Tales of survey derring-do

• What is in formaldehyde? How could you find out? Have they ever told you were you could find this? Have you ever heard of a MSDS?
• What would you do if you were splashed in the face with formaldehyde? How long would you use the eye wash? Where is the closest eye wash?
• What would you do if you were stuck by a needle?
• Do you feel safe working here?
• Did the hospital offer you a flu shot?

Start your stopwatch to help measure eyewash station needs

The topic of eyewash stations comes up a lot.

In general, OSHA requires eyewash stations in locations in which there is a risk of accidental exposure to corrosive or caustic materials.

There are definitely specific environments-including the food services, boiler rooms, high-level disinfection-where I would be looking for eyewash stations, but only after looking at the chemicals involved.

The need to have an eyewash station in close proximity can be ascertained by looking at the chemical’s first aid instructions, either on the container or on the MSDS. If the first aid information indicates that an exposure to the eyes requires flushing for 15 or more minutes, then you need to have an eyewash station.

If the first aid instructions do not indicate a 15-minute or longer flush after exposure, then you do not “need” to have an eyewash station–though nothing’s stopping you from installing one.

By the way, those lovely little wall-mounted plastic bottles do not meet the standard for emergency eyewash as would be required for conditions noted above.

Don’t just implement ILSMs–analyze them, too

Let me don my performance improvement robes for a moment as it concerns interim life safety measures (ILSMs).

A hundred pennies for your thoughts

Does the proposed emergency management chapter clarify or confuse?

I’ve been pondering this pending change of The Joint Commission’s (formerly JCAHO) emergency management standards chapter for quite some time.

Now that the draft changes have been revealed, I can’t help but ask the very rhetorical question: How does this help hospitals be better prepared for managing emergencies?

Recently I have come to a realization–or maybe it’s just that I’ve been able distill it down to a cliche–that if you look at baseline preparedness, hospitals are less well-prepared when they are confused.

And every time the Joint Commission re-jiggers the standards, things become more confusing for hospitals.

In all the reading I’ve done, the fundamental concepts of emergency management are littered with references to plain language, no jargon, and other stuff like that. Even a brief look at the proposed EM chapter shows that The Joint Commission has increased the number of EPs–mostly, if not exclusively, by splitting current EPs into even tinier requirements. Woo hoo!

Which leads me to another rhetorical question: Why is it that The Joint Commission can’t adopt the component requirements relating to NIMS and use them as the compliance structure? Maybe throw in FEMA’s Homeland Security Exercise and Evaluation Program requirements for exercises, too, and call it a day.

Though I suppose you could say that these separate but most parallel pursuits serve as a metaphor for the current state of emergency management. Stay tuned . . .

Is there anything it can’t do? It slices, it dices, it prepares you for disasters

I’d like to promise you that this is the last I’ll have to say about the topic of emergency management and the 96-hour rule under EC.4.12, but we both know that would be at best a complete break with reality.

This story from The Joint Commission front was kind of interesting as it’s recent (January ‘08) and speaks a little bit as to what folks might expect during the emergency management session during their survey.

During the survey in question, there was a clear indication that the surveyor was looking for an emergency operations plan that was based on risk assessments (there’s that phrase again–if I had a dollar for every time I’ve typed it…).

These folks had their 96-hour ops plan set up more as a function of event sequence, but were able to demonstrate to the surveyor that they had accounted for the required performance elements and management of risks.

I’m not going to bore you by going back over my little bits and pieces of advice regarding the management of the 96-hour event (though if you have an unbelievable hankering to revisit that discussion, the Mac’s Safety Space archives to the right contain way more discussion of this than any normal person would require). At any rate, be prepared to discuss the 96-hour deal and the risk assessment process, primarily as a function of your HVA process.

Which came first, the assessment or the assessment?

An interesting recurring theme during surveys revolves around the age-old question of, “What did you know and when did you know it?” and the definition of “proactive.”

Every challenge you might be called upon to manage has some sort of sequence. Well maybe not every challenge–sometimes things really hit the wildly spinning fan blades all at once. Hope you’re not having one of those days.

Take construction/renovation projects, for example. You start by:

• Looking at what’s involved
• Identifying the risks
• Assessing the risks
• Determining the interventions most likely to succeed
• Going from there

Please, please, please make sure that somewhere in the vast wasteland of documentation, you’ve indicated succinctly that the risk assessment occurred upstream of the project start-up.

If you have a discussion prior to start-up that involves the identification of risk, assessment of the risk, identification of interventions–that’s a proactive risk assessment–don’t be afraid to say so.

Ring the church bells, hang lanterns in the steeples, send the white smoke up the chimney: “We have a new risk assessment!”

There seems to be a movement afoot that if you don’t call it a “proactive risk assessment” then Joint Commission surveyors can jump ugly with you. Granted, it’s not a very nice way of going about anything, but you need to be mindful of this possibility.

Distant early warning

How long will you have to mobilize on the first day of your Joint Commission (formerly JCAHO) survey? Presuming that your organization has someone monitoring your Joint Commission extranet site on a regular basis, then how early are they looking? How long will it take for the word to reach you, whoever you might be?

This is a point where one of those nasty little cliches comes into its own: You only have one chance to make a good first impression, and the sooner you can “get to it,” the better.

Try to take advantage of some pro-activity as well because setting the stage is key. For example, make sure that there’s a process for neatening up those high-profile public restrooms early in the day. Even surveyors have to take a break, and you don’t want them to walk into the proverbial pigsty.

Also, ask your security staff on the overnight shifts to keep an eye out for law enforcement officers with a patient in tow. Make sure that the officers at least receive some sort of briefing as to the ways and means of your organization. A number of folks have had success with cobbling together a little brochure to hand out to forensic staff (and contractors, too) to provide them with a broad-stroke overview of your processes.

For some reason, surveyors seem to be attracted to forensic/law enforcement officers, so ensure the experience is a positive one for all involved. You and your HR department (that Joint Commission EP lives in HR standards) will be glad you did.

The cause and effectiveness of ILSMs

Those of you who have been paying any attention know that the scrutiny of interim life safety measures (ILSMs) and their practical application has in no way subsided.

In some instances, interpretations are heating up in this regard, and my best advice is to be thinking about the effectiveness of your process and practice. As with any risk assessment, it is not merely enough to conduct an initial ILSM assessment. You really need to look at the effectiveness of the intervention in order to keep out of the CON 04 doghouse, which can lead to a finding of conditional accreditation.

For example, a hospital that was surveyed in January got into trouble because the surveyor reportedly felt that the ILSMs the facility implemented were “not working” and “weren’t specific enough” and, to boot, weren’t sufficiently detailed.

That situation brings up a contradiction of sorts. If memory serves me, EC.5.50, EP 2 provides very specific detail as to the provenance of each ILSM. Are we to think that these “administrative actions to be taken” in the event of deficient conditions are somehow not sufficiently detailed to adequately protect our facilities from excessive life safety risks?

In the vernacular, what up with that?

I have my standards book in front of me, I’m looking at those 11 ILSMs, and in all candor, I don’t see a whole lot of gray. But as I think about it, is this an exercise in compliance or is it more about doing what is right and appropriate to ensure the safety of your facility’s occupants?

Yeah, you got me–it is both. But let’s stipulate that if you take care of the latter (doing the right thing), the former will be well cared for. I’m kind of liking that as an operational imperative.

Pharmacy locking: Stand-alone system or part of the bigger picture?

There was a question on our Safety Talk discussion group today about whether there is a regulation that mandates a pharmacy must have a stand-alone locking system, or whether it can be part of a bigger system.

I’ve seen some different configurations of systems, and the question also brought to mind a condition I found recently during a consulting engagement. And it also brings to mind that most favorite of subjects, the risk assessment.

In the hospital where I grew up, the folks in the pharmacy were always very insular when it came to their security systems. Every aspect was managed by them, through them, etc., with absolutely no interface whatsoever with the organization at large.

I admit that at first I was a little tweaked by that, but over time I came to realize that pharmacy is an enormous undertaking and the fewer fingers in that pie, the better the likely outcome. During today’s discussion on Safety Talk, some folks cited state-level requirements, which should definitely be the starting point for this stuff. But what about those instances in which the state-level guidance is non-existent or just plain not helpful?

Why then you’d do a risk assessment, which kind of leads me back to the initial question of whether the pharmacy’s access system should be stand-alone.

Ultimately, I think the decision point is a determination of how impregnable your general access system would be and if there is a chance that someone could violate the pharmacy through the general system. You need to determine your comfort level with how “remote” that chance might be. If that chance exists to a degree, then you need to make sure that there is sufficient “separation” to ensure appropriate security levels.

To take the example in a slightly different direction, recently I visited a hospital in which the “brains” of their infant security system were in a cabinet (albeit a locked one) in a soiled utility room. There were no other defenses other than the locked cabinet–the utility room was unlocked, there were no cameras or other monitoring devices, etc.

Now, we can absolutely stipulate that there is no specific Joint Commission requirement for this one. But the question sort of becomes: Is this really the way we want to set this up?

I know that sometimes you need to go with what your infrastructure can support, but at other times you just have to say, “We’ve got to find a better way of doing this.”

So the question you have to ask yourself–besides, “Do you feel lucky, punk?”–amounts to whether this is the best we can do (whatever “this” might happen to be). And, you know the answer you’d be looking for…