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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.

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…

This week in hell: What about the damn dampers?

We are certainly in the (very) early stages of the departure of The Joint Commission’s Plans for Improvement (PFI) process from our midst (Is it possible for a process to have abandonment issues? I suspect we’re going to be feeling something like it for quite some time to come.) and there continues to be much to chew on. This week, I’m going to break it down into a couple of chunks that will hopefully allow us to more easily digest this big mouthful of unpleasantness, but first, a rant (ooooh, big surprise):


  • I honestly don’t have a dog in this particular fight beyond my position as an observer of accreditation and regulatory compliance activities in healthcare, but I continue to “bump” up against the practice of TJC revealing substantive (and substantial) changes in forums that are not completely accessible to everyone with a dog in the fight. I don’t know about you, but my boss is generally inclined for me to be busy doing productive work, so I don’t oft (okay, never) get to the annual ASHE conference (and yes, I recognize the educational value, etc., of such gatherings, but, as you all probably know pretty well, that can be a very tough sell). Consequently, I (and perhaps a whole bunch of “yous” out there in the audience) was not present when the discontinuation of the PFI process was announced. I don’t know if there was a Q&A that followed the announcement, so I have no idea if questions were asked and answered, asked and deferred, asked and not answered, etc. I suspect if we all had known what was coming down the pike this year, between adoption of the 2012 Life Safety Code® (LSC) and PFI getting kicked to the curb, we might all have made a little bit of an extra effort to get to ASHE (well, perhaps you would have—I was having way too much fun tripping around Texas). At any rate, at the very least, I would love to see a transcript of the presentation as well as any Q’s and A’s that might have occurred. As an alternative thought, I also believe that something this monumentally important is deserving of a free webinar from TJC that includes a live Q&A (or if not a live Q&A, answers to pre-submitted questions would be okay)—this has the potential to be enormously painful for facilities and safety folks over the next little while (the optimist in me says “little while,” my fear is fairly long while) and, as customers, I think those same facilities and safety folks deserve a little time with the powers that be.
  • So what do we do with the damn dampers? As near as I can tell (with absolutely no empirical data beyond the number of questions I’ve received on the topic), there are a fair number of folks who have taken advantage of the PFI process for managing inaccessible dampers. When the PFI process goes away, does this mean all those dampers have to be brought in to compliance within the 60-day window? I am truly hoping that something specific to this issue is forthcoming before folks start tying up all the mechanical contractors in the US. Perhaps there’s a categorical waiver in the future for this piece of business—I think that would be a nice surprise. One thing I can tell you is that I know of at least one hospital that CMS required to clean up the damper issues identified on the PFI, so I have no reason to think that leniency will be the order of the day.
  • For those of you that reflect the PFI process in either your management plans or your ILSM plans/policies, you should probably pull those out and update the process as a function of no PFI process (I’m still not quite over the initial shock of that). Certainly for many, many years, a fundamental part of the standards-based requirements relative to ILSM was the management of LSC deficiencies that could not be immediately corrected (or corrected immediately, depending on your perspective), which brings us squarely into the realm of the PFI process. At any rate, make sure you make a quick of any policies/processes (hey, maybe even in your work order system) to make sure that you expunge all evidence of the PFI process.
  • As to the discontinuation of the Basic Building Information component of the Statement of Conditions, one of the things that’s “driven” by the information contained therein is the number of survey days, based on the square footage of healthcare occupancies in your facility. I don’t believe that the square footage question is asked during the organizational application process (might be worth checking with the individual in your organization charged with filing the application to verify what may or may not be in the mix), which makes me wonder how they will make the determination if folks don’t update the eBBI information. I suppose they have a basic starting point now, so it probably won’t change that much, but I also think of the SOC as a great means of communicating certain information to the surveyors—existing waivers/equivalencies (which makes me wonder: are we looking at a day when all the existing waivers/equivalencies granted by TJC go away or at least have to be resubmitted to CMS?), locations and square footage of suites, level of sprinkler coverage, and other unique aspects of the building can all be memorialized in the comment section of the SOC. But if the surveyors aren’t going to look at the SOC any more, do we print out the information and provide it to them directly or does this become one more potential sticking point during a survey? I guess a lot of the same information can be included on the life safety drawings, but I know a lot of folks don’t have the wherewithal to manage the drawings themselves so they use an architect or fire protection engineer for updates, etc.


All that said, I guess we’ll just have to keep our fingers crossed that some level of sanity is restored to the process, but given the state of the world, I don’t think I’m going to be holding my breath while I wait.

Breaking news: PFIs take a flyer!

Well, I suppose there was a certain element of inevitability to this. First, the expulsion of the most global “FIs” in the Joint Commission arsenal—the Requirement for Improvement (RFI) and the Opportunity for Improvement (OFI)—which left only one FI to be expelled, our good friend and (sometimes) benefactor, the Plan for Improvement (PFI). And that day has come (I don’t think there are any intact FIs kicking around, but I could be mistaken…)!

In what will likely end up being filed under the “no good deed goes unpunished” category (I’m more or less characterizing the adoption of the 2012 Life Safety Code® (LSC) as a good deed, though I will submit to you that, if only coincidentally, there has been an unleashing of a most distressing pile of poop), The Joint Commission has announced that, beginning August 1, 2016, it will eliminate the PFI process as a means of managing LSC deficiencies that cannot be immediately corrected and will take longer than 45 days to resolve. Yes, you did not misread that last sentence: say so long, farewell, auf wiedersehen, good bye (can I get an au revoir or adios?!?) to one of the most beloved characters in all of regulatory nuance. So, in place of the PFI process is an expectation for life safety deficiencies to be corrected within 60 days—unless, of course, you want to pursue a time-limited waiver with the friendly folks at your regional CMS office (don’t that sound like a party?). This information comes to us courtesy of the good folks at the American Society for Healthcare Engineering (ASHE), who provided this to members as an advisory released late yesterday afternoon.

When Jay Kumar, my editorial foil at BLR/HCPro asked me for my initial thoughts, there were several expletives that came to mind (and I suspect they are coursing through your collective craniums as well), but I do know that a fundamental means of having some element of control (even if it was somewhat illusory in nature) in managing conditions in the physical environment has pretty much been ripped from our hands. I guess we could look at this as one more piece of the “becoming more like CMS” movement that has been afoot for quite a few years now. Or maybe, as CMS never really accepted the PFI process as an alternative means of LSC compliance, they finally told TJC to cease and desist. I’m thinking this probably also pretty much quashes any thought that the Building Maintenance Program will ever be anything more than it is now (at this point, I’m not really sure what it is beyond a means of organizing the maintenance of certain life safety building features, not a bad thing, but not quite as compelling as it once was).

The process as outlined in the ASHE Advisory goes a little something like this:


  • Deficiencies will need to be corrected within 60 days of being identified unless the CMS regional office approves an extension.
  • All requests for extensions will be handled by CMS regional offices. However, The Joint Commission will allow facilities to submit requests and receive a receipt to show they are in the pipeline waiting for an extension.
  • The Joint Commission will not review open PFI items, and PFIs will not be a part of final reports.

Now before you get overly panicky, apparently we will still be able to use the PFI process as an “internal management process,” so everything’s good—right?

I guess we’re going to have to wait and see how this all unfolds in the field, but I have a sneaking suspicion that, of all the changes we’ve encountered this year, I suspect this one is going to result in the greatest amount of disruption, at least in the short term.

But hey, we work in healthcare—we embrace change! We grab change by the throat, throw it on the ground and kick it ’til it stops moving. We love change!

A clear case of compliance interruptus

Greetings one and all from high above the 2012 Life Safety Code® (LSC) compliance track with a quick update on CMS plans for administering surveys, etc., in the wake of official adoption of the 2012 LSC. I’m climbing out on a limb just a little bit as the latest missive in this regard from The Joint Commission indicates that it will begin surveying to the requirements of the 2012 LSC on July 5 (Happy freakin’ Independence Day), but it appears that CMS has other ideas. In a member alert disseminated late last week, our friends at the American Society for Healthcare Engineering (ASHE) are reporting that a memorandum was issued by CMS to the various and sundry accreditation agencies (TJC, DNV, HFAP, M-O-U-S-E) indicating that hospitals have until November 7, 2016 before this new shiny hammer is wielded during accreditation surveys. Now, I think it was likely that there would be some sort of transition period for this process (the accreditors would have to update their standards manuals, etc., and I don’t think that happens overnight, but maybe there are manual elves that come in under cover of darkness), so I guess that has come to pass and the end date for that transition is November 7 (I guess they didn’t want to wait until the following month’s day of infamy).

As I’ve noted in this space recently, a lot of the basic tenets of compliance are going to pretty much stay the course. We will continue to manage rated barriers (walls, decks, doors); we will continue to manage egress (perhaps a little more simply, but clutter will still be clutter) and so on. There may be some efficiencies to be gained in the practical application of the various fire alarm and fire suppression system inspection, testing, and maintenance processes (I’ll have to do some edumacation on those), but I really think that the devil in all these details is going to come from how the requirements of NFPA 99 Standard for Health Care Facilities are administered and/or otherwise enforced. NFPA 99 has always kind of hovered in the background, but I think is going to be very much a coming out party. At any rate, ASHE has made available a fair number of resources (some readily accessible, some for members) and I would encourage you to do a little digging if you have not already done so. I still think the physical environment is going to figure quite strongly in the survey process, but maybe this is where we get to share the most frequently cited standards lists with the clinical folks.

On a closing, and most somber note, in the wake of events in Orlando this weekend (thoughts and prayers to all the victims, their families, the community at large, and pretty much everybody else), I can’t help but think that there’s got to be a better way. I know the circumstances that can lead up to events like these are extraordinarily polarizing—and I’ve noted that the polarization didn’t waste any time manifesting itself in the halls of social media. I wish that I had some sage bit of advice or encouragement, but nothing is coming right now beyond this old cliché (doesn’t make it any less useful or true)—cherish your loved ones…right now! We will all be better for it.

Everybody here comes from somewhere else…

First off, just wanted to wrap up on the missives coming forth from our compadres at The Joint Commission and ASHE relative to the adoption of the 2012 Life Safety Code® (LSC) by CMS. The word on the street would seem to be rather more positive than not, which is generally a good thing. Check out the statements from TJC and ASHE; also, it is useful to note that the ASHE page includes links to additional materials, including a comparison of the 2000 and 2012 editions of the LSC, so worth checking out.

At this point, it’s tough to say how much fodder there will for future fireside chats. It does appear that the adoption of the 2012, while making things somewhat simpler in terms of the practical designation of sleeping and non-sleeping suites (Don’t you wish they had “bumped” up the allowable square footage of the non-sleeping suites? Wouldn’t that have been nice.), combustible decorations and some of the other areas covered by the previously issued CMS categorical waivers (If you need a refresher, these should do you pretty well: ASHE waiver chart and Joint Commission), isn’t necessarily going to result in a significant change in the numbers and types of findings being generated during Joint Commission surveys. From my careful observation of all the data I can lay hands on, the stuff that they’re finding is still going to be the stuff that they are likely to continue to find as they are the “deficiencies” most likely to occur (going back to the “no perfect buildings” concept—a lovely goal, but pretty much as unattainable as Neverland). I’m not entirely certain what will have to occur to actually bring about a change in EC/LS concerns predominance on the Top 10 list; it’s the stuff I can pretty much always find (and folks usually know when I’m coming, so I’ve pretty much lost the element of surprise on the consulting trail). Now, it may be that the new matrix scoring methodology will reduce the amount of trouble you can get into as the result of existing deficiencies—that’s the piece of this whole thing that interests me the most—but I see no reason to think that those vulnerabilities will somehow eradicate themselves. I suppose there is an analogy relative to the annual review of our hazard vulnerability analysis (HVA)—the vulnerabilities will always exist—what changes (or should change) is our preparedness to appropriately manager those vulnerabilities. Makes me wonder if it would be worth doing an EC/LS HVA kind of thing—perhaps some sage individual has already tackled that—sing out if you have. At any rate, I’ll be keeping a close eye on developments and will share anything I encounter, so please stay tuned.

Hopping over to the bully pulpit for a moment, I just want to rant a bit on what I think should be on the endangered species list—that most uncommon of beasties—the kind and decent person. I know that everyone is nice to folks they know (more or less), but there seems to be a run on a certain indifference to politeness, etc., that, to be honest, makes me see a little read from time to time. But then I think to myself that it is probably just as rude to overreact to someone else’s rudeness, so take some deep cleansing breaths and let it go. Now I would love to hear from folks that they haven’t noticed this shift and that their encounters with folks are graced with tolerance, kindness, etc.; it would do my heart good. Maybe it’s just me…but somehow I’m thinking maybe not.

Please enjoy your week responsibly and we’ll see what mischief we can get into next week.

Portal chortling: Who wants to be surveyed at Christmas?

I know that this is typically characterized as a season of giving, but I have somewhat of a huge favor to ask of you folks out there in the depths of the blogosphere, so I hope you will bear with me.

With an almost astonishing regularity, the first of each month continues to bring with it a new module being posted in the Environment of Care portal. For the month of December 2015, the featured topic is the Built Environment, inclusive of elements covered under EC.02.06.01, which (as you may recall) was the #1 most frequently cited standard during the first six months (Freudian typo: When I first typed this passage, I came up with “first sux months”—make of that what you will…).

Since I know a lot of folks have been tapped on this one (both as a function of the published data and my own experiences), I was keen to look over the new material—including the latest fireside chat from our partners in compliance George Mills, director of engineering at TJC and Dale Woodin, executive director at ASHE, which covers EP 1 and EP 13 (in separate episodes). One of the interesting things I noticed was, in describing the many and varied findings that are generated under EP 1, a direct comparison was made to OSHA’s General Duty Clause as a function of how this particular EP is being used. Now, the GDC concept as a part of TJC’s survey efforts is certainly not unknown to us (in the “old” days, EC.02.01.01 used to be the catch-all for general safety findings) and basically it comes down to pretty much anything that isn’t quite as it should be (what I have taken to euphemistically describing as imperfections). Could be stained ceiling tiles, could be non-intact flooring, wall, or horizontal surfaces. Could be nurse call cords that are not properly configured (too long, too short, too wrapped around restroom grab bars), could be improperly segregated compressed gas cylinders. The list of possibilities is pretty much infinite.

The second video episode talks about maintaining temperature, humidity, and air-pressure relationships in the “other” locations (pretty much everywhere that isn’t an invasive procedure area or an area that supports invasive procedure areas). I know that there’s been some consternation from findings relating to issues such as pressure relationships in clean utility and soiled utility rooms (clean rooms have to blow and soiled rooms have to suck, so to speak), pressure relationships in pharmacies (positive), laboratories (negative) and so on. There’s some discussion about how these types of conditions might manifest themselves in the environment and the importance of staying on top of these things, particularly during surveys (personal note: my consultative advice is to have an action plan for checking all these various areas that have pressure relationship requirements the moment you learn that “Elvis,” my code name for TJC, is in the building). It is very, very clear that the Life Safety surveyor is going to be checking pressure relationships early on in the survey process—you want to have a very, very good idea of where you stand in the applicable areas.

At any rate, the favor I have to ask (and I’m sure I’ve gone on long enough that the favor is blissfully in the past) is for those of you who’ve viewed the contents of the portal (according to TJC figures, there were 48,000 views of the first two modules; I know I account for a couple of those, but clearly others have checked things out, though it might be interesting to see how many of that number are TJC surveyors…), particularly those of you who have been surveyed in the last few months: Has the material actually been helpful? Part of me feels that the materials are presented in such a general fashion that it makes them less useful from a practical standpoint (perhaps the better part of me), but since I don’t have to worry so much about day-to-day stuff anymore, I will freely admit that I’m too far away from it to be able to say. That said, I am really keen to hear if you think they’ve done a good job, not-so-good job, or somewhere in between. Pretty much any sense of whether the material has been helpful (of course, I could ask the same question about this space, as well, so feel free to weigh in—I always like feedback).

As a final note for this week’s epistle, you may be curious to read about what TJC’s leadership thinks about the portal. You may recall a bit of hand-wringing at the beginning of the year, by Mark Pelletier, the COO of accreditation and certification operations at TJC, regarding the recent “spike” in EC/LS findings (you can find my comments, including a link to Mr. Pelletier’s comments from January, here). As we all know very well, the torture in the EC/LS world has continued (presumably until morale is restored), but the EC Portal is being looked upon as “a light at the end” (at the end of what, I’m not sure, as it isn’t specifically indicated). The thing I keep coming back to in my mind’s eye, is that the typical list of findings is what (again, my “imperfections”) are the types of conditions and practices that, while not perfect (yes, we are imperfect) are not conditions that significantly increase the risks to patients, staff, visitors, etc. If these imperfections are not managed correctly, they could indeed become something unmanageable, but I’m just not convinced that the environment is the big boogie man when it comes to healthcare-acquired infections, which is pretty much the raison d’etre for this whole focus. I keep telling myself that it’s job security, but it frustrates the bejeezus out of me…

Mr. Pelletier’s latest can be found here.

And on that note, I wish you a most joyous holiday season and a safe and inspiring New Year! I may find the urge to put fingers to keys twixt now and the end of the year, but if I do not, please know that it’s taking every ounce of my self-control not to pontificate about something. Consider the silence my gift to you!

Be well and stay in touch as you can!

Come together, right now over…more heavy breathing

Talk about your regulatory supergroups: it’s almost like the second coming of Crosby, Stills, Nash, Young and all manner of goodness or maybe the Fantastic Four (or in this case, the Spectacular Six)! Back on September 21, the modern healthcare environment equivalent of the Justice League (AAMI, ASHE, AORN, ASHRAE, APIC, and FGI) published a Joint Interim Guidance (JIG) on HVAC in the Operating Room and Sterile Processing Department. The intent of this JIG (sometimes acronyms can be fun) is to address what the Spectacular Six deem “the biggest challenge for owners and designers of health care facilities,” which is “to understand the purpose and scope of the various requirements” of the “conflicting and sometimes unclear” standards and guidelines for the management of heating, ventilation, and air-conditioning (HVAC) so “patient and staff safety and comfort can be managed.” You can check out the JIG document here.

Without spoiling too much of your interest in discovering all the particulars, the JIG speaks to the dichotomy inherent between the minimum design requirements and criteria that are used to construct an HVAC system (the FGI/ASHRAE/ASHE side of the equation) and the guidelines that “are intended to guide the daily operation of the HVAC system and clinical practice once the health care facility is occupied (this is where AAMI/AORN/APIC come in). As any number of you have experienced in real (and sometimes really painful) time, this dichotomy is very much at the heart of the regulatory survey process at the moment (somehow in my heart of hearts I knew that we could be continuing this conversation). But mayhap there is a light at the end of the tunnel (that is not an oncoming train!): the Spectacular Six have begun working towards a harmonization of the HVAC guidance in the various standards. They’ve been working on this since late April and the JIG is, for all intents and purposes, their first work product. I think it’s an excellent start and I hope that their work is allowed to continue with minimal interference from outsider influences (who that could be, I have no idea…).

An important part of the JIG is their advice to healthcare organizations (it’s on p. 2 of the document—I’ll let you reflect on it in your spare time) and those of you who’ve been following this space for a while will guess that my fave-o-rite topic is going to feature quite prominently in this movement: our old friend, the risk assessment! (Admit it, you knew it was going to go that route!) The goal of the assessment is to make a determination of HVAC operating parameters for critical areas that meet patient, personnel, and product storage needs, with an eye towards the identification of appropriate corrective measures to mitigate risk, etc. I think we’ve been honking this horn a bit as we’ve traversed this landscape, but I think the critical opportunity/challenge is going to be based on the Spectacular Six’s intent to communicate/advocate directly with the regulatory folks in this regard. I haven’t yet seen anything official from CMS in this regard, but based on its adoption of the tenets of the Joint Quality Advisory from January of this year (again, a number of web locales for info, including this one), I think we can reasonably anticipate some level of guidance to the surveyor corps in the not-too-distant future.

So perhaps we can work through this in relatively straightforward fashion; at the end of the day, our charge is to ensure that we are providing the safest possible environment for patients, staff, and visitors. But in meeting that charge, we also need to make sure that we are not writing checks that our building systems can’t cash. We should be able to identify appropriate, safe performance parameters that appropriately address all the risk factors and identify a response plan that we can effectively implement when we have conditions that increase the risk to unacceptable levels. If you ask me, that sounds like business as usual…

Cue the drum roll: Ladies and gentlemen, I give you the Portal of Perception!

Not so very long ago, The Joint Commission and ASHE announced the creation of an information resource to assist with all those pesky EC/LS findings that have been reproducing like proverbial rabbits (here’s coverage of that announcement  and coverage of those rapidly reproducing findings).

Well, since that announcement, the elves have been very busy cobbling together bits and pieces of this and that, with the end result being a rather interesting blend of stuff (please note that I did not employ the more severe descriptor—stuff and nonsense), with titles like “Is Your Hospital’s Air Ventilation System Putting Your Patients At Risk?” (this one’s in the Leadership module, so I guess they’re asking the question of organizational leadership). I truly hope that your response to that particular query would be “absolutely not,” but I’ve also been working this part of the street long enough to know (absolutely, if you will allow me a brief moment of hyperbole) that there are few absolutes when it comes to the management of the physical environment.

Which leads me to the follow-up thought: Recognizing that there is always the potential for the performance of air ventilation systems to drift a little out of expected ranges, at what point does the performance of air ventilation systems actually put patients at risk? And perhaps most importantly, have you identified those “points” in the performance “curve” that result in conditions that could legitimately cause harm to our patients? And please know that I understand (in perhaps a very basic sense, but I think I can call it an understanding) how properly designed and maintained HVAC systems contribute to the reduction of HAIs, etc. But with any fluid situation, there is an ebb and a flow to conditions, etc., that, again, may veer into the “red” zone from a compliance standpoint. But let me ask you—particularly those of you who have experienced out-of-range conditions/values—have those conditions resulted in a discernible impact on your infection control rates, especially those relating to surgical site infections?

BTW, I’m asking because I really don’t know what you folks are experiencing. And, for those of you that have identified shortcomings on the mechanical side of things, are your Infection Control folks keeping a close (or closer) eye on where those shortcomings might manifest themselves as a function of impact to patients? From the information posted in the Portal (I think I’m going to capitalize), remedying compliance issues in this regard is a simple four-step process (You can find the example of improved compliance there). Who knew it would be so easy? (I could have had a V8!) I don’t think anyone in the field is looking at this as a simple, or easy, task.

At any rate, despite the best efforts of the Portal, until we have buildings (and staff) that are a little closer to perfect, I think we’re going to continue to see a lot of EC/LS findings during survey. Ohboyohboyohboyohboyohboy!

Also, as I think about it, please be sure to check out the Clarifications and Expectations column in the September issue of Joint Commission Perspectives; there are some interesting points to be gleaned, the particulars of which we will cover in a wee bit, so watch this space!