RSSRecent Articles

I’m fixing a hole

For our next topic of conversation regarding George Mills’ address to the folks in ASHE last year, we take up the ever-vexing task of managing penetrations. Now, there’s certainly been a lot of ire pointed towards the folks who run cabling in healthcare—IT, cabling contractors, etc. But this represents something of a sea change in the public face of this problem—while there certainly any number of “perps” when it comes to making holes in rated barriers, there is a very clear sense that appropriate management of the process results in the buck stopping at a single destination: the desk of the facilities management professional.

So, a quick show of hands: How many folks are using an above the ceiling work permitting process? That many? That’s a pretty good number. But how are you administering that process? Have you told the entire organization about the process? Maybe established a bounty for finding folks working in the ceiling without a permit? You have tens of thousands, if not hundreds of thousands, of square feet in which mischief can occur above the ceiling. If you establish the condition that anyone (and that means  folks employed by the hospital—everyone is equal in the eyes of a penetrated rated barrier) working above ceiling must display a permit on the ladder or lift—and get folks to call in when someone is working without a permit, then you can start to manage the process. By the way, I’m a great believer in rewarding folks who drop a dime for this and don’t be cheap; at least buy ’em lunch somewhere nice. And if you find you’re spending too much money feeding your dime-droppers, then that means that your permit process is not working very effectively!

When you find someone working above the ceiling without a permit, throw the bum out! Nothing draws attention to a process like a good swift kick in the pocketbook. If someone does not want to work by our rules, then they can work elsewhere, pure and simple. Then they can explain to their boss why they couldn’t finish a job, as opposed to you having to explain to your boss why you’re getting an RFI for rated barrier penetrations. I know which scenario I’d prefer…

One last thought: As for “existing” penetrations, Mr. Mills clearly indicated the expectation that facilities will undertake an above-the-ceiling inspection at least once per year to catch any deficiencies that were not captured by the normal process. Then you either fix them properly or manage them as a PFI (with applicable ILSM assessment—please don’t forget that piece of the puzzle). It’s really just that simple.

Suites for the sweet

Continuing our coverage of George Mills’ address to the ASHE folks last fall, we turn to what was described as an area with a “lot of problems”:  The management of suites.

So, before we get started on this one, I’d like you to make a mental list of all the areas in your organization that have been designated as suites (if you’re not sure what a “suite” is, please e-mail me on the side at the address listed below and I will try to help you to get acquainted with this most useful of life safety concepts). Now that you have that mental list appropriately populated, take out your life safety drawings and check to see how many of those suites are specifically identified (this means the perimeter boundaries of the suite, as well as the square footage of the suite). If you have suites that you have mentally designated, but haven’t gone through the process of having them identified on your life safety drawings, in all likelihood you are looking at RFIs for anything from corridor storage to non-latching corridor doors (suites can have stuff and patient rooms doors that don’t latch – benefit!).

In some ways, this very much comes under the category of things that you have to “know”; it is not nearly enough to “think” that something is compliant. If you expect to successfully navigate the survey process, you have to translate the “think” to the “know.” As a facilities management professional, it is incumbent upon you to have absolute knowledge of where your facility “lies” on the compliance chart. By all means, use your vendors and service folks to gain that knowledge, but be assured of one thing: They won’t be the ones in the “hot seat” come survey time—and you’d better know how to cool off that seat.

It’s up to you to heed the call out

If you’re reading this, then in all likelihood you’re a regular subscriber to this august publication (august in February—what kind of crazy talk is that, but I digress). In which case, I’m sure you read with some interest the article a couple of weeks ago in which one Mr. George Mills (of the Joint Commission Mills) called out facilities professionals for something akin to dereliction of duty (okay, that might be a wee bit hyperbolic, but this topic, and Mr. Mills stance on said topic, are as serious as all get out), based on the continued frequency of findings in the EC/LS part of the survey process.

At any rate, back in October 2012, Mr. Mills addressed a group of facility managers during a webinar sponsored by ASHE. During the webinar, there was much discussion of the persistence of  EC/LS findings during surveys, including attribution of many of those findings to what was characterized as a “lack of management.”  I think we can agree that, as characterizations go, that is a very strongly worded characterization indeed.  So what types of things are resulting in this level of unhappiness in Chicago? Stay tuned and we’ll find out (by the way, be prepared not to be surprised about much, or even any, of the sticking points during surveys. If you’ve been following this space for any period of time, you are already intimately familiar with the foibles and follies of the modern-day survey process.

PFI – Pretty Freaking Important – you’d better believe it!

I’m reasonably certain that we’ve dealt with this before, but there’s been a wee bit of a bump in survey findings relative to the practical assessment of PFI’s as a function of Interim Life Safety Measures.

It’s really quite simple, when you come right down to it. The Joint Commission standards require us to assess for Interim Life Safety Measures, based on the criteria in our policy, any Life Safety Code® (LSC) deficiencies that cannot be immediately corrected (BTW – it’s a good idea to define immediately in your policy – the standard holds no specific definition, so it’s a bit of self-determination – but don’t go crazy trying to define immediately as something much more than the end of the shift/end of the day). Okay, that’s a pretty solid LSC deficiency that we can’t fix right away.

So, the next question in this little chain is this – what is the defining characteristic of a PFI? Why, it’s a Life Safety Code deficiency that is going to take some time to resolve (something very much less than immediately)! So, as a simple quid pro quo arrangement (or equation, if you like), we have:

PFI = ILSM Assessment

Where you have the first, you must also have the second, otherwise you could find yourself staring down the barrel of a Situational Decision and potential Joint Commission re-survey. Is there anyone in the studio and broadcast audience that has any desire to endure that fate?

I didn’t think so – so, make sure you have ILSM assessments for each of your PFI’s and you will avoid this particular world of hurt. You should go check right now…

A little more conversation

Another contractor-related “impression” that’s surfaced lately (and this is not just in hospitals – this can be in your own backyard) is that fascinating phenomenon of the contractors that show up not exactly when you were expecting them and before you got a chance to let your neighbors know that there will be a project going on.

Admittedly, this (hopefully) doesn’t happen too often in healthcare (it better not, at any rate), but I still run across instances when clinical and other staff in areas adjacent to construction/renovation projects feel that they haven’t received much in the way of effective communication prior to the onset of the crash, bang, boom.

Now I know sometimes this is a little bit of the “it’s easier to get forgiveness than it is to get permission” concept (and yes, I also understand that that is a frequent mantra when it comes to taped-over door latches, door wedges, and other sins upon the life safety components of the building), but it’s not like the work isn’t going to happen, so the bestest thing you can do is to reach out to the neighbors to enlist their advocacy on your behalf. Face it, there’s going to be commotion that’s going to reach the eyes/ears/noses of everyone in adjacent spaces – including patients (the reason we are here, n’est-ce pas?)

If we can get the folks managing care to act as advocates for our sawing and drilling and dropping stuff and (quietly) swearing and playing the radio, etc., then (as with so many things) patients might not feel as inclined to provide negative feedback (no guarantees, but it certainly increases the chances of heading a complaint off at the pass).

One of the truisms of modern healthcare is that we cannot communicate enough, but if we keep everyone in the loop, the likelihood of a successful, complaint-free project increases quite a bit (I was tempted to use the exponential qualifier here, but you don’t need me to go all hyperbolic on you at this late date). So, start talkin’!

One of our subs is missing (with apologies to T. Dolby)

In recent months, I’ve encountered a couple of instances in which some contractors doing various and sundry projects for hospitals did something (what follows is merely my opinion) incredibly boneheaded – namely leaving roof access doors unsecured and unmonitored.

I’ve also encountered some instances in which contractors had gone to lunch (yes – they really were out to lunch!) and left their “work” unattended on a patient care unit (thankfully not a behavioral health unit, but still) – electrical closets open/unsecured, open ceilings, the whole gamut.

Now, one of my favorite observations is that the human race has an enormous capacity for doing stupid stuff (insert whatever relevant current event you think might be apropos evidence of such a sweeping generalization). And while we generally have pretty good controls over the folks who are working for us (that still doesn’t mean nothing will happen, but that measure of control can really pay dividends over time), but—and this seems to be on the increase—when we bring in folks from the outside (nominally because we are a wee bit under-resourced on the home front), we have to relinquish at least some of that control.

So I ask: When it comes to orienting contractor staff, on what topics do you focus? Do you make a general “don’t do anything stupid” statement as well as more specific concerns? I sometimes think that contractors forget about the complexities of providing a safe environment for patients. I honestly don’t think it’s a lack of capacity on anyone’s part, but in the heat of the battle, so to speak, and we’re charging towards a project completion date, etc., sometimes…

Anyone out there want to share any interesting examples of close calls / near misses, or even a sense of what you’ve done/learned to keep things on an even keel during construction/renovation projects involving external contractors? I know I’m not alone on this one – how about a little sharing?

Living on a thin line…

One of the realities of modern healthcare has been the shift (not everywhere, but in a lot of places) from inpatient volume to outpatient volume, with the result being a number of facilities that close and re-open patient care units based on demand. Now, certainly an organization has to be able to allocate resources appropriately, so consolidation, etc. is a very viable strategy.

But there are some states that can get a bit testy when it comes to the discussion of licensed beds, etc. and pushing the focus back on hospitals to be able to quickly (there’s no hard and fast number; what’s your state say?) restore those rooms/bed positions to service in the event of an increase in census.

Recently, I chatted with an organization that was facing a real challenge because some of the vacated patient units had been converted to other uses (offices, etc.); they are maintaining all the systems that are needed to return these spaces to patient care (just covering over the utilities in the headwall, etc. with a removable panel), so they’re good on that count. But where things have kind of squirted out the sides of the bag is the management of all the patient room furniture that has been displaced – can’t leave all that stuff in the corridors, etc.

So, this organization is looking at establishing a relationship with a medical furnishings vendor who can provide them with patient room furnishings within 48 hours (that’s the state mandate in this particular instance). This is after investigating the potential for off-site warehousing of the furniture now in service, etc., but it was decided that to do so with be extremely labor/resource intensive and since it’s been a while since they’ve actually had to flex back up, they’ve decided to try and work this through an external source.

So I thought that was pretty cool, but then the question became – how would CMS / TJC look at the farming out of the furniture component of their flex plan?

My first thought was they generally wouldn’t have much to say about stuff concerning licensed beds, etc. (beyond the application process), but then I was thinking that this could be an important component of your Emergency Operations Plan, particularly as a function of having to manage an influx of patients in an emergency. In which case, you’d need to be able to evaluate this process as a function (potentially) of your 96-hour plan, etc. I guess ultimately everything relates to everything else and any substantive changes you might make from an operational standpoint can come under scrutiny during survey. Is anybody out there in the listening audience faced with anything similar—maybe seasonal ebb and flow?

Ride the lightning…tales from the survey wars!

Just a quick little list of recent survey findings – not necessarily having anything to do with the Top 20 most frequently cited standards. That said, I do think that this provides ample indication that the survey process is intent on identifying any EC/LS/EM deficiency that could be lurking in the furthest (farthest?) regions of your facility. So, how about:

Have you included (those of you who have them) lightning protection systems in your Utility Management inventory – or completed a risk assessment that indicates inclusion in the inventory is not appropriate?

Do you still maintain (at least) one hard copy of your organization’s Material Safety Data Sheets? If not, what’s your backup and how do you know it’s effective?

What about those rooftop exhausts for isolation rooms—have they been labeled? The biohazard symbol on your rooftop exhausts (or any isolation exhausts) makes quite a statement – and never goes out of style.

What about those flexible and rigid endoscopes? Have you included them in your medical equipment inventory or completed a risk assessment that indicates inclusion in the inventory is not appropriate?

How about those electrical receptacles in locations within 6 feet of sinks and other water sources—are they on GFCI protection? Could be the outlet, could be at the panel, but you need to know, ‘cause if you don’t…

Those of you who are performing manual disinfection of patient care devices / instruments, most frequently using an OPA product: Have you evaluated the process as a function of what is actually required by the manufacturer? This is a very complicated process (with lots of steps to go awry) and perfection is not merely the goal, it must be attained at every step, every time. Perfect, perfect, perfect…

What about those open floor plan areas (frequently ED’s, ICU’s, PACU’s, OR’s) where staff have all manner of equipment and stuff parked outside the rooms (hopefully not obstructing access to the zone shutoff valves) – have you officially designated those areas as suites, and updated the life safety drawings to reflect that designation? If you haven’t, that’s a survey slam dunk for an RFI – better get on it!

I know we’ve spoken of this in the past (or at least I think we have), you have to pay very close attention to the ins and outs of LS.02.01.30 EP #2, which has to deal with combustible storage areas greater than 50 square feet in area. (Storage room = door that self or auto-closes and latches.) And if there’s a “former” patient room (including procedure rooms in the OR, etc.) that’s been converted to storage (particularly if the conversion occurred after March, 2003), then you are looking at the requirements for “new” healthcare, which means sprinklers, one-hour walls, with a 45 minute fire-rated door. I know folks are trying to minimize corridor clutter, but you get right into a whole ‘nother pickle if you don’t watch for these kinds of transformations.

Anything ring any bells for anyone? Might be worth a little mental checklist to make sure you’ve got these areas covered.

Things that go bump (or don’t) in your egress stairwells

There has been a little increase in findings relative to various items (utility system components, security cameras, evacuation devices) being located in egress stairwells. NFPA 101-2000 Life Safety Code 7.1.3.2.1 (e) gets pretty specific about what you can have in terms of penetrations into and openings through an exit enclosure assembly:

(1) Electrical conduit serving the stairway

(2) Required exit doors

(3) Ductwork and equipment necessary for independent stair pressurization

(4) Water or steam piping necessary for the heating or cooling of the exit enclosure

(5) Sprinkler piping

(6) Standpipes

This means, strictly speaking, that things like security cameras, water lines, phone/radio system repeaters, electrical conduit that does not serve the stairwell, etc. are pretty much off the table, particularly if they have been installed after March, 2003 (the official dividing line between new and existing construction).

There is an exception for existing penetrations as long as they are appropriately protected (firestopping, etc.), but if you’ve got newer than ’03 stuff in your egress stairwells, you may have some work ahead to square things away (I’d start with a conversation with either your state AHJ or maybe the engineers at TJC).

Keeping things cool in the hot lab

In reviewing “stuff” from the past few months (September and October were pretty busy on the regulatory front), I wanted to mention (in case this hadn’t crossed your path) the Government Accountability Office’s (GAO) report on the security of radioactive materials in hospitals as a function of the Nuclear Regulatory Commission’s (NRC) existing requirements. The GAO found the NRC requirements to be somewhat lacking, based on a sample of 26 hospitals and medical facilities.

According to the highlights of the report (you can find the whole megillah at: www.gao.gov/products/GAO-12-925), the NRC did not agree or disagree with the findings of the report, feeling that existing security requirements are adequate. Some of the security lapses found during the GAO survey were such items as unsecured medical equipment containing radioactive material, unescorted access to radiological sources, even (darn it!) numerical keypad lock combinations inscribed on door frames.

Now I will tell you that this is all stuff I’ve encountered periodically during my consulting life (a boss of mine once told me “you can’t mandate intelligence”; then Ron White distilled that into “you can’t fix stupid”) and I will also tell you that sometimes all you can do is shake your head about this stuff. That said, I have no reason to think that the good folks at The Joint Commission (or indeed anybody else with a horse in the regulatory survey derby) are not abundantly aware of this report and it’s contents. So what follows is purely consultative in nature:

Read the report, look at the recommendations, perform a gap analysis at your facility, identify any improvement opportunities, present the risk assessment to your EOC committee and move forward. You may want to consider identifying the necessity for recurring review (which, natch, you should be doing as a function of your annual evaluation of the security management program), if you think you might lose track of this, but I think this should cover things quite nicely.

For those of you go-getters who’ve already run this race – what kind of stuff did you find? Any suggestions for the rest of the classes? Inquiring minds want to know!