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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.

I’m feeling a little (medical) gassy…

One Joint Commission survey finding I’ve noticed cropping up in a couple of instances has to do with the routine inspection, testing, and maintenance of critical components of medical gas and vacuum systems. I thought it might be useful to chat a bit about this, particularly as the standard/performance element language is among the more open-ended in terms of what may or may not be required.

EC.02.05.09, EP 1 indicates that the hospital must, in time frames defined by the hospital, inspect, test, and maintain critical components of piped medical gas systems, which include master signal panels, area alarms, automatic pressure switches, shutoff valves, flexible connectors, and outlets. These activities must be documented. So, we’ve got a couple of things going on—“time frames defined by the hospital” and “critical components of piped medical gas systems”—but not a whole lot of indication as to what the heck these are supposed to mean. Or is there something  that would lead us on a path towards conduction of a (you may have guessed this) risk assessment (did you guess, huh, did you? I bet you did…)?

Actually, as a starting point, EC.02.05.09 has a note that gives us a little something to grow on: See also EC.02.05.01, EP 3. Moving on (or back in the standards to EC.02.05.01, we see that EP 3 requires us to identify, in writing, inspection and maintenance activities for all operating components of utility systems on the inventory. Okay, so we have to have written procedures/protocols/ something that we can use to demonstrate compliance; BTW, there are a number of different approaches to maintenance that are allowable—predictive maintenance, reliability-centered maintenance, interval-based maintenance, or metered maintenance are all in the mix—and you can choose whichever of the strategies is appropriate to whatever you are maintaining. Pretty cool, yes?

So we establish what activities are going to be identified and what maintenance approach(es) we are going to be using, which gets us closer to the time frame, but perhaps not quite all the way there. And there is still the matter of how we might define “critical components of piped medical gas systems.” Stay tuned for our next installment…see you next week!

Take an ‘M’ down, pass it around—now you’ve got SDS

In case you missed it, OSHA’s Hazard Communications Standard has been revised to align with the United Nations Globally Harmonized System of Classification and Labeling of Chemicals (GHS) and the first important “to do” date is rapidly approaching (you’ve got a little less than six months—December 1, 2013 is the target). Lots of information can be found here, including an OSHA FactSheet on the topic.

The expectation before us regarding the December deadline is to provide education to our staff on the new label elements and the Safety Data Sheet (SDS) format. Ultimately, this process will result in a much more standardized “look” for the hazard information folks will access to determine how best to manage the risks in their workplace.  The training must include information on the standardized format, including the information contained in the various sections as well as how the information on the product label(s) relates to the SDS.

As a gentle reminder as you embark on this education journey, always remember that OSHA requires you to present information to staff in a manner and language that your employees can understand (this likely represents different types of challenges for each of you). The OSHA page above has links to educational information in English and Spanish, but some of you may have to come up with materials in other languages. I believe that this will be beneficial in the long run, but it represents change, so there will be barriers to be managed. Funny how change erects all sorts of interesting challenges.

As a final note (for the moment) in this regard, the “other” things on the to-do list are to continue to update safety data sheets as new ones become available; continue to provide education on the new label elements; and (this is an important one) update your hazard communications program if new hazards are identified. I’m hoping that any changes to your HazComm plan will be minimal, but you definitely want to start thinking about those updates (June 1, 2016 will be here before you know it).

Jeannie needs a shooter (well, an active shooter response plan…)

The time has come, the Walrus said, to talk of many things…and so today’s tusk (excuse me, task) is to find out where all you good folks out there in radio land are relative to developing active shooter plans for your organizations (either as ground zero, in response to an event in the community, or a combination of both). While there are certainly a majority of communities that have not experienced the horror of an active shooter occurrence, I think that the time where we could “risk assess” our way out of needing to have a response plan for such events has pretty much gone by the wayside.

So, how are you folks working through this? I would think that you’d be interfacing with local (and perhaps regional) law enforcement folks in coming up with a comprehensive response plan. How’s that been going? Any lessons learned you’d be inclined to share with this community? Have you encountered any internal staffing issues as you develop operational plans (depending on your facility layout, you may have a whole bunch of doors to be secured in the event of a lockdown)? Are you going to identify and educate door “monitors” ahead of time or do you think that Just in Time education is going to prove sufficiently effective?

My hope is that no one else is going to get the chance to find out how effective their response plan is, but my fear is that hope is going to take a back seat to reality before too long. But I will remain optimistic until proven otherwise.

Do you have to be so negative/positive?

Time for a little update from the field during survey year 2013. If there’s one topic (or topical set, if you will) that’s causing much angst in the survey world, it’s the focus being paid to areas that have specific environmental performance requirements (e.g., air pressures, temperature, humidity). Last year there seemed to be a little bit of a “run” on issues relating to low humidity, but with the issuance of the CMS categorical waiver, I think the low humidity problems are going to fade into the sunset. But that still leaves us with high humidity conditions and those pesky pressure relationships—I can pretty much guarantee that, for the foreseeable future, Joint Commission surveyors are going to be scrutinizing your logs, field testing your pressure relationships and all manner of mischief when it comes to this stuff. So, I would advise you to start doing the same. Check those logs going back to last year’s rather toasty environs. Did you experience out-of-range values in your procedure rooms? If so, were there any documented actions in response to those out-of-range values? Clearly, if there was no documented response, you are potentially looking at a finding during survey, but if you can demonstrate that you have a well-controlled process now, then maybe you can convince the survey team that past performance doesn’t indicate current or future results and you can negotiate a more favorable settlement. Remember, this is an area that can drive a condition-level finding for CMS in no time flat. You need to have an effective process in place or you will definitely suffer the slings and arrows of outrageous survey fortune—and I don’t think any of us wants that. I know I wouldn’t like it…

Clinical alarms: Getting the word out

All things being equal, I suspect that folks are wrestling with the very expansive elements of the Sentinel Event Alert regarding the management of medical device alarms (Sentinel Event Alert #50). I think the important thing to do is to first document a risk assessment that takes into account the various clinical alarm systems, identifying those that might legitimately be considered critical and use that as the starting point. I think it would behoove you to involve the folks in clinical engineering as they probably have performance data that would be very useful (equipment that they find during preventive maintenance activities that perhaps are not appropriately configured for audibility, etc.), it would also be important to include any potential occurrence reporting data that might indicate that there have been issues involving audibility of clinical alarms, etc. To be honest, I am not so sure that any one organization’s approach will be sufficiently universal to be used across the board beyond a simple “these are the specific risks involved with the clinical alarms you’ll be using” (in recognition that this may vary based on clinical location/service) and “these are the specific strategies we are using to appropriately eliminate/mitigate those risks.” I know that may sound like an overly simple approach, but if you do a good job on the risk assessment groundwork, you will have everything you need to manage the education process. As a further enticement, the Sentinel Event Alert web page noted above also includes links to a couple of podcasts that discuss the Alert in pretty fair detail. I don’t know that I’d recommend listening to it on the treadmill, but it’s probably a good way to combine work and exercise…

It’s not the heat, it’s the humidity (no, really…)

Good news for those of you who might be struggling a bit with low humidity levels (below 35%) in your surgical procedure areas. CMS issued a categorical waiver based on the recent changes to the FGI Guidelines for the Design and Construction of Health Care Facilities (including the recently updated ASHRAE 170 standard) that allows for relative humidity (RH) values in surgical procedure areas down to a 20% level. Could this be an example of science triumphing over bureaucracy? Only time will tell.

As always, there are some caveats involved: the waiver does not apply if more stringent humidity levels are required under state or local law or regulation or if the reduction of the RH would negatively affect ventilation system performance (which means you need to “know” where you stand relative to state/local requirements as well as the design specifications for your HVAC equipment—and if that sounds like a risk assessment, quack quack!).

Also, the waiver does not specifically establish an upper limit for RH in these areas; it does, however, strongly recommend that an upper level of 60% be maintained based on ASHRAE keeping that upper limit. So I guess those of you in more swampy areas of the world are going to have to keep on keeping on with that. Make sure you’ve got your response to out-of-range values process in good working order.

Administratively, while you will not have to apply in advance for the waiver or wait until you’ve been cited (which is always a fun thing), you must document that you’ve decided to use the waiver. Also, be prepared to notify the survey team assessing Life Safety Code® compliance at the opening conference of the survey that you have decided to use the waiver. Failure to provide documentation of your prior decision to use the waiver could result in a citation.

I guess this is just one more step on the road to the adoption of the most contemporary of codes and regulations. Can you say 2012 edition of NFPA 101? Sure you can! And hopefully, we’ll all be able to say that before too very long…

News to me

Recently, a client sent me a question regarding assessing his surgical procedure rooms as wet locations. This was primarily as a function of the changes to NFPA 99, which brings the concept of wet locations and surgery back into the mix (the 2012 edition of NFPA 99 defines wet procedure locations as the “area in a patient care room where a procedure is performed that is normally subject to wet conditions while a patient is present, including standing fluids on the floor or drenching of the work area, either of which condition is intimate to the patient or staff,” NFPA 99 – 2012: 3.3.184). Previously, operating rooms were not considered wet locations as a rule, but now it appears that the pendulum has swung in the other direction.

To that end, the American Society of Healthcare Engineering (ASHE) issued an advocacy statement last year recommending that organizations form a risk assessment group to develop a process for evaluating surgical procedure rooms to determine which of these areas, if any, might legitimately be considered wet locations. Now based on the definition from NFPA 99, you could probably rule out a lot of procedure areas (rooms designated for eye surgery, neurosurgery, ENT surgery, etc.), but in other areas it may require some observations of the procedures being performed to determine the extent of standing fluids, etc. Once you’ve determined that you have wet locations, then you would need to move to provide appropriate protection (GFCI protection, isolated power, etc.). And there are other considerations as well, based on the activities in the space, the “state” of the equipment used in the space, etc. There can be any number of contributing factors that could increase the risk to staff and patients in wet locations; Appendix B of the 2005 edition of NFPA 99 speaks of such things as line-powered equipment that is within reach; a damaged line cord, attachment plugs, or exposed metal presenting a risk of direct exposure to a conductor; damaged equipment with “live” metal, exposed metal that has become ungrounded, a person making contact with a live metal surface, etc.

As with so many things, the key process is the almighty risk assessment, so if you’ve not yet wrestled with this bear, you might find it useful to start the process (in full disclosure, the ASHE advocacy statement came out last year—and if you don’t think certain three-letter regulatory agencies are not familiar with this bit of news, I would encourage you to think otherwise).  Sometimes codes change for good reasons, sometimes maybe not so much, but we have an obligation to provide the safest possible environments for patients and staff and this looks like something that can be at least determined fairly simply (fixing this if you have issues is likely to be much less simple).

We are the champions

Now there may be some folks out there who are thinking that there are certain topics to which I have administered beatings akin to the deceased equine, but sometimes there are other folks who appear to share at least some of my “wacky” perspectives on how to manage safety in the healthcare environment.

So, I encourage you to contact the individual in your organization responsible for coordinating Joint Commission accreditation and ask them to share with you the February 2013 issue of Joint Commission Perspectives. And, if you turn to p. 9, you will find the latest column penned by George Mills entitled “Safety Champions—Making Health Care Safety Everyone’s Business.” And to this, I say hallelujah! Those of you who’ve been with me since we started this little space (it’s been years and years, I tell you, years and years) will recognize this as a common theme (I think I’ve twisted it every which way, over time, but you should recognize the basic form) and still one that I believe holds a key to compliance success ( I refrain from referring to it as “the” key, because the education “key” is pretty gosh-darn important as well).

And, interestingly enough, Mr. Mills’ column in the March 2013 issue of Perspectives focused on, wait for it…


Can I get an A(ssess)MEN(ts)! Stay tuned: You know I’ll have something to add to that conversation…

He ain’t HVA, he’s my opportunity

An interesting topic came across my desk relative to a January 2013 survey, and it pertains to the use of your HVA process as a means of driving staff education initiatives.

During the Emergency Management interview session during this particular survey, the surveyor wanted to know about the organization’s hazard vulnerability analysis (HVA) process and how it worked. So, that’s pretty normal—there are lots of ways to administer the HVA process—I prefer the consensus route, but that’s me.

But then the follow-up question was “How do you use the HVA to educate staff and their actions to take?” Now, when I first looked at that, I was thinking that the HVA process is designed more as a means of prioritizing response activities, resource allocations, and communications to local, regional, and other emergency response agencies, etc., but staff education? Not really sure about that…

But the more I considered the more I thought to myself, if you’re going to look at vulnerability as a true function of preparedness, then you would have to include the education of staff to their roles and responsibilities during an emergency as a critical metric in evaluating that level of preparedness. The HVA not only should tell you where you are now, but also give you a sense of where you need to take things to make improvements and from those improvements, presumably there will be some element of staff education. A question I like to ask of folks is: “What is the emergency that you are most likely to experience for which you are least prepared?” Improvement does not usually reside in things you already do well/frequently. It’s generally the stuff that you don’t get to practice as often that can be problematic during real-life events. One example is the management of volunteer practitioners—this can be a fairly involved process. But if you haven’t practiced it during an exercise, there may be complexities that will get in the way of being able to appropriately respond during the emergency. Which is why I recommend if you haven’t practiced running a couple of folks through the volunteer process, what better time than during an exercise?