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Do we really hafta?

Recently I received a question from the field regarding whether employers are required to provide antibody testing at the conclusion of the Hepatitis B vaccine administration process. Now, this is an interesting one in that the guidance is a wee bit circuitous, but I think we can navigate the murk and arrive at a point that makes things somewhat more clear.

In looking at what OSHA has to say about the Hepatitis B vaccine (you can find the OSHA Fact Sheet here), it only mentions the antibody testing in the context of pre-screening employees to see if they need the vaccine (employers are not required to provide the antibody testing as a means of pre-screening, so if new employees don’t know if they have the antibodies, they would have to have the testing done on their own). However, the Fact Sheet indicates that the vaccine must be administered in accordance with the recommendations of the United States Public Health Service (USPHS) that are current at the time the procedure takes place. The Fact Sheet goes on to indicate that “To ensure immunity, it is important for individuals to complete the entire course of vaccination contained in the USPHS recommendations.”

That sends us off to find the USPHS recommendations. A quick search of the Web takes us back in time to June 2001 when the USPHS recommendations were last updated. In the recommendations of the USPHS, while there is not a specific mandate regarding the antibody testing, it is recommended that the testing occur: “HCP who have contact with patients or blood and are at ongoing risk for percutaneous injuries should be tested 1-2 months after completion of the 3-dose vaccination series for anti-HBs.” So, we have USPHS saying the testing “should” happen and we have OSHA saying that the vaccine “must” be administered in accordance with the USPHS recommendations. To my way of thinking (putting my occupational safety/risk management hat on), while the antibody testing is not specifically mandated by OSHA, they mandate administering the vaccine in accordance with the USPHS recommendations, which recommend antibody testing. Again, somewhat circuitous, but I feel very strongly that failing to administer the antibody testing in accordance with the USPHS recommendations would not pass the compliance test with an OSHA inspector.

How many feet in a mile? How many square feet in a smoke compartment?

I recently came across a survey finding that I thought would be worth sharing with the class. In this particular survey, an organization was cited because it had not identified the square footage of their smoke compartments on its life safety drawings (this was a Direct Impact finding relative to maintaining a current e-SOC). In looking over the information published in the October 2012 issue of Perspectives (See the highlight box on p. 12 entitled “What to Include in Life Safety Code Drawings.” Please check it out if you have not yet done so; anything that shows up in Perspectives is enforceable as a standard!), I clearly see that there is a requirement to include the square footage of any areas designated as suites.

The only mention of smoke compartments indicates that they are required to be identified by location, but there is no mention of the square footage. Now this would seem to be a case of a surveyor interpreting (perhaps even over-interpreting) a requirement based on information that has not appeared in either the standards manual or in Perspectives (square footage for smoke compartments isn’t mentioned in the February 2012 issue of Environment of Care News either). I think this would be a good survey finding with which to practice using the clarification process and I suspect that the organization in question is going to make good use of that process.

Many too many…high numbers

In looking through the ol’ e-mail bag, I received a request for info relative to what the “magic number” was to be able to “count” an influx exercise in compliance with the Emergency Management standards. In looking at this question, I thought to myself that I don’t know that we’ve tackled this one yet here in the blogosphere and since my experience has generally been that questions like this rarely occur to just one set of folks, I figured there’s no time like the present. And so…

In looking at the performance element in question, all it says is that at least one of the two emergency response exercises includes an influx of simulated patients…and that’s all it says (you can go check!) Which means, in the parlance of the survey world, it is up to each organization to define what level of incoming patient volume is sufficient to be characterized as requiring implementation of the emergency response plan. In short, there is no “magic number” to guide us, so it becomes something akin to a risk assessment in that we need to determine what number and acuity (in some ways, acuity is the more important metric when discussing such matters) of incoming patients pushes our “normal” response capabilities past the point where response would still be considered normal. For smaller hospitals, the influx number is likely to be smaller; one really sick or injured patient might be enough to tip the scales where larger organizations might be able to manage volumes in the tens (I’m thinking hundreds is a bridge too far for the purposes of this conversation) without breaking a sweat.

To be honest, my experience has been that a lot of hospitals (perhaps even most hospitals) “do” influx on a regular basis. Volume is rarely a static reality—it ebbs and flows like the tide, though not nearly as predictably. And since it is for all intents and purposes impossible to predict what types (illness/injury/level of acuity) of patients your organization might have to manage, you have to employ some level of response flexibility.

Getting back to the magic number, it’s going to be pretty much up to each organization to determine what constitutes an influx. To complete the thought relative to managing influx on a regular basis, I’m not entirely certain why the standards-based requirement hasn’t morphed (Evolved? Mutated?) into a requirement for an evacuation exercise. We do influx all the time; evacuation, not so much. So what’s your magic number?

Now that the world is going to (legalized) pot…

A number of states have passed (or are in the process of passing) laws legalizing the use of medical marijuana. Now, I don’t really have a dog in this fight as far as it goes, but I do think it may present some challenges for security professionals in hospitals as to how best to manage cannabis as a personal possession. What was once a fairly straightforward “it’s not legal” situation could now become rather a point of contention when someone wants to know what happened to their prescription pot (I’m thinking that this could bring a whole new meaning to medication reconciliation…).

At any rate, to those of you in the studio audience who are in (various) states of legalized marijuana: How are you managing this as a potential customer interaction? How have you managed this type of contraband in the past and how are you going to manage it in the future? Back in the day, confiscated pot could be turned over to the local police; are they even interested anymore?  The DEA still classifies medical marijuana as a Schedule I substance and I suspect that there are any number of hospitals that are licensed only for Schedules II-V, so your pharmacy director may have some insight into a way forward. At any rate, if anybody out there has actually been able to come to grips with this issue, I would love to hear what you’ve got going.

Catch a waiver and you’re sitting on top of the world

Lots going on in the regulatory landscape lately—much of it potentially very beneficial to you folks out there in radioland.

On August 30, the folks at CMS issued a whole new set of waivers for consideration including such party-ready favorites as:

  • Medical gas master alarms
  • Openings in exit enclosures
  • Emergency generators and standby power systems
  • Doors (just doors, not The Doors)
  • Suites
  • Extinguishing requirements
  • Clean waste and patient record recycling containers
  • Clarification of the process for adopting the March 9, 2012 waivers

We’ll be discussing some of the ins and outs of the whole waiver scene in coming weeks, but I didn’t want to let too much time go by without letting you folks kick this around. Which reminds me: If anyone has any particular questions on any of the above-noted topics, please feel free to weigh in as we go through them. Not sure that we’ll be doing one per week (maybe two per week—depends on how long-winded I get), but I’d love to include any thoughts or concerns you folks might have.

Finally, if you want to start the required reading in this regard, an excellent starting point would be with the ASHE folks (if you’ve not already tapped into that resource).

Do you want to know a secret?

Apropos of nothing, on the face of it, I wanted to share with you a cautionary tale relative to the importance of accurate (and complete) communications, particularly in those perilous moments when you have a less than satisfied customer. As you might guess, I travel by air a fair amount of the time (and no, this isn’t a beef about delays. I count myself pretty fortunate in that regard. Delays are an inevitable function of any commute, doesn’t matter what mode, but I digress) and, without getting into too much detail, a process that had always worked in the past suddenly did not “go” the way I expected/had experienced literally tens, if not hundreds, of times in the past.

The initial encounter with the airline folks did not yield much in the way of satisfaction; in fact, I don’t think I would be hyperbolic in describing the handling of that interaction as bordering on indifferent. I try to keep an even keel in such matters, but I will tell you that I was a wee bit frustrated. I also knew that there was a process for airing my concerns, so I elected to save it for another day.

At this point (and yes there is a point to all this and I’m almost there), I had a pretty good idea of what was going on (clearly, at least in my mind, it was a systems issue and one part of the system wasn’t communicating very effectively with another part of the system), so I contacted customer service and explained my plight. The person I spoke with was very empathetic and offered a solution that she guaranteed would resolve the issue; I came away with a very positive feeling, but guess what? The solution didn’t work. There were a few more back and forths with a few more ideas/solutions, but nothing that really addressed what I was convinced was the issue.  The customer service folks promised to investigate and let me know.

Well, it turns out that it was a systems issue and at least some folks at the airline knew of its existence and had been working on it for a couple of weeks. They weren’t sure when the issue would be resolved, but I was okay with that—because I now knew what was going on. The “problem,” as I now see it, is that the folks who knew there was a problem and what the “symptoms” of the problem were, didn’t let everyone in the customer service process know what was going on. There is nothing more effective in answering someone’s questions than being able to speak directly to the issue—even if the resolution is not immediate.

How many times in our work lives have we been less than proactive in providing everyone in the process a complete picture of what’s going on? Inevitably, one can look back and figure out exactly when full disclosure fell by the wayside and frequently results in hard feelings, etc. It all kind of dovetails back to the mantra of “if you see something, say something,” though in this case, it’s more along the lines of “if you know something, say something.” While one may not intend to be secretive, sometimes it’s tough to defend “compartmentalization” or whatever euphemism you might adopt.  When it comes to safety, the more everyone knows, the more effectively risk can be managed.

I get (EVS) week at the knees…

Those of you who’ve followed this space for a while know that my first “life” in healthcare was working in various positions in what we now call Environmental Services (used to be Housekeeping and/or Building Services where I “grew up” in healthcare). So, in the spirit of “once a housekeeper, always a housekeeper,” I entreat you to join me in recognizing some of the folks in the trenches as we celebrate Environmental Services and Housekeeping Week from September 8-14. My stance has been that it is nigh on impossible to appropriately prevent infection if the environment is not properly maintained—and that process goal is frequently in the hands of the EVS folks. As with any frontline position, there are challenges galore (it takes a lot of diligence and pride to have to clean up after folks—I did it for a long time and truth be told, I still pick up stuff off the floor, etc.), so I think it an excellent opportunity to let these folks know how important they are in the management of the physical environment. And I will add my own thanks to the folks who wash the floors, clean the toilets, pick up the trash, and a myriad other tasks that, if left undone, would result in a much less tidy experience for our patients and our colleagues. Hip, hip, hooray!

Prioritize this…

During a recent survey, an interesting question was posed to the folks in Facilities, a question more than interesting enough to bring to your attention. The folks were asked to produce a policy that describes how they prioritize corrective maintenance work orders and they, in turn, asked me if I had such a thing. In my infinitely pithy response protocol, I indicated that I was not in the habit of collecting materials that are not required by regulatory standard. Now, I’m still not sure what the context of the question might have been (I will be visiting with these folks in the not too distant future and I plan on asking about the contextual applications of such a request), but it did give me cause to ponder the broader implications of the question.

I feel quite confident that developing a simple ranking scheme would be something that you could implement without having to go the whole policy route (I am personally no big fan of policies—they tend to be more complicated than they need to be and it’s frequently tougher to follow a policy 100% of the time, which is pretty much where the expectation bar is set during survey). I think something along the lines of:

Priority 1 – Immediate Threat to Health/Safety

Priority 2 – Direct Impact on Patient Care

Priority 3 – Indirect Impact on Patient Care

Priority 4 – No patient care impact

Priority 5 – Routine repairs

would work pretty well under most, if perhaps not all, circumstances. The circumstance I can “see” that might not quite lend itself to a specific hierarchy is when you have to run things on a “first come, first served” basis. Now I recognize that since our workforces are incredibly nimble (unlike regulatory agencies and the like), we can re-prioritize things based on their impact on important processes, so the question I keep coming back to is how can a policy ever truly reflect the complexities of such a process without somehow ending up with an “out of compliance with your policy” situation? This process works (or I guess in some instances, doesn’t) because of the competence of the staff involved with the process. I don’t see where a policy gets you that, but what do I know?

If only it were a tankless job…

And yet another story from the survey wars, this time regarding the number of oxygen cylinders that are allowed in a smoke compartment. As was the case regarding the eyewash station risk assessment discussion, this one comes from a Focused Standards Assessment (FSA) survey that I did not personally attend, so if you feel the grain of salt is once again needed, I will wait for you to fetch said salt before I start. Ready? Okay.

Anyway, in this particular survey, the FSA surveyor informed the organization that it could only have 12 oxygen cylinders in a smoke compartment, in this case, the ED. But wait, you say, what’s wrong with that? Read on, read on! Further discussion ensued in which the surveyor indicated that the 12 oxygen cylinders included the cylinders that were on, for example, the stretchers in the individual bays in the ED (this particular ED is designated as a suite of rooms). Now this kind of (okay, very much so) flies in the face of the whole “in use” versus “storage” concept where you can have “storage” of no more than 12 cylinders in a smoke compartment, but you can also have a number of cylinders that are considered “in use.” You will find a most excellent examples of how this works (and please try not to focus on the irony of this information source) in the December 2012 issue of Perspectives; on the right hand column of p. 10, George Mills describes a situation that uncannily resembles the condition that the FSA surveyor indicated was not compliant. And says that it’s okay, because the cylinders on the stretchers would be considered “in use.” If that don’t beat all…

I guess this ultimately goes back to the importance of “knowing” where you stand in terms of compliance. “Knowing” that the oxygen cylinders are considered in use and thus, within allowances, then you can respectfully (perhaps even silently) disagree with the surveyor and go back to more important things. And I suppose if you wanted to be fresh, you could suggest the surveyor sign up for a subscription to Perspectives. Unfortunately, they don’t have those little cards that fall out and can be mailed in as a gag…

What’s the frequency, Kenneth?

In our continuing coverage of stories from the survey beat, I have an interesting one to share with you regarding my most favorite of subjects: risk assessments. During a recent FSA survey (what’s that, you ask? Why, that’s the nifty replacement for the “old” PPR process—yet another kicky acronym, in this case standing for Focus Standards Assessment), a hospital was informed by the surveyor that it was required to conduct an annual risk assessment regarding emergency eyewash stations. Now I will admit that I got this information secondhand, so you may invoke the traditional grain of salt. But it does raise an interesting question in regards to the risk assessment process: Is it a one-and-done or is there an obligation to revisit things from time to time?

Now, purely from a contrarian standpoint, I would argue against a “scheduled” risk assessment on some specific recurring basis, unless, of course, there is a concern that the management of the risk (in question) as an operational consideration is not as easily assured as might otherwise serve the purpose of safety. If we take the eyewash equipment as an example, as it deals primarily with response to a chemical exposure, I would consider this topic as being a function of the Hazardous Communications standard, which is, by definition, a performance standard. So as long as we are appropriately managing the involved risks, we should be okay. And I know that we are monitoring the management of those risks as a function of safety rounds and the review of occupational injury reports, etc. If you look at a lot of the requirements relating to monitoring, a theme emerges—that we need to adjust to changes in the process if we are to properly manage the risks. If someone introduces a new chemical product into the workplace, then yes, we need to assess how that change is going to impact occupational safety. But again, if we are monitoring the EC program effectively, this is a process that “lives” in the program and really doesn’t benefit from a specific recurrence schedule. We do the risk assessment to identify strategies to manage risks and then we monitor to ensure that the risks are appropriately managed. And if they aren’t being appropriately managed…then it’s time to get out the risk assessment again.