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Dance on a volcano: Keeping tabs on those that keep tabs on us…

As we’ve discussed in the past, the world in which we exist—and the stories and challenges contained therein—is never ending. And the subtext of that constancy revolves around our efforts to stay (as it were) one step ahead of the sheriff.

Part of me is railing against my chosen topic this week because I always feel like this space can (and, admittedly, does) have a tendency towards a Joint Commission-centric vision of the compliance universe, but while they may not be the largest primate in the compliance universe (once again violating all manner of metaphoric-mixing indignities), they are (more or less) the organization with the most robust customer-forward presence, through Perspectives to the FAQ pages to the topic-specific offerings we’re covering this week. All things being equal (which, of course, they never really are), I would encourage you to poke around a bit on these sites as there is a mix of stuff that is almost ancient, but some tools, etc. that you might find useful in demonstrating compliance.

The Physical Environment portal is kind of the granddaddy of this whole construct; it started out as a collaboration with the American Society for Health Care Engineering (and may very well continue to be so, but it’s kind of tough to tell) with the goal of providing information on the most frequently cited standards. Unfortunately (for me, but not so much for you), a lot of the information, including “surveyor insights,” is accessible only through your organization’s TJC extranet portal, but there is some stuff that’s worth a look. For example, there is a fire drill matrix that gives a sense of what areas should be considered for your high-risk fire drills (or would it be fire drills in high-risk areas…); the one on the matrix I found of some interest was Cath/EP lab making the high-risk list. I guess the overarching thought is to make sure you carefully consider those areas in which surgical fires a present as a risk.

There are also portals for emergency management, healthcare-acquired infections (I would keep a close eye on that one; lots of indication that this is the next “big thing” for survey), and workplace violence. Keep an eye on them: You never know what might pop up!

You’ve got to get in to get out: New safety adventures in ambulatory care

Hoping that this is more treat than trick, I had cause (albeit minimal) to reflect on what I see as a reasonably significant increase in EC findings being generated in the ambulatory care world. If we accept (and I certainly do) that one of the primary drivers to the survey process is the generation of findings, then it makes all the sense in the world to start “pushing” the survey process in those environments over which we have less control/influence/oversight. I talked a little bit about tools for the ambulatory setting back in January of this year (continuing our program of a self-referential October), and the good folks at ECRI are offering what they are terming a “deep dive” into safe ambulatory care (if you scroll about 1/3 of the way down the ECRI homepage, you’ll find the link to download the report for the low purchase price of some contact information).

The report breaks things down into four key areas: Diagnostic testing, medication safety, falls, and, safety & security. While I recognize the latter two may be of primary interest to this audience, I would encourage you to check out the information relating to diagnostic testing and medication safety. Everything in healthcare (and pretty much any and everywhere else) “exists” in the physical environment (thinking of concentric circles with the patient at the center and the physical environment being the outermost circle), so the interactions between “disciplines” can generate a lot of opportunities when it comes to the practical application of safety and the environment. Taking that with the (at times infuriating) “grayness” of what is required from a regulatory standpoint, it really prompts a level of vigilance that is unlikely to subside any time soon.

To close things out for this week/month, another resource that you might find of interest is a podcast dealing with all things water treatment; you’ve heard (metaphorically speaking) me speak of Matt Freije and the good work he’s spearheading at hcInfo.com and he appears on an episode of the ScalingUp podcast. I found it pretty interesting, but that may just be me. That said, I think the focus and attentions paid to water management plans during survey activities is going to continue to rise and I can see a future in which funky water values will drive Condition-level survey results. Now is the time to start educating ourselves to what it all means and I think this podcast is a good start for folks. Check it out!

And a happy and safe All Hallows Eve to you all…

Who remembers pop-o-matic Trouble?

In something of a variation on another bloggy evergreen, I ask the rhetorical question: To what, if any, extent have you included consideration of  board games in your physical environment risk assessments for behavioral health? As I think towards a generation (are they already here?) for which the glories of board games will be forever lost, our friends in Chicago offer the latest challenge in managing risks with our all-too-vulnerable patient populations (for those of you of a certain vintage, the description of a board game is very nearly worth the price of admission).

The article describes the quite inventive use of a plastic board game piece to defeat the reptilian tamper-resistant screws and suggest some alternative products that do not so easily surrender to such efforts. I don’t know that I’ve been privy to a lot of discussion relative to board games in the behavioral health setting, but I suppose this would come under the heading of “everything has an inherent, though perhaps not apparent, risk.” Based on some recent surveys, it seems that Joint Commission surveyors have been rather inventive in looking for physical environment elements that have not been specifically accounted for in the assessment process. The classic example is including medical beds in the risk assessment, but not specifically mentioning the risks associated with the ligature-resistance (or not) of the side rails, bed frame, etc. Sooooooo, if they have not yet been included in your risk assessment activities, it might be a good time to pull a little group together and ponder the use of board games (and perhaps other such items) as a function of the behavioral health physical environment risk assessment.

Should we think about Halloween candy as well?!?

Check and mate!

Sticker shock: Compliance your way (not someone else’s)!

As we continue our October re-visitation of some of your more evergreen topics and I was thinking that I had covered this particular topic recently, but it turns out it was rather a long time ago—2012, to be exact (my, my, my, how time flies!).

I guess the general thought/concern relates to whether any particular piece of equipment has to have a due date sticker or some variation thereof. And, interestingly enough, while this still surfaces from time to time, the requirement (or lack thereof) has not really changed in the last seven or so years. Is there a benefit to having a due date so line staff can include a visual when they are using a piece of equipment? Absolutely! If you use color-coded outdate stickers, can it make it easier to discern when something is in arrears? It sure can! Can an outdate sticker call into question the efficacy of your process if there are too many of the “wrong” color floating around? Yup!

If you’re going to use them, then by all means make full use of them. Make sure line staff understand what information is contained on the sticker. Make sure they understand that if a sticker gets removed during the cleaning process, that is an important piece of information to communicate to clinical engineering or whoever is responsible for maintaining the equipment. And, please—for the love of all that is good and practical—try to stay away from policies that speak to the necessity of a sticker being present; another evergreen survey truth is that non-compliance with an internal process is one of the toughest survey findings to clarify. Everything (and anything) you do that is not specifically required by code and regulation should make sense from an operational standpoint. If there’s a program element that has, shall we say, evolved (or mutated) over time and is giving you compliance fits, take it out, dust it off, and make sure that whatever it is brings value to the process. And if it doesn’t? Time to move on!

Crying my eyes out: The never-ending story of emergency eyewash equipment!

October seems to be shaping up into a “greatest hits” kind of month as we once again dig back into the closet of perennial findings—this week finds us in the realm of managing occupational exposure to chemicals.

With the information contained in the September issue of Perspectives, it looked like findings relating to hazardous materials and wastes (which were mostly related to eyewash stations) had dropped off the Top 10 list (it was the #9 most-frequently cited standard for 2018), which I saw as a good thing. Generally speaking, I’ve found that the knowledge-base of the surveyor corps relative to the management of occupational exposures to hazardous materials leaves a little bit to desire, and rather prone to over-interpretation of what does and what does not constitute an inappropriately managed risk. You could, of course, (and I certainly have) give voice to the thought that over-interpretation is something of a standard practice amongst the surveyors of the world and you’d get very little in the way of argument from me. But there are a couple of recent findings that kind of crystallized (at least for me), the intersection of over-interpretation and a limited knowledge of the practical/operational aspects of appropriate management of occupational exposure to hazardous chemicals.

So, we have the following:

  • A single container of bleach in a storage room becomes a finding of moderate risk because the pH level of bleach requires the installation of an eyewash station

Now, purely from a reasonable risk assessment standpoint (and in recognition of the very remote likelihood that the container of bleach is going to somehow vomit its contents), the mere presence/storage of a corrosive does not (in my mind) constitute a risk of occupational exposure. If someone is pouring the bleach into another container (which is not the case here—again, only storage), then the risk of occupational exposure comes into play. The image that I conjured up relative to this is the local grocery store—gallons upon gallons of bleach—and nary an eyewash in sight (and yes, while OSHA doesn’t really jump ugly relative to customer exposure, the risks to customer and in-house staff is probably about equal). I suppose the best course for a corrective action would be to remove the bleach and be done with it. That said, this seems a bit of a reach…

  • Two eyewash stations (one in a soiled utility room and one in a scope decontamination room) that were located at dirty sinks in these areas, increasing the risk of staff exposure to contamination

Now, my philosophy regarding the location of emergency eyewash equipment is that you want to install them in locations as close to the point of likely exposure as is possible/reasonable, which sometimes (maybe even often) means that you install them on the only sink in a soiled utility room, etc. And you do that because?!? You do that because, the emergency eyewash station is equipped with protective covers to ensure that the emergency eyewash does not get contaminated, so you can install them in the locations in which they would be of the greatest benefit in an emergency, which might very well be in a soiled location.

It seems that the mystery of eyewash stations will never be completely solved…

Wanna buy a watch? How about a patient watch?

It’s been a while (OK, more than a while: It would seem it’s been something more than a decade. My, how time flies!) since we’ve discussed the matter of using security officers to watch patients. I can absolutely say that it is often a topic of conversation when I meet with security folks over the course of consulting as it not infrequently has a significant impact on security staffing resources. As I have maintained for a very long time, it is very difficult to carry out security rounding, etc., when your security staff is eyeballing patients from a fixed post. If you’re interested in the “historical” perspective, please feel free to use the Wayback Machine to review the state of things in 2008!

If we have learned nothing else over the years, it is the truth in that old saw: “The more things change, the more things stay the same” (or variations thereof). I came across an article at the beginning of September referencing recent guidance from the International Association for Healthcare Security & Safety (IAHSS), which includes the advice of not to use security officers for patient sitting/watch activities. There are certainly any number of complexities that come into play—competency and education, “backfilling” security activities when security officers are caught up in patient care activities, etc. And with the increasing number and types of risks relating to security occurrences in hospitals, being able to effectively respond to those risks, should they occur, could make the difference in ensuring organizational viability. I personally (and particularly in those days in which I had operational responsibility for security) continue to believe that the use of security officers for “general” patient watches is an inappropriate use of resources. Sure, there will be those instances in which a security presence beyond a quick response is needed, but I can think of few more useless applications of security resources than a security officer watching a sleeping patient. Patients should receive care from caregivers, and not that security officers are uncaring, but their training and competence are “designed” for other duties.

As a quick closeout for this week (and perhaps it is the turning of the season that causes reflection on past experiences), for those of you that may be embarking on a managerial position for the first time or for those of you that have been managers for so long that your inception is lost in the mists of time (those mists, of course, are the result of the earth cooling), I ran across a piece that I think might be helpful or at least prompt some reflection on current and/or past experiences. “What I Wish I’d Known As A First Time Manager” offers 10 thoughts on those (sometimes tenuous) first steps into managerial bliss (yeah, right!). I don’t know that there’s anything particularly earth-shattering, but sometimes it’s nice to hear some practical thoughts in a place other than in your own mind. We are, after all, in this thing together, so improving one improves all—and if that’s not a pretty nifty raison d’être, I don’t know what is.

It’s a lot like you: The dangerous type of emergency risks!

I know we chatted just last week about emergency management concerns, but once again, there’s more news stuff relating to the management of utility systems (it’s not just about water features) during emergencies and it does appear that the consequences of inadequately managed risks can get you into trouble with more than just the usual regulatory suspects.

A USA Today story from a couple of weeks ago outlined the charges/arrests resulting from the deaths of a number of nursing home patients in the aftermath of hurricane Irma, back in 2017. The sticking point, as it were, was the failure of the facility to evacuate once they lost the ability to effectively cool the facility. The news story paints a bleak picture of negligence, failure to call 911, etc., but also provides some indication that 911 calls from the facility received no response. I imagine that some details will emerge during trials as to what may or may not actually have transpired, including the existence of a “fully functional hospital across the street” to which (apparently) evacuation was not an option. I still maintain the most important part of any emergency response plan (and if not the most important, one of the very, very most important) is having a very clear understanding of what the trigger points are that would result in a need to evacuate. The worst thing that can happen with evacuation is to wait so long that a safe evacuation is not possible. I guess we’ll (hopefully) see what circumstances led up to this circumstance.

On a related (somewhat) note, our friends at the CDC have collaborated with the American Water Works Association to develop an Emergency Water Supply Planning Guide to assist healthcare facilities in their efforts to prepare for, respond to, and recover from, a total or partial water supply interruption. The Guide is designed to help folks assess water usage, response capabilities, and water supply alternatives. I suspect that this might be especially useful to folks in areas that tend to experience drought conditions, so if you want to check out the CDC Guide, you can find it here, along with links to some other preparedness resources.

Closing out things for this week, I’d like to share with you folks an article that I found to be of interest; while I don’t personally have managerial oversight in my current role, I saw enough parallels to “back in the day” to prompt the thought that “I wish there was something like this available when I was starting out.” So, in case you’re starting out in the amazing field of management or are interested in what’s going on in management theory, I think this would be worth your while. There’s a quote from Warren Buffett that I think really captures the essence of the compliance wars: “What the human being is best at doing is interpreting all new information so that their prior conclusions remain intact.” I bet that everyone reading this knows at least one human being like that…

You can find the whole article here.

If you don’t signal, how will I know where you want to go? Emergency management and its discontents (Just What You Needed)!

Kind of a mixed bag this week, though it all fits under the heading of emergency management, so here goes nothing…

A few weeks ago, USA Today did a story on the preparedness levels of the United States based on an analysis of state-by-state metrics. The story was based on a study, the National Health Security Preparedness Index, prepared by the Robert Wood Johnson Foundation and covers a lot of ground relative to trends in preparedness, including governmental spending on preparedness and some other stuff. The reason I “noticed” this was the indication that my home state was “best prepared” for disasters, etc., but the overarching message was that, even in the face of some setbacks in individual regions, the nation continues to improve emergency preparedness. Of course, it being USA Today, there are color slides indicating where each state ranks among the fabulous 50, so if you thought there was no scorekeeping on this front…

OK, maybe not keeping score, but a certain accreditation agency is keeping an eye on all things relating to preparedness. In this blog post, Jim Kendig (field director for the Life Safety Code® surveyors at The Joint Commission, and a very knowledgeable fellow when it comes to this stuff) provides a really good overview of the Preparedness Index and describes it in terms of how the various pieces can (and do) fit together and provide the foundation for an effective emergency management program. I see no reason why we can’t expect something more of a deep dive in the coming survey cycle and I think you’ll find the information Jim shares to be really helpful.

As a final thought for this week, it is always the case that what constitutes a mass casualty incident varies from organization to organization, but if you want to catch a glimpse of how this gets framed within the context of one of the largest metropolitan areas on the planet, the Greater New York Hospital Association developed a Mass Casualty Incident Response Toolkit that you might find worth checking out. There’s a ton of information, tools/forms, and links to more tools/forms, etc., to review in this space, but I encourage you to give the materials a look-see. It does appear that the nature of what we can expect to show up at our collective front doors is shifting and anything that facilitates better positioning to deal with an emergency is worth our time and energies.

Ground Control to Major Compliance: EOC, baby!

As September brings around the unwinding of summah, it also brings around The Joint Commission’s annual state of compliance sessions in locations across the country, better known as Executive Briefings. And, one of the cornerstone communications resulting from the Briefings is the current state of compliance as a function of which standards have proved to be most problematic from an individual findings standpoint.

Yet again (with one exception, more on that in a moment), EOC/Life Safety standards stand astride the Top 10 list like some mythical colossus (the Colossus of Chicago?), spreading fear in the hearts of all that behold its countenance (OK, maybe not so much fear as a nasty case of reflux…).

You can find the Top 5 most frequently cited standards across the various accreditation programs; you’ll have to check out the September issue of Perspectives for the bigger compliance picture, which I would encourage you to do.

At any rate, what this tells us is that (for the most part) the singular compliance items that are most likely to occur (for example, we’ve already discussed the loaded sprinkler head hiding somewhere in your facility—way back in April) are still the ones they are most likely to find. According to the data, of the 688 hospitals surveyed in the first six months of 2019, 91% of the hospitals surveyed (626 hospitals) were cited for issues with sprinkler/extinguishment equipment—and that, my friends, is a lot of sprinkler loading. I won’t bore you with the details (I think everyone recognizes where the likely imperfections “live” in any organization), but (at least to me) it still looks like the survey process works best as a means of generating findings, no matter how inconsequential they might be in relation to the general safety of any organization. I have no doubt that somewhere in the mix of the Top 10 list, there are safety issues of significance (that goes back to the “no perfect buildings” concept), particularly in older facilities in which mechanical systems, etc. are reaching the end of their service life—I always admired Disney for establishing a replacement schedule that resulted in implementation before they had to. It’s like buying a new car and having the old one still on the road: Are you going to replace the engine, knowing that the floor is going to rust through (and yes, I know that some of you would, but I mean in general)? But if the car dies on the way to the dealer to pick up the new one, you’re not going to do anything but tow it to the junkyard. But we can’t do that with hospitals and it’s usually such a battle to get funding/approval for funding/etc. that you can get “stuck” piecing something together in order to keep caring for your patients. It sure as heck is not an ideal situation, but it can (and does) happen. Maintaining the care environment is a thankless, unforgiving, and relentless pursuit—therein is a lot of satisfaction, but also lots of antacid…

One interesting shift (and I think we’ve been wondering when it would happen) is the appearance of a second infection control (IC) standard, which deals with implementation of an organization’s IC plan. I personally have always counted the IC findings relating to the storage, disinfection, etc. of equipment as being an EOC standard in all but name, but I think we may (finally) be seeing the shift to how appropriately organizations are managing infection risks. According to Perspectives, 64% of the hospitals surveyed in the first six months of 2019 were cited for issues relating to implementation, but not sure how the details are skewing. Certainly, to at least some degree, implementation is “walking the talk,” so it may relate to the effectiveness of rounding, etc. Or, it may relate to practice observed at point-of-care/point-of-service. I think we can agree that nosocomial infections are something to avoid and perhaps this is where that focus begins—but it all happens (or doesn’t) in the environment, so don’t think for an instant that findings in the environment/Life Safety will go gentle into that good night. I think we’re here for the long haul…

Reusables vs. single-use: The next round in the World Series of Risk Assessments?

As summer starts its (hopefully) gradual fade into the record books and the marathon of the baseball season starts its kick to the finish line, it seems that we are (yet again) faced with some guidance from the federales that I think will be best served by having a risk assessment in your back pocket.

Over the past few years (truly, more than a few, but we can focus on the most recent past), there has been a lot of scrutiny regarding the management of endoscopes, including how much of a role clinical engineering might play in managing the scopes as devices, how to ensure effective processing of the scopes once they have been used, etc. And just the other day, I encountered an article discussing the FDA’s recommendation to begin transitioning to scopes with disposable parts, nominally to ensure the efficacy of the post-use processing process (don’t you just love a processing process!). You can find the meat and potatoes of the FDA’s recommendation here. I’d encourage you to read this very carefully as there is mention of process elements, such as the use of adenosine triphosphate (ATP) test strips to assess scope cleaning—a use that is not currently sanctioned by FDA—to the point that the FDA is asking facilities not to rely on the ATP test strips to assess scope cleaning. There’s some other stuff that is worth consideration, so (again), please check it out.

The recommendation does indicate (and, to a certain extent, provides for) a period of transition to the disposable scopes, but now that the proverbial horse is out of the barn, I think it is only a matter of time before our friends in the various accreditation organizations start digging into the transition process as a function of patient safety (I don’t think there’s any among us that would dispute this as a patient safety concern), particularly as to how we are keeping folks safe during the transition period. And how do we typically provide evidence of the process for mitigating risks? Why, it’s our old(er) friend the risk assessment process. I think it is crystal clear that this serves as yet another example of the collaborative process between infection control, clinical engineering, perioperative services—and I encourage you to make good use of the risk assessment process. Even more so, if you are scheduled for an accreditation survey any time in the next 12-18 months (until the use of single-use scope technology is more pervasive), I would get this on your to-do schedule as soon as possible. As with so many things, you may have lots of data to support that your existing procedures, etc., are not putting anyone at risk, but (as these things tend to devolve) we’ve already seen how a really (and I mean really, really) small incidence rate (that of risk de ligature) drive a veritable cornucopia of significantly painful survey findings. And there’s every reason to include this in the list of contenders for the next heavy duty survey focus area.