Getting locked in the bathroom: A risk assessment awaits

I was discussing recently the idea of staff members’ ability to rescue patients who lock themselves in a bathroom. Ultimately, your plan in this regard revolves around a risk assessment.

Such an evaluation should be based on the configuration of the patient bathroom locks in your facility.

I can tell you that there are still surveyors that like to do the “I’m locked in the bathroom and having chest pains, how fast can you get me out” scenarios during visits to patient care areas.

From a strictly risk management perspective–as getting locked into a bathroom is an event that could be expected with some degree of certainty–it is incumbent upon the organization to ensure an appropriate response (including availability of whatever means is necessary to achieve emergent access).

Ban on TB fit-testing is now officially over

Hi everyone, it’s Scott Wallask checking in from HCPro.

It appears the dissolution of the annual tuberculosis fit-testing prohibition is now official, as President Bush signed the fiscal year 2008 budget for labor and health and human services in late December. A record of the bill–numbered H.R. 2764–indicates it is now public law.

OSHA’s budget falls under this bill. In prior years, it was within this area of the budget that you’d find the prohibition of OSHA enforcing annual TB fit-testing. But that prohibition isn’t in the current budget’s wording, which brings to an end a several-year ban on such fit-tests.

Let us know what you think by clicking the comments link below.

Thanks,

Scott Wallask

swallask@hcpro.com

Emergency prep–it’s more than just compliance

When thinking about recovery efforts from disasters, you should consider Joint Commission (formerly JCAHO) standards EC.4.13 through EC.4.18, aka the six “critical areas” of emergency management:

• Communication
• Resources and assets
• Safety and security
• Staff responsibilities
• Utilities management
• Patient clinical and support activities

A key component of this whole process is coming up with a prioritized approach based on your organization’s real-life challenges. Once you’ve established the priorities, then it’s just a question (OK, with a whole heck of a lot of grunt work) to come up with the plan for each event.

But remember, there may be events for which you’re not going to have to address each of the critical areas, so if you don’t have to do it, don’t feel like there’s some sort of obligation to do so. Your responsibility is to prepare your organization in an appropriate fashion–no more, no less.

And so, when it comes to survey time, take an organized, logical approach to whatever the issue at hand might be.

Ultimately, the acid test is whether you are comfortable that you have prepared the organization to the extent necessary. If you can look yourself in the mirror and say, “We’re in good shape”–knowing full well that perfection in this area is nothing but elusive–then your comfort and confidence will carry the day during survey.

Compliance during survey is way down the list of objectives for this process. Adequate preparation for emergencies is everything, and Joint Commission compliance is a happy byproduct.

A Joint Commission reference raises EC questions

There is a footnote in the proposed life safety standards relative to the manual transmission of alarms that references an issue of Environment of Care News, which is a Joint Commission newsletter.

Does this somehow introduce EC News into the realm of “enforceable” information sources? Or is it merely mentioned in the context of the draft and the mention will be removed when the chapter is finalized?

I find it curious that the reference cites the Joint Commission’s “policy on the manual transmission of fire alarm signals.” I can’t say that I’ve ever run across their “policy.” Is it in the Comprehensive Accreditation Manual for Hospitals? Has it been in Perspectives?

What the heck are they talking about?

Is the hole opening up for life safety citations?

You know, it occurred to me the other evening in the wee small hours that the separation of the Life Safety Code into its own accreditation chapter could have devastating results when it comes to counting RFIs towards conditional and preliminary denial.

Prior to this, life safety citations all rolled under EC.5.20 (with maybe slight diversions into EC.5.10). Now we’re looking at nine life safety standards to score.

Can you imagine if surveyors find stuff in a couple of different directions? You could be dead in the water at the end of day one–ouch, ouch, ouch!

Thumbs tacks, bulletin boards, and risk

I was corresponding with a plant operations manager recently about using thumb tacks on bulletin boards in patient care corridors.

Because there are no standards-based requirements for bulletin boards, you can pretty much do whatever you feel is a safe practice–which, of course, invokes the mighty risk assessment.

There are one or two concerns you might want to consider along the way:

• The likelihood that a person could use thumb tacks as weapons
• The possibility that someone could ingest the thumb tacks

Don’t just think of this in terms of suicidal patients–you might want to extend consideration beyond that patient population and include visitors. And how about pediatric patients? They might be an “at risk” population for mischief.

The other possible issue relates more to the amount of postings on the bulletin boards. Some surveyors have been known to pick on generously configured bulletin boards for increasing the combustible load. In fact, I’ve witnessed George Mills of The Joint Commission (formerly JCAHO) push the issue a little bit during a survey.

You may end up deciding that the best way to manage the whole thing is to have enclosed bulletin boards with some sort of security hardware. That way the tacks are out of harm’s way and the combustible load aspect becomes a non-issue.

A Crocs link many of you will want to see

Hi everyone -

It’s Scott Wallask checking in. I saw a posting on the listserv run by the Association for Professionals in Infection Control and Epidemiology, in which someone was kind enough to post a link to OSHA’s 2006 informal opinion about Crocs in healthcare settings.

As many of you know, few fashion concerns bring up a good ol’ fashioned debate as well as Crocs do. I actually saw a Crocs store in downtown Boston a few weekends ago.

Anyway, the OSHA posting isn’t official, nor is it a letter of interpretation, so take it for what it’s worth.

Happy holidays,

Scott W.

swallask@hcpro.com

About those little plastic outlet cover thingies

Also of survey note is the wonderful world of electricity and at-risk patient and visitor populations.

One of the perennial favorites of surveyors is the whole issue of appropriate safeguards in waiting rooms, patient rooms, and other locations in which certain folks (the at-risk population in question) might be inclined to introduce metal objects into the electrical receptacles.

I know a lot of folks use those plastic outlet cover insert thingies as a means of protection, and though I know that there is limited guidance in terms of requirements, I would counsel you to explore other protective measures in this regard.

For those of you who don’t know me, my first 17 years in healthcare were in the environmental services realm, so please understand that I am not picking on anyone when I say this: Any time I find places that use the inserts, I invariably find uncovered outlets, too, at which point I jokingly guess that the housekeepers who vacuum the area have piles of these plastic inserts on their bureaus at home.

Never a bad idea to remind folks to put these inserts back in when they’re done using the receptacles.

But how about using tamper-resistant receptacles in those at-risk areas? I know they’re more expensive that the little plastic inserts, but there’s gotta be a break-even point somewhere, yes?

Tamper-resistant receptacles are so much more effective as interventions. They never wander away or get stuffed in someone’s pocket. They’re always there 24/7–now that’s service! This word brought to you by the outlet board…

Surprise, surprise, surprise

Just a few weeks ago I was involved with an unannounced survey by The Joint Commission (formerly JCAHO). I encountered one of those funny little happenstances that really isn’t that funny: a surveyor who expressed surprise when the data that he had recorded during the survey was sufficient to warrant a requirement for improvement (RFI) under EC.5.20.

For the record, I wasn’t surprised–and I don’t think it has anything to do with math skills.

Now for those of you who “believe” in the 95% rule based on the practical implementation of a building maintenance program (and especially to those who have disagreed with my interpretation of how the BMP gets surveyed), please consider this in the spirit of holiday giving. The following items added up to an RFI:

• A single exit sign that the surveyor thought should be pointed in a different direction
• A single smoke door with a gap greater than 1/8 inch and no astragal
• A single penetration in a rated wall
• A single location requiring fire-proofing of a steel beam

Oh, by the way, the exit sign, smoke door, and rated wall had all been repaired before the end of the survey.

Now I am very hopeful that these citations (with the possible exception of the beam) will be overturned on clarification. The folks in question have a solid BMP in place, but the numbers involved (1+1+1+1 = RFI) are important to keep in mind as you go through survey.

I’ve likened this, probably ad nauseum, to a death by a thousand cuts. But thing that really gets me: Do the surveyors really not understand how the scoring works? Was he really surprised at the RFI?

I know that the mark for just about any B or C element of performance is:

• Zero to one instances of not meeting the EP means you fully comply
• Two instances is generally partial compliance
• Three or more instances is noncompliant

The above scoring is in effect during survey. Post-survey becomes a lesson in determining compliance percentages (90-100% for full, 80-89% for partial, and you know what happens when you go south of that point).

So where’s the surprise, especially with four instances of noncompliance under EC.5.20? Oy!

You need to do your presurvey assessments very carefully and keep a close eye on those mounting instances of noncompliance. All those supplementals of years past are living together in the land of the surprise RFI–and that’s one “foreign” land that doesn’t require a government-issue passport for entry.

It’s not 96 hours or bust for EC.4.12

Contrary to popular interpretation, EC.4.12, EP #6 does not require hospitals to be self-sustaining for 96 hours.

No, really!

There is a note following this EP that indicates an “acceptable response effort would be to temporarily close or evacuate the facility, consistent with their designated role in their community response plan.” And, interestingly enough, this is a “B” element of performance, so the burden of proof is on the organization to determine what they need to do to meet this EP.

So, what EP #6 does require is that each organization has some sense of how such an event (effectively being cut off from the outside world for 96 hours) would be managed. Some hospitals might be able to do a 96-hour solo standing on their heads, while others might struggle to do 24 hours.

One of the clear lessons learned during Katrina is that many (if not most) of the hospitals involved didn’t know that an “acceptable” part of their response plan would be to get out in the event that they could no longer safely care for patients. I think this is partially the result of the whole “defend-in-place” strategy that has always applied to hospitals from a fire and life safety perspective. I think somehow defend-in-place crossed over into the management of disasters and catastrophes.