Recent Articles
Joint Commission softens emergency management enforcement, for now
Hi everyone, it’s Scott Wallask over at HCPro jumping in today.
We obtained an interesting e-mail from a Joint Commission official that seems to indicate the heat is being turned down in 2008 on some of The Joint Commission’s provisions within emergency management standards EC.4.11 through EC.4.18 after hospitals expressed concerns.
At a meeting on April 17, a Joint Commission committee “approved not counting noncompliance with [certain] new emergency management standards in accreditation decisions during 2008,” wrote Gail Weinberger, director of accreditation and certification policy and administration at The Joint Commission.
“This means although noncompliance with these requirements will continue to be cited in an organization’s report and will be required to be addressed in an evidence of standards compliance (ESC), they will not be included in the count of the requirements for improvement contributing towards a conditional accreditation or a preliminary denial of accreditation decision,” Weinberger wrote. Her e-mail went to a list of “corporate liaisons” who weren’t specified in the copy we obtained.
The decision applies to the following specific requirements, as listed by Weinberger:
- EC.4.11, EP 9 (documenting an inventory of assets and resources)
- EC.4.11, EP 10 (monitoring quantities of assets and resources)
- EC.4.12, EP 6 (meeting the 96-hour provisions)
- EC.4.13, EP 7 (communicating with vendors of essential supplies and services)
- EC.4.14, EP 8 (sharing of assets and resources with healthcare facilities outside the community))
- EC.4.14, EP 10 (transporting patients, medications, equipment, and staff members to alternate care sites)
- EC.4.15, EP 2 (coordinating security activities with outside agencies)
- EC.4.15, EP 3 (managing hazardous materials and wastes)
- EC.4.15, EP 5 (for long-term care facilities, identifying residents who might wander)
- EC.4.16, EP 2 (training staff members about their roles in emergency response)
- EC.4.16, EP 3 (communicating to licensed independent practitioners about their roles in emergency response)
- EC.4.17, EP.4 (determining alternative supplies of fuel for building operations or essential transport activities)
- EC.4.18, EP 4 (managing mental health needs of patients)
- EC.4.18, EP 5 (managing mortuary services)
- EC.4.18, EP 6 (documenting and tracking clinical information)
Steve Mac will share some of this thoughts about this development in the next day or two.
Thanks…Scott W.
April 24, 2008 | Scott Wallask | Comments 0
Business continuity plans: Use HVAs and the Joint Commission’s six critical areas
Business continuity in general is a very organization-specific undertaking, and (like everything else) starts with the results of your hazard vulnerability analysis (HVA).
Focus on identifying a couple of different things:
- Those events or conditions that would result in something from which you would need to recover. For all intents and purposes, the depth of recovery is going to be fairly minimal for most events and conditions you’re likely to encounter. Any event that can disrupt your organization is good fodder.
- Those key aspects of business that would be sufficiently impacted to require some sort of recovery. You can certainly start (and perhaps end, depending on what you find) with Joint Commission standards EC.4.13 through EC.4.18, a.k.a. the “six critical areas” of emergency management: communication, resources and assets, safety and security, staff responsibilities, utilities management; and patient clinical and support activities.
What you could do is develop a matrix (similar to the configuration for the HVA), but list the “heavy hitter” events along the left side of the matrix, the six critical areas across the top, and do an evaluation of what the disruptive impact of each event would be in each of the critical areas.
For the most part, different events and conditions are going to have varying levels of impact on each of the areas. Then you could establish a benchmark score above which you would need to have a concrete business continuity plan, and everything else becomes either a non-event or something to address later on in the process.
April 23, 2008 | Steve MacArthur | Comments 0
Check out free audio clips with Dean Samet, Steve Mac, and Brad Keyes
Hi everyone –
It’s Scott Wallask writing in today. I wanted to let you know that we’ve just posted three free audio interviews on the main page of this Web site that I conducted with presenters at our upcoming Hospital Safety Symposium.
The interviews include discussions with:
- Dean Samet, director of regulatory compliance services at Smith Seckman Reid, who talks about The Joint Commission’s 2008 emergency management standards and what surveyors will focus on
- Brad Keyes, a safety consultant at the Greeley Company, who discusses why smaller hospitals need to pay special attention to the duties of The Joint Commission’s life safety specialists
- Steve MacArthur, primary author of this blog and also a Greeley consultant, who reviews how surveyors look at safety risk assessments under EC.1.10
To listen to the interviews, click on the Hospital Safety Center logo at the top of your page and then go to the right-hand column. Please be patient as the audio downloads may be slow depending on your system. I hope you find the info in the interviews to be helpful.
Thanks,
Scott W.
April 21, 2008 | Scott Wallask | Comments 0
Joint Commission queries about lockdowns
I caught wind of some recent Joint Commission survey notes, including what came up during an emergency management tracer.
In discussing the organization’s preparations for the six critical areas, the surveyor asked if the organization had ever conducted a lockdown drill. Then, upon an affirmative response from the hospital, the surveyor asked about the results of the most recent lockdown drill.
(By the way, in this era of ever-increasing demands for escalating drill scenarios, lockdowns are a nifty way to change the dynamic of even the most basic exercises. And if you’re feeling really lucky, try including the lockdown with minimal warning to staff at large–and don’t forget to take pictures!)
Then the surveyor asked a kind of interesting question in follow-up: Where does the organization get the manpower to implement lockdown procedures?
I’m not quite sure what prompted the question specifically, but sometimes the ways of the surveyor are many and varied. This issue actually dribbles over a bit into EC.4.16, which requires you to manage staff roles and responsibilities during responsibilities.
Now, for some organizations, staffing a lockdown might be the most simple of tasks, but I’d wager that, depending on the type of event, you might not want to “waste” your designated security resources to implement the lockdown.
In which case, you need a reliable and well-stocked resource pantry, a.k.a. the manpower pool. And also ideally a plan. A poorly handled lockdown, even during a drill, can be a customer service nightmare. “What do you mean I can’t come in to see my sick mother?”
Something to think about . . .
April 16, 2008 | Steve MacArthur | Comments 0
The late-arriving life safety surveyor (or the continuing saga of surveyus interruptus)
There’s a story coming out soon in the next issue of our Healthcare Life Safety Compliance newsletter about how on occasion, The Joint Commission’s life safety specialists are arriving at different times than the regular survey team.
Just to confirm this, I had a client recently surveyed who was informed that the life safety surveyor would be on site “sometime in the next two to three weeks” (I’m quoting the client, not necessarily the survey team).
One of the fascinating dynamics is that when the regular survey team members left, they only provided a verbal report of their findings–nothing in writing until the life safety tour is completed.
It’s my understanding that The Joint Commission is hoping to get things on track by sometime this summer (or as we say here in the Boston area, “summah”). However, those folks in the mix until then are likely going to have some anxious moments (not at all like waiting for the next installment of your favorite blog entries, but I digress) as they try to identify post-survey strategies.
On the consultative advice front, I guess my best thought would be not to take any concrete post-survey steps until you have the full survey report in hand. The absolute key to post-survey response is to base either your clarification or evidence of standards compliance on the exact verbiage in the survey findings.
And, please, please, please (I’m channeling James Brown again–do it on the one, heh!) don’t fix something that isn’t broken. You know what compliance looks like in your house, so embrace the courage of your convictions and you’ll be doing the right thing–once the life safety surveyor comes and goes.
Talk about building suspense.
April 15, 2008 | Steve MacArthur | Comments 0
Three useful CMS links regarding the Life Safety Code
Hi everyone, it’s Scott Wallask over at HCPro jumping into the blog today. I thought it might be a good idea to give everyone a trio of links that I’ve found very helpful over the years when it comes to tracking CMS developments with the Life Safety Code (LSC).
1. LSC page. This gives an overview of CMS’ enforcement of LSC provisions for hospitals, nursing homes, ambulatory surgical centers, and other medical settings.
2. Downloads of CMS forms. The fire safety forms fall under the 2786 series of forms, to which you can scroll down or search for by typing in “2786,” which will then open a zip file.
3. Memos to state agencies. These memos outline CMS rulings or interpretations of LSC requirements and are useful documents to have handy before and during inspections. You’ll see they’ve already been busy with two postings from January. You may need to play with the sorting tool to view the most recent posts. www.cms.hhs.gov/SurveyCertificationGenInfo/PMSR/list.asp#TopOfPage
Thanks,
Scott W.
p.s. It’s not too late to join us in Las Vegas for the Second Annual Hospital Safety Symposium. Caesars Palace is calling your name . . .
April 11, 2008 | Scott Wallask | Comments 0
Tales of survey derring-do, part two
Last week I ran some questions that have been asked by surveyors during Joint Commission visits to hospitals this year-and I promised more, so here goes:
- How does the hospital meet the six critical elements outlined by The Joint Commission for emergency management (i.e., communications, resources, safety/security, staff responsibilities, utilities, and clinical activities)?
- What if employees can’t get to a hospital during a community emergency?
- How will the hospital get more ventilators during an influenza outbreak?
- What prevents someone from coming into a pediatric unit on the tail of someone else without formally getting buzzed in?
- What does the hospital do with chemotherapy waste?
- Do staff members don gowns in the chemo unit?
Once again, note how the questions focus on managing your processes and identifying your risks.
I’ll be digging into risk assessment strategies more at the Second Annual Hospital Safety Symposium May 8-9, so I hope you’ll be there.
April 09, 2008 | Steve MacArthur | Comments 0
Tales of survey derring-do
I hope I’ll have the opportunity to meet a lot of you out in Vegas May 8 and 9 during our Second Annual Hospital Safety Symposium. I can promise you these twos won’t be so terrible.
One of the topics we’ll be covering in a variety of permutations is what to expect during your 2008-2009 survey. To kind of tease discussion of the topic in Vegas, we’ve assembled this brief compendium of questions that have been flying around during surveys since the first of the year.
As you’ll see, the questions are very much focused on process and, what’s most important, the focus is clearly on how you manage your processes (e.g., how you identify risks, make improvements, all that good stuff).
You might even try using some of these questions at your next safety committee meeting to get some good discussion going. You can never do too much prep work when it comes to the EC.
In this particular bunch, these questions were asked of an employee:
- 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?
More to come . . .
April 02, 2008 | Steve MacArthur | Comments 0
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.
April 01, 2008 | Steve MacArthur | Comments 0
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).
If we start with the thought that the implementation of ILSMs evolves out of the risk assessment process, can we not further carry it into the realm of process improvement? And, as a function of process improvement, do we not periodically monitor and evaluate the effectiveness of, and potentially rethink, the interventions already in place?
But, of course we do–or for the Francophiles, mais certainment!
You can’t always pick a winner, but as you collect and analyze ILSM data, you can develop a pretty good track record over time. That’s where your surveillance rounds support your decisions because that’s the data upon which you make future ILSM determinations.
It’s not so much about the frequency of the inspections (though don’t forget the daily inspection of egress routes from the construction area if you use that particular ILSM), but the quality of the data collected as the result of those inspections.
You have the means of effectively evaluating the effectiveness of your ILSMs, so you might just as well use them.
March 26, 2008 | Steve MacArthur | Comments 0
