the temperature and humidity rabbit all the way back to the Interpretive Guidelines, we see that the surveyors are instructed to ask to see “records,” so it all comes down to what you can produce in terms of a deliverable that reflects that temperature and humidity levels are appropriate/acceptable and levels that were not within acceptable parameters (which they do not define, so you better have a sufficiently flexible definition) were dealt with in a “timely manner” (again, not defined, so it’s up to you, based on your risk assessment).

As a closing thought on this (for now), apparently there are some folks that have determined that they don’t have to monitor both elements (temperature and/or humidity) and if there is nothing else that you derive from this week’s missive, it is this: You gotta do both! You can determine the frequency (though I would recommend at least daily—if you recall, the question that started this conversation in 2011 was whether quarterly monitoring was sufficient), but you clearly want to be able to use performance data to make that determination (and from whence comes that data—regular monitoring). You can determine what is acceptable/appropriate (based on utilization, types of procedures, preference of surgical staff, etc.); you can determine what is a timely timeframe for corrective action (Timely Timeframe—that sounds like a name Stan Lee would’ve loved). But you gotta do the monitoring; to do otherwise risks too much if the CMSers darken your door (which is becoming a much more common occurrence).

One last quick note for this week: There seems to be a bit of a groundswell of survey findings relating to hand sanitizer dispensers not having drip trays. It would seem that there must have been some recent mention of this in surveyor education as there are some surveyors indicating that this is a new requirement, but the overarching requirement has been in place for rather a while. To whit (and, again, the State Operations Manual becomes then go-to resource):

  • 482.41(b)(9) (ii) The dispensers are installed in a manner that minimizes leaks and spills that could lead to falls; with the associated Survey Procedure being: “Determine whether the hospital maintains the ABHR 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.”

Now, nowhere in the regulatory canon does it discuss drip trays (though, when you come right down to it, how else are you going to manage the threat of leaks/drips, especially over hard-surface flooring?). But apparently drip trays have become the “gold standard” for leak/drip control, so you might want to keep an eye on this for the future. These things do tend to spread and who wants to be chasing this during a (or post) survey? Not me.

Eat, drink, and be safe: Some guidance on the care and feeding of staff

One of the more universal conditions I find is the whole issue of where staff can grab something to eat or drink in the midst of busy periods, particularly when staffing levels don’t necessarily dovetail with leaving the work space to go to the cafeteria, etc. And there’s always the specter of someone, somewhere having invoked the “You can’t eat there, it’s against TJC regulations” or “You can’t drink there, it’s against regulations” and so forth and so on. And what better strategy than to use a regulatory presence from outside the organization to be the heavy.

Many’s the time I’ve tried to convince folks that, from a regulatory perspective (with some fairly well-defined exceptions, like laboratories), there is nothing that approaches a general prohibition when it comes to the how, when, and where of eating and drinking in the workplace (and yes, I absolutely understand that prohibition is the easiest thing to “police,” but I think prohibitions also tend to “drive” more creative workarounds). And in the March 2019 edition of Perspectives, our friends in Chicago provide a couple of clarifications for folks, and if you think that there’s a risk assessment involved, then you would be correct.

So, the clarifications are two in number:

  • There are no TJC standards that specifically address where staff can have food or drink in the work areas.
  • You can identify safe spaces for food and drink as long as those locations  comply with the evaluation (read: risk assessment) of the space and your exposure control plan as far as risks of contamination from chemicals, blood, or body fluids, etc.

The guiding light in all of this, if you will, are the regulations provided by the Occupational Safety & Health Administration, and while they have a lot to say about such things (Bloodborne Pathogens and Sanitation), a careful analysis should yield a means of designating some spaces. I have seen a lot of designated “hydration stations,” particularly in clinical areas, to help keep folks hydrated over the course of the working day, so clearly some folks are working towards providing some flexibility based on a risk assessment. This is a good thing both in terms of staff support, but also in not drawing a line in the sand that they don’t have to. Prohibitions can bring about some of your toughest compliance challenges, so if you can work with folks to build in some flexibility, it could mean fewer headaches during rounding activities.

Making a checklist, making it right: Reducing compliance errors

As you may have noticed, I am something of a fan of public radio (most of my listening in vehicles involves NPR and its analogues) and every once in a while, I hear something that I think would be useful to you folks out in the field. One show that I don’t hear too often (one of the things about terrestrial radio is that it’s all in the timing) is called “Hidden Brain”, the common subject thread being “A conversation about life’s unseen patterns.” I find the programs to be very thought-provoking, well-produced, and generally worth checking out.

This past weekend, they repeated a show from 2017 that described Dr. Atul Gawande’s (among others) use of checklists during surgical (and other) procedures to try to anticipate what unexpected things could occur based on the procedure, where they were operating, etc. One of the remarks that came up during the course of the program dealt with how extensive a checklist one might need, with the overarching thought being that a more limited checklist tends to work better because it’s more brain-friendly (I’m paraphrasing quite a bit here) than a checklist that goes on for pages and pages. I get a lot of questions/requests for tools/checklists for doing surveillance rounds, etc. (to be honest, it has been a very long time since I’ve actually “used” a physical checklist; my methodology, such as it is, tends to involve looking at the environment to see what “falls out”). Folks always seem a little disappointed when the checklist I cough up (so to speak) has about 15-20 items, particularly when I encourage them not to use all the items. When it comes to actual checklists that you’re going to use (particularly if you’re going to try and enlist the assistance of department-level folks) for survey prep, I think starting with five to seven items and working to hardwire those items into how folks “see” the environment is the best way to start. I recall a couple of years ago when first visiting a hospital—every day each manager was charged with completing a five-page environmental surveillance checklist—and I still was able to find imperfections in the environment (both items that they were actually checking on and a couple of other items that weren’t featured in the five-pager and later turned out to be somewhat important). At the point of my arrival, this particular organization was (more or less) under siege from various regulatory forces and were really in a state of shock (sometimes a little regulatory trouble is like exsanguination in shark-infested waters) and had latched on to a process that, at the end of the day, was not particularly effective and became almost like a sleepwalk to ensure compliance (hey, that could be a new show about zombie safety officers, “The Walking Safe”).

At any rate, I think one of the defining tasks/charges of the safety professional is to facilitate the participation of point-of-care/point-of-service folks by helping them learn how to “see” the stuff that jumps out at us when we do our rounds. When you look at the stuff that tends to get cited during surveys (at least when it comes to the physical environment), there’s not a lot of crazy, dangerous stuff; it is the myriad imperfections that come from introducing people into the environment. Buildings are never more perfect than the moment before occupancy—after that, the struggle is real! And checklists might be a good way to get folks on the same page: just remember to start small and focus on the things that are most likely to cause trouble and are most “invisible” to folks.

Waste not, want not: The rest of the CMS Emergency Preparedness picture

Moving on to the rest of the guidance document (it still lives here), I did want to note one last item relative to emergency power: There is an expectation that “as part of the cooperation and collaboration with emergency preparedness officials,” organizations should confer with health department and emergency management officials, as well as healthcare coalitions to “determine the types and duration of energy sources that could be available to assist them in providing care to their patient population. As part of the risk assessment planning, facilities should determine the feasibility of relying on these sources and plan accordingly.

“NOTE: Hospitals, CAHs and LTC facilities are required to base their emergency power and stand-by systems on their emergency plans and risk assessments and including the policies and procedures for hospitals. The determination of the appropriate alternate energy source should be made through the development of the facility’s risk assessment and emergency plan. If these facilities determine that a permanent generator is not required to meet the emergency power and stand-by systems requirements for this emergency preparedness regulation, then §§482.15(e)(1) and (2), §483.73(e)(1) and (2),

  • 485.625(e)(1) and (2), would not apply. However, these facility types must continue to meet the existing emergency power provisions and requirements for their provider/supplier types under physical environment CoPs or any existing LSC guidance.”

“If a Hospital, CAH or LTC facility determines that the use of a portable and mobile generator would be the best way to accommodate for additional electrical loads necessary to meet subsistence needs required by emergency preparedness plans, policies and procedures, then NFPA requirements on emergency and standby power systems such as generator installation, location, inspection and testing, and fuel would not be applicable to the portable generator and associated distribution system, except for NFPA 70 – National Electrical Code.”

I think it is very clear that hospitals, et al., are going to be able to plot their own course relative to providing power during emergency conditions, but what’s not so clear is to what depth surveyors will be looking for you to “take” the risk assessment. I suspect that most folks would run with their permanently installed emergency generators and call it a day, but as healthcare organizations become healthcare networks become healthcare systems, the degree of complexity is going to drive some level of flexibility that can’t always be attained using fixed generator equipment. If anyone has any stories to share on this front (either recent or future), I hope you’re inclined to share (and you can reach out directly to me and I will anonymize your story, if you like).

Wrapping up the rest of the changes/additions, you’ll be pleased to hear that you are not required to provide on-site treatment of sewage or waste, but you need to have provisions for maintaining “necessary services.” Of course, the memo indicates that they are not specifying what “necessary services for sewage or waste management” might be, so a little self-definition would appear to be in order.

If your organization has a home health agency, then you need to make sure that the communication plan includes all the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. I think that one’s pretty self-evident but may be worth a little verification.

Next up are some thoughts about providing education to folks working as contracted staff who provide services in multiple surrounding areas; the guidance indicates that it may not be feasible for these folks to receive formal training for each of the facilities emergency response plan/program. The expectation is that each individual (and this applies equally to everyone else in the mix) knows the emergency response program and their role during emergencies, but each organization can determine how that happens, including what constitutes appropriate evidence that the training was completed. Additionally, if a surveyor asks one of these folks what their role is during a disaster, then the expectation would be for them to be able to describe the plan and their role(s). No big surprise there (I suspect that validating the competency of point-of-care/service staff is going to be playing a greater role in the survey process—how many folks would they have to ask before somebody “fumbles”?)

The last item relates to the use of real emergency response events in place of the required exercises; I would have thought that this was (relatively) self-evident, but I guess there were enough questions from the field for them to specify that you can indeed use a real event in place of an exercise. Just make sure you have the documentation in order (I know I didn’t “have” to say that, but I figure if it’s important enough for CMS to say it, then who am I…). The timing would be one year from the actual response activation, so make sure you keep a close eye on those calendars (unless, of course, you have numerous real-life opportunities…).

I do think the overarching sense of this is positive, at least in terms of limiting the prescriptive elements. As is sometimes the case, the “responsibility” falls to each organization to be prepared to educate the surveyors as to what preparedness looks like—it has many similar components, but how things integrate can have great variability. Don’t be afraid to do a little hand-holding if the surveyors are looking for something to be done a certain or to look a certain way. You know what works best in your “house,” better than any surveyor!

Walking in the shadow of the big man: CMS isn’t done with emergency preparedness

Imagine that!

The turn of February brought with it the latest epistle from our friends at CMS as they continue to noodle on the preparedness of the nation’s hospitals. I don’t know that this represents a ton of hardship for folks and I do know, for at least some folks, the latest directive is fairly straightforward as a function of their emergency preparedness programs, activities, etc. As we’ve discussed once or twice over the years (decades?!?), emergency preparedness is a journey, it is not a destination. And while we do have the opportunity to plot our own course on this, it seems that the regulatory oversight piece will never be very far away.

So, the first piece of this (you can find the whole missive here) is the pronouncement that planning for using an all-hazards approach to emergency management (and who isn’t?!?) should also include consideration of emerging infectious disease (EID: Influenza, Ebola, Zika, etc.) threats. The guidance goes on to indicate that planning for EIDs “may require modifications to facility protocols to protect the health and safety of patients, such as isolation and personal protective measures.” I think my immediate inclination would be to include EID threats as a separate line item for your HVA (my fear being if you integrate things too well into your existing, then you’ll be that much harder-pressed to “pull out” the EID portion of your organizational analysis). And/or if you combine all the IC stuff into one, then you might make changes to your plan to address the higher-risk stuff and create some operational challenges for your “normal” stuff. It’s early in the game on this one, so we’ll see how the process matures.

Next up we have some discussion relative to the use of portable/mobile generators as part of our emergency preparedness activities. It would seem that a lot of folks reached out to CMS to see if they were going to have to replace portable/mobile generators with the typical generator equipment found in hospitals, and (hooray!) the answer to that question is no, you don’t have to: unless your risk assessment indicates that you should. Apparently, there were other questions relating to the care and feeding of portable/mobile generators and the ruling on the field is that you would have to maintain them in accordance with NFPA 70 (and, presumably, the manufacturers’ IFUs), which includes:

  • Have all wiring to each unit installed in accordance with the requirements of any of the wiring methods in Chapter 3.
  • Be designed and located to minimize the hazards that might cause complete failure due to flooding, fires, icing, and vandalism.
  • Be located so that adequate ventilation is provided.
  • Be located or protected so that sparks cannot reach adjacent combustible material.
  • Be operated, tested and maintained in accordance with manufacturer, local and/or state requirements.

It also mentions that extension cords and other temporary wiring devices may not be used with the portable generators, so make sure that you have those ducks in a row.

There are a few more things to cover, but I think those can wait until next week. See you then!

Don’t bleed before you are wounded, and if you can avoid being wounded…

…so much the better!

Part of me is wondering what took them so long to get to this point in the conversation.

In their latest Quick Safety utterance, our friends in Chicago are advocating de-escalation as a “first-line response to potential violence and aggression in health care settings.”  I believe the last time we touched upon this general topic was back in the spring of 2017 and I was very much in agreement with the importance of “arming” frontline staff (point of care/point of service—it matters not) with a quiver of de-escalation techniques. As noted at the time, there are a lot of instances in which our customers are rather grumpier than not and being able to manage the grumpies early on in the “grumprocess” (see what I did there?!?) makes so much operational sense that it seems somewhat odd that we are still having this conversation. To that end, I think I’m going to have to start gathering data as I wander the highways and byways of these United States and see how much emphasis is being placed on de-escalation skills as a function of everyday customer service. From orientation to periodic refreshers, this one is too important to keep ignoring, but maybe we’re not—you tell me!

At any rate, the latest Quick Safety offers up a whole slate of techniques and methods for preparing staff to deal with aggressive behaviors; there is mention of Sentinel Event Alert 57 regarding violence and health workers, so I think there is every reason to think that (much as ligature risks have taken center stage in the survey process) how well we prepare folks to proactively deal with aggressive behaviors could bubble up over the next little while. It is a certainty that the incidence rate in healthcare has caught the eyes and ears of OSHA (and they merit a mention in the Quick Safety as well as CDC and CMS), and I think that, in the industry overall, there are improvements to be made (recognizing that some of this is the result of others abdicating responsibility for behavioral health and other marginalized populations, but, as parents seem to indicate frequently, nobody ever said it would be fair…or equitable…or reasonable…). I personally think (and have for a very long time, pretty much since I had operational responsibilities for security) that de-escalation skills are vital in any service environment, but who has the time to make it happen?

Please weigh in if you have experiences (positive or negative are fine by me) that you’d feel like sharing—and you can absolutely request anonymity, just reach out to the Gmail account (stevemacsafetyspace@gmail.com) and I will remove any identifying marks…