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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.

Logic doesn’t always prevail…a luxury you can’t afford!

By my observations over time, I’ve found that, all-too-often, logic finishes a distant third behind self-interest (which sometimes manifests itself as crimes of convenience) and panic. Unfortunately, if you currently work in the healthcare industry, you must cling to the bastion of logic as those “other” winds threaten to pull you under.

But sometimes even bureaucracies manage to act judiciously; the good folks at the Centers for Medicare & Medicaid Services (CMS) have elected to curtail some of their “regular” survey activities to afford healthcare organizations the opportunity to focus on COVID-19 preparedness (you might want to bookmark the CMS FAQ page—they’ll be updating frequently). While this doesn’t mean CMS is going to halt all survey activity, it outlined how it would be prioritizing survey activities over the next little while:

Effective immediately, survey activity is limited to the following (in priority order):

  • All immediate jeopardy complaints (cases that represent a situation in which entity noncompliance has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment, or death or harm) and allegations of abuse and neglect
  • Complaints alleging infection control concerns, including facilities with potential COVID-19 or other respiratory illnesses
  • Statutorily required recertification surveys (Nursing Home, Home Health, Hospice, and ICF/IID facilities)
  • Any revisits necessary to resolve current enforcement actions
  • Initial certifications
  • Surveys of facilities/hospitals that have a history of infection control deficiencies at the immediate jeopardy level in the last three years
  • Surveys of facilities/hospitals/dialysis centers that have a history of infection control deficiencies at lower levels than immediate jeopardy

While that does narrow down the field somewhat, those last two possibilities might be well-served by digging out any survey reports from the past couple of years to see if there are any IC-related issues lurking in the weeds.

According to the information provided to surveyors, the aim is to keep on-site survey time to no more than two days, with a particular focus on (you guessed it!) infection control, particularly as it relates to COVID-19 preparedness. You can see the meat and potatoes of the CMS memos to providers here:

https://www.cms.gov/files/document/qso-20-12-allpdf.pdf-1

https://www.cms.gov/files/document/qso-20-13-hospitalspdf.pdf-2

https://www.cms.gov/files/document/qso-20-14-nhpdf.pdf

As a final note for this week’s entertainment, our friends at ASHE have dedicated a webpage to provide COVID-19 information and resources; some of the materials require membership to access, but this is probably another page you’ll want to visit regularly as the next few weeks unfold.

Manage the environment, manage infection control risks

In looking back at 2018 (heck, even in looking back to the beginning of 2019—it already seems like forever ago and we’re only a week in!), I try to use the available data (recognizing that we will have additional data sometime towards the end of March/beginning of April when The Joint Commission (TJC) reveals its top 10 most frequently cited standards list) to hazard a guess on where things are heading as we embark upon the 2019 survey year.

First up, I do believe that the management of ligature risks is going to continue to be a “player.” We’re just about two years into TJC’s survey focus on this particular area of concern; and typically, the focus doesn’t shift until all accredited organizations have been surveyed, so I figure we’ve got just over a year to go. If you feel like revisiting those halcyon days before all the survey ugliness started, you could probably consider this the shot heard ’round the accreditation world or at least the opening salvo.

As to what other concerns lie in wait on the accreditation horizon, I am absolutely convinced that the physical environment focus is going to expand into every nook and cranny in which the environment and the management of infection control risks coexist. I am basing that prediction primarily on the incidence of healthcare-associated infections (HAI) and related stuff (and, as was the case with ligature risk, I suspect that having a good HAI track record is not going to keep you from being cited for breakdowns, gaps, etc.). We’ve certainly seen the “warning shots” relating to water management programs, the inspection, testing, and maintenance of infection control utility systems, management of temperature, humidity, air pressure relationships, general cleanliness, non-intact surfaces, construction projects, etc. Purely from a risk (and survey) management perspective, it makes all the sense in the world for the survey teams to cast an unblinking eye on the programmatic/environmental aspects of any—and every—healthcare organization. Past survey practice has certainly resulted in Condition-level deficiencies, particularly relative to air pressure relationships in critical areas, so the only question that I would have is whether they will be content with focusing on the volume of findings (which I suspect will continue to occur in greater numbers than in the past) or will they be looking to “push” follow-up survey visits. Time will tell, my friends, time will tell.

But it’s not necessarily just the environment as a function of patient care that will be under the spotlight; just recently there was a news story regarding the effects of mold on staff at a hospital in New York. TJC (as well as other accreditors including CMS) keeps an eye on healthcare-related news stories. And you can never be certain that it couldn’t happen in your “house” (it probably won’t—I know you folks do an awesome job, but that didn’t necessarily help a whole lot when it came to, for example, the management of ligature risks). Everything filters into how future surveys are administered, so any gap in process, etc., would have to be considered a survey vulnerability.

To (more or less) close the loop on this particular chain of thought (or chain of thoughtless…), the Centers for Disease Control and Prevention are offering a number of tools to help with the management of infection control risks in various healthcare settings, including ambulatory/outpatient settings. I think there is a good chance that surveys will start poking around the question of each organization’s capacity to deal with community vulnerabilities and these might just be a good way of starting to work through the analysis of those vulnerabilities and how your good planning has resulted in an appropriately robust response program.

A hospital in trouble is a temporary thing: Post-survey blues!

As you might well imagine, based on the number of findings floating around, as well as CMS’ continuing scrutiny of the various and sundry accreditation organizations (the latest report card is out and it doesn’t look too lovely—more on that next week after I’ve had a chance to digest some of the details), there are a fair number of organizations facing survey jeopardy for perhaps the first time in their history. And a lot of that jeopardy is based on findings in the physical environment (ligature risks and procedural environment management being the primary drivers), which has resulted in no little chagrin on the part of safety and facility professionals (I don’t think anyone really thinks that it would or could in their facility, but that’s not the type of philosophy that will keep the survey wolves at bay). The fact of the matter is (I know I’ve said this before, though it’s possible that I’ve not yet bent your collective ears on this point) that there are no perfect buildings, particularly in the healthcare world. They are never more perfect than the moment before you put people in them—after that, it is a constant battle.

Unlike any other time in recorded history, the current survey epoch is all about generating findings and the imperfect nature of humans and their interactions with their environment create a “perfect storm” of opportunities to grow those numbers. And when you think about it, there is always something to find, so those days of minimal to no findings were really more aberrant than it probably seemed at the time.

The other piece of this is the dreaded adverse accreditation decision: preliminary denial of this, termination of that and on, and on. The important thing to remember when those things happen is that you will be given (well, hopefully it’s you and not your organization sailing off into the sunset without you) an opportunity to identify corrective action plans for all those pesky little findings. I can’t tell you it doesn’t suck to be in the thick of an adverse accreditation decision because it truly, truly does suck, but just keep in mind that it is a process with an end point. There may be some choppy seas in the harbor, but you have the craft (both figuratively and literally) to successfully make landfall, so don’t give up the ship.

Everybody here comes from somewhere: Leveling the post-survey field

Well, if the numbers published in the September Perspectives are any indication, a lot of folks are going to be working through the post-survey Evidence of Standards Compliance process, so I thought I would take a few moments to let you know what has changed since the last time (if ever—perhaps your last survey was a clean one) you may have embarked upon the process.

So, what used to be a (relatively) simple accounting of Who (is ultimately responsible for the corrective action), What (actions were taken to correct the findings), When (each of the applicable actions were taken), and How (compliance is going to be sustained) has now morphed into a somewhat more involved:

  • Assigning Accountability (for corrective actions and sustained compliance)
  • Assigning Accountability – Leadership Involvement (this is for those especially painful findings in the dark orange and red boxes in the SAFER matrix – again, corrective actions and sustained compliance)
  • Correcting the Non-Compliance – Preventive Analysis (again, this is for those big-ticket findings – the expectation is that there will be analysis of the findings/conditions cited to ensure that the underlying causative factors were addressed along with the correction of the findings)
  • Correcting the Non-Compliance (basically, this mashes together the What and When from the old regimen)
  • And last, but by no means least, Ensuring Sustained Compliance

This last bit is a multifocal outline of how ongoing compliance will be monitored, how often the monitoring activities will occur (don’t over-promise on those frequencies, boys and girls; keep it real and operationally possible), what data is going to be collected from the monitoring process, and, to whom and how often, that data is going to be reported.

Now, I “get” the whole sustaining correction “thing,” but I’ve worked in healthcare long enough to recognize that, while our goal may be perfection in all things, perfection tends not to exist within our various spheres of influence. And I know lots of folks feel rather more inadequate than not when they look at the list of findings at the end of survey (really, any survey—internal, external—there’s always lots to find), which I don’t think brings a ton of value to the process. Gee thanks, Mr. Surveyor, for pointing out that one sprinkler head with dust on it; gee thanks, Ms. Surveyor, for pointing out that missing eyewash check. I believe and take very seriously our charge to ensure that we are facilitating an appropriate physical environment for care, treatment, and services to be provided to patients in the safest possible manner. If I recall, the standards-based expectation refers to minimize or eliminate, and I can’t help thinking that minimization (which clearly doesn’t equal elimination).

Ah, I guess that’s just getting a little too whiny, but I think you see what I’m saying. At any rate, be prepared to provide a more in-depth accounting of the post-survey process than has been the case in the past.

The other piece of the post-survey picture is the correction of those Life Safety Code® deficiencies or ligature risk items that cannot be corrected within 60 days; the TJC portal for each organization, inclusive of the Statement of Conditions section, has a lot of information/instruction regarding how those processes unfold after the survey. While I know you can’t submit anything until you’ve been well and truly cited for it during survey, I think it would be a really good thing to hop on the old extranet site and check out what questions you need to consider, etc., if you have to engage a long-term corrective action or two. While in some ways it is not as daunting as it first seems, there is an expectation for a very (and I do mean very, very) thorough accounting of the corrective actions, timelines, etc., and I think it a far better strategy to at least eyeball the stuff (while familiarity is said to breed contempt, it also breeds understanding) before you’re embroiled in the survey process for real.

Musings from Rantopolis

There are a couple of developments on the Joint Commission front. They’re deleting some 131 performance elements from across the accreditation manual; a few are EC-related, but none in the EM or LS chapters, I want to take a few moments to look at the tea leaves before I weigh—maybe I’ll include in our upcoming edition of portal chortlings—we’re about due for a fireside chat, but anyways…

This just in: The Clarifications and Expectations column penned by Mr. Mills is “on hiatus,” but scheduled to return in June 2016. Curiouser and curiouser…

Last week I was working with a client on answering a citation that had come up during a TJC survey (not their survey, but someone else’s—sometimes folks will share post-survey intel). The finding was related to the storage of toilet paper and paper towel in a housekeeping closet, based on (presumably) the notion of the housekeeping closet as a “soiled” area and the toilet paper and paper towel being “clean” supplies (remembering that when we use toilet paper, the rolls are right next to the toilet OMG…OMG…OMG!). Now I am reasonably certain that (much like some other conditions and/or practices I will note in a moment) there are no specific regulatory standards that speak to how and where one is to store paper supplies, etc., so, once again, we come up against the assumed role of the surveyor cadre in prescribing practices instead of assessing how well a risk is being managed. Are there housekeeping closets that are somewhat less reputable looking than others? Absolutely! Are there risks associated with storing paper products in housekeeping closets? Absolutely! Are there risks associated with storing paper products in clean utility rooms, including the potential for pests? Absolutely! Is this a discussion that could go on forever? Absolutely!

To paraphrase the late, great Lewis Allen (you probably know him just as “Lou”) Reed, I am sick of it. I am sick of seeing findings like “linen cart cover was not down,” “solid bottom shelf was not in place,” “materials stored under a sink,” “toilet paper and paper towel stored in a housekeeping closets,” “cardboard boxes in clean utility rooms.” The whole concept of the management of the physical environment is supposed to be based on managing the risks is that very same physical environment. Show me how whatever condition being cited is actually resulted in a risk that is being appropriate managed—not merely the possibility of a potentially increased risk if the planets are in the correct alignment, etc., etc., ad nauseum. Every time I think about the “war on cardboard,” I grind my whole being (not just my teeth); yes, there are places where cardboard ought not be broken down (sterile supply areas, etc.) but those locations are very limited. Show me that we’re not managing the cardboard appropriately. Show me real evidence (not online pictures) that we are legitimately dealing with cardboard critter condos. I absolutely, beyond any shadow of doubt, understand and recognize the risk potential of cardboard, but if there’s no evidence that the cardboard boxes are doing anything more than appropriately holding the contents of said boxes, how does that become a citable offence? When I think of the hundreds of thousands of dollars that have been wasted purchasing plastic bins that (channeling T. Swift here) never, ever, ever, ever (is that too many “evers”?)  get cleaned…check ’em out if you don’t believe me. And never mind the kabillion of labor hours devoted to removing all the whatevers from those cardboard boxes and putting them in the plastic bins as opposed to delivering the box full of stuff and then throwing that every same box away when it is empty. In fact, I would submit to you that by getting rid of the cardboard, we have made it exponentially more difficult to manage expiring product. Old days: case with expiration date on it; when case is empty, throw case away—boom! New days: plastic bin almost empty so we dump more product in on top of the old stuff (Oh sure, we’re taking the old stuff out and then placing it in a bag on top of the new stuff to ensure the old stuff gets used first. Yup, that’s what’s happening, yes indeedy…) I’m sure each of you can think of some “practice” that’s being enforced in your organization that is based on not much in the way of logic (logic doesn’t seem to prevail as much as it used to—I can’t think that that’s a good thing). I think we need to take a stand. (“I’m rather unhappy about the current state and I’m not inclined to support it any longer” or the more pointed “I’m mad as hell and I’m not going to take it anymore.” We safety professionals are more inclined towards the genteel first versions when in polite conversation, but deep inside, you know what I’m talkin’ about!)

Okay, that’s probably enough on that topic for the moment (I’m going to guess that there may be one or two heads nodding in the affirmative at this point in my screed, though perhaps there are others that might disagree). If there’s such a strong feeling about this stuff, then the regulators should be very clear about those “clarifications and expectations.” There’s a process for reviewing the survey results before the final results are provided to each organization. Use it to remove these findings that are truly no more than surveyor bias (yeah, it’s like how tough it is to reverse an official decision in sports). Unless, of course, the purpose of the current survey process is to generate as many findings as humanly possible…nah—who’d believe that!

So join us next week as we add another section to our construction of the immortal portal cortile chortle…