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The other shoe is starting to fall: Moving beyond ligature risks!

Well, it does seem like there are a couple of compliance themes asserting themselves in 2018, concerns related to emergency management (relatively simple in terms of execution and sustainability) and concerns relating to the management of behavioral health patients and the management of workplace violence (relatively complicated in terms of execution and sustainability). I think we can say with some degree of certainty that there are some commonalities relative to the latter two (beyond being complicated to work through) as well as some crossover. And while I wish that I had a ready solution for all of this, if I have learned nothing else over the last 39+ years, it is that there are no panaceas when it comes to any of this stuff. And with so many different regulatory perspectives that can come into play, is it enough to do the best you can under the circumstances? As usual, the answer to that question (at least for the moment) is “probably not.”

In last week’s Hospital Safety Insider, there was a news item regarding OSHA citations for a behavioral health facility in Florida for which inadequate provisions had been made relative to protecting staff from workplace violence. As near as I can make out from the story, the violence was being perpetrated mostly in patient encounters and revolved around “failing to institute controls to prevent patients from verbal and physical threats of assault, including punches, kicks, and bites; and from using objects as weapons.” Now, in scanning that quote (from information released by the Department of Labor), it does seem rather daunting in terms of “preventing” patients from engaging in the listed activities. This is one of those really clear division between federal jurisdictions—OSHA is driving the prevention of patients from engaging in verbal and physical threats while CMS is (more or less) driving a limited approach to what I euphemistically refer to as the “laying on of hands” in the management of patients. That said, I think it’s worth your while to take a look at the specific correction action plan elements included in the DOL release—it may have the makings of a reasonable gap analysis if you have inpatient behavioral health in your facility. It appears that the entity providing some level of management at the cited facility was also cited at another facility back in 2016 for similar issues, so it may be that some of this is recurrent in theme, but I think it probably makes sense to take a look at the details to see if your place has any of the identified vulnerabilities.

Wanting to end this week’s installment on an upbeat note, as well as providing fodder for your summer reading list, I was recently listening to the id10t podcast and happened upon an interview with astronaut Leland Melvin, who navigated a number of personal and profession barriers to become the first person to play in the NFL and go into space as an astronaut. His book, Chasing Space, is a fun and thought-provoking read and really captures the essence of what we, as safety professionals, often face in terms of barrier management. I would encourage you to check out the book as well as the interview. As a side note, I’m not sure if you folks would all be familiar with Chris Hardwick and his Nerdist empire, but I think he’s become a most winning and empathetic interviewer, and since I’ve never been afraid to embrace my inner (and outer) nerd, I will leave you with that recommendation (and please, if you folks have stuff that you’re reading and think would be worth sharing with our little safety community, please do—fiction, non-fiction—a good read is a good read!)

That’s the FAQ, Jack!

It may be that I am covering one topic of conversation more than necessary (it’s getting to the point where this might eclipse the discussion of eyewash stations—yow!), but I cannot help but be very concerned about the amount of play that the management of the environment in which we place behavioral health patients is receiving in the annals of The Joint Commission. April 24 saw an electronic update announcing the “birth” of a new standards FAQ regarding ligature risks that appears to be aimed at dovetailing with Sentinel Event Alert #56 and includes mention of a “Suicide Risk Booster” (who comes up with these names?!?). As we have discussed before, FAQs, Sentinel Event Alerts, and stuff that finds its way into Perspectives all take on the weight of standards when applied in the field, so clearly organizations need to have all their ducks in a row. (And this is starting to look like a whole mess o’ ducks to be “rowed”, which brings new meaning to that Willie Nelson classic “On The Rowed Again,” but I digress—and who wouldn’t?) The question I keep coming back to is whether there’s been an uptick in actual events in which patients have come to harm as the result of poorly or inappropriately managed ligature risks. Or is this the result of surveyors in the field citing organizations for having ligature risks and not being able to produce a risk assessment of the existing conditions and the identification (and communication to staff—key point, that one) of mitigation strategies to manage the identified risks?

Part of the challenge with this particular issue (and this is true of a great many things in the physical environment) is that it is virtually impossible to provide an environment that is entirely, absolutely (please insert your favorite qualifier here) impossible to provide a completely risk-free environment—at least on this planet (perhaps there are safer planets in the Federation, but I couldn’t say for sure), so there’s always going to be something with which patients intent on hurting themselves might use to that end. Now I know that not every healthcare setting is set up to deal with behavioral health patients (and somehow, I do think that for any hospital that has not come face-to-face with the management of BH patients in areas not designed for that purpose, it is just a matter of time) and I also know that the BH patient volumes can be very mercurial. Even if you have one “safe” room, there are no guarantees that, at any given moment, that will be enough to handle however many patients you have in the queue—and you really can’t leave these folks out in the waiting room. Again, I’m not convinced that the issue here is that there is data to support that folks are not managing things appropriately, but rather more along the lines of not being able to consistently communicate the process for assessing and identifying risks, educating staff to be able to speak to the mitigation strategies being used to manage the identified risks, etc. I would (as I have been for a while now) encourage you to really take this topic and do a deep dive into the particulars of your organization. I firmly believe that this is not going to be one of those “one and done” instances of risk assessment and that you will be well-served by periodically revisiting the initial assessment (if it has been completed) to ensure that the conditions upon which you based your initial assessment have not changed (and that includes the volume and acuity of the patients). There is every indication that TJC is going to be hammering on this for some time to come (remembering that EC.02.06.01 was the most frequently cited standard in 2016; the ligature risk findings tend to show up there when cited) and, much as issues with the surgical environment and interim life safety measures, process gaps can get you in a heap of trouble. A little extra work on this (and those others) can only increase your chances for a successful survey (or at least a not spectacularly ugly survey).

As a closing note, after a dinner discussion with my wife (who happens to be a nurse), I’ve been contemplating how the role of the safety professional has changed over the last 10-15 years, including my surprise when I encounter evidence of “old school” approaches to safety. To my mind (such as it is), where safety compliance was once the result of (more or less) coercion, sustained compliance can truly only come as the result of collaboration with the folks who have to manage the environment on a day to day basis—pretty much everyone at point of care/point of service. It is not enough for a safety professional to periodically stroll through an area and point out deficiencies, there has to be a conversation and there has to be problem-solving. I think the old coercive style was based on something approaching a lack of faith in the folks out in the environment to be able (or willing) to “do the right thing.” But in this era of “just” culture and empowerment, etc., safety has to happen all the time and that, my friends, can only come with an atmosphere of collaboration. If people hide stuff or behave more appropriately when they hear you are coming, then it makes the surveillance process less useful. And if you don’t work with folks to figure out how to resolve the issues that you “keep finding,” the likelihood of it fixing itself on its own is pretty remote. I freely admit that problem-solving is my favorite part of my safety consulting work (meeting folks is also a fave); there is nothing better than talking through a problem and achieving some sort of consensus on how to proceed. It’s not always easy, but it is worth every moment you put into it!

I understand all destructive urges

It seems so perfect…

A couple of somewhat disparate, but important, items for your consideration this week. I’m still somewhat fixated on how the survey process is going to manifest itself (regardless of which accrediting organization is doing the checking—including the feds). There are one or two clues to be had at the moment and I am most hopeful that the reason there is so little information coming out of the survey trenches is because there have been minimal change of a drastic nature/impact.

So, on to the discussion. As noted above, while the topics of conversation are indeed somewhat disparate, they do share a common theme—perhaps the most common theme of recent years (not to mention the most common theme of this space): the hegemony of the risk assessment. The topics: management of the behavioral health physical environment, and the risk assessment of systems and equipment indicated by NFPA 99-2012 Health Care Facilities Code. Fortunately, there are resources available to assist you in these endeavors—more on those in a moment.

For the management of the behavioral health physical environment, it does appear that our good friends in Chicago are making the most use of their bully pulpit in this regard. Health Facilities Management had an interesting article outlining the focus that would be well worth your time to check out if you have not already done so. I can tell you with absolute certainty that you need to have all your ducks in a row relative to this issue: risks identified, mitigation strategies implemented, staff educated, maybe some data analysis. As near as I can tell, not having had an “event” in this regard is probably not going to be enough to dissuade a surveyor if they think that they’ve found a risk you either missed or they feel is not being properly managed. If I have said this once, I couldn’t tell you how many times I’ve said it (if I had a dollar for every time…): It is, for all intents and purposes, impossible to provide a completely risk-free environment, so there will always be risks to be managed. It is the nature of the places in which we care for patients that there is a never-ending supply of risky things for which we need to have appropriate management strategies. And I guess one risk we need to add to the mix are those pesky surveyors that somehow have gotten it in to their heads that there is such a thing as a risk-free environment. Appropriate care is a proactive/interactive undertaking. We don’t wait for things to happen; we manage things as we go, which is (really) all we can do.

As to the risk assessment of systems and equipment, as we near the first anniversary of the adoption of the 2012 edition of the Life Safety Code® (LSC) (inclusive of the 2012 edition of NFPA 99), the question is starting to be raised during CMS surveys relative to the risk assessment process (and work product) indicated in Chapter 4 Fundamentals (4.2 is the reference point) and speaks of “a defined risk assessment procedure.” I would imagine that there’s going to be some self-determination going on as to how often one would have to revisit the assessment, but it does appear that folks would be well-served by completing the initial go-through before we get too much closer to July. But good news if you’ve been dawdling or otherwise unsure of how best to proceed: our friends at the American Society for Healthcare Engineering have developed a tool to assist in managing the risk assessment process and you can find it here. I think you will find that the initial run-through (as is frequently the case with new stuff) may take a little bit of time to get through. (In your heart of hearts, you know how complex your building is, so think of this as an opportunity to help educate your organization as to how all those moving parts work together to result in a cohesive whole.)

 

These things have a habit of spreading very quickly in the survey world, so I would encourage you to keep at it if you’ve already started or get going if you haven’t. Even if you don’t have an immediately pending survey, a lot of this stuff is going to be traceable back to your previous survey and with that first anniversary of the LSC adoption rapidly approaching, better to have this done than not.

If being accredited by you is wrong, I don’t want to be right…

I’ve recently encountered some survey results that gave me pause and I wanted to take a moment to share some thoughts on the perceived infallibility of regulatory surveys (and consultants), some of whom are pretty much unassailable (the most dangerous of situations for an organization—if you read this as the organization represented by the moniker Charlie Mike Sierra, you’d not be far off the mark), others somewhat less so, but you need to be very careful when taking on any of the three-letter accrediting agencies. While they may be in error in citing something, it is of critical importance that you are sufficiently conversant with what compliance looks like to make your case.

I’m going to start with a somewhat non-EC related finding, but it serves as a pretty good example of how a survey finding can go awry. A recent survey (the surveyor in question had been a perioperative clinical director prior to becoming a surveyor) cited an organization for inappropriate storage of a medication in a secure dispensing system (you know, those big honking boxes that create such a lovely heat load in your medication rooms). The citation was very clear, very nicely framed, etc., but it was based on information that was out of date relative to the medication cited (at issue was the stability/expiration of the product when it was stored at room temperature). It seems that in the past, this particular product was only viable for 14 days once it was removed from refrigeration, so that became the nature of the finding. However, the organization knew (and was able to present documentation from the manufacturer) that the stability of the product was good for up to 91 days after being removed from refrigeration. Now, we’ve spoken a fair amount lately of the importance of manufacturers’ Instructions For Use (IFU) when it comes to appropriately managing storage and using equipment and such, so this would be the point where you would invoke the clarification process to have the finding removed from your survey report. That said, the point I really wanted to focus on was that the surveyor presented what appeared to be an unassailable (and thus, infallible) finding, but (at least in this case) that infallibility was very clearly in the past. Who knew infallibility was transient?

Another area where surveyors can raise a ruckus is in the behavioral health environment, particularly when you are dealing with a surveyor who is not a specialist in behavioral health. The tipping point is that behavioral health professionals recognize that is pretty much impossible to provide a completely risk-free physical environment for behavioral health patients (and I’m talking just about the way the facility is built, etc.) so the key to appropriately managing those risks is working towards minimizing the risks to the extent possible and then identifying the mitigation strategies (and this typically is where staff oversight and monitoring comes in). But then you have surveyors who see ligature points everywhere they look in the behavioral health environment and they start “dinging” you for all those “risks.” Strictly speaking, the only way that you can defend yourself is by making sure that you have a comprehensive risk assessment of the behavioral health environment, based on your state guidelines or on a resource such as the Design Guidelines for the Built Behavioral Health Environment (now available from our friends at the Facilities Guidelines Institute), in your back pocket. But (and this is perhaps the most important piece of this) you also need to periodically revisit the assessment. I don’t know about your experiences, but mine have shown that the behavioral health patient population is not anything close to being static—the types of patients seen, the acuity and diagnoses—and, by extension, the risks will change over time. My consultative recommendation would be to include specific mention of the behavioral health environment when you do your annual evaluation of the safety management program at your organization (I’m a big fan of using the annual evaluation process to affirm/reaffirm the validity of your risk assessment processes). I know things can get a little crazy when it comes to this stuff, but there’s also be a spate of survey findings relating to risk assessments not completed for a specific concept (for example, where your organization chooses to have emergency medical response equipment and procedures beyond calling 911—talking about off-site clinics, etc.) or not updating the risk assessment in response to a regulatory survey finding.

(I have a hard time getting my head around this one: A “competing” regulator comes in, cites you for a condition, you engage in a corrective action plan with that regulator and then, about six months later, you get cited for not having updated the risk assessment to reflect the findings from the earlier survey. It just seems like a bit of “piling on” to me.)

At any rate, every time you do hazard surveillance rounds, you are (hopefully) collecting compliance data. Make sure you use that data to perform an analysis of “the state of the environment” and make the determination of whether risk is being managed appropriately/effectively. As I tell folks about once a week (and sometimes more), regulatory surveyors will always reserve the right to disagree with anything they (or anyone else) have told you, or, indeed, any decision that you have made relative to the management of risk (I guess this blooms out of the whole infallibility thing). And while you don’t necessarily want to get into a urination competition with a surveyor at the time of survey, as long as you “know” and can demonstrate that you are appropriately managing the risk and have a process for periodic evaluation of the risk management process, then you are in a position to use the post-survey clarification process. Surveyors can be incorrect (or, as a kinder, gentler descriptor) or mistaken about how a condition they encounter in your organization is in compliance with the standards, but you have to be quite clear within yourself how what you are doing is in compliance. It’s the only way to push back. Surveyors can be exquisitely convincing in the moment—and make you doubt what you’re doing—but you know what works best in your organization. You have intimate knowledge of the organization’s culture, how processes work (or not), etc. They’ve only just met you and while they have a job to do, you also have a job that you’ve been doing. That, in my mind, gives you a bit of a leg up on the outsiders…but that may just be me!

Some risk assessment targets that you should aim at

Overall, risk assessments are really useful in two general instances:

  • When you have a risk that you cannot eliminate and you need help identifying the means of reducing that risk to the extent possible
  • When you have a risk for which there is no regulatory guidance or requirement and the “way” is not clear

With those thoughts in mind, there are plenty of situations that can benefit from a risk assessment, such as [more]