…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!
Or, for the less aged folks, we could use Penelope Pitstop’s Preposterously Perilous Permutations…
I’ve recently had the opportunity to review some fourth quarter (2016) Joint Commission survey reports and I have to tell you that I’m not seeing indication of the rosiest of futures when it comes to the physical environment. (I keep trying to convince myself that it is merely because of my perspective that things seem to be weighted so heavily in the direction of the physical environment—it is, after all, my “beat.”) That being said, there does seem to be a trend in “where” the findings are being found, so to speak. And that, my friends, is in the outpatient setting, particularly physician office practices.
The story kind of starts with the “reveal” of TJC’s prepublication of the 2017 EC and LS chapters. I suspect that we will continue to discuss the various and sundry permutations of peril that will befall us as we move through the process, but this week I wanted to focus on a corner of the Life Safety chapter that doesn’t necessarily get a lot of attention: the Ambulatory Health Care Occupancy standards and performance elements.
Contained within the Ambulatory Health Care Occupancy section are some notes, one of which appears to be very much like business as usual when it comes to determining what rules in and what rules out when it comes to ambulatory surgery services, and so we have something to the effect that the ambulatory-related standards apply to care locations where four or more patients (at the same time) are provided either anesthesia or outpatient services that render those patients incapable of being able to save themselves in an emergency (I’m paraphrasing a bit here—our friends in Chicago are very attentive to verbatim quotes of their content—you’d think that the Cubs win might put them in a better frame of mind, but that’s too much risk. Maybe they’re sore winners…).
So, we got that one, yes? Pretty straightforward, very much in keeping with how we’ve been managing our outpatient environments, etc.
But then we move on to the second note, and the slope gets a bunch more slippery (and again, I paraphrase): if you use TJC accreditation for deemed status purposes, the ambulatory LS standards apply to outpatient surgical departments in hospitals—regardless of how many patients are rendered incapable (so that’s one patient all the way up to however many patients you can render incapable of self-preservation…ouch!). Now, I guess we could have some fairly lengthy discussion about exactly what constitutes “outpatient surgical departments in hospitals.” Does that mean physically within the four walls of the hospital? Does it mean operated under the hospital’s license or CMS Certification Number (CCN)? At the moment, I’m tending to lean towards the latter, just because it would be so much more messy.) It will be interesting to see how this whole thing rolls out into survey reality; it is entirely possible that folks are already having these discussions with their TJC account reps as planning for the 2017 survey season begins in earnest, if anyone has some indication on how, for instance, office-based surgical procedures are being accounted for in the process. Can you imagine having an LS surveyor heading out to all those physician offices in which surgical procedures are occurring? It’s about half past Halloween, but that’s a pretty scary thought. Sooooo, you might want to start evaluating your offsite locations for compliance with the LS.03.01.XX standards and performance elements.
Some other potential vulnerabilities relate to the management of high-level disinfection activities in these same office environments. I’m seeing a lot of the same types of findings that were once associated with areas like ultrasound, cardiology, etc., basically locations in which instruments and equipment are being manually disinfected. Lately I’ve seen findings relating to eyewash stations (check those disinfectant products to make sure that if you have a corrosive product, you’ve got a properly ANSI-configured eyewash station and if you have one, make sure it’s being checked on a weekly basis), management of disinfectant temperature, ensuring there is sufficient ventilation, making sure secondary containers are properly labeled (including biohazard labels), using PPE in accordance with the disinfectant product’s Instructions for Use, etc. The real “danger” here is that this appears to be becoming a mix that results in significant survey impact relative to the physical environment, infection control, even surgical services. These are findings that can “squirt” (small pun intended) in many different directions, causing a big freaking mess, particularly when it comes down to clinical surveyors conducting the outpatient portion of the survey. You might want to make sure you’ve got a very robust means of communications from the outpatient sites to ensure that you can nip these types of findings in the bud. But you also probably want to do a little focus education with the folks out in the hinterlands to ensure that PPE is available and used, products are being used properly, etc. I know it becomes “one more thing” to do, but I think we have to come to grips with the reality that the surveyors are becoming very adept at generating lots and lots of findings in the physical environment; they understand that there are locations in almost any healthcare organization that are not “attended” quite as robustly and that if they pick at certain common vulnerabilities, they will be rewarded with findings. We need to take that away from them, toot sweet!
Keep documenting those risk assessments: the Conditions of Participation and other regulatory rapscallia still do not tell us how to appropriately maintain a safe environment, so we have to be diligent in plotting our own course(s). We get to decide how we do this, but we do have to actually make those decisions—and make them in a manner that provides evidence of the process. I know it probably seems like a lot of drudge work, but it’s pretty much what we have to do.
As a closing note, I’d like to thank all the veterans for their service, pride and dignity—we are all the better for it!
Earlier this week, I received a question regarding the need to do a risk assessment that would allow (or prohibit) the use of toasters in break rooms, etc., due to the open heating element. I should probably mention that this “finding” was not at the hands of The Joint Commission, but rather one of the other acronymic accreditation agencies, but these things do tend to travel across agency boundaries, so it may be a topic of conversation for your “house.” At any rate, the request was aimed more at identifying a format for documenting the risk assessment (an example of which follows), as the surveyor who cited the toasters indicated that a risk assessment supporting continued use of the toasters would be sufficient. Special survey hint: If a surveyor indicates that a risk assessment would be an acceptable strategy for whatever practice or condition might be in question, you should consider that a pretty good indication that there is no specific regulatory guidance in any direction for the subject at hand. Though I will also note that if a surveyor does not “bite” on a risk assessment, it doesn’t mean that there is a specific regulation/statute/etc. that specifies compliance, so even if there appears to be no relief from a risk assessment, a thorough review of what is actually required is always a good idea. Which probably represents a good point to discuss the risk assessment components:
- Issue Statement. Basically a recap of what the condition or practice that has been identified as being problematic/a vulnerability, etc.. Using this week’s topic—the use of open element appliances in break rooms, etc. (no reason to confine the discussion to toasters; might as well include toaster oven, grills, and other such appliances)
- Regulatory Analysis. Reviewing what is specifically indicated in the regulations: CMS Conditions of Participation; Accreditation Agency standards and performance elements; state and local laws and regulations should definitely be discussed, as well as any other Authorities Having Jurisdiction (AHJ) that might weigh in on the topic. For the open element appliance discussion, I always encourage folks to check with their property insurer (they are a very important, and frequently overlooked, AHJ); they might not tell you that you can or can’t do something (again, based on whether there is an actual regulatory requirement), but they might tell you that if you do X and have a fire, etc., they might elect not to cover damages.
- Literature Review. Review any manufacturer recommendations or information from specialty society or trade associations. Staying with our friends the toasters, most of the devices in use in your organization are probably manufactured “For Household Use Only”; you might be hard-pressed in the risk assessment to be able to indicate definitively that the devices are being used in accordance with that level of use (I mean I love toast as much as the next person, but I don’t toast a whole loaf every day…). As a consultative aside, my philosophy has always been to encourage (okay, mandate, but only when I was in a position to make the call) the use of commercial-grade toasters. Yes, they are more expensive, but they are also less likely to self-immolate, which (in my book) is rather a good thing. We definitely don’t need things bursting into flames in our break rooms, etc.
- Review of Safety, Quality and Risk Management Data. Check your records. You know you’ve had accidental activations of the fire alarm system (though I do believe that toaster events have faded to a distant second behind microwave popcorn). Is there evidence that your organization is not doing an appropriate job of managing these devices/appliances. I suppose you could take into consideration anecdotal data, but I would be very careful as that can be tricky.
- Operational Considerations and Analysis. Discuss how things are being managed now; how often are the appliances being cleaned, serviced, etc. Is that often enough? Is there sufficient smoke detection, suppression, etc.? Do you need to have “official” guidelines for safe toaster use (no sticky, gooey toaster strudels, etc.)? If you’re going to allow something (recognizing that a prohibition is the easiest thing to police from a surveillance perspective), you may find that folks will require a bit of sensible direction to manage the risks effectively.
- Organizational Position and Policy Statement/Approval and Adoption. Once you’ve figured out what you want to do, just outline the position you are adopting, make sure that what you’re doing is not in opposition to any existing policy or plan, and then run it through the appropriate committees for final approval and adoption by the organization. In most instances, there is absolutely no reason to establish a specific policy for these things; set it up as a guideline or a protocol or a standard operating procedure (SOP). There are really very few policies that are required by law or regulation. Please don’t feel the need to populate your EOC manuals with a million and one incidental policies (I think this might be a good topic of future conversation).
There are many ways to “skin” a risk assessment and the methodology indicated above may not be suitable for all audiences, but it is a very good way to document the thoughtful analysis of an issue (be it identified during a survey or during your own surveillance activities), particularly when logic does not immediately prevail. (And believe me, logic doesn’t prevail as often as it used to. It makes me sad to think about all the gyrations that have been “committed” because we’ve been forced to deal with something that is “possible” as opposed to “probable” or “actual.” And if you’re thinking that the management of cardboard is somewhere in that equation, you would indeed be correct…) It all goes back to the subtle dynamics between what you “have” to do versus what you “could” do—to a very large extent, at least in terms of the regulations, we get to make our own way in the world. But that world is full of surveyors who are perfectly willing to disagree with any decision we’ve ever made; and they tend not to allow us to do the risk assessment math in our heads (pity, that). This is a pretty straightforward way to get your work on paper. I hope you find it useful.
Two relatively disparate topics of conversation this week; one that I suppose could be characterized as good news, the other not so much…
First, the good news: The Joint Commission is continuing in its review and revision of the various and sundry accreditation programs and has earmarked a number of EC performance elements for the scrap heap, one of which is kind of interesting (and none of which is what I had really hoped for—the management plans, like the monster in some horror flicks, just keep coming back for more). So the requirements that are either redundant or will be left up to the decision of each organization are as follows:
- The requirement to monitor and report all incidents in which medical equipment is suspected in or attributed to the death, serious injury, or serious illness of any individual. Reason: All required by the Safe Medical Devices Act of 1990.
- The requirement to have procedures that address how to obtain emergency repair services. Reason: Issue should be left to organization discretion.
- The requirement to provide emergency access to all locked and occupied spaces. Reason: Should be left to organization discretion.
- Requirement for staff and LIPs to describe or demonstrate methods for eliminating and minimizing physical risks in the environment of care. Reason: Left to organization discretion.
- Requirement for staff and LIPs to describe or demonstrate how to report EC risks. Reason: Left to organization discretion.
- Requirement for semiannual environmental tours in patient care areas. Reason: Left to organization discretion.
- Requirement for annual environmental tours in non-patient care areas. Reason: Organization discretion.
- Requirement to use environmental tours to identify environmental deficiencies, et al. Reason: (all together now!) Organization discretion.
- Requirement for representatives from clinical, administrative, and support services to participate in the analysis of EC data. Reason: You guessed it!
- Requirement to evaluate changes to determine if they resolved environmental safety issues. Reason: not quite what you might be thinking—It’s because this element is implicit in the requirement for your organization to take action on the identified opportunities to resolve environmental safety issues. But wait: How are we going to identify opportunities if we are wicked discreet about the environmental tours? Hmmm…
So we lose 10 performance elements that will now become “ghost” standards (don’t get any ectoplasm on you…icky!) Clearly the expectation that these elements are going to be present somehow and/or somewhere in your EC program is not going away and, to be honest, I’m not convinced (at least at the moment) that you’ll be able to risk assess your way out of a lot of this stuff. I’m most disappointed (after the management plans—I really, really, really don’t have a whole lot of use for them—they bring no intrinsic value to the process and are naught but an exercise in paperwork) in the removal of the specific requirements for staff to be able to describe or demonstrate methods for eliminating risks and to be able to report EC risks. I suppose you could decide that folks don’t have to know that stuff, but I have spent a lot of time and energy beating the drum for the “spread” of safety to point of care/point of service folks. Safety does not live on a committee; it does not live on a periodic survey process. Safety lives everywhere in your “house” every moment of every day. Somehow removal of those two EP’s makes me a little verklempt…
But not as verklempt as some of the folks in Chicago might be of late. Quick background: Periodically, CMS is charged with notifying Congress as to how the various and sundry accreditation organizations are faring when it comes to surveying to the Conditions of Participation, which is pretty much the fundamental task of the deemed status process. At any rate, the information that CMS shared with those pesky Congresspersons can be found here. Of particular interest to this conversation is the information beginning at the bottom of p. 38 of the document, where you will find a table that outlines the disparity rate between Condition-level findings identified by the accrediting organizations (referred to as AOs in the report) and those found by CMS during validation surveys. While (and I don’t think it’s much of a surprise) CMS does ferret out things that were missed during the regular accreditation survey, of the “big three” accreditors of hospitals (AOA/HFAP, DNV, TJC), only TJC did not improve its disparity score in FY 2014 (as the only accrediting agency for psychiatric and critical access hospitals, it didn’t do real well there, either—see pp. 39-40).
But where things get kind of ugly for us is the table (lucky #13) on p. 44, which lists the types of findings missed most frequently in hospitals by the accreditation organizations as compared to CMS. And the most frequently missed Condition of Participation? Why, it’s our old friend, the Physical Environment! The environment fares somewhat better in psychiatric hospitals (which, to be honest, surprises me a little, but it may be a question of a small sample size; unless, of course, your sample size is HUGE!) and about the same in critical access hospitals. At this point, I think I’ve probably yapped enough for one week, but I would encourage you to check out the analysis of the physical environment findings starting on p. 49. It doesn’t paint a particularly bright picture, particularly if there were any of you folks anticipating a return to the clinical side of things during surveys. All signs point to even more scrutiny (happy, happy, joy, joy!) of the physical environment…imagine that.
Batten down the hatches, mateys—we’re in for quite a blow!