First off, a mea culpa. It turns out that there was an educational presentation by CMS to (nominally) discuss the final Emergency Preparedness rule, with a focus on the training and testing requirements (you can find the slide deck here; the presentation will be uploaded sometime in the next couple of weeks or so) and I neglected to make sure that I had shared that information with you in time for you to check it out. My bad!
That said, I don’t know that it was the most compelling hour I’ve ever spent on the phone, but there were one or two (maybe as many as three) aspects of the conversation that were of interest, bordering on instructive. First off, when the final rule speaks to the topic of educating all staff on an annual basis, the pudding proof is going to be during survey when staff are asked specific questions about their roles in your plan (presumably based on what you come up with through the hazard vulnerability assessment—HVA—process). Do they know what to do if there is a condition that requires evacuation? Do they know how to summon additional resources during an emergency? Do they know what works and what doesn’t work as the result of various scenarios, etc.? This is certainly in line with what I’ve seen popping up (particularly during, but not limited to, CMS/state surveys)—there is an expectation (and I personally can’t argue against this as a general concept) that point-of-care/point-of-service staff are competent and knowledgeable when it comes to emergency management (and, not to mention, management of the care environment). As I’ve noted to I can’t tell you how many folks, the management of the physical environment, inclusive of emergency preparedness/management does not live on a committee and it is not “administered” during surveillance rounds or during fire drills. Folks who are taking care of the patients’ needs to know what their role is in the environment, particularly as a function of what to do when things are not perfect (I’ll stop for a moment and let you chew on that one for a moment).
Another expectation that was discussed (and this dovetails a wee bit with the last paragraph) is that your annual review of your emergency preparedness/management process/program must include a review of all (and I do mean all) of the associate/applicable policies and procedures that are needed for appropriate response. So far (at least on the TJC front—I’m less clear on what some of the other accrediting organizations (AO)—might be doing, though I suspect not too very far from this. More on the AO front in a moment), the survey review of documentation has focused on the emergency plan (or emergency operations plan or emergency response plan—if only a rose were a rose were a rose…), the exercise/drill documentation, HVA, and annual evaluation process. But now that the gauntlet has been expanded to include all those pesky policies and procedures. I will freely admit that I’m still trying to figure out how I would be inclined to proceed if I still had daily operational responsibility for emergency management stuff. My gut tells me that the key to this is going to be to start with the HVA and then try to reduce the number of policies and procedures to the smallest number of essential elements. I know there are going to be individual response plans—fire, hazmat, utility systems failures, etc.—is it worth “appendicizing” them to your basic response plan document (if you’ve already done so, I’d be interested to hear how it’s worked out, particularly when it comes to providing staff education)? I’m going to guess that pretty much everybody addresses the basic functions (communications, resources and assets, safety and security, utility systems, staff roles and responsibilities, patient care activities) with the structure of the E-plan, which I guess limits the amount of reviewable materials. There was a question from the listening audience about the difficulty in managing review of all these various and sundry documents and the potential for missing something in the review process (I am, of course, paraphrasing) and the response was not very forgiving—the whole of it has to be reviewed/revised/etc. So, I guess the job is to minimize/compact your response plans to their most essential (the final rule mentions the development of policies and procedures, but doesn’t stipulate what those might be) elements and guard them diligently.
The final takeaways for me are two in number. Number 1: Eventually, there will be Interpretive Guidelines published for the Emergency Preparedness final rule, but there is no firm pub date, so please don’t wait for that august publication before working towards the November implementation deadline. Number 2: While there is an expectation that the AOs will be reviewing their requirements and bringing them into accordance with the CMS requirements, there is no deadline for that to occur. Something makes me think that perhaps they are waiting on the Interpretive Guidelines to “make their move”—remembering it’s not going to be fair any time soon. I think the important dynamic to keep in mind when it comes to our friends at CMS (in all their permutations) is that they are paying hospitals to take care of their patients: the patients are CMS’ customers, not us. Which kind of goes a ways towards explaining why they are not so nice sometimes…
Or extend your hand?
First up, as a general rule of thumb (which could be one of the pointed fingers represented above, unless you don’t think a thumb is a finger), when CMS identifies an implementation date that is in the future, I think that we can safely work towards being in full compliance with whatever the Cs are implementing—on that implementation date. Apparently there’s been enough confusion (not really sure who may or may not have been confused, but sometimes it’s like that) for CMS to issue something of a clarification as to what is expected to be in place by November 15, 2017, which means education and exercises (and any other pesky items in your EM program that didn’t quite synch up with the final rule on emergency preparedness for healthcare organizations). Since this is very much brave new world territory when it comes to how (though perhaps the correct term would be “how painfully”) CMS is going to administer the final rule as a function of the survey process. I think it initially, unless we hear something very specific otherwise, means that we need to be prepared to meet the full intent of the language (making sure that you have trained/educated “all” staff; making sure that you participated in a community-wide exercise of some level of complexity) until these things start to sort out. My gut tells me that if they were going to engage in any more exculpatory/explanatory/clarifying communications, it would have been included in the above-noted transmission. And while I have little doubt that there will be some variability (states do not necessarily coordinate response) as to how this all pans out in the field, the education of “all” staff and participation in the communitywide exercise deal seem to be pretty inviolable. Certainly there have been instances in the past in which healthcare organizations have struggled to coordinate exercises with the local community(s), but my fear is that if you fall short on this, you will need to have a very compelling case of why you weren’t able to pull off a coordinated exercise. Community finances and fiscal years and local emergency response hegemony are all contributing factors, to be sure, but where you could “sell” that as a reason for not dancing with the locals to some of the accreditation organizations, I’m thinking that (as is usually the case) reasonableness and understanding might not be the highlights of any discussion with the feds and those that survey on their behalf. From what I’ve seen in the field, when it comes to CMS and the survey process, you are either in compliance or you are not in compliance and there is very little gray in between. Community drill done—compliant! Community drill not done—not compliant! Wouldn’t it be nice if life were always that simple?
At any rate, just to use this a reminder that the first anniversary of the 2012 Life Safety Code® is coming up—make sure you get all that annual testing and such out of the way—and don’t forget to make sure that all your fire alarm and suppression system documentation includes the correct version of the applicable NFPA code used for testing. I am dearly hoping to retire EC.02.03.05 from the most frequently cited standards ranks and while I fear the worst with this change. (To my mind, getting tagged for having the wrong NFPA year on the documentation would pretty much suck—please excuse my coarse language—but sucking is exactly what that type of finding would do.)
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.
…when you don’t know the reason…
Some Joint Commission goodness for your regulatory pleasure!
For those of you in the audience that make use of the online version of the Accreditation Manual, I would implore you to make sure that when you are reviewing standards and performance elements that you are using the most current versions of the requirements. I think we can anticipate that things are going to be coming fast and furious over the next few months as the engineering folks at TJC start to turn the great ship around so it is in accordance with the requirements of the 2012 edition of just about everything, as well as reflecting the CMS Conditions of Participation. To highlight that change, one example is the requirement for the testing of the fire alarm equipment for notifying off-site fire responders (decorum prevents me from identifying the specific standard and performance element, but I can think of at least 02.03.05.5 things that might serve as placeholders, but I digress); the January 1, 2017 version of the standards indicates that this is to occur at a quarterly frequency (which is what we’ve been living with for quite some time), but the January 9, 2017 version indicates that this is to occur on an annual basis, based on the 2010 edition of NFPA 72. In looking at the 2010 edition of NFPA 72, it would appear that annual testing is the target, but I think this speaks to the amount of shifting that’s going to be occurring and the potential (I don’t know that I would go so far as to call it a likelihood, but it’s getting there) for some miscommunications along the way. At any rate, if you use the online tool (I do—it is very useful), make sure that you use the most current version. Of course, it might be helpful to move the older versions to some sort of archived format, but that’s probably not going to happen any time soon.
Speaking of updates, last week also revealed additional standards changes that will be taking effect July 1, 2017 (get the detailed skinny here). Among the anticipated changes are the official invocation of NFPA 99 as guidance for the management of risk; some tweaking of the language regarding Alternative Equipment Management (AEM) program elements, including the abolition (?!?) of the 90% target for PM completion and replacing it with the very much stricter 100% completion rate (make sure you clearly define those completion parameters!); expansion of the ILSM policy requirements to include the management of Life Safety Code® deficiencies that are not immediately corrected during survey (you really have to look at the survey process as a FIFI—Find It, Fix It!—exercise); the (more or less) official adoption of Tentative Interim Agreements (TIA) 1, 2, and 4 (more on those over the next couple of weeks) as a function of managing fire barriers, smoke barriers, and egress for healthcare occupancies; and, the next (and perhaps final) nail in the coffin of being able to sedate patients in business occupancies (also to be covered as we move into the spring accreditation season). I trust that some of this will be illuminated in the upcoming issues of Perspectives, but I think we can safely say that the winds of change will not be subsiding any time soon.
Also on the TJC front, as we move into the 2017 survey year, those of you that will likely be facing survey, I encourage you to tune in to a webinar being presented on the SAFER (Survey Analysis For Evaluating Risk) matrix, which (aside from being transformative—a rather tall order and somewhat scary to consider) will be the cornerstone of your survey reports. We’ve covered some of the salient points here in the past (this is quickly becoming almost very nearly as popular a topic for me as eyewashes and general ranting), but I really cannot encourage you enough to give this topic a great deal of attention over the coming months. As with all new things TJC, there will be a shakedown cruise, with much variability of result (or this is my suspicion based on past experiences)—it is unlikely that this much change at one time is going to enhance consistency or it’s hard to imagine how it would/could (should is another matter entirely). At any rate, the next webinar is scheduled for Tuesday, March 7, 2017; details here.
Please remember to keep those cards and letters coming. It’s always nice to hear from folks. (It almost makes me think that there’s somebody out there at the other end of all those electrons…) Have a safe and productive week as we await the arrival of Spring!
And we’re still in the first month!
As I’ve been working with folks around the country since November 8, there’s been a lot of thought/concern/etc. relative to how the new administration is going to be impacting the healthcare world and the end of January may have offered us a taste of what’s to come with the issuance of an executive order to reduce regulatory influence/oversight of the healthcare industry by establishing a plan that requires federal agencies to remove two existing regulations for every one new regulation that they want to enact (for the healthcare take on this, please check out the Modern Healthcare article here. As with pretty much everything that’s been happening lately, there appear to be widely (and wildly) disparate interpretations on how this whole thing is going to manifest itself in the real world (assuming that what we are currently experiencing is, in fact, the real world), so for the moment I am adopting a wait and see attitude about the practical implications of these moves (and acquiring truckloads of antacid). I don’t know of too many healthcare organizations that are so fantastically endowed from a resource ($$$$) standpoint to be able to endure further reimbursement reductions, etc. In fact, once you start looking at the pool of available cash for capital expenditures (and for too many, it’s more of an almost-dried up puddle), it hardly seems worth the effort to plan on expenditures that are likely never to come to fruition. Quick aside: section 482.12(d) of the Conditions of Participation requires each participating organization to have an institutional plan and budget, including a capital expenditure plan for at least a three-year period, though for far too many 3 x 0 is still a big fat goose egg, but still you must plan.
I would like to think that there’s a way forward that will result in greater financial flexibility for hospitals—in spite of some late-2016 chatter about allowing failing hospitals to do just that—fail! There were some closures last year. Hope nothing that impacted you; I couldn’t find anything that specifically indicated how many hospitals might have closed in 2015, so I can’t tell if last year was an aberration or business as usual. I do know that it is very tough when safety and facilities have to compete with some of the sexier members of the technology family; particularly those that generate revenue—growl! I couldn’t tell you the last time I saw an ad saying how clean and comfortable a hospital was (I think it would be a nice change of pace). And while I absolutely recognize the importance of wait times, technology advances, etc., if the physical environment is not holding up its end of the equation, it doesn’t really make for the best patient experience and that’s kinda where things are headed. It’s the total patient experience that is the measure of a healthcare organization—you’ve got to do it all and you have to do it good.
So, I guess we’ll have to keep an eye on things and hope that some logic (in spite of recent tendencies) prevails.
As we find 2017 reapplying time’s onslaught against pop culture icons, once again there’s a small “c” cornucopia of stuff to cover, some perhaps useful, some most assuredly not (that would be item #1, except for the advice part). Allons-y!
As goes the passage of time, so comes to us the latest and latest edition of the Joint Commission’s Survey Activity Guide (2017 version). There does not appear to be a great deal of shifting in the survey sands beyond updating the Life Safety Code® (LSC) reference, reordering the first three performance elements for the Interim Life Safety Measure (ILSM) standard, and updating the time frame for sprinkler system impairments before you have to consider fire watches, etc. They also recommend having an IT representative for the “Emergency Management and Environment of Care and Emergency Management” (which makes EM the function so nice they named it twice…), which means that, yes indeedy, the emergency management/environment of care “interviews” remain on the docket (and review of the management plans and annual evaluations—oh, I wish those plans would go the way of the dodo…) for the building tour as well. Interestingly enough, there is no mention of the ILSM assessment discussion for any identified LSC deficiencies (perhaps that determination was made to late in the process)—or if there is, I can’t find it. So for those of you entertaining a survey this year, there’s not a ton of assistance contained therein. My best advice is to keep an eye on Perspectives—you know the surveyors will!
And speaking of which, the big news in the February 2017 issue of Perspectives is the impending introduction of the CMS K-tags to the Joint Commission standards family. For those of you that have not had the thrill of a CMS life safety survey, K-tags are used to identify specific elements of the LSC that are specifically required by CMS. Sometimes the K-tags line up with the Joint Commission standards and performance elements and sometimes they provide slightly different detail (but not to the point of being alternative facts). As TJC moves ever so closely to the poisoned donut that is the Conditions of Participation, you will see more and more readily discernible cross-referencing between the EC/LS (and presumably EM) worlds. At any rate, if I can make one consultative recommendation from this whole pile of stuff, I would encourage you to start pulling apart Chapter 43 of the 2012 LSC – Building Rehabilitation, particularly those of you that have been engaged in the dark arts of renovation/upgrading of finishes, etc. You want to be very clear and very certain of where any current or just-completed projects fall on the continuum—new construction is nice as a concept (most new stuff is), but new construction also brings with it requirements to bring things up to date. This may all be much ado about little, but I’d just as soon not have to look back on 2017 as some catastrophic survey year, if you don’t mind…
Until next time, have a Fabulous February!
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…
As the ol’ Physical Environment Portal remains barren of new goodies (maybe we will awake the morning of December 25 and find crisply wrapped interpretations under the tree—oh, what joy for every girl and boy!), we will turn yet again to the annals of Perspectives to mayhap glean some clarity from that august source of information. I suspect that as the December issue is chock-a-block full of life safety and emergency management goodness, we’ll be chatting about the contents for a couple of sessions. First, the big news (or what I think/suspect is the news that is likely to have the most far-reaching implications for survey year 2017): a survey process change relative to the evaluation of Interim Life Safety Measures. Actually, I should note that, as the changes were effective November 17, 2016, those of you experiencing surveys ‘twixt then and the end of the year will also be subject to this slight alteration.
So, effective 11/17/16 (the 46th anniversary of the recording of Elton John’s landmark live album 11/17/70—coincidence? Probably…), the evaluation of your ILSM process (inclusive of the policy, any risk assessments, etc.) will be expanded to include discussion of how, and to what extent, ILSMs will be implemented when there are LS deficiencies identified during your survey that (presumably) cannot be immediately corrected, based on your ILSM policy. Sounds pretty straightforward, but it does make me wonder how the LS surveyor is going to have enough time to review your documentation, thoroughly survey your facility, and then sit down to review any LS findings and discuss how your ILSM policy/process comes into play. I have to tell you, when I first read this, my thought immediately went to “one more day of LS surveying to endure for any reasonably-sized hospital” and, taking into consideration all the other changes going on, while I hope I am incorrect, it does make me wonder, wonder, wonder. Also, the ILSM(s) to be implemented until the deficiency is resolved will be noted in the final survey report, so it probably behooves you to have a process in place to be able to FIFI (find it, fix it) every LS deficiency as it is encountered—and since everything counts with the abolition of the “C” performance elements, you know what you probably need to do.
At any rate, with the announcement that we can expect full coverage of the ILSM standard, there was also a note that an additional performance element has been added to provide for any additional ILSMs you might want to use that are not specifically addressed in the other performance elements for this standard. I’m not exactly sure how this would play out from a practical standpoint; maybe you could specifically include in your policy a provision for checking exit routes in construction only when the space is occupied, etc. As near as I can remember, the only instance I can think of somebody being cited for having an ILSM in their policy that did not precisely reflect the performance elements in the standard was back when the EP regarding the prohibition of smoking was discontinued from the standard; there were a few persnickety surveyors who cited folks for not having removed that from their policy (persnickety is as persnickety does), but that’s all I can think of.
Next week, we’ll chat a bit about some of the pending changes to the Life Safety chapter wrought by the adoption of the 2012 Life Safety Code®. In a word, riveting!
Another hodgepodge of stuff this week. I suppose with the holidays, I could be lazy and break these up into smaller chunks of bloggy goodness—maybe next week, but first some ponderings.
I was penning some thoughts relative to the current state of accreditation and a common theme kept reasserting itself: the recent changes are going to absolutely nothing to help decrease the number of findings in the physical environment and, in fact, are much more likely to increase the number (and probably types) of findings experienced during regulatory inspections. Now, I suppose this is rather an extension of the alignment with CMS (I mean, whoever received a visit from those folks and escaped completely unscathed? Perhaps some, but not a whole bunch, I’d venture to guess) and how that philosophy (scorched earth seems like a particularly apropos descriptor—at least at the moment) aligns with the idea/sense/concept that perfection is a noble goal, but not particularly obtainable on this particular space-spinning blue sphere. I’ve said it before, I’ll (no doubt) say it again: they are going to find “stuff” when they visit you—they have to! But that brings me back to the age-old question of what value does this level of attention to minutia bring to the process. I don’t think there’s anyone among us that believes that we have achieved a level of perfection of heretofore untold proportions—has a lot to do with why we have to show up at work every day, n’est-ce pas? There has got to be a better way to facilitate improvement in the management of the healthcare environment without brandishing the regulatory equivalent of a sharp stick (if not a cattle prod). So, as we wind down the 2016 season, those one-off OFIs have now been converted into a cluster of regulatory middle fingers—ouch! Okay, hopping down from the soapbox.
In the December 2016 issue of Perspectives, there is a fair discussion on how the Interim Life Safety Measures (ILSM) process is going to be utilized (perhaps even evaluated) during the survey process. In the October Perspectives, there was coverage of how a completed project (that involved ILSM implementation) would be reviewed to evaluate the effectiveness of the ILSM process. There was also discussion indicating that construction-related deficiencies would not be cited as specific RFIs but rather as a function of the ILSM performance elements. But the December publication offers yet another nuance to the process—when you have a Life Safety Code® deficiency identified during survey, there will be a resultant “discussion” of the deficiency and an inquiry as to which ILSM will be implemented to protect building occupants until such time as the deficiency (or deficiencies) is corrected. I think the important thing to keep in mind here is that the requirement is to implement your ILSM policy, which would then provide criteria for determining what, if any, of the ILSMs would be implemented. I also think that now would be a really good time to dust off your ILSM policy and run it through a couple of test deficiencies to ensure that your policy supports a reasonable approach to ILSM implementation. Finally (on this subject), in the days when clarification of findings was a worthwhile endeavor, it never “paid” to fix stuff during the survey (fixing a condition was tantamount to admitting that you had messed up), but now that everything gets cited, the simplest ILSM to implement is “none at all because we fixed the condition.” Can somebody give me a “that’s a pain in the posterior”? Amen!
As a final thought (or perhaps thoughts) for the week, I think we have to treat any construction or renovation activities as an invasive procedure, so we need to come up a process akin to the Universal Protocol adopted by the folks in surgery to make sure that everyone is on the same page before the activity starts (and that especially includes contractor staff—I am absolutely convinced that we could do a better job with that process). As an offshoot of this, I think it might be time to adopt a process for periodically evaluating the construction/renovation management process, much as we evaluate the 6+1 EC/EM functions. I can’t think of a single “normal” process that has more potential for disruption, angst, chaos—you name it—than the construction and renovation process. Some folks are fortunate enough to have in-house resources for the management of these activities, but even then there can be opportunities for improvement–the communications process springs to mind as being frequently flawed.
Until next time, I bid you as much holiday cheer as you can tolerate!
First off, please accept my bestest wishes to you and yours for a most joyous and restful (or as restful as you want it to be) Thanksgiving holiday.
To paraphrase a certain musical ensemble, what a long, strange compliance year it’s been. Hopefully, 2016 will head off into the realm of history with a whimper (I think we’ve experienced enough “bangs” to take us well into 2017 and beyond). And so, a little casserole of safety stuff to tide you over ’til next week. First up, some risk assessment deliciousness, courtesy of NFPA 99.
I had intended to discuss this back a few weeks, but there has been a lot to discuss these past few weeks. At any rate, I was able to get a look at the CMS update portion of the Executive Briefings presentation and it appears that there was some discussion relating to the practical application of how a space is used to determine the risk category for the equipment and/or systems used to support that space. My sense of this is that it’s not so much the space itself as it is, but rather what processes, etc., exist within the space you are evaluating, using the definitions from NFPA 99. So, the methodology focuses on an analysis of facility systems and equipment based on the risks associated with failures of those systems:
Category 1—Facility systems in which failure of such equipment or system is likely to cause major injury or death of patients or caregivers
Category 2—Facility systems in which failure of such equipment or system is likely to cause minor injury to patients or caregivers
Category 3—Facility systems in which failure of such equipment is not likely to cause injury to patients or caregivers
Category 4—Facility systems in which failure of such equipment would have no impact on patient care.
So, moving to the definitions in NFPA 99, you sort the above concepts based on how the space is used:
- Facility systems and equipment for critical care rooms would be Category 1
- Facility systems and equipment for general care rooms would be Category 2
- Facility systems and equipment for basic care rooms would be Category 3
- Facility systems and equipment for support rooms would be Category 4
Each of the chapters in NFPA 99 (gas and vacuum systems, gas equipment, electrical systems, HVAC, etc.) have provisions for the different categories, as applicable, so it appears that the expectation (at least as it was presented at Exec Briefings) is that the organization of the facilities systems and equipment would reflect this methodology. To be honest, I think this may be more of an issue with re-packaging how things are equipped and maintained; maybe including the category designation on work orders, etc. I don’t know that this is going to extend to TJC’s activities, though with the bad marks it received on its CMS report card, it seems unlikely that TJC will become more reasonable…time, as they say, will tell.
Another potential complication for survey year 2017 (I’m pretty confident of this, but not yet certain about the timeline for implementation) is a broadening of the Evidence of Standards Compliance (ESC) process to include at least two more considerations. At the moment, the ESC process requires a response to the following categories: Who (is responsible for the correction); What (was done to correct the deficiency); When (the corrective action was completed); How (the corrective action was implemented and will be sustained), and Measure of Success (for those pesky “C” performance elements—to which we will bid a hearty “adieu” on January 1, 2017). I think we’re all pretty familiar with that part of the process (I can’t imagine that anyone’s had a survey with no findings in the physical environment, though I suppose the infamous “bell” curve might dictate otherwise), but there is indication that with the removal of the Measure of Success category, we will have two additional elements to document within the framework/context of the corrective action: Leadership Involvement and Preventive Analysis. At the moment, it appears that the sequence will look something like this:
I think being able to account for leadership involvement is a pretty straightforward response (I think probably the best way to frame this would be to identify the boss of whoever the “who” would be; and perhaps that boss’ boss, depending on the circumstance), but I suspect that the Preventive Analysis portion of the response could get quite complicated. As near as I can tell, it would be an amalgam of the root cause that resulted in the finding and the strategy for preventing future deficiencies, although minimizing the risk of recurrence might be a more useful viewpoint—as I like to tell folks, it’s the easiest thing in the world to fix something and the among the most difficult things to keep that something fixed. Hopefully, this will end up being no more than a little more water under the bridge, but I guess as long as findings in the physical environment remain a focus, the sustainment of corrective actions will be part of the conversation.
And on that note, I bid you a Thanksgiving to eclipse all yet experienced: gobble, gobble!