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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.

Abduction drills as emergency response exercises

One of the survey stories I hear from time to time deals with the efficacy (or the perceived efficacy as a function of Joint Commission surveyors) of using an infant abduction exercise as an emergency management exercise, with the “opinion” usually being that you “can’t” use them. My sense of that has always been that, if you think about it, there are few more disruptive events in any healthcare organization than an abduction event. So while an abduction exercise is not expressly mentioned in the standards, neither is an abduction exercise specifically excluded from the mix.

I believe (and this belief was borne out during a recent survey) is that as long as you plan, execute, monitor, and evaluate an abduction exercise at/to the same degree as you would any other emergency response activity, then there is no real reason why you couldn’t “count” an abduction exercise towards your annual allotment (and yes, I do recognize that an abduction exercise is not an influx exercise, but it could be part of an escalating scenario or as a means of practicing with the local community).

Standing up your incident command structure in response to the abduction exercise—yes, you would definitely want to do that. You also want to make sure that you evaluate the six critical function areas: communications; resources and assets, safety & security; utility systems, staff roles & responsibilities, and patient care and support activities should all be considered in the critique of the organization’s response. For any improvement opportunities that cannot be immediately implemented, make sure you identify any interim measures to bridge those opportunity gaps until they can be finalized. Opportunities and strengths should be communicated to the EC Committee and (ultimately) senior leadership. Basically, it’s the process you should already be using for your “regular” exercises and “real” emergency response plan implementations. If you keep these requirements in mind when, then you can feel confident that you have met the required elements. Bring on the survey!

Hey, how about that new app(liance focus during TJC surveys)?

I don’t know that it represents a significant focus change or if it’s just one of those blips that one might encounter when you hear about survey results, but there is a little groundswell relative to the management of appliances (basically everything that is not clinical equipment, which it appears could extend to utility systems equipment, but there’s no clear sense of that just yet).

I think we can agree than the healthcare environment is chock-a-block full of all manner of devices and appliances from toasters and microwave ovens to refrigerators; from desk lamps to radios and who knows what else. So in that great expanse of possibilities, there have been at least two recent surveys in which the process for managing these types of appliances/devices have come under come scrutiny, resulting in some RFIs for folks.

Now, there are no specific standards or EPs that speak to the management of these appliances/devices, but it appears that where opportunities in this realm are being funneled is our old friend EC.02.01.01, generally a “there was no policy or risk assessment in place to indicate how the risks associated with…” (quotes are mine as I am paraphrasing the general concept). Not that long ago we talked about how far one might need to go when it comes to the ever-present specter of the risk assessment process, and I guess the short answer is: Here’s another instance to flex the ol’ risk assessment muscles.

And so I ask of you: How are you guys managing these pesky appliances? Incoming functional safety inspection (you turn it on and presto, it works) with periodic visual inspections during surveillance rounds? Regularly scheduled preventive maintenance (PM) activities? Re-inspection when something gets busted and is repaired? Inquiring minds (as they are wont to do) await your input!

Thela Hun Ginjeet (and a great big dose of humidity)

Not to belabor or otherwise abuse the deceased equine, I wanted to share with you a potential solution for those of you who might be struggling with high humidity levels in your surgical procedure areas. Let me first say that I’m not an engineer, so I can’t necessarily speak to the science/mechanics of this strategy, but my friends in a nationwide hospital system have employed this with some success. As they say on TV (and radio, and just about anywhere there’s a legal disclaimer), actual results may vary. Consult your (insert professional here) if conditions persist…

And so we have this: Set the discharge temperature of the air handler(s) feeding your ORs (or any other spots where you are having challenges with humidity) to a lower setpoint, to where the reheat coils come on and dry the air. The colder supply air temps from the air handler should trigger the reheat coils to come on, and potentially dry some of that moist air.

Just to give you some geographical context, the folks who appear to be having some luck with this strategy for managing humidity are in those quintessentially arid locations such as Florida, the Carolinas, and Mississippi (when these folks get a new sweater for Christmas, it’s not necessarily something they’d wear). So in the interest of sharing (which generally equates with caring), I figured I’d throw this out there for consideration.

Any folks out there in radioland who’ve tried this and had successes (or not), let me know in the comments. I don’t think this one’s going away any time soon as a survey hot topic, so anything we can do to help each other makes a lot of sense to me, but that might just be me…

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

This just in: Absolutely nothing

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

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

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

You may want to smoke during surveys

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

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

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

A-0726

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

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

Interpretive Guidelines §482.41(c)(4)

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

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

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

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

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

• Laboratory locations.

 

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

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

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

Survey Procedures §482.41(c)(4)

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

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

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

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

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

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

 

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

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

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

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

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

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

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

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