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Will meeting in person ever come back?

And perhaps more importantly: Does it make a difference?

As I’ve been working with folks over the past few months, it’s been kind of interesting to see how much impact social distancing and its component elements have had on the management of the care environment, at least from an oversight standpoint. Folks have been able to keep their eye on the prize for the most part, but it’s tough to figure out how effective meetings are when participation and other more traditional metrics are almost impossible to determine, never mind measure. For you folks out there reading this: Has this been something discussed during meetings, included in annual evaluations, or have you kept your head down and plowed through the past year (I suspect there’s a fair amount of plowing)? COVID has been such an attention-seeker in so many ways and remains the center of attention for so many folks—it seems impossible to think that we won’t be unraveling things for quite some time to come.

Turning to the May edition of Perspectives, it’s interesting to note that our friends from Chicago say they managed to conduct over 1,100 surveys in hospitals during 2021 (Does that means 1,100 hospitals were surveyed? Somehow, I’m thinking not). What is also interesting is that the presentation of the survey findings data has taken something of a turn in that the focus is not only on specific performance elements, but also on those findings that generate the findings of greatest survey criticality (read: adverse survey decisions). From looking at the hospital data, it appears that only a couple of findings of immediate threat to health/life were in the mix (mostly relating to the management of patients with suicidal ideation, though there was on related to infection control), but it would seem that there are a whole bunch of findings in the “red” (the highest risk category in the matrix). By my reckoning, now that the physical environment is not occupying all the top spots, the hot spots for high risk in the care environment are ventilation, safe, clean areas for patients, and the management of chemical risks (hmmm, could that be a euphemism for eyewash stations?), with a side order of whatever relates to infection control concerns like high-level disinfection and the management of patient care equipment.

I don’t know that there’s anything that is particularly shocking about the slate of focus areas; that said, it will be interesting to see how findings shift (or not) now that the onsite surveys are back on line with the intent of poking around more in the outpatient settings. As an indicator, can we intuit anything from the Ambulatory Care Top 10? Indeed, I think there is—and that “anything” is anything in the environment that has an impact on infection control—disinfection, ventilation, cleanliness, ITM of sterilizing equipment. The common themes do emerge without too much scrutiny.

I think we know what we have and I think we know where they are going with all of this, though it makes me sad that loaded sprinkler heads won’t be at the top of the list. Although I suspect that it will remain among the most frequently cited single conditions; how could it not?

So, that’s this week’s missive. I hope you all continue to be well and are working to stay safe. If you’re finally thinking about embracing travel, please take measures to protect yourself. I’m seeing a lot of variation when it comes to masking, but I can’t tell who has been vaccinated and who hasn’t (unless everyone starts wearing a t-shirt…).

Be well and I’ll be back at you next week, which, if my calendar is correct, will be May. Who’d a thunk it?

Are you transmitting? Late night fire drills and alarm signals…

I think we can safely say that sometimes it is tough to pinpoint specifics when it comes down to what performance elements are cited during regulatory surveys, be they virtual or actual. In this regard, I really couldn’t say to what extent this particular item is being cited, but I know that it happens and often that happening results in some level of consternation of the “How am I supposed to do that?” variety.

The Life Safety Code® (LSC) NFPA 101-2012 19.7.1.4 requires that: “(f)ire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions.” Section 19.7 (section 19.7.1.7, to be precise) goes on to indicate that “(w)hen drills are conducted between 9:00 p.m. and 6:00 a.m. (2100 hours and 0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.” I suspect that, over time, a lot of folks have ended up equating the transmission of a fire alarm signal and the use of a coded announcement as being equivalent, but that really isn’t the case. 19.7.1.7 allows you to conduct a fire drill without disturbing patients, etc., but, as it turns out, you still have to include the transmission of the fire alarm signal (that’s the signal that actually “leaves” the building and goes to the central monitoring service, 911 call center, etc.). If you need further indication, I submit to you the “opinion” (or you could call it an interpretation) of one of our favorite AHJs. I think this gives you a good sense of the separation of what happen inside your facility versus making sure that pesky alarm signal finds its way outside.

But the question then becomes, how does one accomplish this if one has a fire alarm system that doesn’t provide an easy way of turning off the internal signals and still allowing for the transmission of the signal? This question bounced my way recently and I decided to do some poking around to see if there were any scholarly works, etc., and I came across some guidance published back in 2016 (the document is dated June 2016, so it would precede the official adoption of the 2012 LSC by CMS), that outlines some of the particulars of fire drills to be conducted in Minnesota.

One of the interesting elements is a note that deals with today’s discussion: “Note: When a coded announcement is used instead of audible alarms on the night shift, the fire alarm should be sounded first thing in the morning the following day to meet the requirement that each drill include ‘transmission of a fire alarm signal.’” Now I recognize that AHJ interpretations are many and varied (to an almost frightening degree), but I was wondering if anyone had been able to negotiate this type of process with their AHJ. It certainly makes sense to me that you could “extend” completion of the fire drill a few hours to ensure proper operation of the fire alarm system, but I also suspect that you’d probably be reticent to go that route without getting some sort of permission and you’d probably need to write it in to your policy or management plan as a standard practice or procedure, but it seems a rather elegant solution to me ( as a non-AHJ). What say you all?

Hoping this finds you well and staying safe; I figure every week brings us closer to whatever’s coming next, so let’s get there together!

Gimme a break…or a spare circuit breaker

One of the more common findings (as it were) over the past few years has been the condition in which a circuit breaker is in the “on” position and it is either not labeled or labeled as a “spare.” It would seem that the codified guidance in this regard is sufficiently “gray” to push our friends in Chicago to issue an official interpretation. In olden times, this information would be shared either in Perspectives, the FAQs or the standards manual(s) and I can’t seem to find mention of it anywhere other than from ASHE. Perhaps it’s nothing (from a process standpoint, this is going to be a pain in the butt; from a practical standpoint, how many circuit breakers do you have?) but, like the ubiquitous “loaded” sprinkler head, there always seems to be one breaker that’s not going in the right direction. And I suppose if a surveyor is willing to put in the time to find it, all you can do is thank them…

At any rate, I did want to take a moment to thank each and every one of you for keeping things together (both figuratively and literally) over the past months. I know these have been among the most trying times imaginable and we’re certainly going to be “in it” for a while longer, but you folks have done what needed doing and are still doing everything you can do to keep everyone safe and your facilities operational. I am proud to be associated with such a fine bunch of folks. We’ve got this!

Until next time, be well and stay safe!

When you’ve done all you can do, what do you do?

As I start this, I’m thinking it will be kind of brief, but you and I have both been at the receiving end of my brevity, so we’ll see what happens.

As I ponder the various and sundry processes that make up an effective program for managing the physical environment, I cast my mind back to some instances in which self-identified corrective actions were not completed before our friends from the regulatory world parachuted out of their black helicopters to conduct accreditation surveys (I will freely admit that sometimes those black helicopters look exactly like commercial airliners—I’m not sure how the technology works, but it looks to be pretty seamless…) and the questions are inevitably raised as to (more or less) “How come it’s taking so long?”

There’s also the possibility (it may even be a likelihood, but I shy away from pronouncements based on a small data sample) that when there are findings relating to the physical environment, the general concept of the organization’s responsibility vs. just the Environment of Care (EC) folks sometimes flies out the window. Only you folks know what kind of culture you have in your organization and how much acknowledgement of shared responsibility is going to occur post-survey. But, in response to that “knowledge,” I would ask you to think carefully about how the EC program escalates issues that are difficult, if not impossible, to resolve within the EC program. Sometimes I get the sense that folks are less inclined to “air their dirty laundry” in the direction of organizational leadership, but (in my mind) one of the most important capabilities of any management process is knowing when to ask for help. Clearly, you don’t to “cry wolf” too often, but sometimes you just have to raise your paw…

By way of providing context, as this is generally the time of the annual evaluation (as opposed to the time of the season, though they may coexist), I would encourage you, in your “look back” over the year, to consider whether there were issues identified for which resolution has not been forthcoming. Part of this (OK, perhaps quite a lot of this) may have to do with all things COVID—if the effectiveness of our “product” is based on the juggling of (at times competing) priorities. Much as September 11, 2001 shifted the safety/preparedness world in an unanticipated direction, likewise COVID has pushed things around rather a lot. I suspect that everyone is going to have a COVID list of things that either didn’t get done or didn’t get done as well as one would like. Now is a good time (as we start to close on the birthday of the declared emergency) to quantify the impact of those “things.” I don’t know that it needs to be the sole focus of the annual evaluation process, but if you were to do so, I think you (and your organization) might be well-served for it.

As we rocket through January, I hope this finds you well and staying safe—we will get through this!

Be afraid, be very afraid…but do it anyway!

Something of a mixed bag this week: Basically a couple of brief items with some interpolative commentary.

First off, in what is probably not really a surprise, the feds have not updated the status of the Public Health Emergency (PHE) (here’s the most recent correspondence in this regard) in a little bit, but I am hopeful that our sprint towards the New Year will prompt a revisitation. I guess one of the key thoughts moving forward is at what point are regulatory surveys impacted. It would seem that we are in a bit of a spike in cases (though how one can tell definitively is something of an art form), based on the information provided to folks traveling in and out of Massachusetts (which would include yours truly). While I can’t say that I’m getting used to being swabbed, I suspect that between now and Christmas, I’ll have a few more opportunities to embrace the swab.

At any rate, I’d be curious as to how folks are “falling” within their normal accreditation survey cycle. Early? Late? Pretty much on time? At some point, something’s going to have to give (and maybe that something involves virtual building tours and the like). I guess at this point all we can do is “stay the course,” and wait for the vaccine distribution challenge (we know it’s coming sometime)…

In other news, our friends in Chicago announced a revision to one of the performance elements dealing with the life safety implications of maintaining fire suppression systems. You might recall we chatted a bit about this back at the beginning of July, at least in terms of the whole spare sprinkler thang. If you accept (as I pretty much have at this point) that any change to a physical environment standard or performance element is “designed” to provide an opportunity for generating more findings (the sterling being the impending focus on the ambulatory care environments), then I think it would be prudent to really kick the tires on your spare sprinkler maintenance program to ensure that you are meeting not just the requirements of the revised performance element, but also the other related requirements. (The blog post above should serve as a good starting point, if you are so inclined.)

As always, please be well and stay safe. I appreciate everything you are and everything you do!

Just when you thought it couldn’t possibly get any stranger…

But first (as promised), a word about fire drills (there will be more, maybe next week, depends on what comes flying over the transom…): About a month ago, I mentioned the possibility of a shift in fire drill frequencies for business occupancies from annual to quarterly. This was based on actual experiences during a state/CMS survey in the Southeast. At the time, it seemed a bit incongruous, but the lead Life Safety surveyor was very pointed in indicating that this was the “real deal.” Well, as it should turn out, it appears that somewhere between that pointed closing, and the receipt of the survey report and follow-up, there may have been a little excess stretching of the interpretive dance that we’ve all come to know (and not love). As of the moment, business occupancy fire drills will continue to be on the annual calendar and not the quarterly one. So, three cheers for that!

But the oddest headline of the past couple of weeks revolves around CMS and their “sense” that our friends in Chicago are being, for lack of a better term, overly transparent during the survey process, particularly during exit conferences at the end of each survey day. The thought given voice is The Joint Commission (TJC) is “(p)roviding too much detail or having extensive discussions before or during a facility inspection survey can potentially compromise the integrity of the survey process. Based on the level of detail shared, a facility could correct potential deficiencies mid-course, which would skew the findings and final outcome of the investigation,” (you can read the source article here). Exactly how this determination was made is not crystal clear to me, but it did occur during the process through which TJC’s deemed status was renewed—but only for two years.

For those of you who have participated in surveys over the year, I think we are in agreement that excessive clarity was not one of the hallmarks of the survey process, though it shivers my timbers to think of how they could become even less so. I have noticed a marked decrease in useful information, per issue, in Perspectives over the past few years, so maybe that’s one of the forums that will be less instructive as we enter the post-COVID era of accreditation surveys. We know that much of what goes down during a survey is the result of interpretation of regulations that are as broadly-scoped as they could possibly be (or are they?), so it would seem that we are looking at an even more opaque survey process—holy moley!

Until next time, be well and stay safe. We need each other—and perhaps never more than now!

Yes, I know I said fire drills, but…

Please feel free to accuse me of “dogging it,” but since I am on vacation this week and you all probably need something of a vacation from me, here’s just a quick blast relating to our latest conversation thread.

Hopefully, you noted the recent headlines indicating The Joint Commission’s (TJC) continued status as an accreditation organization with deemed status; you probably also noted that CMS continues to tighten the leash (if you will), approving their accreditation status for only two years. The CMS indicated, among other things that they “…are concerned about TJC’s review of medical records and surveying off-site locations, in particular for the Physical Environment Condition of Participation (CoP).” Talk about waving a red flag in front of a bovine nose or two!

I think we can intuit that the folks from CMS (not unlike, say, The Man from Glad, or UNCLE) were reasonably pointed in their discussions with TJC prior to making the announcement and, in the face of what might reasonably be interpreted as an existential threat, we can expect lots of attention paid to the outpatient setting(s) in general, and a keen focus on all things relating to the care environment. Certainly, the level of angst generated by this “omen” will hinge closely on how widespread your organization is and (potentially) how well your corporate structure compartmentalizes offsite locations. If you’re not sure, one thing you might consider doing is hopping over to TJC’s website for searching accredited organizations and see how your place “shakes out.” Nominally, each of the care locations they think you have should be represented, and it’s always fun to see if what’s there matches up with what you think you have. I can tell you with absolute certainty that there have been some surprises in the past and I have no reason to think the future holds anything different.

So, that’s our missive for this week  and we’ll cover fire drills next time—I wicked promise! Unless something else happens…

Take care and stay safe!

Probably not the final word on outpatient clinic settings

Sometimes I have a difficult time finding a unifying “thread” for the weekly chronicle and other times the way forward is fairly clear. This week may be more towards the former, but I think I can tie things together with a little bit of judicious “bridging.”

First we’ll start with what can only be described as “old news,” though the topic (CMS continues to make frowny faces towards the various accrediting organizations, coupled with the odd glare or two) is as old as the hills. At any rate, if one were an accreditation organization (AO), one might look at the ongoing skirmishes ’twixt the Federales and their deemed status minions as an existential threat (the exact degree of the threat is tough to figure out: Can CMS “fire” all the AOs and still be able to ride herd on healthcare? I’m not so sure). It can’t be pleasant to be berated on a regular basis, reminded of one’s failings, etc., so the natural tendency would be to try to get out from underneath. And the one sure way of making that happen is to work towards generating lots and lots (and lots!) of findings, and if you can tie those findings to various levels of criticality, then you can demonstrate your value to the process. Certainly, the various AOs have generated a lot of findings within the hospital settings over the last few years and (at least for our friends at TJC) there’s been some branching out into the “field.”

One of the trends I’ve noticed as this “shift” has been occurring is a fair number of findings relating to eyewash stations  in all sorts of areas and I think a recently updated (June 26, 2020) TJC FAQ for hospital and hospital clinic settings may be instructive as a function of setting the stage (or the table—you pick) for increased focus on those instances in which surveyors feel you need an eyewash station and perhaps you do not have a risk assessment prepared that would indicate otherwise. As we have discussed in the past (you can find pretty much all of those mentions here), eyewash stations (or the lack thereof, of the care and feeding of) tend to generate findings, but (as long as you do the math) you only have to have them under certain very specific circumstances—circumstances with which surveyors are sometimes only passingly familiar.

That said, one other trendy thing I’ve noticed is that glutaraldehyde is starting to creep back into the healthcare safety landscape, which poses its own fair share of complexities when it comes to managing risks (some useful thoughts on that subject on Tim Richards’ blog). And sometimes, just sometimes, when one is discussing the far reaches of an organization, the creeping of something like glutaraldehyde can be much less noticeable than if it were under the white hot lights of the main campus (or the mothership, if you prefer). Sooooo, particularly for those of you with lots of offsite locations (or even only a few), keep an eye out for those funky things that “show up” at generally less than useful times. You might find out it’s the difference between survey success and having to write plans of correction for weeks on end…

Hope you are all staying safe and staying positive. It’s looking like the first wave of COVID-19 is not quite done with us (and I don’t think we can have a second wave until the first one is done), but I know you folks are keeping a lid on things: Keep up the good work!

They’re baaaack: TJC returns to the fray!

Last week, our friends in Chicago announced that they will be resuming the survey grind in June (in all candor, I too will be heading out on the highways and byways of the consulting world, though I can’t help but think how “neatly” June sets up, June 1 being a Monday and all—I know nature likes symmetry, etc., but this seems almost too convenient. But I digress).

While it is not yet completely clear how things will be different, it does sound like there will be a fair amount of analysis and communications with facilities being surveyed to ensure that the survey process goes as smoothly as possible from an operational perspective. To that end, if you happen to be at a facility “in the queue” for survey, the account executive coordinating the process will be reaching out to your organization to determine the impact the pandemic has had on your operations and what things look like in their “current state.”

It is also clear that social distancing will be in full force for the next little while (again, I’ll have a chance to weigh on some of those particulars as I recommence client visits), including limiting the number of individuals “present” in group sessions (audio and/or video conferencing will take on much wider application—I know some of your EOC/EM committees have a lot of moving parts); minimizing participants in tracer activities; appropriate use of PPE (as provided for each organization’s requirements—TJC expects you to provide whatever is appropriate); driving in separate cars for off-site location and/or home visits, etc.

The announcement also indicated that the focus of the process will be a thorough assessment, but not a retroactive review of compliance (I am curious as to how that will manifest itself, particularly in terms of inspection, testing and maintenance activities, and other elements of compliance in place prior to the onset of the pandemic). The announcement also indicates that implementation of your emergency operations plan will not be the focus of the survey so much as the development of an understanding of how your organization has adapted to the pandemic and look at current practices to evaluate the extent to which safe care, and a safe working environment are being provided.

 

What a short, strange trip it’s been…

I think we can safely say that 2020 has manifested itself in a lot of (vaguely unpleasant) ways, but this one has the potential for really shifting the compliance landscape for the next little while.

You probably have already heard this through various sources, but our friends in Chicago are suspending all regular Joint Commission survey activity, effective this past Monday, March 16 until further notice, with no anticipated restart date. I suppose those of you for whom a survey visit was imminent, this gives you a little bit of breathing room (and given the tenor of the times, even a little bit feels pretty darn good), but it also requires you to sustain your compliance and oversight efforts just that much longer (I have always maintained that accreditation surveys look best in the rear view mirror), which could prove challenging.

That said, I have absolute confidence in you folks to keep your organizations sharp and on point (sorry for the mixed metaphor there). We can only prepare one day at a time, and so, can only sustain progress one day at a time. I think we can predict that infection control and prevention will experience focus like never before (but hey, we knew this was coming), so make sure all your infection control-related risk assessments are up-to-date and minty fresh (actually, reviewing all your risk assessments is probably a good way to spend this “grace” period).

There’s a lot going on, but if the past two months+ are any indicator, 2020 has more surprises in store (hopefully not…), you don’t want a bad survey to be one of them.