A client I was working with recently had a really good Joint Commission survey from an EC/LS/EM standpoint, but had identified some opportunities buried in some policies that prompted them to earmark an in-depth policy review to prepare for the next survey. Upon hearing this, I thought of some advice that I think could be useful in a general sense, so if you don’t mind a little pontificating, here goes nothing…
First ask whether the policy is really necessary. Some policies are vestiges of that bygone era when Joint Commission preparation meant shining up the policy books, including having a policy for everything. Don’t be afraid to retire a policy if it doesn’t make operational sense.
If a policy reflects management of a key, or widespread process, once you have determined what is actually “required” (which is when you have the answer to the question—where in the regulations does it say that we have to do this); make sure that the policy reflects the process to the extent allowed by regulation. All too frequently, organizations craft these beautiful policies and procedures that make absolutely no operational sense whatsoever. We need to know that the policy enhances the practical implementation of the policy, otherwise you get workarounds (not that that would ever happen in healthcare, but I digress…).
The more you can introduce common sense (which, I will freely admit, ain’t as common as it once was) into the conversation, and get it to stay in the front of the discussion, you are much more likely to come up with a product that will work in the real world. Analogous to that, it’s also important to remember that sometimes you have to birth the thing to see if it can work in the real world. All too often I see folks torturing themselves trying to make a “perfect” policy and never really deliver anything. Don’t be afraid to launch the boat—just don’t do it in the middle of the harbor—if it’s going to leak, it will leak just as nicely (though perhaps not as dramatically) in shallow water as it will in the deep.
If you need an external eye to look at something, or indeed if you are having difficulty gaining traction on an issue, I am happy to act as a sounding board. My second favorite consulting duty is to play the role of devil’s advocate, which helps favorite #1, the problem solving thing. So please feel free to shoot up a flare if you get stuck on something.
During a recent Joint Commission survey, a concern was raised because the hospital’s pediatrics and OB units were not “equipped” with the same security system, etc. I’m not certain whether the result was a specific finding, but the question, in and of itself, is instructive when it comes to the science of assessment.
First off, I’ve never actually seen the areas in question, so I will engage in a little bit of conjecture, but I think the general themes can be applied in your house, particularly if you don’t have a whole lot of pediatric patient volume. Now certainly, the historical focus on abduction prevention has been primarily on the security of newborns, which I think we can all agree is a vulnerable patient population. That said, there are certainly risks involved in providing for the security of pediatric patients (and maybe some adult patients as well—it’s getting kind of crazy out there in the world), risks that would have to include abduction.
From a regulatory standpoint, there is very little specific guidance beyond the caveat of ensuring that you are not compromising life safety concerns as you install security systems. Locking doors in egress paths can be tricky and, in virtually every instance I can think of, the process was much more complicated than was originally presumed, but that’s a story for another day. We know what the result will be if our security efforts are not sufficient/appropriate, etc.: something will happen and that something will not be good. But that raises the somewhat rhetorical question of whether you can “rest” based on nothing bad happening. Is that a legitimate conclusion to make? Variations on this theme have become very noticeable during surveys this year. Maybe it’s something identified by a vendor that you haven’t gotten around to fixing, maybe it’s a new piece of technology that you have budgeted for next year, but that’s going to take time to purchase, install, educate staff, etc. Maybe (as is more or less the case in the recent survey mentioned above) from an operational standpoint, your pediatrics unit is in a small part of a regular medical/surgical unit and the geography of the space does not lend itself to the same security measures as you have on your OB unit.
These are all real life occurrences and each has its own security or EC implications that need to be managed. But (and this is a sizable one), you have to be able to articulate where you are in the process and how you are making sure that any elevated risks that are the result of not being able to do something right now are being appropriately managed. I hate to say this, but it’s been coming up far too often in surveys this year for this to be ignored: you absolutely need to discuss and document the management of these types of risks, including those all-important interim measures (if they are needed). Otherwise, you leave yourself vulnerable to a survey finding for which it is very difficult to negotiate a “settlement” either during survey or as part of the clarification process.
There are no standards that specify a time frame for completion, a technology enhancement, etc. That’s the responsibility of each organization to manage. But with that responsibility comes the obligation to manage any associated risks in fairly transparent fashion (I think I’ve managed to avoid invoking the transparency card until now): frontline point of care/point of service staff need to be able to articulate how we are managing risk until such time as solutions can be implemented. If they can’t, the risk of a survey finding rises exponentially. It’s no longer enough for leadership to know what’s going on, the folks in the field have to know, too. Pediatrics staff need to articulate how they are managing abduction risks for their patients. And if you have pediatrics in the ED, there needs to be some competency there as well. We can’t always do what we want when we want to do it, which is the reality of healthcare. But we do need to understand and share the risk implications of all those decisions and non-decisions.
One of the critical processes when one embarks upon a program of construction and/or renovation is the management of infection control risks, particularly if the work is to be done in, or adjacent to, occupied patient areas. Now, I’m sure that you are all more than familiar with the infection control risk assessment (ICRA) matrix (you can find one in HCPro’s Infection Prevention Policy and Procedure Manual for Hospitals as well as in a number of locations on the Web). One question I’ve encountered recently is not so much about the risk assessment piece itself, but rather how one determines the amount of oversight (including how frequently IC rounds would be done in construction areas, and who would be qualified to conduct those rounds, etc.) and operational considerations like waste removal (i.e., frequencies and methodologies), cleaning floors (i.e., frequencies and methodologies), what types of walk-off mats to use, and stuff like that.
Now, if we know anything about anything, we know that there is not generally a great deal of guidance when it comes to the specifics of these types of things. And by now, we also know that there’s going to be some sort of risk assessment when it comes to making those decisions. So, the question I put to you folks in the field, in the spirit of sharing: How are you working through these types of operational decisions? Have you done anything that worked really well? Anything that worked so poorly that you get hives just thinking about it? The ICRA will help us determine what we have to do. How then do we take the next step to effectively implementing those identified strategies?
I look forward to hearing from you all, even if it’s to ask pointed questions. Operators are standing by…call now!
One of the universal challenges facing Environment of Care/safety committees is the task of actually getting things done in the way of meaningful improvement, generally for the more controversial issues an organization might encounter. Sometimes it’s because opinions and interpretations are sufficiently diverse that common ground is tough to even imagine, or it could be that there is an agreement that a problem exists, but the solution resides within the more stratospheric pay grades.
One of the most useful means of breaking these deadlocks (I was going to say filibuster, but that sounds way too congressional—I don’t want to paint anyone with that brush) is by adopting a process for obtaining consensus from the group. Consensus provides a framework that allows for some disagreement (and ideally helps moderate those disagreements), but arrives at a work product that is acceptable to the group at large and allows things to move forward (you and I both know that every once in a while there will be a topic of conversation that never, ever goes anywhere—it just keeps burbling along in the minutes and frustrates the heck out of everyone in the room when the topic rears its ugly little head).
Now, consensus shouldn’t be confused with majority rule. In fact, majority rule, if you have strong personalities involved, can be a recipe for stalemate (the old saw regarding physicians: What do you call a medical staff vote of 99 to 1? A tie!) as can be impossible to move beyond those peculiar sticking points.
A nifty (that word doesn’t get used enough anymore, if you ask me) tool to help move towards this type of decision-making looks a little something like this:
+3 We must do this
+2 We should do this
+1 I support this
0 I’m neutral
-1 I don’t support this but won’t oppose it
-2 We should not do this
-3 We must not do this
So, for those thorny issues, everyone has a position, and in all likelihood, that position is represented somewhere on this continuum. As you can see the “decision point” for moving something forward is actually at -1, with everything below being clearly indicative of a stopping point. So, the process works like this: one person, one vote (I think the founding fathers would like that). My preference, but it is entirely up to you, would be for everyone to participate—and I do mean everyone—but that’s one of the ground rules you can (and, to my mind, should) establish. It’s not exactly like not going to bed angry, but it provides a framework (there’s that word again) for moving something forward or moving something off the board (you should also consider in the rules of engagement whether something is being moved off the board permanently or whether it can come back, given certain conditions).
I would encourage you to consider using this tool—and I would encourage you even more strongly to share with the safety community your successes (and failures—everything is a learning opportunity).
Try to keep cool!
Q: Regarding patient/nonpatient care areas, what about performing site visits to off-site doctor offices run by the medical center? Once yearly or twice yearly?
A: That’s one that could go either way; strictly speaking, the two per year requirement is in the standards specific to hospitals and various assorted healthcare occupancies, but you could make the case that it’s best practice to extend that to physician office practices. What you could do is, if you decide to adopt the once a year, go at it as a function of a risk assessment and leave the option of increasing the frequency if conditions dictate, then wrap the whole thing up as part of the annual evaluation of the program scope. The other thing you could do (and this might be a good compromise) is to create a 10 to 15 item checklist (it can be less, I wouldn’t do more) that someone in the office can do and then do an “official” site visit to make the two per year. Generally speaking, physician office practices don’t endure a lot of variability, so the safety conditions, etc., while not exactly static, are of a much more manageable pace that the acute care setting, so it is entirely appropriate to administer the program accordingly.
Catching up on some recent e-mail questions, there was one regarding hazard surveillance activities and the oversight of off-site buildings (not identified under the hospital’s license) where there are no patient services provided. So the question became whether these locations had to be included in the hazard surveillance program and whether they would be subject to a Joint Commission visit during survey.
So, taking a look at the Joint Commission “role,” while it is most unlikely that the survey team would visit an off-site location with no patient services (not quite 0%, but something very close to that), a pain-in-the-butt surveyor might check the hazard surveillance round documentation vs. the list of hospital departments. Now the standard/elements in question, EC.04.01.01, EPs 12 and 13, only refers to patient and nonpatient care areas, so I think the thing to do is to be very specific in identifying locations in the scope of your management plans (I mean, what exactly is a nonpatient care area? A nonpatient area—got that; a patient care area—got that. But this hybrid is a little vague). Ultimately, the whole process sets up based on what you’ve identified as the appropriate inclusions, etc., so you can certainly make the determination of what would rule in to the program, or indeed rule out of the program.
That said, I have a concern in the event that OSHA were to rear its ever so lovely head. It would be of critical importance to demonstrate some sort of oversight; one strategy that comes to mind would be to develop a self-inspection process for those areas and fold that into the formal surveillance process. As a safety professional, I’m having a hard time saying that these “other” locations can be culled out of the main process (in my experience, it is never a good thing for people to think that they are somehow being ignored or not appropriately tended). I think the thing to do is to set up a less-invasive process that will allow some sort of feedback loop if environmental issues crop up in these other locations. Better you find out about issues than to have somebody drop a dime to the big “O.”
Recently I fielded a question from someone who was reviewing an MRI safety plan and was curious about how the four-zone “defense” would work when the MRI is in a self-contained trailer that is not part of the building. Now my first thought on this was whether the MRI service is provided under contract (including staffing) or whether the service was staffed by hospital folks and the trailer under some kind of lease arrangement. My somewhat snotty response would have been to lean on the contract folks to work out how it all fits together, but then I was thinking: What if we had to work it out on our own, for whatever reason?
At first blush, I can see establishing three zones without too much difficulty. It may be necessary to combine Zones 2 and 3, but Zone 1 (i.e., general public) would be outside the trailer and Zone 4 (i.e., screened MRI patients under constant direct supervision of trained MRI personnel) would be in the magnet room, so that’s pretty reasonable. But again, what about Zones 2 (i.e., unscreened MRI patients) and Zone 3 (i.e., screened MRI patients and personnel)? I don’t think there would be enough room in the trailer for screened and unscreened folks, but maybe Zone 1 could be the ground level outside the trailer, Zone 2 could be the area just outside the trailer (on the lift and/or stairs—depends on the configuration of the trailer), which would leave Zone 3 in the control area.
Or I suppose you could do a risk assessment to demonstrate that the risks can be appropriately and reliably managed without adoption of the four-zone setup, but one would need to make sure that all staff in the area (and I do mean “all” staff) can speak to the protection measures in place. Querying of staff has been coming up in recent TJC surveys and if staff cannot speak to the zones and differing levels of safety/protection, it results in citations under the management of hazardous energy sources element of the Hazardous Materials and Waste Management standard. Probably not a bad thing to check on after lunch this afternoon.
Not that long ago, I participated in a discussion regarding the terminal cleaning of surgical procedure rooms, particularly the recommended frequency of using wet vacuums and a liberal application of water to ensure appropriate results. As a function of that discussion, it appeared that the organization in question had adopted a weekly frequency for the use of wet vacs, and it also appeared that the OR rooms were noted to have a buildup of materials (you know what they are—no need to get graphic here) in the corners of the rooms. The overarching question was what the TJC survey risk might be given the current practice and conditions.
Now I honestly don’t know why people struggle so much with this, but here goes (and yes, for those of you keeping score, before we finish this conversation, I will invoke the mighty risk assessment).The Joint Commission standards do not specify any particular methodology for the cleaning of operating rooms, primarily (to my way of thinking) because there is far too much variability in the surgical environment for them to “require” anything more than what they do now: EC.02.06.01, EP 20, which requires that “areas used by patients are clean and free of offensive odors.” And that, as they say, is that. (By the way, in case I have not previously noted this, this EP is now a Direct Impact finding and is showing up with far greater frequency in survey results. I characterize this as the “return of the white gloves.”)
Based on the conversation related above, if there is a buildup of nasty stuff in the corners, then clearly whatever frequency and/or method they are employing is not particularly effective—even if they are using a wet vac only once a week, they shouldn’t be getting a whole lot in the way of buildup in the corners, so putting my EVS hat on, there is at least some competency/education opportunities lurking in them thar corners. Will a water vac be enough? Read on…
Even the CDC, in its Guidelines for Environmental Infection Control points to other “published” guidance when it comes to the cleaning of OR’s , which, to my mind, points to the AORN recommendations (I don’t know if there is a more contemporary edition; this is from 2007, but I think the basic concepts still apply). Now there are a whole slew of things to do in the AORN guidance, including a process for before/between-case cleaning (which indicates the process would be in place even after the room is terminally cleaned). As a bit of consultative advice, I would be inclined to advise folks not to cherry-pick the “easy” pieces from the AORN guidance. If one were to consider the AORN guidance as a “best” practice, then we would need to look at is as a whole, at least as a starting point. As with all universal guidance documents, the “one size fits all” aim almost never results in universal applicability, but if we are going to adopt something along the lines of a hybrid kind of deal (wait for it!), we would need to have this framed within the context of a risk assessment.
So if, for instance, a surveyor were to cite a hospital for not following the AORN guidance (and there is not TJC standard that says you have to; good idea, yes, mandate, no), without citing some level of failure relative to the cleaning process, then that would be an opportunity for clarification. But, if the organization can demonstrate that whatever methodology it is using is effective, based on data analysis, infection rates, etc., then who’s to say that its “strategy” is not every bit as valid as the recommendations of AORN? But, if the same hospital gets cited because it has sanitation opportunities in their OR’s, then it is dead in the water, so to speak. As something of an editorial comment, it has been a very long time since I’ve been in an OR that I would call clean; most are okay, but for instance, it is very rare indeed that the anesthesia machine does not have a buildup of dust. Now I know that the dust comes primarily from linen and the undoing of surgical packs, etc. in the room (that stuff does nothing but aerosolize lint—yuck!), which means pretty much every time an OR room gets used, we are introducing more stuff that will need to be cleaned.
In conclusion: Buildup in the corners will likely lead to a TJC or CMS finding and that is as it should be; folks who are experiencing less-than-ideal levels of cleanliness need to look at changing their process, but I don’t think it necessarily makes sense to tie your future to adopting anyone’s specific guidance, until you’ve figured out the reasons for having a deficient process in the first place. That way, if you should choose not to adopt what can legitimately be characterized as a best practice (the AORN guidance), then they better have a real good reason (which would include validation of the effectiveness of the alternative) for doing so.
This is just like the cardboard issue. There is no regulatory mandate in any direction on this, but it is a risk to be managed effectively. Nowadays, each organization’s responsibility, and, strangely enough, The Joint Commission’s expectations, is to know whether it is managing identified risks appropriately. There can truly be no more reliance on the “no news is good news” philosophy—reactive risk management will only cause trouble during survey. Improvement is a beautiful thing, but you need to understand how and why improvement occurred.
Boston’s buzzing today as hockey fans celebrate the Bruins winning their first Stanley Cup in 39 years, but that’s not the only action that took place here this week. Earlier in the week, the National Fire Protection Association (NFPA) held its 2011 Conference and Expo in Boston, which was followed by the NFPA Technical Meeting on Tuesday and Wednesday.
Of particular interest to healthcare facilities folks, at the Technical Meeting the association approved new versions of NFPA 101, Life Safety Code® (LSC), and NFPA 99, Standard for Health Care Facilities. The 2012 editions of each standard are expected to be published officially in the next few months.
Once the 2012 editions are published, CMS and The Joint Commission are expected to follow suit and adopt the 2012 editions. Currently, both require hospitals to comply with the 2000 edition of the LSC. The most recent edition of the LSC was published in 2009.
It could take up to 18 months before CMS adopts a newer edition of the LSC. Once that happens, The Joint Commission, Det Norske Veritas, and the Healthcare Facilities Accreditation Program will also adopt it, and then accredited hospitals must comply with the new requirements.
Visit the NFPA’s Conference blog for more information on the votes and see the upcoming issue of Healthcare Life Safety Compliance for details and analysis of these actions and what they’ll mean for your facility.
By now, I suspect that most of you have heard about some of the “editorial” changes that will be taking effect in a couple of weeks—just in time for the Independence Day festivities, though I don’t know that this should result in much in the way of fireworks.
So the first item revolves around the whole business occupancy as emergency services provider and/or community-designated disaster receiving station, which I suppose is a concern for some folks. But I can’t think of too many folks with business occupancies that provide emergency services or (even less likely I’m thinking) community-designated disaster receiving stations, and even if you do, why would you not include these locations in your regular exercise schedule? Again, something of which to be mindful, but I shouldn’t think would be a problem as long as you’re paying attention. Which leads me to the “other” point, otherwise known as Note 4 under EM.03.01.03, which appears to pile on a bit when it comes to your post-emergency exercise activities.
As with so many of the more intricate meanderings of the Joint, as far as I’m concerned, this merely clarifies what was already implied in the standard. To be honest, the exercise section of the Emergency Management chapter is actually kind of useful (along with the standards covering the management of volunteer practitioners during an emergency—that is a very well-crafted set of standards/expectation and can actually assist folks in identifying appropriate strategies, but I digress).
My interpretation of the whole EM.03.01.03 magillah is that it is a clear move to a classic performance improvement cycle: You do an exercise, you identify improvements, implement the improvements, use the next exercise to evaluate the changes, identify more improvements, implement them, use the next exercise to evaluate those changes, and so on. Where this can be tricky is when you’re “playing” with the community because they will almost invariably have a different agenda for the exercise than the hospital will, so the hospital then has to become creative in building their improvements (and the evaluation thereof) of that drill. Sometimes the improvements are so broad-ranging that they will easily “fit” in any scenario, but others maybe not so much. The other point to keep in mind (and this dovetails very nicely with the recent blog item on interim gas measures) is that if you cannot implement an identified improvement prior to the next drill, you are supposed to identify interim measure to “bridge the gap” until implementation (the “note” for EM.03.01.03, EP 16 states that when modifications requiring substantive resources cannot be accomplished for the next response exercise, interim measures are put in place until final modifications can be made). As far as I’m concerned the “requirement” in the new note already existed as EP 17, which requires subsequent exercises to reflect the modifications and interim measures identified in previous exercises. They’ve changed the language some (and perhaps made it more clear, but I thought that what they had was clear enough. It may be that they did no one favors by burying it at the end of the chapter and decided to move it to a position of greater prominence. All we have is conjecture at this point. So, my advice would be to utilize your organization’s performance improvement model to track exercises and performance therein and keep the ball rolling.
As to how this may impact organizational resources (or the lack thereof), I don’t know that I’m prepared to throw that towel in just yet. I see far too much procrastination when it comes to emergency management efforts; it’s almost always part of someone’s job, but not the primary part, so accountability for emergency planning slides down the hierarchy. Part of it is, from a historical basis, most hospitals don’t have to deal with what I will loosely describe as “overwhelming” events, so it becomes a cost- (or risk-) benefit analysis. We have to devote our resources towards the stuff that’s most important. Now I’m certainly not prepared to say organizations feel that emergency preparedness is not important, but when you don’t have the resources to even make critical infrastructure improvements (which can actually increase the likelihood of an overwhelming event), you spend more time fixing stuff, putting out fires, etc. As I’ve noted in more places than I care to think, emergency preparedness is a journey not a destination. We will never get to a point where we can look back and say that we’ve done all we can (unless, of course, the Mayans are correct about next year, then maybe, just maybe we won’t have to worry as much about this stuff).