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It’s these little things, they can pull you under…

I guess this week’s entry (as it appears that Spring is actually going to spring) falls into the “a little bit of this, a little bit of that” category; nothing monumentally earth-shattering, but (hopefully) useful.

First up, a recent post from the American Society of Health Care Engineering’s (ASHE) YouTube channel (somehow, it escaped me that such a thing existed—shame on me!) popped up on some feed somewhere (it may have been LinkedIn, but I can’t say for sure) and I found it a very interesting topic of conversation: “The Cost of No.” Given the givens, I suspect there are not too many in the audience who haven’t been at the receiving end of a “no” response (as opposed to no response, which is equally frustrating), and this video may give you some food for thought in how best to manage that impregnable wall. It’s not often that we get what we want, when we want, but I think the video offers some insight into how to plead a better case—to the point that it might increase the chances for a positive response “next time.” The video is pretty short (you can spare 158 seconds, can’t you?) and there are a number of other short videos that are worth checking out, so don’t forget to subscribe. You can start with “No” right here, but please check out the other stuff as well.

Moving on, in a designation that doesn’t seem to have been influenced by Hallmark, March is National Ladder Safety Month (I would have sent a card, but couldn’t even find a birthday card with a ladder that could have been repurposed) and I think we can all agree that ladders are an important part of the compliance picture. I’ll let you find your own “ladder unsafety” images—there are more than I can count, but I think we can also agree that the safe use of ladders could be more thoroughly hardwired into a lot of folks’ practice, including inspecting the ladders before use.

At any rate, I encourage you to set up a ladder safety session for your folks, particularly if you haven’t done so in a while – and what better month to do so. Here are some resources to help ensure folks embrace the heights of safety:

Until next week, hope you are well and staying safe. We’ve made it this far and I am confident we can make it through this 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!

Feeling pretty psyched: Some good news to share!

In full recognition that the longer the COVID-19 condition persists, the crazier it gets to folks on the front lines, so my intent is to (try—we’ll see how this works out—you know me) limit editorializing and provide you with brief episodes of useful content.

This week, it gladdens my heart to let you know that the good folks at the American Society for Health Care Engineering (ASHE) published a template (and guidance information) to facilitate facilities and safety professionals’ requests for an 1135 Waiver relating to the potential for compliance gaps relative to inspection, testing, and maintenance of fire safety and other equipment. You can find the template and table at the ASHE website. It’s a fairly straightforward process and the template (and corresponding table) really simplifies the thought process; I would encourage each and every one of you to check out these materials and get your waiver requests in the queue. To my way of thinking, this will make things a whole lot easier as we deal with survey activities in the aftermath of COVID-19 and, in the short term, allow you to focus on the important things: Supporting patient care at your organization.

Stay safe and stay in touch as you can—you guys rock!

Rock on: Where do we go from here?

It would seem that the subtext to all we are experiencing/dealing with now is how long we can anticipate this “siege” to last, and (as is typical of these types of events) we probably won’t have a clear sense of the timing until the clouds break and the “sun” comes out. From a practical standpoint, the current situation is a very robust test of each organization’s continuity of operations plan (COOP), as well as the opportunity to witness the intricacies of the 1135 Waiver process as it unfolds. Of course, the other element that is unfolding is the number of COVID-19 cases worldwide (I’ve found the Johns Hopkins University case map of particular use in watching the spread of cases, both worldwide, but particularly in the United States; if you haven’t “found” it yet, it’s definitely worth a look).

At any rate, from a planning perspective, we’ve gotten to the point where some preparations need to be made to ensure sufficient capacity in the event regions are not successful in their attempts to “flatten the curve.” And those preparations will probably involve real-life/real-time actions to be ready to establish alternate care sites (to see what that looked like 100 years ago, you can scroll down this page to see my old stomping grounds at Brockton Hospital). To aid in that pursuit, just yesterday (March 30), CMS unveiled a number of regulatory changes to encourage thoughtful expansion of capacity, including provisions for what is described as “hospitals without walls.” I would encourage you to review these new materials as they do have some restrictions (mostly checking to make sure your planning dovetails with your state’s planning for alternate care sites).

From a practical standpoint, our friends at the American Society for Health Care Engineering have included with their COVID-19 resources some guidance (including links to other materials) on options for establishing/converting alternate care sites. Again, looking at the COVID-19 map, it is fairly easy to discern where bed capacities are likely to be in greatest demand and hopefully those most dire of conditions will not spread everywhere, but there’s no reason to delay consideration of what can be done in advance to be able to flex up capacity at your facility. I know there’s a lot going on right now and the struggle to attain some level of normalcy is all too real, but it is clear that we are in the process of redefining the magnitude of planning and preparation activities. Anything we can do to stay at least a couple of steps ahead is worth our time and energies.

Stay safe until next time!

People get ready: There’s a (survey) train a-coming!

When it comes right down to it, I think it is nigh on impossible to have access to too many resources or, indeed, to have access to too many perspectives on the various and sundry processes that make up our little EOC world (OK, maybe not so little), so I’m always on the lookout for stuff that I think might be worth sharing with you folks. (It’s one way I’ve managed to not run out of things to say over the past 600+ weeks since I started this journey.)

Our good friends over at ASHE’s Health Facilities Management magazine recently published an article describing some of the ways facilities and safety professionals can effectively manage the accreditation process, primarily as a function of survey preparedness/readiness. I don’t know that there was anything of great surprise contained therein (with the important note that surveying hospitals is pretty much my life’s work, at least at the moment), but I think the authors did a nice job of providing an overview of the survey process with some key information points that may give you a “leg up” on your next survey.

The one thing we “know” is that we really don’t know when they’re coming next, so the general concept of continuous survey readiness is one that really needs to be taken to heart. But one of the key components of which you need to be mindful is that CMS is definitely ratcheting up on the “looking over the shoulder” aspect of the validation survey process. Where previously, CMS would conduct a validation of survey of the various accreditation organizations within 60 days of the accreditation survey activity, now CMS resources are observing the accreditation organization process as it happens. At the moment, any organization encountering the “enhanced” (my characterization) survey process are notified ahead of time, so you can do a little planning (not sure how much notice is given—if anyone out there can shed some light, based on experience, I’d love to hear from you). But there will come a time when it will be a (more or less) complete surprise!

At any rate, if you want to read about the opening salvo in this little endeavor, you can find it here, and the latest news on this front can be found here, which includes a link to the proposed rule change that deals with changes of ownership, etc. of accreditation organizations. Not very exciting stuff…yet! But I think the pendulum is going to continue swinging in the direction of more oversight (and probably, intervention) for the next little while…

It’s knowing (hoping) that this can’t go on forever: A little bit of regulatory mishegas…

It being only the third week of the New Year, it’s a little early for any trends to fully manifest themselves, so a couple of odds and ends to get you caught up on (or, upon which to get you caught up, for any hard-core grammarians in the crowd…).

The latest issue of Health Facilities Management has a couple of articles (and a risk assessment available to ASHE members—gotta love a new risk assessment) that should prove of some value/interest over the next little bit:

  •  ASHE issues update on CMS ligature-risk policy – this is basically a recap of the CMS memo issued in December (details here) but also includes mention of an environmental ligature risk tool (updated to include a worksheet for EDs) that is available to ASHE members. I’m not sure if the “hand in glove” relationship between ASHE and TJC will remain the same with the departure of George Mills, but there is every reason to feel that ASHE’s position as an advocacy group will continue. In that light, probably a good idea to check out the ligature risk tool and adopt any elements that you may not have yet considered. I still feel that you have to rule everything in as a risk until you can start ruling stuff out, but I also think that we should be checking out any and all available resources.
  • An interesting article on airflow in the OR; to be honest, I love this kind of digging around into the corners of what makes the surgical environment such a bear from a compliance standpoint and where regulatory scrutiny might be headed as a function of increasing attention to the infection control impact of the environment. I’m not suggesting you have to mimic the study, but it might help you anticipate some pointed survey questions or requests.
  • Also in the latest issue of HFM, there’s an update on the CMS interpretations relative to rolling latches and related concerns as well as a request for volunteers to assist in gathering information, policies, etc. on how folks are keeping things quiet at night.

Moving on to our friends from Chicago, in the continuing unfolding of information regarding the management of ligature risks, the latest issue of Joint Commission Online includes further guidance relating to “other” (my quotation marks) behavioral health environments such as residential treatment, partial hospitalization, intensive outpatient and outpatient treatment programs. The guidance indicates that these settings are not required to be ligature resistant, but then goes on to indicate that a risk assessment should be conducted in these environments, and then policies and procedures implemented to address how to manage patients in these settings that may experience and increase in symptoms that could result in self-harm or risk of suicide. The piece also indicates that the expert panel met again in December and there will be additional guidance relating to suicide risk assessment and safe monitoring of high-risk patients. And so the conversation continues…

Thank you falletin me: Some survey-related (and otherwise random) thoughts

The first order of business is a word of thanks to anyone and everyone within the sound of my “voice” – I truly appreciate you (sometimes invisible) folks out there in the audience. It continues to be a rare treat having the opportunity to converse with you on a regular basis (the rarer treat is when I get to actually meet folks in the flesh—definitely a delightful happenstance when it occurs) and I hope that I’ve managed to carry on this little slice ‘o safety without being boring, pedantic, etc. Oftentimes, compliance stuff is rather more torturous than not, but what’s the point of doing something if you can’t have a little fun amidst the abject seriousness of it all…

Next up, a couple of items that have appeared during recent surveys that signal (in some instances) a clarification of intent and/or a change in the focus of the physical environment surveys. Some of this you will find endlessly aggravating, particularly if you get cited for it; some of it has the overpowering stench of inevitability as the regulatory folks find new and inventive ways to keep the numbers of findings at record levels. In no particular order:

 

  • In the wake of the clarifying information relative to the management of ligature risks, make sure that (and this is primarily in the ED/regular inpatient settings) for the risk items you have identified as being medically or clinically necessary/essential to the appropriate care of behavioral health patients, make sure that your risk assessment specifically identifies the inherent risks of the remaining risks. For example, if you need to have a medical bed (with side rails, etc.) in the room, make sure that all the specific risk elements of that (or “the”) medical bed are clearly enumerated in the risk assessment. Saw a survey result recently for which the finding was not that the bed was in the room (the finding specifically noted that the bed was medically necessary), but that the risk assessment did not clearly identify the individual components of the bed: side rails, electrical cord, etc. The survey finding indicated that the risk management strategy employed by the organization was appropriate (in this instance, using 1:1 staffing for the at-risk patients), the only “issue” was not identifying the component risks in the risk assessment. I think/hope that this is something of an overreach and if I find out that there is some clarifying information forthcoming, I will surely share it with you.
  • Those of you with older facilities (and perhaps some “younger” facilities as well) are often faced with the proliferation of electrical panels (and sometimes medical gas zone shutoff valves) that are located in spots for which it is almost impossible to ensure that equipment, etc., is not parked directly in front of the panel, etc. Sometimes the panels, etc., are located in the corridors (it really does make one appreciate electrical closets!); some of you may even have the abject misfortune of having electrical panels in your utility rooms (my condolences); and others have panels out in the operational area of busy locations like food services/kitchen areas. I wish that I had good news to impart, but there do seem to be at least a couple of surveyors heck-bent on citing each and every instance of obstructed access to electrical panels. And don’t get me started on corridor med gas shutoffs with electrical receptacles installed directly underneath. Sometimes I wonder if we would run into these types of conditions if the folks doing the design work actually had to live in the space once it is constructed…
  • Staying on the electrical side of things, I’ve also seen an increase in recent findings relating to the use (primarily in patient care areas) of relocatable power taps/power strips/etc. I know the appropriate management of these devices has been “hittable” for a little while now and perhaps there was an unspoken “honeymoon” period for the industry to get things going in the right direction. If that is the case, it appears that the honeymoon is over, so you (particularly if “you” are in the bucket for survey in the next little while) probably should focus a bit on power arrangements in the areas where equipment use and power needs tend to be exponential. I still think the resources provided by ASHE are worth checking out if you have not already done so. It just might save you a painful survey experience.

Closing out, I leave you with this thought/opportunity; I won’t pretend to have an answer for it, but perhaps someone out there in the audience might. Fortunately, it doesn’t happen very often to me personally, but as I get to visit and meet new folks all the time, I am always fascinated by a certain type of individual: they will pledge that they will do anything to help the cause, with the unspoken understanding that that help hinges on their not having to do anything. Sort of a “ask me anything and if it involves no effort on my part, I’ll be all over it.” Again, fortunately, there doesn’t appear to be a proliferation of these folks in healthcare, and if the sounds completely foreign to you, that’s great. But if anyone has any tips for managing the eager-to-pledge non-participant, I’m all ears.

A most joyous and restful Thanksgiving to you and yours!

One less thing to pull out of your arsenal…

As we play yet another round of mishegas, it occurs to me that it’s been a while since I’ve really been able to tee off on something. Oh well, I guess it’s the little stuff that makes things interesting…maybe the February issue of Perspectives will provide fodder for my rant-mill… stay tuned.

First up, we have the (probably timely) demise of that titan of healthcare apparel, the powdered medical glove. It seems that the Food & Drug Administration (FDA) has determined that the risks to the health of users and those upon whom those gloves are used (including bystanders) are so egregious that it instituted an immediate ban on their use, effective January 18, 2017. The potential dangers include severe airway inflammation from inhalation of the powder; wound inflammation and post-op adhesions from contact with the powder, and allergic reactions from breathing powder that carries proteins from natural rubber latex gloves. You can get the whole picture here. While I do believe that powdered wigs are still de rigeur in certain circles (constitutional re-enactors, for one) despite the opening line in the VIN News article, I hope that these actions are not a prelude to restrictions on powdered doughnuts (or donuts, depending on your preference—for the record, my favorite is raspberry jelly!)

Breaking it down with TJC

Our friends at the American Society for Healthcare Engineering (ASHE) announced this week that they will be offering a series of webinars aimed at uncovering the mysteries of deep space, no wait, to introduce us to the inner workings of the 75 new performance elements in the Joint Commission standards, effective, well, pretty much right now. The featured presenter for the kickoff presentation is none other than Joint Commission’s Director of Engineering George Mills and it promises to be a rollicking good affair. That said, I do hope you are an ASHE member: if you are, the webinar is free; otherwise it’s $125, which seems a little steep for a single program (the advertising says this is a series of webinars, but this appears to be the only program scheduled at the moment, so your guess is as good as mine at this point). If I may indulge in a short rant, I’m still not convinced that having to pay to obtain access to TJC information that is not otherwise available as part of one doing business with the accrediting agency is a good thing. Not everyone has money in their budgets to do this (either membership in professional organizations or accessing educational programs) or the personal means to do this stuff on their own. While I am absolutely in favor of participation in professional organizations, I’m not sure that access to the insight of regulators is, while nice, the way things should be. Shutting up now…

Cue heavy breathing…

And let us end on a note of “Holy smokes, that was a near miss” (and I definitely did not see this one at the time—nor did I hear a ton of squawking). Last May, CMS decided to disallow hospitals from having security units that provide care for justice-involved individuals such as inmates and those in the custody of law enforcement or the state Department of Corrections. I’ve not worked with a ton of hospitals that have forensic units, but they are an important means of enabling hospitals to provide a safe environment for all while ensuring your forensic patient populations have appropriate access to needed inpatient healthcare services. Again, I didn’t hear a lot about this one, so it may be that the hue and cry was aimed in other directions; the American Hospital Association took up the cause and were able to convince CMS to rescind the “ban” (you can see the revised Survey & Certification memorandum here). This would have been a big time pain in the posterior for at least some number of folks, and may still be – I would encourage you to take a peek at the memorandum, including the scenarios presented at the end of the document—probably worth sharing with your organization’s leaders. I’m not exactly sure why CMS would have elected to go the route of disallowing security units for “justice-involved individuals” (that makes ’em JIIs—probably not an acronym that will catch on), though I would guess that ensuring patient rights are not violated in the process is a likely contributing factor. That said, any time a memorandum goes out on a specific topic, it seems to result in that topic becoming a wee bit hotter in the aftermath. No guarantees, but this might be a focus area in the coming months…

The song changes and yet remains the same…

There was a time when The Joint Commission actually seemed to be encouraging folks to fully engage with the clarification process in all its bountiful goodness. And I certainly hope that folks have been using that process to ensure that they don’t (or didn’t) have to “fix” processes, etc., that might not have been absolutely perfect in execution, but were not, by any stretch of the imagination, broken. But now, it appears that the bounty is going to be somewhat less bountiful as TJC has announced changes to the process, effective January 1, 2017. Please forgive my conspiracy theorist take on this, but it does seem that the new order in the accreditation world appears to lend itself to survey reports that will be increasing in the number of findings, rather than a reduction—and I am shocked! Okay, perhaps “shocked” is a tad hyperbolic. BTW, in a new Advocacy Alert to members, it appears that ASHE has come to the same conclusion, so it’s not just me…hoorah!

And so, the changes:

 

  • Any required documents that are not available at the time of survey will no longer be eligible for the clarification process (basically, the vendor ate my homework). It is important for everyone to have a very clear understanding of what TJC means by “required documents”—there is a list on your organization’s Joint Commission extranet site. My advice, if you have not already done so, is to immediately coordinate the download of that list with your organization’s survey coordinator (or whoever holds the keys to accessing that information—it may even be you!) and start formulating a process for making sure that those documents are maintained in as current a fashion as possible. And make sure your vendors are very, very clear on how much time they have to provide you with the documentation, as well as letting you know ASAP whether you have any deficiencies/discrepancies to manage—that 60-day correction window can close awfully quickly!
  • While I never really liked to employ this strategy, there were times when you could use clerical errors in the survey document to have things removed from the survey report. Areas that were misidentified on the report (non-existent to your facility; not apropos to the cited finding, for example, identification of a rated door or wall where there is none, etc.) or perhaps the location of the finding was so vague as to be impossible to identify—these have all been used successfully, but (apparently) no more. Now whether this means that there will be more in-depth discussions with the survey team as they prepare the report is unknown at this time, but even if one slips by (and I can tell you, the survey reports in general are much more exact—and exacting—in their description of the deficiencies and their locations), it won’t be enough to remove it from the report (though it could make your ESC submittal a bit more challenging if you can’t tell what it is or where it is).
  • The other piece of this is, with the removal of “C” Elements of Performance, you can no longer go the audit route to demonstrate that you were in substantial compliance at the time of survey. So now, effectively, everything is being measured against “perfection” (son of a…); miss one month’s check on a single fire extinguisher and—boom—finding! One rated door that doesn’t latch? Boom—finding! One sprinkler head with dust or a missing escutcheon? Boom—finding! And, as we touched on last week, it’s not just your primary location (aka, “the hospital”) that’s in play—you have got to be able to account for all those pesky little care sites, even the ones for which you are not specifically providing services. Say, for example, the landlord at one of your off-sites is responsible for doing the fire extinguisher checks; if something is missed (and hey, what’s then likelihood of that happening…), then you are vulnerable for a finding. So, unless you are prepared to be absolutely, positively perfect, you’d best be making sure that your organization’s leadership understands that the new survey reality is not likely to be very pretty.

I would like nothing better than to tell you that with the leadership change in Washington there will be a loosening of the regulatory death grip that is today’s reality, but somehow I don’t think that’s gonna happen…

If accredited you wish to be, you must answer these questions three!

And other tales: If you thought the dervishes were whirling last week…you ain’t seen nothing!

Hortal hears a chortle from the portal: The much-anticipated (you tell me how hyperbolic that characterization might be…) return of updated content for the Joint Commission (oops, THE Joint Commission)’s Physical Environment Portal (PEP) has finally reached these shores. O frabjous day! Callooh! Callay! He chortled in his joy (from Jabberwocky by Lewis Carroll; see, chortling has been around for a while…).

The new content breaks down into three sections: one for facilities and safety folks, one for leadership, and one for clinical folks, lending further emphasis to the ongoing melding  of the management of the physical environment into a tripod-like structure (tripods having more stability and strength than a one- or two-legged structure—think about that one for a moment). At any rate, interestingly enough, the suggested solutions for both the clinical and leadership “legs” of the tripod are aimed at “supporting” the facilities “leg” through endorsement of the key process(es) as well as keeping smoke doors closed, not compromising closing devices (how may doors can a doorstop stop if a doorstop could stop doors?), and participation during construction activities. So, if you visit the noted URLs, you will find a whole bunch of stuff, some of it downloadable, to share with the other “legs” in your organization. It seems pretty evident to me, that at least part of the intent of the information shared, particularly the stuff earmarked for leadership and clinical folks, is to ratchet up the “investment” of those two groups in the management of the physical environment. On the face of it, nobody in healthcare has “time” to shoulder this burden on their own, hence the practical application of the tripod (sort of: that may be a bit of a reach on my part, but there’s some truth lurking around somewhere—and we will ferret it out).

Also breaking recently was the information (funneled from our fine friends at ASHE) that TJC is going to be including a set of three questions in the pre-building tour portion of the survey process (I think this is in addition to other questions that might be asked, including whether you have any identified Life Safety Code® (LSC) deficiencies). The intent, as described by Jim Kendig, TJC’s field director for surveyor management and development (I worked with Jim, like, a million years ago. Hi, Jim!), is to gather some pertinent/useful information before setting out to tour your facility.

Question 1: What type of firestopping is used in the facility?

Question 2: What is your organization’s policy regarding accessing interstitial spaces and ceiling panel removal?

Question 3: Which materials are used for high-level disinfection or sterilization?

On the face of it, I’m thinking the response to Question 1 might very well be the most challenging as I can’t recall too many facilities that have just one manufacturer’s product protecting their rated barriers. My consultative advice is you would be well-served to have some sort of document that identifies the various products in use, where they “live” in your organization, perhaps even color pictures of the products in situ so the surveyors will know what they are looking for (and please don’t try to pass off that yellow expanding foam stuff as an appropriate product—no point in getting into a urination competition with a surveyor over that). As to the other questions, as near as I can tell they’re pretty straightforward; the surveyor is going to have plan for extra time if a containment has to be erected/constructed for every ceiling tile removal or perhaps they will identify specific locations for inspections and just run through those one after the other. As to high-level disinfection and sterilization, lots of environmental and infection control opportunities for bungles there (BTW, it’s probably a very good idea to have a very good idea where those processes are occurring; it can be more widespread than you would prefer).

As a final thought for this week, I would encourage you to participate in ASHE’s survey of the potential impact of CMS’s requirement for all hospital outpatient surgery departments to be classified as Ambulatory Surgical occupancies under chapters 20 and 21 of the 2012 LSC. There is a fair amount of potential that this requirement is going to have an impact on facilities in which dental or oral surgery is being performed, plastic surgery, endoscopy, laser surgeries, etc. To help with the assessment of the impact of this change, ASHE is asking folks to complete a survey for each of the facilities you oversee that will be affected; you can find the survey here. https://app.smartsheet.com/b/form?EQBCT=c66f01e829184b648b4b0db3fd2cc552

I think it’s probably well worth your time to at least see what they’re asking about; I’m beginning to think that we are going to look back on 2016 as a really ugly year (compliance, popular culture, you name it!). Where’s that fast-forward button…or do we talk to Mr. Peabody and Sherman about that Wayback Machine…