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Burning with optimism’s flame: A future state in which surveys are less frightening…

As you are all no doubt familiar at this point, one of the key management processes promulgated by (or is it through?) the 2012 edition of NFPA 99 Health Care Facilities Code is that of the risk assessment as a means of determining how to best manage risks to folks using our facilities—patients, staff, visitors—it’s a tall order no matter how you parse it.

That said, I read a very interesting article in ASHE’S Health Facilities Management publication on how the industry might be able to start moving towards a standard process/practice with the (more or less) aim of being able to develop data that can truly demonstrate that the risk factors being used to determine the level of risk are supported by the numbers. Ultimately, the go-forward on this would be to have a robustly data-driven program for the management of equipment (utility systems equipment as well as medical equipment) that establishes a framework for performance, determining effectiveness, etc. that would be bulletproof during a survey. As a description of a useful future state (as opposed to the same ol’, same ol’ survey process of calm interspersed with periods of insane demands from our “customers”), I think you’ll find a lot to think about, so I encourage you to give it a look.

Moving on to what may be a trending esoteric finding, it appears that covering any outside cylinder storage locations might be one of which to be mindful. Strictly speaking, we are on the hook for protecting stored cylinders from overheating (with a target temperature of 130 degrees F—pretty hot stuff), which one might suppose is a least to some degree,  a function of geography (I would imagine there are some locales for which 130 degrees of ambient temperature might be an occurrence of some rarity. That said, if you do have cylinder storage space exterior to your facility, it might behoove you to document a little risk assessment (perhaps in coordination with your medical gas and vacuum testing vendor) to determine whether your cylinders are too hot to handle (strictly from a code perspective).

Identifying issues and finding solutions…

…versus identifying issues and pointing fingers.

I think we can all agree that (at least for the moment) our friends in the regulatory survey services world have misplaced the location of their customers and, as a result, have become significantly more punitive in administering the survey process. Of course, the accreditation survey team always tells organizations that, despite the umpty-ump number of findings, they are a quality organization and really, this was a good survey. I have yet to hear of any instances in which the survey team “supported” anything other than a positive vibe, but it seems that, in growing numbers, that vibe is not really translating past the point of the exit conference.

Now, I know that it is not the role of the accreditation organizations to do anything more than identify deficiencies (I have hopes that a more consultative approach will re-emerge before too long, but I am not holding my breath), but what I keep bumping into are instances in which the folks (internal and external to an organization) charged with preparing organizations for survey are almost as punitive in their administration of the survey prep process. The purpose of environmental rounding/touring, etc., is to help folks become as prepared as possible and to identify strategies for sustaining compliance. It is not about the “gotcha,” with follow-up paperwork. My personal philosophy (as a safety professional in general, but certainly as a consultant) is that my obligation to the process is to help get things going in the right direction, even to the point of cleaning up a spill or picking something up off the floor while touring. Certainly, I can (and do) identify lots of things that need attention, because there are always lots of things to find that need attention (this goes back to my “no perfect buildings” philosophy; probably too much philosophy for so early in the year, but so be it). But I go into this having suffered at the hands of consultants (and others) who are not as interested in helping work through an issue to achieve some sort of sustainable solution.

As an example, I recently heard about an instance in which the environment of care rounding team had identified a resolution to a pesky issue (in this case, ensuring that specimen containers were appropriately labeled) but did not share that resolution with the entire organization. So last time, a “sticky” label was affixed to the container, but the label didn’t stick so well; this “failure mode” was communicated to the folks in infection control, but there was no immediate follow-up. So, next rounding activity, a specimen container to which a “sticky” label had been affixed was, in the local parlance (not really), nekkid in terms of labeling. Well, after the labeling issue had been cited, it was “revealed” that, after some consideration (may have been careful consideration, but less careful in the communication), it was determined that the containers would be stenciled in more permanent fashion. Interesting thing, the “finding” still required response, etc. even though the “finding” was the result in a communications misfire.

At any rate, as I think I’ve noted here before, there’s no regulatory statute that requires us to shoot ourselves in the foot, or, indeed, to engage in friendly fire. To my way of thinking, internally punitive surveying is not helpful and since we know the “real thing” isn’t particularly helpful (to healthcare organizations, at any rate), doesn’t it make more sense to work together towards sustainable compliance?

Quick closing question: While I was having some lab work done today, I noticed that the emergency eyewash station in the sink area was covered with a clear plastic bag. Has anyone out there in blogland encountered this or are practicing it? I’m thinking that this adds a step to activation of the eyewash station, but perhaps there’s a risk assessment that supports it. Just asking for a friend…

On your marks, get set, sweat!

But hopefully not a Billy Idol kind of sweat…

Our friends in Chicago are once again tweaking the survey process, with the result being less time for surveyors to wait for organizations to muster their troops at the outset and pretty much no time at all before they are out and about doing tracers. Basically, what used to be the surveyor planning session in the morning of the first survey day is now being flipped and combined with the special issue resolution session at the end of the day. For organizations to adapt their process to the changes, folks should be prepared to do the following:

  • Prompt alert of/to the leadership team of any on-site survey to facilitate their availability for a prompt opening conference (I can’t think of too many folks who are not already doing this)
  • Prepare all required documentation and deliver those documents to the survey team immediately after the team is escorted to their “base” (the list of required documents is available in the Survey Activity Guide, although it begs the question as to whether this includes the life safety documentation…)
  • Gather the scribes together so they are ready to hit the pavement as soon as the (ever-so-brief) opening conference is completed

Somehow I think this may all tie across with the folks from CMS accompanying the Joint Commission folks as part of the validation process—anyone who has dealt with a state and/or CMS survey will tell you, there’s not a lot of time (or indeed, inclination) for pleasantries. The job of being prickly requires a lot of inflexibility, which does seem to be the hallmark of the current survey process.

These changes to the survey process are effective March 2020.

I sit at my table and wage war on myself—and earn an OSHA citation!

While I have a sneaking suspicion that this Top 10 list doesn’t change a whole lot from year to year (other than position in the hierarchy), I thought it would be of interest to trot out which occupational safety considerations are manifesting themselves across industries. I can certainly see where any of these might crop up in healthcare.

And so, to the list:

10: Personal Protective and Lifesaving Equipment – Eye and Face Protection

9: Machine Guarding

8: Fall Protection – Training Requirements

7: Powered Industrial Trucks

6: Ladders

5: Respiratory Protection

4: Lockout/Tagout

3: Scaffolding

2: Hazard Communication

1: Fall Protection

Again, no big surprises, but I guess it does point out some areas for future consideration, mostly as a function of initial and ongoing safety education. These are the types of things, especially when dealing with contractors, that can result in a very uncomfortable situation if something goes sideways on your campus—even if it’s not your staff. Once the Big O gets through the door, it’s tough to contain their interest in all things safety.

Closing out this week, one of the questions that seems to be coming up with greater frequency during Joint Commission surveys relates to how your organization determines that the individual(s) tasked with doing your rated door inspections are knowledgeable/competent (we know from our intense scrutiny of NFPA 80 that these folks do not need to be certified; it is a handy way to demonstrate that an individual is knowledgeable, but you can certainly evaluate/validate competency in other ways). And pondering that equation made me a little more interested in the following news story than might normally have been the case (there isn’t a time when I wouldn’t have been interested, but this was an especially telling confluence). It seems that an individual has been accused of defrauding some VA hospitals by billing them for work that had not been performed; a little more detail can be found here. I know a lot of folks have struggled over the years with vendors who prefer to “come and go as they please,” which typically results in less control over the process, including timely notifications of discrepancies. I’m curious as to how this ends up when it makes its way through the courts, but I can see a time when those pesky surveyors might start to ask about how one knows that the service for which they have documentation actually occurred. Hopefully this case is all a big misunderstanding and there were no real gaps in oversight…

What we all want: If everything is priority one, then everything is priority none

As our friends from Chicago appear to be embarking in earnest on their charge to be as unpredictable as possible (I know of one instance in which a triennial survey “landed” about 10 months early—if that doesn’t merit a “yow,” I’m not sure what does…), the general concept of constant readiness would seem to be in flux (I think we all “knew” that the true survey window was considerably more limited than what it could be).

To that point, lately I’ve been working with folks who are well and truly within a survey window (lots of folks poking around in healthcare organizations these days…) and I’ve been noticing a tendency for folks requesting things to use “tomorrow” (or something similarly unrealistic) when identifying a requested completion date. And then raising a fuss when things are not repaired/replaced/refurbished almost instantly, which puts the folks who actually have to get the work done in a rather precarious position, depending on how quickly/dramatically the fussiness gets escalated. I think we can agree that expectations like instantaneous gratification do not lend themselves to thoughtful assessment of risk, or even (truth be told) basic triaging of tasks. I know that in crisis mode things can become a little unhinged, but the way the survey process is starting to turn, if we don’t find a way to really hardwire that classic finder/fixer dynamic as a way of like, the potential for chaos as a way of life is fairly strong.

So, the question I have for you out there in the studio audience is this: Does anybody have any unique methodologies they’d be inclined to share? I will freely admit to being at something of a disadvantage in that it has been a very, very long time (other than some interim gigs) since I’ve had day-to-day operational responsibilities in a hospital so there are probably technology solutions, etc., that could be leveraged in pursuit of focused order. But I also know that there is still a fair amount of what I like to call the “corridor work order request,” which, in my younger years, was probably not that big a deal, but now, as I approach my dotage, I find that I am not able to instantly recall quite as much “stuff” (I’m still pretty good, but the seams are much more apparent now).

I’m sure you are all following (with perhaps varying degrees of trepidation) the events unfolding in China relative to the Wuhan coronavirus; if you’re not making a regular stop at the CDC website for updates, etc., I would highly suggest it be a touch point at least every day or so. It’s starting to manifest itself a  bit stateside and I suppose, given the omnipresence of travel these days, it’s only a matter of time before it starts showing up in less-populated regions of the country. You can find as much information as is available here. Hopefully, this one subsides quickly, but preparedness, it seems, is everything these days.

Don’t get soaked by your water management program!

I don’t know about you, but lately I’ve been finding the most interesting stuff being published in Perspectives are the articles entitled “Consistent Interpretation” because I am fascinated by the data they are collecting that drives taking particular note of the standard or performance element being featured. For example, the January 2020 issue covers the intricacies of managing the risks associated with waterborne pathogens, a topic that I’ve been keeping an eye on if only because of the attentions paid to that topic by our friends at CMS (if you’ve lost track of where they are in the fray, feel free to make the jump—but don’t forget to come back!). I figure there are just enough peculiarities involved for this to wreak some havoc during accreditation surveys, and while there are ways for survey findings to be generated, it would appear (based on the just under 4% citation rate during the first half of 2019) that you folks out there in the field are making pretty good headway.

So, where things can go awry include: Not having a water management plan to deal with waterborne pathogen risks (not sure how someone would have missed that, but perhaps it was a question of a slower than normal implementation track); failing to include a new piece of equipment (for instance, a brand new cooling tower) in the program (I should think the time for risk assessment and inclusion is during the commissioning of new equipment); failing to maintain the water in the system in accordance with the levels called for in the water management plan; failing to document scheduled testing and monitoring; and failing to establish acceptable ranges and/or control measures to be taken when levels are out of range.

It would seem that decorative water features, ice machines, and water dispensers were in the mix as well, including issues with equipment not being maintained in accordance with the manufacturers’ instructions for use, but in looking at all the different ways water management concerns could be cited, I suspect a lot of the cited conditions (you can find more specifics in the January Perspectives) were not widely observed.

That said, since a lot of the nuts and bolts implementation of water management programs may be accomplished by “others,” I think that going forward, the surveyors will be especially attentive to reviewing your water management plan and any deliverables from testing and monitoring activities. There are a lot of moving parts in this endeavor; best to be ahead of the curve and keep a close eye on those reports.

You might find this week’s post somewhat shocking!

One of the survey findings that I’ve noted as trending towards a standard “gotcha” (primarily during state surveys) relates to the topic of arc flash safety and, most particularly, to the labeling of your electrical panels. Generally speaking, much of this stuff is covered by NFPA 70E-2012 Standard for Electrical Safety in the Workplace, with the labeling requirements (section 130.5 (C)) being: “electrical equipment such as switchboards, panelboards, industrial control panels, meter socket enclosures, and motor control centers that are in other than dwelling units, and are likely to require examination, adjustment, servicing, or maintenance while energized” to be field marked with a label containing all the following information: (1) at least one of the following: a. Available incident energy and the corresponding working distance; b. minimum arc rating of clothing; c. required level of PPE; d. highest hazard/risk category (HRC) for the equipment; (2) nominal system voltage; (3) Arc flash boundary. NFPA 70E also requires the method of calculating and data to support the information on the label to be documented.

I know we tend to focus on hospital-specific safety concerns in this forum, but findings relating to the absence of arc flash safety labeling have surfaced enough (at least to my mind) to make it worth a mention. Part of my concern in this regard is that I see a fair number of electrical panels, etc., for which there is no arc flash safety labeling and, as near as I can tell, there appear to be no provisions for “grandfathering” existing non-compliant conditions. So you may want to take a look at your electrical panels and any other energized equipment that are “likely to require examination, adjustment, servicing, or maintenance while energized.”

And, while we’re on the subject, EC & M has a very nicely crafted presentation on arc flash safety and compliance; you’ll probably have to pony up an e-mail contact in exchange for a viewing, but I found the content to be fairly illuminating (and yes, that was a pretty gosh-darn hideous pun). Visit their site to find this info (and some other stuff as well).

The place of working dangerously: The importance of kitchen safety

Recently, I fielded a question regarding fire response plans for food services and got me to thinking about the importance (and challenges) of good safety practices in the kitchen.

My firm belief has always been that,  for all intents and purposes, the kitchen is among the most “dangerous” locations in the hospital (when you think of pretty much all the classic safety “risks”, the kitchen has them—fire, slips, trips, cuts, chemical exposures, etc.) and also possesses among the most (if not the most) transient work forces in healthcare. Add to that the frequency of the entry-level folks being new not only to healthcare, but sometimes the working world, success really rests on the effectiveness of education, from the point of onboarding through regular department education, including the conduction of fire drills.

In poking around on the web, I came across some information provided by the Lafayette (Indiana) Fire Department relative to commercial kitchen fire safety that I think is well worth checking out for some cues in how to work with the Food & Nutrition folks to ensure the education process is all that it can be. I have noticed over the years (my wife is a big fan of cooking shows) that the celebrity chefs don’t focus as much on fire safety as they do on food safety (though I suspect Gordon Ramsey might have a few choice words if one of his restaurants had a fire). And I also know that some of the key components of fire response in a kitchen is a little counter-intuitive relative to how folks are trained in general, particularly the activation of the suppression system before one tries to use an extinguisher. I think these folks deserve a fair amount of focused support and the information contained here. It really provides you with a good road map for ensuring that your kitchen areas are as safe as they can be.

2020 starts with a whimper…probably mine!

A fairly brief opening salvo for the New Year: I am hoping it will continue to be difficult to come up with material for this space because that will likely mean we’ve reached something of an equilibrium relative to funky compliance stuff. After the last decade, I think we can probably all use a bit of a rest from the madness…

For those of you keeping track of the goings on in Chicago, you’ve no doubt received any number of exhortations over the past couple of weeks to check out the “new” (the “improved” is somewhat implied, but if you order in the next five minutes, they’ll double your order!) Joint Commission website.  I will say that they have definitely spiffed up the look of the place—everything looks bigger and brighter. But (and isn’t there almost always one of them?), in retooling things, some of the less recent links to material are no longer working. To that point, I had saved a couple of links to share this week, and now that they don’t work, I can’t quite say what it was that I found of particular interest (shame on me for not leaving a better trail of bread crumbs, though perhaps those pesky birds…). So, if you do some archival digging in this space (and perhaps others as well), you may find yourself at the business end of an error message indicating a non-functioning link. Having said that, if you should follow a link from Mac’s Safety Space that dumps you somewhere in the ether, please let me know and I will either try to find the “current” whereabouts of the information you’re looking for or provide some level of analysis to assist you in your efforts.

As an almost completely unrelated item to finish this up for the week, I wanted to bring to your attention a recent finding relating to space heaters that might prove timely given this age of polar vortices (vortexes?) and all manner of cold weather. The finding relates to a portable space heater in a nurse station, with the enjoinder that, for the purposes of this performance element, nurse stations are considered patient treatment areas (looping back on the prohibition of portable space heaters in smoke compartments containing sleeping rooms and patient treatment areas). You can have them in offices that meet the definition of non-sleeping rooms, which are occupied by staff and separated from the corridor and are permitted to have portable space heaters (the heating elements must not exceed 212°F). I’m sure you know where the folks with the cold feet live, so make sure you keep a close eye on the heater situation.

Getting a word in edgewise: Take back the power!

We’re looking at a lot of cusps this week—the ending of one year and the beginning of another; the end of a decade and the beginning of the latest edition of the roaring ’20s, so I figured I’d do a quick kickoff post for your consideration.

I suspect that at some point in time over the years (or perhaps even over the minutes of each and every day), you have found yourself in a conversation that is more of a soliloquy (and not your soliloquy) as you attempt to “get a word in edgewise.” I find that engaging with a conversational steamroller is among the most frustrating occurrences (not the least being the steamroller’s seeming inability to “listen” and/or “hear” what anyone else is saying). So, as I was looking over various feeds last week, I came across an article about just this topic. Truth be told, while I found the information contained therein very thought-provoking, I haven’t been able to put these concepts to the test just yet so I can’t personally vouch for their efficacy. But I “see” the logic (and the simplicity) of the suggestions enough to definitely want to give it a try moving forward. I don’t know that I would call it a “New Year’s Resolution,” but anything that can increase the effectiveness of personal communications can’t be a bad thing.

On that note, please accept my fondest wishes for a 2020 full of personal and professional success and development and my thanks for sticking with me through the vagaries of my “head” space. I’m glad to have you all aboard!