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A statement of the survey conditions

So, what’s up in the 2007 survey year?

The short (and not at all sweet) answer-environment of care RFIs! And with no end in sight as far as 2008 is concerned.

An interesting, related phenomenon to the rise of RFIs in the EC is how they’ve impacted the world of the survey coordinator. But let’s take look at the level of exposure.

Currently, there are 24 EC standards, which means there are 24 opportunities in the EC by which organizations can receive an RFI (and that number will rise to 31 in 2008 with the newly configured emergency management standards). When you’re dealing with an increasingly shrinking threshold for conditional and/or preliminary denial of accreditation (use this link to see the thresholds for your organization: http://www.jcrinc.com/14866/), having this much potential for adding to the RFI “nut” creates concern on the part of survey coordinators everywhere.

And, of course, we have the presence of two standards that can result in conditional or preliminary denial without getting a whiff of a threshold:

  • EC.5.20, EP #5-Sufficient progress toward the completion of your PFIs
  • EC.5.50, all three EPs-Identifying and implementing interim life safety measures

I think that we can stipulate that many, if not most, survey coordinators have a fairly limited comfort zone when it comes to all things great and EC. But a common theme has been bubbling to the top this year, and that is the sweeping assurances from the EC folks in the hospital that everything is A-OK, only to find that the survey teams have a significantly differing assessment.

As we continue through the process, it is quite possible that you’ll see more input from resources external to your organization (perhaps, dare I say, in the guise of consultants-please don’t shudder at the thought). And so, it may become a big part of your job to “manage” these resources to the benefit of your practice and your organization.

My best advice, consultative though it may be, is to reach out to the folks charged with managing the survey process in your house. Your input in the decision-making process might be the difference between a torturous review of your program and an opportunity to use this external voice to advocate for your position.

Tired of waiting for a Joint Commission survey?

Well, up here in the Northeast, there’s a wee hint of fall in the air, and a not-so-young man’s fancy turns to thoughts of what’s in store in the closing months of the year and the opening of the 2008 unannounced survey season (which I suspect is the last year that we can depend on our survey “years” actually being a 12-month timeframe).

As I look around the healthcare safety world, I sense the stirrings of a couple of different “emotions”:

  1. Impatience by those organizations that have not yet been surveyed this year (those of you who have already received your visitors, I would have to count you as being luckier than those playing the waiting game)
  2. Concern by those organizations for whom the window opens on January 2, 2008, or thereabouts (though we’re not in panic mode, yet)

For both groups, this past Monday amounted to something of a line of demarcation. Even with some leeway on the calendar, summer is pretty much over, and so it’s time to ratchet things up-the British are coming, the British are coming!

Some folks are looking at three months to get things going in the right direction, while others know with a certainty that their survey window is closing little by little and every day the survey looms a little larger.

For the 2008 group, if you have not done so in the past six months or so, I would encourage you to conduct as comprehensive an assessment of your safety program as possible. If you have issues at the moment, you’re going to have a most difficult time establishing a reasonable track record, so best to jump on it now.

If you will, conduct a mini-periodic performance review of your organization’s compliance at the EP level – dot every “i” cross every “t.”

For the 2007 folks, my sympathies, for I’ve been working with a couple of clients who are expecting their Joint Commission visit any day now and have been since this past January. I’ve experienced the “ramp up” of intensity each week until the first day of the week passes (Mondays for the organizations with 5-day surveys; Tuesday for the 4-days, etc.), and then everyone breathes a collective sigh of relief when the surveyors don’t come that week.

This roller coaster may well be the most challenging survey “risk” to manage, at least for the first time out. Afterwards, it’s all constant readiness, right? Right! And, as I’ve said any number of times, the Joint looks much better in the rearview mirror as you drive away!

Looking at security’s rules of engagement

There’s been a fair amount of media coverage relative to workplace violence in general and healthcare in particular. As safety professionals, we clearly have an obligation to enact whatever prudent measures are necessary to appropriately manage the risks associated with potential for violence in our workplaces.

Since we’ve already talked a bit about risk assessments in general (and by the way, there’s a pretty good assessment form regarding violence and aggression available here), I want to talk a little bit about one of the interventions that seems to be gaining a bit of popularity-the use of armed security officers.

Somehow in the midst of all my work-related activities, I managed to miss the event in Houston in April in which a father was Tasered by a hospital security officer while holding a newborn (use this link to check out the latest on the story, including video footage of the discharge of the Taser).

Even before I saw the footage, I have to admit that I was rather horrified at the description of the event. From a risk management and general liability standpoint, I’m just not keen on aggressively pursuing someone holding an infant (though it appears there was some indication that the father in this case was attempting to leave with the infant in some sort of custody dispute).

I’m seeing the use of armed security officers in hospitals much more frequently, and I am always curious about how well-defined the rules of engagement might be, whether they include the use of lethal force, what education has been provided, how are competencies assessed, etc.

Now you might want to call me a yellow-bellied, Massachusetts liberal type, but I’m really curious about how folks feel about this particular event. Clearly, there are opinions to be had by a great many people, some of whom will probably be involved in the pending lawsuit, but purely as a function of process, what’s up here?

If you were to use this case as a training example, how would you characterize this officer’s actions as a learning experience? Are their improvement opportunities to be had and, if so, what are they? I can’t help but think that The Joint Commission might have similar questions to ask the folks at the Houston hospital in question. If you were in a surveyor’s shoes, what would you say?

A safety committee topic we can all toast to

How well does your safety committee manage “telling people what to do”?

In reviewing safety committee minutes in all different parts of the country, I’ve run into a certain reluctance to mandate compliance with sensible safety practices. The most common issue I’ve encountered is the management of heat-producing appliances in various departments. Yes, I am talking about toaster ovens, household-use toasters, household-use coffee makers and other appliances of that ilk.

I personally think that toaster ovens are among the most risky pieces of common-use equipment I can imagine. You can put something in it, set the temperature, and walk away from it – with the common refrain being, “What’s that smell? Oh, $@?&!!”

When I encounter these appliances during mock surveys, I ask what folks what they’ve done to manage the risks associated with these devices, and the response is frequently a shrug.

Now I don’t advocate an obstreperous approach to enforcement activities, but it is certainly a weapon to have in your arsenal (sort of along the lines of nuclear proliferation – we don’t want to have to go there, but if you insist, we will).

Sometimes corrective measures are perceived as being optional, even when there is a clear advantage to adopting those measures as a standard of practice. But – and I quote one of my former boss’ favorite sayings – you can’t mandate intelligence and in those instances, you sometimes have to mandate a practical application.

I know we didn’t get into this field to boss people around. But sometimes there’s very little standing between disaster and any number of folks working for us. Sometimes you have to risk being a wee bit prickly in order to keep your safety roses in bloom. And that’s enough mixing of metaphors for this session.

So, until next time, this Safety Mac Daddy is signing off…

By the authority granted to me…

An item that I’ve been encountering a more frequently of late revolves around the charge-or perhaps, more appropriately, the authority-of the safety officer or, indeed, the safety committee.

Now EC.1.10, EP #3, requires each organization to identify a “person(s) to intervene whenever conditions immediately threaten life or health or threaten damage to equipment or buildings.”

That’s pretty heady stuff, which leads me to a couple of questions for all you reading to think about:

  • How comfortable are you, as a safety professional, with the extremes of this interventionary authority? How “immediate” would the threat need to be before you felt comfortable with stopping work, sending someone home, etc.?
  • How much support would your boss give you if you played this card?
  • Have you ever had to invoke this authority?

Let’s talk more about this next time.

Steve Mac.

smacarthur@greeley.com

Since I am already on the subject of BMPs…

As a final note on the building maintenance program-and I will admit to having a little obsessive-compulsive disorder about this topic- it is important to periodically review your program’s data.

While the 95% compliance rate might seem like a pretty comfortable margin with which to work, it is important in this less-than-perfect world to validate your assumptions. It is more than likely that 90% of your rated doors function appropriately every time. But it’s those other 10% of “trouble” doors that can get you into hot water.

For the “good” 90%, you might be able to get away with an annual inspection frequency (if the data supports that frequency), but those other 10% might need checking more often.

Remember, the goal is 95% at any given moment in time. If you’ve got maintenance challenges, it is imperative that you identify them and take appropriate actions to ensure proper operation of items in question.

Stay safe,
Steve Mac.
smacarthur@greeley.com

And now for something completely related…

Let’s talk more about The Joint Commission’s building maintenance program. Be forewarned that a BMP is not necessarily a panacea during survey.

Yes, there are some surveyors that might cut you some slack if you have a BMP, but, strictly speaking, if they find three Life Safety Code deficiencies during survey that cannot be reconciled with the items on your current PFI, and cannot be identified as having an approved equivalency, then you can receive an RFI under EC.5.20.

“What?” you might say, “That’s now how I understood it to work!”

Ah, my fine colleague, but what do we actually know about this process? If you look at the Statement of Conditions, it indicates that an organization may choose to resolve each of the noted deficiency types through a building maintenance program and goes on to describe an effective BMP as maintaining the noted life safety features at a 95% compliance rate.

What it doesn’t say is that there is no way, unless you have a very small inventory of a particular item, that a surveyor could inspect a sufficiently-sized sample to render a verdict on your actual compliance percentage.

But don’t jump off the ledge just yet! Where your maintenance data comes in to play is when you have to make your case on the back end, most likely during the clarification phase (each organization has a period of time post-survey in which they can provide The Joint Commission with data to support a finding of compliance).

At that point, through your organization’s survey coordinator, you would submit your BMP data for review by the folks at The Joint Commission’s Chicago headquarters. By the way, the commission has hired additional engineers to assist with the management of all things EC, including review of the electronic Statements of Conditions and PFIs.

Stay safe,
Steve Mac.
smacarthur@greeley.com

Effective building maintenance programs involve the front line

As we move closer and closer to some sort of mandate for The Joint Commission’s building maintenance program (I don’t know that we’ll ever get all the way there, but I am absolutely convinced that eventually, you won’t be able to comply with all the Life Safety Code’s elements without a BMP), it becomes clear that you need to explain the expectations of the program to frontline staff members engaged in maintenance activities.

Frequently, there is reluctance among frontline workers to report negative or deficient findings during their inspections. These folks need to be comfortable (and I suppose you do as well) that there will be no punitive aspect to this reporting, within reason.

Your organization needs that failure data to assess the performance of your BMP. You need to know:

  • What doors “fail” on a regular basis
  • Locations where those mysterious cable guys are not quite good about filling penetrations
  • If there are outdoor egress routes that suffer from an elevated level of snow and ice

Frontline staff members can help you do this if they feel confident of their roles. More about the BMP next time.

Steve Mac.
smacarthur@greeley.com

When you implement a new EC program, don’t forget to look back

A client facility of mine has a really neat process for managing penetrations in rated partitions. They have a little clipboard at the location of each partition (above the ceiling) and the maintenance folks are charged with inspecting these locations on an ongoing basis.

This works really well, up to a point. Any time there’s a penetration, it gets fixed right away, which is very cool.

However, where things broke down is that until the implementation of this process, a lot of penetrations had been filled in without using rated firestopping materials–and sure enough, those unprotected penetrations were the ones found during survey and given an RFI.

This facility’s penetration management process had reported really good compliance, but the building maintenance program couldn’t be invoked to resolve the RFI because of the number of penetrations (and these were probably filled years ago) that were not “properly” sealed.

Stay safe,

Steve Mac.

smacarthur@greeley.com

Watch for the subtleties of the EC standards

Another trend I’ve noticed is a failure mode relative to the familiarity of frontline staff with the expectations and requirements outlined in the standards and EPs.

I recently worked with a client that ran afoul of the new requirements under EC.7.40 for a four-hour generator test. The client had, in fact, operated the generator in question for a period well in excess of four hours, but had failed to provide acceptable documentation to the surveyors. This left the facility in the position of conducting the four-hour test again, which they did.

Ahh, but here’s where things got a little bit off track. In reviewing the documentation, I noted that for the first hour of the test, the generator did not meet 30% of its nameplate rating. When asked, the individual responsible for the testing responded, “we averaged 30% for the four hours, but it took us a bit to get up to where we needed to be.”

The element of performance in question, however, requires a test at 30% for four continuous hours, a subtle difference to be sure. But it was a difference that required them to conduct yet another generator test.