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The Joint Commission’s building maintenance program may change in 2009

Hi everyone — It’s Scott Wallask over at HCPro.

Well, it looks like The Joint Commission’s building maintenance program-long heralded as a useful tool for facilities to use in complying with certain life safety maintenance requirements-may become less prominent in 2009.

However, don’t expect The Joint Commission to let up on fire equipment inspection, testing, and maintenance, which has proven to be a heavily reviewed area by the accreditor’s life safety surveyors.

The BMP’s scoring advantages that facilities enjoy today may not stay in effect in proposed new life safety standards for 2009, consultant William Koffel told us this week. Koffel–owner of Koffel Associates, Inc., in Elkridge, MD–is familiar with the proposed standards, which will likely fall into a new life safety chapter in the Comprehensive Accreditation Manual for Hospitals.

The proposed revisions may undergo field review by the end of the year, according to The Joint Commission. Full details on how the revisions affect the future of the BMP will come out during the field review, Koffel said.

The new chapter will include standards for the electronic Statement of Conditions, life safety assessmsents, and managing the Life Safety Code, according to The Joint Commission. There will also be scoring changes.

As of Wednesday afternoon, The Joint Commission had not returned a request for further comment.

Watch for further details in upcoming issues of Healthcare Life Safety Compliance.

Please post comments to us if you have any thoughts.

When a Joint Commission EP goes “ghost”

Suppose we have a pre-Nixon-era building in which we have not yet introduced emergency power into the patient rooms (no recent renovations of significance, etc.), but we do have emergency power outside each of the rooms.

The area complies with EC.7.20, EP #11 (providing emergency power for areas where electrically powered life-support equipment is used) because patients in this location don’t require ventilators and the usual run of life-support type equipment. If we had to provide emergency care, the defibrillator is plugged into emergency power out in the hall and, if really pressed, we could run an extension cord on a temporary basis into the room until the patient was stable enough for transport.

I mean, after all, we do have emergency power in this area “where electrically powered life-support equipment is used,” according to EP #11, so we-re on solid ground here–yes? Also, we’ve identified as a PFI plans to address this improvement opportunity, so again, we seem good to go.

Ah, not so fast grasshopper! It appears that, from a compliance standpoint, EP #11 is a veritable onion of a standard, with several layers of requirements that come into play.

Note EC chapter references to the American Institute of Architects’ Guidelines for Design and Construction of Hospitals and HealthCare Facilities (2001 edition) and NFPA 99, Standard For Healthcare Facilities (1999 edition).

Both of these august tracts reference a section of NFPA 70, National Electric Code, that requires hospitals to provide one duplex emergency power outlet per bed, connected to the critical branch of the emergency power distribution system, in general care patient rooms.

You might argue that when this building was constructed, these codes referenced above weren’t in effect, and you would be correct. But in a similar real-life case that I’m familiar with, an intrepid Joint Commission surveyor did not quite see it that way, resulting in an RFI under EC.7.20.

It took several back and forths with The Joint Commission before the determination was made that we had been in compliance with the EP as it was written in the standards, but the underlying NFPA 70 requirements had “caused” the noncompliance. Further relief came as the result of grandfathering this area’s configuration due to it not having been updated, since adoption of the applicable codes came long after the condition had been established.

So, the take-home lesson? It is in your best interest to use The Joint Commission’s clarification process and always:

  • Look at what the surveyor has identified as the issue
  • Lock at which EP is cited as the result of that identification
  • Keep at it until you get relief

When a survey ends and you have any number of RFIs, start the clarification process as quickly as possible. Work with your organization’s survey coordinator, your Joint Commission account representative, even engage the assistance of a consultant–the important thing is to leave no stone unturned.

The last thing you want to have to do is to fix something that is not broken. In the long run, you have enough other things that legitimately require your attention.

You can post comments to Mac’s blog now

Hi folks –

It’s Scott Wallask checking in. I just wanted to let all of you know that the “comments” function is finally up and running for Mac’s Safety Space.

To post a comment, you need to log in as a subscriber or trial user to the Hospital Safety Center, though anyone can read the comments without logging in.

Please let us know what you think of Mac’s postings by submitting a comment or share your experiences on a particular topic.

Thanks,

Scott W.

swallask@hcpro.com

Examples of immediate threat to life and safety, Joint Commission style

In my last posting, I talked about when surveyors invoked an immediate threat to life and safety. Let’s take a stroll through the list of “threats” we’ve encountered during client surveys, shall we?

Consider these:

  • Lack of master alarms for medical gas systems
  • An unreliable fire pump
  • Inoperable fire alarm system
  • Fire doors throughout the facility not closing and latching
  • Penetrations in fire walls not sealed with a fire-rated material
  • Main circuit breaker not tested or maintained and raw sewage leaking from pipes in a crawl space beneath a hospital
  • Lack of procedures to identify and maintain fire protection (i.e., lack of an effective means to transmit a fire signal to an external point and the responsible person not knowledgeable on the use of the fire alarm system)
  • No means of exit in an emergency and lack of implementation of interim life safety measures

Do you see a pattern developing? Well, neither do I–just kidding. Some of these situations seem fairly straightforward, but thinking about the fire doors and penetrations (not to mention how one would define an “unreliable” fire pump), there does appear to be some room for surveyor interpretation. As they might say here in the Boston area, that’s a shockah!

I think if I had to give you a piece of advice, it would be to make sure that everyone on your team has a pretty good understanding of how EC issues interrelate and how your organization ensures that all of these working parts come together and result in the safest possible environment for patient, staff members, and visitors.

And staff members may need to articulate this when you’re not around (unless you’re planning on no vacations until the next survey–I know I’d be tired).

If your survey will be between now and the end of the year, then start preparing now. If your survey was last week, start now. If your survey won’t be until at least 2009, start now. This is one of those things that is not at all well-served by procrastination.

Are you threatening me? Do I look like I’m threatening you?

One of the more precipitous aspects of the survey process is the invocation of an immediate threat to health or safety. This would the moment of a survey in which your entire world turns into manure.

Hopefully, such a plight will never darken the hallowed halls of your organization, but there is some indication that this problem has been occurring more frequently of late, so it seemed a good opportunity to cast a little light into this shadowy corner of accreditation lore.

Basically, the ball starts rolling when surveyors believe that they have encountered a situation that has, or may potentially have, a serious effect on someone’s health or safety, and thus requires immediate action to remedy the condition.

The survey comes to a screeching halt, your CEO gets to hear the fabulous news, Joint Commission headquarters near Chicago gets a call, even “appropriate government authorities” are in the loop-it’s all just too lovely. Of course, the impact on your accreditation status can be swift and painful, too. I’ll take root canals for $1,000 please, Alex.

Then there are the things you have to do to get out from underneath this damnation:

  • Take immediate action to completely remedy the situation
  • Prepare a thorough and credible root cause analysis
  • Adopt systems changes that prevent future recurrence of the problem

There are a number of conditions I’ve heard about in the environment of care that have resulted in the invocation of an immediate threat to life and safety. I’ll get into them in my next posting.

Stay safe,

Steve Mac.

smacarthur@greeley.com

Elevator problems cause a scare at a Seattle hospital

Hi everyone -

It’s Scott Wallask checking in here at the Hospital Safety Center.

Those of you who use ISIS model elevators manufactured by ThyssenKrupp should read this story about a hospital that had an elevator failure in Seattle. Luckily, the elevator’s safety brakes worked and no one was injured.

ISIS models use Kevlar ropes that don’t require a machine room. In a letter available at the link above, ThyssenKrupp has outlined a series of actions it will take across the country in response to the hospital mishap.

24 + 24 + 24 + 24 = ?

In visiting with hospitals across the country since the unveiling of the new emergency management standards, there’s been an increasing murmur relative to the presence of a certain temporal indicator that you can find under EC.4.12, EP #6.

96 hours. Four days. 5,760 minutes.

That time span brings with it some questions:

  • Is this a long time to be without the support of the local community?
  • Does it vary within the six critical areas of EC.4.13 through EC.4.18 (communications, resource and asset management, safety and security, management of staff, management of utilities, and management of clinical and support activities)?
  • Does it mean I need to have four days worth of stuff in my warehouse?
  • What if I don’t have a warehouse?
  • How prepared is prepared?

These are all excellent questions for which your organization is going to have to identify answers. For good or ill, there are no correct responses for these questions, and the practical applications are going to vary from organization to organization.

What’s important to remember is that this particular EP is not telling you that you have to do one thing or another (like having 96 hours worth of stuff in your warehouse). What is required is that you have a sense of what would happen if you were cut off from support for those 96 hours. Some organizations might be able to do 96 hours on their own with very little difficulty, while others might struggle to get to 48 or even 24 hours (probably not many in that group, but it is possible). The ultimate questions are: How far can you go? And what do you do when you’ve gone as far as you can go?

One of the clear lessons learned in the aftermath of Hurricane Katrina is that holding on past the point of reason is, well, not a reasonable strategy. But prior to recent tragedies, it’s almost as if the “defend-in-place” strategy of life safety management was carried across to the annals of emergency response. Right or wrong, getting out appeared to be entertained very infrequently in our response plans.

Now we know that in order to even approximate the safe management of a catastrophic event, we must consider the inconsiderable, think the unthinkable, try to gain some measure of control over situations that are, for all intents and purposes, uncontrollable.

What would we do if faced with an event of such magnitude? How far can we go? How do we tell when we’ve crossed that threshold? All questions to answer-and soon.

Use your full compliance data when clarifying RFIs

In my last post I talked about the advantages of using The Joint Commission’s clarification process when you receive an RFI.

Just to give you an example of how this could manifest itself, say you have a couple of off-site clinics that are visited during a hospital survey and surveyors find 10 fire extinguishers that missed a monthly inspection. (By the way, frequently survey verdicts are based on sample size-for all intents and purposes, if surveyors find three or more noncompliant conditions within an EP or standard, they have to score it as a “0” or noncompliant.)

It appears the surveyors have the hospital in a bad situation. As they might say in the U.K., “It’s a fair cop!” But, if you look at that EP (EC.5.40, EP #12), why, it’s a “C” score. Can we do something here? You betcha!

We know how many extinguishers we have in our inventory: 75 extinguishers at the main hospital and another 10 at all of the off-sites, for a total of 85 devices. Ah, but we still don’t make the mark-10 out of 85 is a compliance rate of 88.2%, which may be enough to downgrade to a supplemental citation, but not enough for outright removal of an RFI.

But is that really the case? I’m thinking perhaps not.

As you know, compliance is generally measured as a function of 12-month periods. If you take your fire extinguisher program to the 12-month parameter, you end up with a total number of monthly inspections as a function of the number of extinguishers (85) and the number of inspections per year per extinguisher (12), which yields 1,020 activities.

With that number in mind, if you only missed 10 inspections, then you still have a compliance rate of better than 99%. No RFI for you, my friend. Your compliance data is most useful in the clarification process.

One further note about auditing: You need to base the timeframe for review on the date of your survey. The only sure way to vacate an RFI is to demonstrate that you were in compliance during the survey.

Now you may say my extinguisher anecdote is an extreme example, but I can assure you that this solution absolutely works in real life (this falls under the “been there, done that” category).

But what if my hospital isn’t in any real accreditation jeopardy? What’s the point of chasing these rainbows? Well, turning once more to Joint Commission official Darlene Christianson in her remarks at the Executive Briefings conference, we learn that, beginning in 2008, the number of RFIs you receive during your triennial survey can influence how soon (or not) you can expect your next survey.

Remember, the survey window will be opening to any time from 18-39 months after your most recent survey-a mighty big window, yes? I’d rather see the 39-month-sized window.

And perhaps most importantly, do you really want to submit an “evidence of standards compliance” response and be responsible for fixing a process that wasn’t broken in the first place? Don’t you have enough to do fixing things that ought to be fixed? I thought so…

Butter isn’t the only thing you can clarify…

Okay, Elvis has left the building (picture a Joint Commission surveyor with sideburns, sunglasses and a big ‘ol belt buckle-bell-bottoms optional) and you’re the proud owner of a handful of EC RFIs.

You tried, tried, tried to negotiate a favorable result during the survey, but a couple of things would not go away. Adding insult to injury, your organization is looking at an adverse decision of conditional accreditation (CON) or even preliminary denial of accreditation (PDA) and the rest of the team is giving you the hairy eyeball because you were supposed to have everything under control-right?!?

Well, the departure of the survey team does not signal the end of things. And, importantly, if your organization is facing an adverse accreditation decision, you need to start digging yourself out of that CON or PDA hole.

The best tool for the job? The clarification process.

But don’t spend too much time moping around because the clock is ticking.

Organizations faced with an adverse decision have a mere 10 business days from your final report to submit clarifications for findings during survey. You need to carefully analyze each finding to identify any RFIs for which clarifying evidence will reverse one or more citations. But which one (or ones) do you choose?

At a recent Joint Commission Executive Briefings conference, Darlene Christianson, executive director of accreditation and certification services at the Joint, urged the audience at a minimum to perform a post-survey audit on all RFIs involving C elements of performance and submit the results as a clarification if the audit demonstrates 90% compliance or better.

What’s that? A score of 90% is all I need? Yes, my friends, you heard it right. And, to sweeten the clarification pot even more, an audit compliance percentage of 80%-89% can, in certain cases, result in a reduction from an RFI to a supplemental recommendation.

So I ask-what are you waiting for? More on this in my next posting . . .

Steve Mac.

smacarthur@greeley.com

EPA issues a ruling on epinephrine salts

Hey everyone, it’s Scott Wallask checking in with an interesting note from the EPA. It appears ephineprine salts are officially off the list of P-listed wastes that the agency regulates.

Click here to read the decision.

Sounds like that’s a welcome announcement.