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For those of you not so executively inclined: Mac’s Brief on the September TJC Executive Briefings

To the surprise of almost no one (as far as I can tell), when The Joint Commission (TJC) unveiled the top 10 most frequently cited standards for the first six months of survey year 2011 at the annual Executive Briefings meeting, five (count ‘em) of those standards were in the environment of care (EC)/life safety (LS) world. Each standard relates directly to the increasing coverage of the life safety surveyors. It also appears that their scope is going to be expanding into the realm of infection control (IC), but more on that in the next blog post (stay tuned).

While the EC/LS world had to settle for second place on the list with LS.02.01.20 (taking third: LS.02.01.10, fourth: LS.02.01.30, fifth: EC.02.03.05, and eighth: LS.02.01.35), it is clear there is a great deal of work yet to be done by hospitals to gain a little control over this deluge of deficiencies.

A whopping 57% of hospitals surveyed between January and June were cited on LS.02.01.20, which has everything to do with maintaining the integrity of egress. Hospitals were caught for a number of deficiencies: doors locked in a means of egress, projections, corridor clutter, and configuration/designation of suites.

My colleague Brad Keyes and I have spoken (some would say approaching ranting) about the importance of your life safety drawings and how they facilitate the survey process if they are accurately maintained. It appears the quality (or lack thereof) of life safety drawings are more frequently put to the test during survey, with not-so-glowing results. (I’m interpreting a 43% success rate as something less than A-level performance.) I suspect that a majority of the findings might still relate to corridor clutter (after all, how difficult is it to find two instances of unattended, unallowed stuff in the corridor, hmm?) Interestingly enough it was revealed that one cannot manage the corridor clutter LS deficiency through the plan for improvement (PFI) process, which is kind of stinky.

My opinion is that if you do your risk assessment for interim life safety measures (ILSM) to compensate for the LS deficiency represented by corridor clutter and actually resolve it in some way, then that is an appropriate use of the process. But, in this case—and so many others, it makes my head spin—my opinion matters not a whit. So egress woes top the list.

Moving on to LS.02.01.10, which also has a 57% rate of findings in hospitals for the first half of 2011. This one’s fairly straightforward: doors (not latching), doors (undercuts), doors (lacking closers), more doors (can anyone say door stops?), and then sealing around ductwork penetrating fire-rated barriers. Again, how difficult is it to find this stuff (and yes, I know that it is our job to make it difficult, but still…) Once again, accurate life safety drawings are the key; if your drawings say door is a fire door, then that’s how it will be surveyed, even if it’s a smoke door now since you’ve sprinkled your building–the drawings never lie!)

More top-cited standards will be discussed in the next blog post–stay tuned!

Cappiello named COO of Healthcare Facilities Accreditation Program

We’d like to report some exciting news: former Joint Commission vice president and long-time advisor to HCPro’s own Briefings on The Joint Commission, Joseph L. Cappiello, has been named the chief operating officer for the Healthcare Facilities Accreditation Program (HFAP). Mr. Cappiello has been a great help to HCPro’s Association for Healthcare Accreditation Professionals (AHAP) and Briefings over the years. You also might know some of the books he’s authored, including The Chapter Leader’s Guide to Emergency Management. We’d like to congratulate Joe on his latest endeavor!

From the official press release:

Joseph L. Cappiello has been appointed new Chief Operating Officer of the Chicago-based Healthcare Facilities Accreditation Program (HFAP). HFAP, the nation’s oldest hospital accreditation organization, has been authorized by the Centers for Medicare and Medicaid Services (CMS) to accredit healthcare facilities for compliance with CMS standards since the beginning of Medicare in 1965.

Cappiello served for 10 years as Vice President of Field Operations at The Joint Commission and brings to HFAP a strong history of accreditation management experience. His role at HFAP will be to direct the nimble and educative approach to facility accreditation that exemplifies the organization, and to lead the continuing evolution of an accreditation process that meets the challenges of the complex healthcare environment. Mr. Cappiello will take his post October 3. He succeeds George A. Reuther, who is stepping down after 25 years of service

“As a smaller organization, HFAP can provide facilities with both a rigorous assessment and a resource for improvement, should they miss the mark,” said Michael J. Zarski, HFAP CEO. “We are thrilled to have Joe join our team, to help us further our personalized approach to the accreditation process. His caliber and experience will provide great value to HFAP and the facilities we work with.”

“HFAP is not just as an evaluator, but an educator,” said Cappiello, “which is what first drew me to the organization. It’s also light on its feet—quickly adaptable to the changing quality environment. And it brings a holistic survey process that creates a true partnership with the facilities it serves. I am pleased to be onboard.”

Cappiello was Vice President for Accreditation Field Operations at The Joint Commission from 1998 to 2008, directing key internal functions as well as the 500-member field surveyor cadre. Known as an innovative and dynamic leader, Cappiello reorganized the operational structure of accreditation operations and made dramatic improvements in the training and operational effectiveness of the surveyor cadre.

Spearheading initiatives on emergency management and disaster response, he led evaluation teams to New York City following the attacks of September 11, testified before Congress after Hurricane Katrina, and advised the governments of Israel and Australia on disaster preparedness. From 2008 to the present, Mr. Cappiello led his own consultancy to help healthcare facilities improve quality and maintain compliance with accreditation standards. He holds a BSN from the University of Rochester and an MA in Heath Facilities Management from Webster University.

The Healthcare Facilities Accreditation Program (HFAP) is a non-profit, nationally recognized accreditation organization. It has been accrediting healthcare facilities for over 60 years and under Medicare since its inception. Its mission is to advance high-quality patient care and safety through objective application of recognized standards. More information on the program can be found at

Under Pressure – Positively Clean

In yet another dispatch from the regulatory survey landscape, one item I’ve noticed being cited during surveys are related to the surgical environment–maintenance of temperature and humidity, ensuring appropriate air exchange rates, and making sure that your HVAC systems are appropriately maintaining pressure relationships. The other concern in this realm is making sure that you have a planned response for those instances in which any of the these performance expectations cannot be met. Make sure that the end-users of the environment are clued in to those responses. Depending on where you are, the age of your building systems, etc., you may very well experience (or perhaps have already experienced) performance outside of design/expected parameters (i.e., how’s that climate change working out for your building?)

Minimally, the infection control implications can be far-reaching, and if not appropriately managed, can be devastating to your patients. Likewise, you need to keep a close eye on the pressure relationships between clean and dirty areas; a positively pressured decontamination area can play havoc with the environment in your sterile processing and supply areas. A positively pressured corridor in your surgical area  can have a deleterious effect on your OR procedure rooms.  (Notice I said “area” not “suite”– everyone knows there are no corridors in surgical suites.)

You know how complicated your building systems can be–it’s time to make sure that your end-users understand that when things are not right, we need to collaborate to ensure appropriate protection of our patients. Nobody wants to mess with the OR schedule, but as hospital-acquired infection occurrences venture ever closer to the “never event” it will take a big-time team effort to make sure that our operations (both figuratively and literally) are where they need to be.

This is a public service announcement

This is a public service announcement—with guitars! (Okay, maybe not guitars) or perhaps this will work:

Money well spent…imagine that.

Every once in a while I like to share stuff that folks are developing in other areas of concerns/disciplines, and I think this one is a peach. In fact, I think it’s so useful, I’m just going to thank my good friend and colleague Marge McFarlane for sharing this with me, which helps me to share with you, and then shut the heck up:

The American College of Emergency Physicians is proud to announce the release of its newest training, Hospital Evacuation: Principles and Practices. The training can be found here

We hope that you take the time to view the course and pass the information along. A description of the course can be found below:

“Healthcare facilities must be ready to tackle anything that comes their way. In times of disaster, natural or technological, they must remain open, operational, and continue carrying out their functions. When the situation escalates to a level that endangers the health and/or safety of the facilities patents, staff, and visitors, evacuation of the endangered areas is necessary. Safety and continuity of care among evacuees during a disaster depend on planning, preparedness, and mitigation activities performed before the event occurs. At the completion of the course, hospitals and other healthcare providers with inpatient or resident beds will have basic training and tools to develop an evacuation plan. This one-hour course will take the participant through the stages of preparing for a facility evacuation. It begins by performing an assessment of possible vulnerabilities and the resources available to a facility. Next, the course walks the learner through the development of a functional plan for a healthcare facility, and identification of key personnel positions implemented when a facility evacuates and the roles and responsibilities of each. The course concludes by addressing recovery issues, both plan development and operational.”

Good stuff, and I encourage each one of you with anything more than a passing interest in such things to check it out.

And now for something completely…the same

Time for a quick roundup of some recent survey trends:

  • We’ve talked about the overarching issues with weekly testing of plumbed eyewash stations any number of times over the years and I am always happy to respond to direct questions. The key element here is that if your organization is not conducting an at least weekly testing regimen for your plumbed eyewash stations and has not documented a risk assessment indicating that a lesser frequency is appropriate, it will likely be cited. My consultative advice: If you’re not testing at least weekly, please do so, or do the risk assessment homework.
  • With the extra life safety surveyor time during survey, the likelihood of encounters with frontline staff is on the rise. And apparently, it is not enough for folks to know what they are doing, but there is also an expectation that they will understand why they do what they do, primarily in the context of supporting patient care (which we all do—everything that happens in a hospital can trace back to the patient). I guess it won’t be enough for folks to be able to respond appropriately when asked how they would respond to a fire. They also need to understand how their response fits into the grand scheme of things. I really believe that folks understand why their jobs are important; we just need to prepare them for the question. Probably more on this as it develops.
  • 96 bottles of beer on the wall, 96 bottles of beer—but will that be enough beer to last 96 hours (I guess it depends on how thirsty you are)? So the question becomes this: If a surveyor asks to see your 96-hour capability assessment, what would you do, and perhaps most importantly, can you account for it in your Emergency Operations Plan? My general thought in this regard is that the 96-hour benchmark would be something that one would re-visit periodically, just as you would your hazard vulnerability assessment, in response to changing conditions, both internal and external.
  • As a final thought for this installment, please make sure that you (that would be the royal “you) are conducting annual fire drills in all those lovely little off-site locations listed as business occupancies on your Statement of Conditions. And make very sure that staff is aware that you are conducting those fire drills. There’s been a wee bit of an upsurge in fire drill findings based on the on-site staff not being able to “remember” any fire drills, in some instances, for several years. The requirement is annual and I don’t think any of us wishes to get tagged for something as incidental as this one.

Your mother should know…but what if she doesn’t?

I’ve noticed a little word popping up in recent survey reports, a word that strikes fear in my heart. I don’t know how widespread this might be, so if you folks have an opportunity to weigh in on this conversation, I’d be really interested in what you all are seeing out there. And so, today’s word of the day is “should.” Now scream real loud!

I think we are all pretty familiar with those things that are legitimately (perhaps specifically is a better descriptor) required by the standards. I like to refer to those requirements as “have to’s” – we have to test certain fire alarm components at certain frequencies, we have to conduct quarterly fire drills, etc. Now I’m certainly not someone who is going to complain when a regulator (of any stripe) provides us with concrete strategies (this is where we move from the “have to’s” to the “how’s,” inching ever closer to “should”) for achieving or maintaining compliance.

But the question I keep coming back to is how are we supposed to know about these unwritten requirements (we used to call them ghost standards—boo!) if they are, as noted, unwritten. And the reason I keep coming back to this question is because I’ve been seeing a number of findings lately that revolve around what an organization “should” do. And please, I am not necessarily disagreeing with the wisdom engendered in many, if not most of these findings (we’ll mention a couple of examples in a moment), but there is a point at which the line between what is consultative advice and what is actually required blurs so completely that any tipping point, compliance-wise, is almost completely subjective.

As an example (and remember, I’m not disagreeing with the concept), a recent survey report included a finding because the “clean” side of central sterile was negative to the adjacent corridor, with the qualifier “air flow should always be positive from clean areas to less clean areas”. Concept-wise, I’m down with that (I’m not loving the use of “always” in this type of context—how long is always, or maybe it should be how frequently is always, but I digress), but where in the Joint Commission standard does it say that, apart from the all-encompassing appropriate provision of pressure relationships, etc. That “should” really undercuts the whole statement. Is this something we “must” do within the context of the standard or are we trying to leverage behaviors by acting like something is deficient when it is not necessarily the case?

Another “should” that came up recently involved the results of a vendor’s testing of the medical gas system. Now you and I both know that our vendors are not always the most efficient when it comes to providing written documentation of their activities. In this particular instance, the testing had been done in June, and the report had been delivered in August, mere moments before the survey started. Within the report, there were some issues with master alarms that required repair work—repair work that had not yet been completed. Now, as near as I can tell, each organization still gets to prioritize the expenditure of resources, etc., presumably based on some sort of risk assessment (that’s a “should” for all you folks keeping track), but the finding in question ends with a resounding statement that the facility “should” have required the vendor to provide a deficiency report at the time of the inspection. Conceptually, you’ll get no argument from me, and as consultative advice I will tell you that it is a positively stupendous idea to know what problems are out there before your testing vendors leave the premises. Remember, you “own” the fixes as soon as they are identified, and if there are delays, you’d best have a pretty gosh-darn good reason for it. In fact, I would have to consider that strategy as a best practice in managing maintenance and testing activities, but where does it say that in the standards?

Reasons (not) to be cheerful, part 3

Or perhaps it should be “hit me with your Joint Commission stick”?

What follows is a compendium of recent survey findings, some from The Joint Commission (TJC), some from me. So in no particular order:

  • Rooftop isolation exhaust fans and other “biohazard” areas should be appropriately labeled to identify the hazard. I’d expand this a little to include soiled utility rooms (particularly in outpatient settings) in which medical waste is collected and stored.
  • If you have key utility components (e.g., emergency generators and the like) outside your building, make sure that they are appropriately secured from unauthorized entry. And once you’ve determined what “appropriately secured” means for your organization, document the risk assessment, so if a surveyor just happens to disagree with how you are managing things, you have the basis for a clarification of the finding. Same goes for your solid waste compactors—make sure nobody can monkey with them (all due respect to monkeys).
  • Make sure everyone in the kitchen can locate and explain the operation of the fire suppression system. This is kind of a follow up from an earlier blog post outlining the monthly inspection of the kitchen fire suppression system. TJC recognizes that we, the primary stakeholders in the management of the care environment, have our act together. More and more, the focus has gone to the point of care/point of service staff. Safety lives in the trenches. We need to keep those folks in the loop.
  • Make sure your main supply shutoff valves, including your main oxygen valve, are appropriately labeled. And if you should choose to decide that, for reasons of security, that is not an appropriate strategy, make sure you document the risk assessment that led you to that determination.
  • Make sure you know where you need to have eyewash stations and where you don’t and why. Not every potential exposure requires an eyewash station—OSHA is very specific in that regard—potential exposure to corrosive materials is the determining factor. If you want to adopt a slightly stricter standard, the American National Standards Institute expands things to include corrosive and caustic materials. Beyond that, including blood and other potentially infectious material, you don’t “have to” have eyewash stations for exposure response. As a related aside, try to convince the folks in environmental services (and by extension, infection control) to promote the use of cleaning products that are not corrosive or caustic—that will help you identify an appropriate response capability.
  • Don’t forget those pesky compressed gas cylinders—other than penetrations and doors not latching, I think the most frequently cited specific condition is the unsecured cylinder. And please promise me you won’t say that you have to do additional education. Folks know they’re not supposed to leave the cylinders hither and thither. Find out the root cause of why they can’t do the right thing. And if you find out anything useful in that regard, please let the rest of us know.

Th-th-th-that’s all folks. For now…

Since when should we let folks consider safety as an option?

Dipping into the mailbag once again, I recall a conversation I had with a client who was, with increasing frequency running in to the “everybody is so busy that they are being careless” situation. At that point, the folks around the table would nod their heads and the discussion would come to a screeching halt. Now the characterization of this (please excuse use of the congressional vernacular) filibuster was “counterproductive,” a characterization with which I could not agree more. So in thinking about this perennial sticking point, I offer the following:

There is no doubt that everybody is really busy these days and it is just as clear that the “busyness” contributes to accidents. So it boils down to being able to move beyond the busyness excuse/defense to make a real difference in behaviors.

The fact of the matter is that everyone is really busy, and that has only increased over the last decade—we don’t have more staff, more money, more time—all we have is more to do. Clearly there is a challenge to work “smarter” but sometimes getting to that smarter level takes more time than the end results provide as benefit. So then folks tend to “hide” from anything that might be representative of a “real” change—operationally, behaviorally, etc. So the question then becomes how do we decide what can we afford to be “too busy” to do? As I noted in an earlier blog entry, just after Christmas last year, I read “What If Disney Ran Your Hospital” by Fred Lee. Now I will absolutely say that not everything in the book was of particular value in this discussion, but one point that I keep returning to is the Disney concept of a ladder representing what things are most important: an actual hierarchy, as opposed to a lot of what is common in healthcare, like pillars, which all have (more or less) equal value. The Disney ladder places safety at the top—so naturally I am a bit biased—but one of the things I’ve always noted (and not particularly liked, to be honest) about the Studer columns and Magnet pillars, etc., is that neither structure truly gives safety its due. It’s like cleanliness—if a place isn’t clean it is almost impossible to control infection, but it’s frequently something of an afterthought—and left in the capable hands of the lowest compensated folks in the mix.

So, I guess it comes back to the decision point of “this is where we are too busy to worry about: being safe, providing an appropriately clean environment, whatever issue we are dealing with in the moment. I would like to think that folks could at least agree that something is important enough to merit some attentions, so maybe the follow-up question becomes—how can we be safe, be clean, be attentive, in a way that doesn’t get in the way of other things? I’m a great believer (coming from the land of the New English) that common sense, simple approaches can bear substantial fruits, but it’s back to the forest and the trees—picking the simple path is not always so simple.

Hopefully there’s something in there that’s useful. To close on the Disney thought, at orientation, Disney employees are instructed to hold safety as the most important part of their job, regardless of their “role.” If they see something that is unsafe, the expectation is that they will act on that. If we can get everyone (or even more than half) to actually live that, I think we’ll find that a lot of the stupid stuff will resolve itself before it gets to the point of conflagration. There will always be malcontents (discontents?) in the crowd, but we need to get the rest of the folks to recognize that type of attention-seeking behavior for what it is and understand that it brings nothing to the table in terms of moving things along/ahead/forward.

Veterans of policy wars

A client I was working with recently had a really good Joint Commission survey from an EC/LS/EM standpoint, but had identified some opportunities buried in some policies that prompted them to earmark an in-depth policy review to prepare for the next survey. Upon hearing this, I thought of some advice that I think could be useful in a general sense, so if you don’t mind a little pontificating, here goes nothing…

First ask whether the policy is really necessary. Some policies are vestiges of that bygone era when Joint Commission preparation meant shining up the policy books, including having a policy for everything. Don’t be afraid to retire a policy if it doesn’t make operational sense.

If a policy reflects management of a key, or widespread process, once you have determined what is actually “required” (which is when you have the answer to the question—where in the regulations does it say that we have to do this); make sure that the policy reflects the process to the extent allowed by regulation. All too frequently, organizations craft these beautiful policies and procedures that make absolutely no operational sense whatsoever. We need to know that the policy enhances the practical implementation of the policy, otherwise you get workarounds (not that that would ever happen in healthcare, but I digress…).

The more you can introduce common sense (which, I will freely admit, ain’t as common as it once was) into the conversation, and get it to stay in the front of the discussion, you are much more likely to come up with a product that will work in the real world. Analogous to that, it’s also important to remember that sometimes you have to birth the thing to see if it can work in the real world. All too often I see folks torturing themselves trying to make a “perfect” policy and never really deliver anything. Don’t be afraid to launch the boat—just don’t do it in the middle of the harbor—if it’s going to leak, it will leak just as nicely (though perhaps not as dramatically) in shallow water as it will in the deep.

If you need an external eye to look at something, or indeed if you are having difficulty gaining traction on an issue, I am happy to act as a sounding board. My second favorite consulting duty is to play the role of devil’s advocate, which helps favorite #1, the problem solving thing. So please feel free to shoot up a flare if you get stuck on something.

How soon is now, how safe is safe enough?

During a recent Joint Commission survey, a concern was raised because the hospital’s pediatrics and OB units were not “equipped” with the same security system, etc. I’m not certain whether the result was a specific finding, but the question, in and of itself, is instructive when it comes to the science of assessment.

First off, I’ve never actually seen the areas in question, so I will engage in a little bit of conjecture, but I think the general themes can be applied in your house, particularly if you don’t have a whole lot of pediatric patient volume. Now certainly, the historical focus on abduction prevention has been primarily on the security of newborns, which I think we can all agree is a vulnerable patient population. That said, there are certainly risks involved in providing for the security of pediatric patients (and maybe some adult patients as well—it’s getting kind of crazy out there in the world), risks that would have to include abduction.

From a regulatory standpoint, there is very little specific guidance beyond the caveat of ensuring that you are not compromising life safety concerns as you install security systems. Locking doors in egress paths can be tricky and, in virtually every instance I can think of, the process was much more complicated than was originally presumed, but that’s a story for another day. We know what the result will be if our security efforts are not sufficient/appropriate, etc.: something will happen and that something will not be good. But that raises the somewhat rhetorical question of whether you can “rest” based on nothing bad happening. Is that a legitimate conclusion to make? Variations on this theme have become very noticeable during surveys this year. Maybe it’s something identified by a vendor that you haven’t gotten around to fixing, maybe it’s a new piece of technology that you have budgeted for next year, but that’s going to take time to purchase, install, educate staff, etc. Maybe (as is more or less the case in the recent survey mentioned above) from an operational standpoint, your pediatrics unit is in a small part of a regular medical/surgical unit and the geography of the space does not lend itself to the same security measures as you have on your OB unit.

These are all real life occurrences and each has its own security or EC implications that need to be managed. But (and this is a sizable one), you have to be able to articulate where you are in the process and how you are making sure that any elevated risks that are the result of not being able to do something right now are being appropriately managed. I hate to say this, but it’s been coming up far too often in surveys this year for this to be ignored: you absolutely need to discuss and document the management of these types of risks, including those all-important interim measures (if they are needed). Otherwise, you leave yourself vulnerable to a survey finding for which it is very difficult to negotiate a “settlement” either during survey or as part of the clarification process.

There are no standards that specify a time frame for completion, a technology enhancement, etc. That’s the responsibility of each organization to manage. But with that responsibility comes the obligation to manage any associated risks in fairly transparent fashion (I think I’ve managed to avoid invoking the transparency card until now): frontline point of care/point of service staff need to be able to articulate how we are managing risk until such time as solutions can be implemented. If they can’t, the risk of a survey finding rises exponentially. It’s no longer enough for leadership to know what’s going on, the folks in the field have to know, too. Pediatrics staff need to articulate how they are managing abduction risks for their patients. And if you have pediatrics in the ED, there needs to be some competency there as well. We can’t always do what we want when we want to do it, which is the reality of healthcare. But we do need to understand and share the risk implications of all those decisions and non-decisions.