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Breaking good, breaking bad, breaking news: Ligature Risks Get Their Day in Court

As I pen this quick missive (sorry for the tardiness of posting—it was an unusually busy week), the final vestiges of summer appear to be receding into the distance and November makes itself felt with a bone-chilling greeting. Hopefully, that’s all the bone-chilling for the moment.

Late last month brought The Joint Commission’s publication of their recommendations for managing the behavioral health physical environment. The recommendations focus on three general areas: inpatient psychiatric units, general acute care inpatient settings, and emergency departments. The recommendations (there are a total of 13) were developed by an expert panel assembled by TJC and including participants from provider organizations, experts in suicide prevention and design of behavioral healthcare facilities, Joint Commission surveyors and staff, and (and this may very well be the most important piece of all) representatives from CMS. The panel had a couple of meetings over the summer, and then a third meeting a few weeks ago, just prior to publication of the recommendations, with the promise of further meetings and (presumably) further refinement of the recommendations. I was going to “cheat” and do a little cut and pasting of the recommendations, but there’s a fair amount if explanatory content on the TJC website vis-à-vis the recommendations, so I would encourage you to check them out in full.

Some of the critical things (at least at first blush—I suspect that we, as well as they, will be discussing this for some little while to come) include an altering of conceptual compliance from “ligature free” to “ligature resistant,” which, while not really changing how we’re going to be managing risks in the environment, at least acknowledge the practical reality that it is not always possible to provide a completely risk-free physical environment. But we can indeed appropriately manage the remaining risks by appropriate assessment, staff monitoring, etc. Another useful recommendation is one that backs off on the notion of having to install “alarms” at the tops of corridor doors to alert that someone might be trying to use the door as a ligature point. It seems that the usefulness of such devices is not supported by reported experience, so that’s a good thing, indeed.

At any rate, I will be looking at peeling these back over the next few weeks (I’ll probably “chunk” them by setting as opposed to taking the recommendations one at a time), but if anyone out there has a story or experience to share, I would be more than happy to facilitate that sharing.

As a final note for this week, a shout out to the veterans in the audience and a very warm round of thanks for your service: without your commitment and duty, we would all be the lesser for it. Salute!

 

ADA vs. LSC: Projecting into the Future—Are You Ready to Rumble?

One of the nagging things (at least for me) that’s been looming in the background is CMS’ statement (and restatement, with a side of reiteration) emphasizing that the Life Safety Code® (LSC) is not an accessibility code and, thus, does not ensure compliance with the Americans With Disabilities Act (ADA). You can find that statement and some other funky stuff here.

The web page also includes some specific considerations that I suspect that you will find of considerable interest (well, it did for me) in that it appears to represent some sense of how the ADA vs. LSC joust is going to manifest itself in the field. The following are the relevant sections, with a link to the individual paragraphs from the Federal Register:

SECTIONS 18.2.3.4(2) AND 19.2.3.4(2)—CORRIDOR PROJECTIONS

This provision requires noncontinuous projections to be no more than 6 inches from the corridor wall. In addition to following the requirements of the LSC, healthcare facilities must comply with the requirements of the ADA, including the requirements for protruding objects. The 2010 Standards for Accessible Design (2010 Standards) generally limit the protrusion of wall-mounted objects into corridors to no more than 4 inches from the wall when the object’s leading edge is located more than 27 inches, but not more than 80 inches, above the floor. See Sections 204.1 and 307 of the 2010 Standards, available at http://www.ada.gov/​regs2010/​2010ADAStandards/​Guidance2010ADAstandards.htm [2] (“2010 Standards”). This requirement protects persons who are blind or have low vision from being injured by bumping into a protruding object that they cannot detect with a cane. (https://www.federalregister.gov/d/2016-10043/p-78)

Although the LSC allows 6-inch projections, under the ADA, objects mounted above 27 inches and no more than 80 inches high can only protrude a maximum of 4 inches into the corridor beyond a detectable surface mounted less than 27 inches above the floor (except for certain handrails which may protrude up to 41/2″). See section 307 of the 2010 standards for requirements for handrails and post-mounted objects. CMS intends to provide technical assistance regarding strategies for how to avoid noncompliance with the ADA’s protruding objects requirement, as well as how to modify non-compliant protruding objects.) (https://www.federalregister.gov/d/2016-10043/p-80)

SECTIONS 18.2.3.4 AND 19.2.3.4—CORRIDORS

This provision allows for wheeled equipment that is in use, medical emergency equipment not in use, and patient lift and transportation equipment be permitted to be kept in the corridors for more timely patient care. This provision also allows facilities to place fixed furniture in the corridors, although the placement of furniture or equipment must not obstruct accessible routes required by the ADA. See section 403.5 of the 2010 Standards. (https://www.federalregister.gov/d/2016-10043/p-88)

So, it appears that we may be looking at some changes of fixtures, etc. (including fire extinguishers—lots of those wall-mounted lovelies floating around, not to mention hand sanitizer dispensers) and a re-think of how we’re positioning furniture in corridors—should be an interesting ride. A hearty thanks to Kevin Kozlowski, president of Oval Brand Fire Products for planting the seed that germinated into this week’s missive. Among other things, Kevin and his folks manufacture a fire extinguisher that meets ADA requirements for wall projections.

If you’d like me to discuss a particular topic, please feel free to kick something my way. I figure any question one person has, the likelihood of others having the same or similar question it pretty strong, so don’t be afraid.

Lazy days of autumn: CMS does emergency management (cue applause)!

I suppose you could accuse me of being a little lazy in this week’s offering, but I really want you to focus closely on what the CMS surveyors are instructed to ask for in the Emergency Management Interpretive Guidelines (more on those here; seems like forever ago), so I’ve done a bit of a regulatory reduction by pulling out the non-hospital elements (I still think they could have done a better job with sorting this out for the individual programs) and then pulling out the Survey Procedures piece—that’s really where the rubber meets the road in terms of how this is going to be surveyed, at least at the front end of the survey process.

I suspect (and we only have all of recorded history to fall back on for this) that as surveyors become more comfortable with the process, they may go a little off-topic from time to time (surprise, surprise, surprise!), but I think this is useful from a starting point. As I have maintained right along, I really believe that you folks have your arms around this, even to the point of shifting interpretations. This is the stuff that they’ve been instructed to ask for, so I think this is the stuff that you should verify is in place (and, really, I think you’ll find you’re in very good shape). There’s a fair amount of ground to cover, so I will leave you to it—until next week!

BTW, I purposely didn’t identify which of the specific pieces of the Final Rule apply to each set of Survey Procedures. If there is a hue and cry, I will be happy to do so (or you can make your own—it might be worth it to tie these across to the requirements), but I think these are the pieces to worry about, without the language of bureaucracy making a mess of things. Just sayin’…

Survey Procedures

  • Interview the facility leadership and ask him/her/them to describe the facility’s emergency preparedness program.
  • Ask to see the facility’s written policy and documentation on the emergency preparedness program.
  • For hospitals and critical access hospitals (CAH) only: Verify the hospital’s or CAH’s program was developed based on an all-hazards approach by asking their leadership to describe how the facility used an all-hazards approach when developing its program.

Survey Procedures

  • Verify the facility has an emergency preparedness plan by asking to see a copy of the plan.
  • Ask facility leadership to identify the hazards (e.g., natural, man-made, facility, geographic, etc.) that were identified in the facility’s risk assessment and how the risk assessment was conducted.
  • Review the plan to verify it contains all of the required elements.
  • Verify that the plan is reviewed and updated annually by looking for documentation of the date of the review and updates that were made to the plan based on the review.

 

Survey Procedures

  • Ask to see the written documentation of the facility’s risk assessments and associated strategies.
  • Interview the facility leadership and ask which hazards (e.g., natural, man-made, facility, geographic) were included in the facility’s risk assessment, why they were included and how the risk assessment was conducted.
  • Verify the risk assessment is based on an all-hazards approach specific to the geographic location of the facility and encompasses potential hazards.

Survey Procedures

Interview leadership and ask them to describe the following:

  • The facility’s patient populations that would be at risk during an emergency event
  • Strategies the facility (except for an ASC, hospice, PACE organization, HHA, CORF, CMHC, RHC, FQHC and end stage renal disease (ESRD) facility) has put in place to address the needs of at-risk or vulnerable patient populations
  • Services the facility would be able to provide during an emergency
  • How the facility plans to continue operations during an emergency
  • Delegations of authority and succession plans

Verify that all of the above are included in the written emergency plan.

Survey Procedures

Interview facility leadership and ask them to describe their process for ensuring cooperation and collaboration with local, tribal, regional, state, and federal emergency preparedness officials’ efforts to ensure an integrated response during a disaster or emergency situation.

  • Ask for documentation of the facility’s efforts to contact such officials and, when applicable, its participation in collaborative and cooperative planning efforts.
  • For ESRD facilities, ask to see documentation that the ESRD facility contacted the local public health and emergency management agency public official at least annually to confirm that the agency is aware of the ESRD facility’s needs in the event of an emergency and know how to contact the agencies in the event of an emergency.

Survey Procedures

Review the written policies and procedures which address the facility’s emergency plan and verify the following:

  • Policies and procedures were developed based on the facility- and community-based risk assessment and communication plan, utilizing an all-hazards approach.
  • Ask to see documentation that verifies the policies and procedures have been reviewed and updated on an annual basis.

Survey Procedures

  • Verify the emergency plan includes policies and procedures for the provision of subsistence needs including, but not limited to, food, water and pharmaceutical supplies for patients and staff by reviewing the plan.
  • Verify the emergency plan includes policies and procedures to ensure adequate alternate energy sources necessary to maintain:

o Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions;

o Emergency lighting; and,

o Fire detection, extinguishing, and alarm systems.

  • Verify the emergency plan includes policies and procedures to provide for sewage and waste disposal.

 

Survey Procedures

  • Ask staff to describe and/or demonstrate the tracking system used to document locations of patients and staff.
  • Verify that the tracking system is documented as part of the facilities’ emergency plan policies and procedures.

 

Survey Procedures

  • Review the emergency plan to verify it includes policies and procedures for safe evacuation from the facility and that it includes all of the required elements.
  • When surveying an RHC or FQHC, verify that exit signs are placed in the appropriate locations to facilitate a safe evacuation.

 

Survey Procedures

  • Verify the emergency plan includes policies and procedures for how it will provide a means to shelter in place for patients, staff and volunteers who remain in a facility.
  • Review the policies and procedures for sheltering in place and evaluate if they aligned with the facility’s emergency plan and risk assessment.

 

Survey Procedures

  • Ask to see a copy of the policies and procedures that documents the medical record documentation system the facility has developed to preserves patient (or potential and actual donor for OPOs) information, protects confidentiality of patient (or potential and actual donor for OPOs) information, and secures and maintains availability of records.

 

Survey Procedures

  • Verify the facility has included policies and procedures for the use of volunteers and other staffing strategies in its emergency plan.

 

Survey Procedures

  • Ask to see copies of the arrangements and/or any agreements the facility has with other facilities to receive patients in the event the facility is not able to care for them during an emergency.
  • Ask facility leadership to explain the arrangements in place for transportation in the event of an evacuation.

 

Survey Procedures

  • Verify the facility has included policies and procedures in its emergency plan describing the facility’s role in providing care and treatment (except for RNHCI, for care only) at alternate care sites under an 1135 waiver.

 

Survey Procedures

  • Verify that the facility has a written communication plan by asking to see the plan.
  • Ask to see evidence that the plan has been reviewed (and updated as necessary) on an annual basis.

 

Survey Procedures

  • Verify that all required contacts are included in the communication plan by asking to see a list of the contacts with their contact information.
  • Verify that all contact information has been reviewed and updated at least annually by asking to see evidence of the annual review.

 

Survey Procedures

  • Verify that all required contacts are included in the communication plan by asking to see a list of the contacts with their contact information.
  • Verify that all contact information has been reviewed and updated at least annually by asking to see evidence of the annual review.

 

Survey Procedures

  • Verify the communication plan includes primary and alternate means for communicating with facility staff, federal, state, tribal, regional and local emergency management agencies by reviewing the communication plan.
  • Ask to see the communications equipment or communication systems listed in the plan.

 

Survey Procedures

  • Verify the communication plan includes a method for sharing information and medical (or for RNHCIs only, care) documentation for patients under the facility’s care, as necessary, with other health (or care for RNHCIs) providers to maintain the continuity of care by reviewing the communication plan.

o For RNCHIs, verify that the method for sharing patient information is based on a requirement for the written election statement made by the patient or his or her legal representative.

  • Verify the facility has developed policies and procedures that address the means the facility will use to release patient information to include the general condition and location of patients, by reviewing the communication plan

 

Survey Procedures

  • Verify the communication plan includes a means of providing information about the facility’s needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee by reviewing the communication plan.
  • For hospitals, CAHs, RNHCIs, inpatient hospices, PRTFs, LTC facilities, and ICF/IIDs, also verify if the communication plan includes a means of providing information about their occupancy.

 

Survey Procedures

  • Verify that the facility has a written training and testing (and for ESRD facilities, a patient orientation) program that meets the requirements of the regulation.
  • Verify the program has been reviewed and updated on, at least, an annual basis by asking for documentation of the annual review as well as any updates made.
  • Verify that ICF/IID emergency plans also meet the requirements for evacuation drills and training at §483.470(i).

 

Survey Procedures

  • Ask for copies of the facility’s initial emergency preparedness training and annual emergency preparedness training offerings.
  • Interview various staff and ask questions regarding the facility’s initial and annual training course, to verify staff knowledge of emergency procedures.
  • Review a sample of staff training files to verify staff have received initial and annual emergency preparedness training.

 

Survey Procedures

  • Ask to see documentation of the annual tabletop and full scale exercises (which may include, but is not limited to, the exercise plan, the AAR, and any additional documentation used by the facility to support the exercise.
  • Ask to see the documentation of the facility’s efforts to identify a full-scale community based exercise if they did not participate in one (i.e., date and personnel and agencies contacted and the reasons for the inability to participate in a community based exercise).
  • Request documentation of the facility’s analysis and response and how the facility updated its emergency program based on this analysis.

 

Survey Procedures

  • Verify that the hospital, CAH, and LTC facility has the required emergency and standby power systems to meet the requirements of the facility’s emergency plan and corresponding policies and procedures
  • Review the emergency plan for “shelter in place” and evacuation plans. Based on those plans, does the facility have emergency power systems or plans in place to maintain safe operations while sheltering in place?
  • For hospitals, CAHs, and LTC facilities which are under construction or have existing buildings being renovated, verify the facility has a written plan to relocate the EPSS by the time construction is completed

For hospitals, CAHs, and LTC facilities with generators:

  • For new construction that takes place between November 15, 2016 and is completed by November 15, 2017, verify the generator is located and installed in accordance with NFPA 110 and NFPA 99 when a new structure is built or when an existing structure or building is renovated.  The applicability of both NFPA 110 and NFPA 99 addresses only new, altered, renovated or modified generator locations.
  • Verify that the hospitals, CAHs and LTC facilities with an onsite fuel source maintains it in accordance with NFPA 110 for their generator, and have a plan for how to keep the generator operational during an emergency, unless they plan to evacuate.

 

Survey Procedures

  • Verify whether or not the facility has opted to be part of its healthcare system’s unified and integrated emergency preparedness program. Verify that they are by asking to see documentation of its inclusion in the program.
  • Ask to see documentation that verifies the facility within the system was actively involved in the development of the unified emergency preparedness program.
  • Ask to see documentation that verifies the facility was actively involved in the annual reviews of the program requirements and any program updates.
  • Ask to see a copy of the entire integrated and unified emergency preparedness program and all required components (emergency plan, policies and procedures, communication plan, training and testing program).
  • Ask facility leadership to describe how the unified and integrated emergency preparedness program is updated based on changes within the healthcare system such as when facilities enter or leave the system.

 

To close out this week’s bloggy goodness, Diagnostic Imaging just published a piece on emergency preparedness for radiology departments that I think is worth checking out: http://www.diagnosticimaging.com/practice-management/emergency-preparedness-radiology . Imaging services are such a critical element of care giving (not to mention one of the largest financial investment areas of any healthcare organization) that a little extra attention on keeping things running when the world is falling (literally or figuratively) down around your ears. I think we can make the case that integration of all hospital services is likely to be a key element of preparedness evaluation in the future—this is definitely worthy of your consideration.

Reefing a sail at the edge of the world…

What to do, what to do, what to do…

A couple of CMS-related items for your consideration this week, both of which appear to be rather user-friendly toward accredited organizations. (Why do I have this nagging feeling that this is going to result in some sort of ugly backlash for hospitals?)

Back in May, we discussed the plans CMS had for requiring accreditation organizations (AOs) to make survey results public, and it appears that, upon what I can only imagine was intense review and consideration, the CMS-ers have elected to pull back from that strategy. The decision, according to news sources, is based on the sum and substance of a portion of Section 1865 of the Social Security Act, which states:

(b) The Secretary may not disclose any accreditation survey (other than a survey with respect to a home health agency) made and released to the Secretary by the American Osteopathic Association or any other national accreditation body, of an entity accredited by such body, except that the Secretary may disclose such a survey and information related to such a survey to the extent such survey and information relate to an enforcement action taken by the Secretary.

So, that pretty much brings that whole thing to a screeching halt—nice work of whoever tracked that one down. Every once in a while, law and statute work in favor of the little folk. So, we Lilliputians salute whomever tracked that one down—woohoo!

In other CMS news, the Feds issued a clarification relative to the annual inspection of smoke barrier doors (turns out the LSC does not specifically require this for smoke doors in healthcare occupancies) as well as delaying the drop-dead date for initial compliance with the requirements relating to the annual inspection of fire doors. January 1, 2018 is the new date. If you haven’t gotten around to completing the fire door inspection, I would heartily recommend you do so as soon as you can—more on that in a moment. So, good news on two fed fronts—it’s almost like Christmas in August! But I do have a couple of caveats…

I am aware of 2017 surveys since July in which findings were issued because the inspection process had not been completed, and, based on past knowledge, etc., it is unlikely that those findings would be “removable” based on the extended initial compliance date. (CMS strongly indicates that once a survey finding is issued in a report, the finding should stay, even if there was compliance at the time of survey.) So hopefully this will not cause too much heartburn for folks.

The other piece of this is performance element #2 under the first standard in the Life Safety chapter. (This performance element is not based on anything specifically required by the LSC or the Conditions of Participation—yet another instance of our Chicagoan friends increasing the degree of difficulty for ensuring compliance without having a whole mess of statutory support, but I digress.) The requirement therein is for organizations to perform a building assessment to determine compliance with the Life Safety chapter—and this is very, very important—in time frames defined by the hospital. I will freely admit that this one didn’t really jump out at me until recently, and my best advice is to get going with defining the time frame for doing those building assessments; it kind of “smells” like a combination of a Building Maintenance Program (BMP) and Focused Standards Assessment (FSA), so this might not be that big a deal, though I think I would encourage you to make very sure that you clearly indicate the completion of this process, even if you are using the FSA process as the framework for doing so. In fact, that might be one way to go about it—the building assessment to determine compliance with the Life Safety chapter will be completed as a function of the annual FSA process. I can’t imagine that TJC would “buy” anything less than a triennial frequency, but the performance element does not specify, so maybe, just maybe…

But I got the crystal ball, he said!

And he held it to the light…

In their (seemingly) never-ending quest to remain something (I’m not quite sure what that something might be, but I suspect it has to do with continuing bouts of hot water and CMS), our friends in Chicago are working towards modifying the process/documentation for providing post-survey Evidence of Standards Compliance (for the remainder of this piece, I will refer to the acronymically inclined ESC). The aim of the changes is to “help organizations focus on detailing the critical aspects of corrective actions take to resolve” deficiencies identified during survey. Previously, the queries included for appropriate ESC submittals revolved around the following: identifying who was ultimately responsible for the corrective action(s); what actions were completed to correct the finding(s); when the corrective actions were completed; and, how will you sustain compliance (that is, as they say, the sticky wicket, to be sure).

The future state will be (more or less) an expansion of those concerns, as well as including extra-special consideration for those findings identified as higher-risk Requirements For Improvement (RFIs) based on their “position” in the matrix thingy in your final report (findings that show up in the dark orange and red areas of the matrix). The changes are roughly characterized as delving “deeper into the specifics” of the original gang of four elements, so now we have the following: assigning accountability by indicating who is ultimately responsible for corrective action and sustained compliance (not a big change for that one); assigning accountability for leadership involvement (only for the high-risk findings—whew!) by indicating which member(s) of leadership support future compliance; corrective actions for the findings of noncompliance—this will combine the “what you did” with the “when you finished it”; for high-risk findings, you will also have to provide information on the corrective actions as a function of preventative analysis (this sounds like a big ol’ pain in the rumpus room, don’t it?); and , finally, an accounting of how you will ensure sustained compliance, which will have to include monitoring activities (including frequency), the type of data to be collected from the monitoring activities, and how, and to whom, the data will be reported.

In the past, there was always the lurking (almost ghoulish) presence of what’s going to happen if you have repeat findings from survey to survey, and this new process sounds like it might be paving the way for more obstreperous future survey outcomes. But I’d like to know a little bit more about what might be considered a repeat finding—does it have to be the same condition in the same place or is it enough to get cited for the same standard/performance element combo. If the former is the case, then I “get” them being a little more fussy about the process (in full recognition that every organization has some repeat-offender tendencies), but if it’s the latter, then (insert deity of choice) help us all, ‘cause it’s probably going to get more ugly before we see improvement. Or maybe it will just be repeats in the high-risk zone of the matrix—I think that’s also pretty reasonable, though I do think they (the Chicagoans) could do a little better in ensuring consistent approaches/interpretations, particularly when it comes to ligature risks.

All that said, I stand on my thought (and let me tell you, that’s not an easy task) that there are no perfect buildings, no perfect physical environments, etc., and that’s pretty much supported by what I’ve seen being cited during surveys—the rough edges are where the greatest number of findings can be generated. And since they only have to find one instance of any condition in order to generate an RFI, the numbers are not in favor of the folks who have to maintain the physical environment. If you’re interested in the official notice, the links below will take you the announcement article, as well as a delightful graphic presentation—oh boy!

If brevity is the soul of wit…

Hope everyone enjoyed a festive and (most importantly) safe Independence Day—with any luck, today (July 5) does not mark the end of summer (as some do say) so much as it marks the beginning of the end of spring (up here in the Northeast, spring was loath to depart, but it does seem that pre-autumn weather has finally made a commitment to spending some time in the northern hemisphere).

I was looking recently at past blog posts for a reference to the CMS stance on law enforcement interactions with patients as a function of restraints and patient rights—always a fun topic—and I noted that the posts used to be a mite briefer than tends to be the case of late. (You can be the judge of whether my decline in brevity has left me soulless or witless.) I absolutely recognize that there’s been a lot of stuff to cover over the past 18 months with the firestorms of compliance that swept the healthcare environment, which has (no doubt) promoted some of the “volume” of bloggery. But it has caused me to wonder whether I am consuming the compliance elephant in sufficiently small bites to be of use to you folks out there in the field. As near as I can tell, the purpose of this whole thing (as much as I enjoy having a place to pontificate) is to provide information and thoughts on what is happening at the moment to you, my faithful audience of safety folk. And (as near as I can tell) it never hurts to ask one’s audience whether this works for you—please feel free to give me an e-dope slap if you think the “Space” has gone intergalactic in a less-than-useful way. At any rate, I am going to experiment with smaller bites of information in the coming weeks so you’ll have more time for other things—perhaps outdoors…

As far as news goes, things are relatively quiet as we observe the anniversary of CMS’s adoption of the 2012 Life Safety Code. Hopefully you all have done your NFPA 99 risk assessments; polished off those door inspections and are speeding towards the completion of activities relating to initial compliance with the Emergency Preparedness Final Rule. Health Facilities Management This Week discussed some prepublication EC/LS standards relating to the testing of emergency lighting systems; inspection and testing of piped medical gas and vacuum systems; and updating pertinent NFPA code numbers. The pre-pub stuff is aimed at behavioral health care, laboratory, nursing care center, and office based surgery accreditation programs. You can find the details here: https://www.jointcommission.org/prepublication_standards_%E2%80%93_standards_revisions_to_environment_of_care_and_life_safety_chapters_related_to_life_safety_code_update_/

(I guess some of those links are about as brief as I am…)

Thanks, as always, for tuning in—I really appreciate having you all out there at the other end of the interweb…see you next week!

Plan be nimble, plan be quick

As we have discussed (pretty much ad nauseum) in this hallowed hall of electrons, there is likely to be a renewed (and I don’t mean renewed in a healthful way, this would be more like a subscription to a magazine that someone sent you as a prank) interest/scrutiny in how you and your organization are complying with all these lovely (and pesky, can’t forget pesky) new emergency management considerations. But there is one word of caution that I wanted to inject into the conversation, and while it probably doesn’t “need” to be said, I try not to leave any card unplayed when it comes to compliance activities.

Over the years (officially 16 of consulting—time flies!) I have found that sometimes (OK, maybe more frequently than sometimes), the prettiest plans, policies, procedures, etc. end up falling to the ground in demonic spasms because they did not accurately reflect the practice of the organization. The general mantra for this is “do the right thing, do what you say, say what you do,” but sometimes it’s tough to figure out exactly what constitutes “the right thing” (as opposed to “The Right Stuff,” natch). When it comes to emergency preparedness, response, recovery, etc. probably the single most important aspect of the plan (at least I think it’s an aspect—if you can think of a better descriptor, please sing out!) is that it is flexible enough to be able to react to minute-by-minute changes that are (frequently) the hallmark of catastrophic events. I think anyone who has worked in healthcare for any length of time has seen what happens to a rigid structure, be it policy, plan, expectations, buildings, flora and fauna—whatever, when things get to swirling around in intense fashion—things start to pull apart (figuratively and/or literally) and sustaining your response becomes that much more difficult.

So, as we “embrace” the challenges of the changes, I would encourage you to think about how you’ll maintain (and test during exercises) that flexibility of response that will give you enough wiggle room to weather the storms (of outrageous and other fabulous fortune). Exercise scenarios can push (or be pushed) in any number of directions (strangely, it is very much like real life)—make sure you take full advantage of those folks in the Command Center—if they’re not sweating—turn up the heat!

And then came the last days of May…

There’s been a ton of activity the past few weeks on both the Joint Commission and CMS sides of the equation (and if you are starting to feel like the ref in a heavyweight prize fight who keeps getting in the line of fire, yup, that’d be you!) with lots of information coming fast and furious. Some of it helpful (well, as helpful as things are likely to be), some perhaps less so than would be desirable (we can have all the expectations we want as to how we’d ask for things to be “shared,” but I’m not thinking that the “sharers” are contemplating the end users with much of this stuff). This week we’ll joust on TJC stuff (the June issue of Perspectives and an article published towards the end of May) and turn our attentions (just in time for the solstice—yippee!) to the CMS stuff (emergency preparedness and legionella, a match made in DC) next week.

Turning first to Perspectives, this month’s Clarifications & Expectations column deals with means of egress—still one of the more frequently cited standards, though it’s not hogging all the limelight like back in the early days of compliance. There are some anticipated changes to reflect the intricacies of the 2012 Life Safety Code® (LSC), including some renumbering of performance elements, but, for the most part, the basic tenets are still in place. People have to have a reliable means of exiting the (really, any) building in an emergency and part of that reliability revolves around managing the environment. So, we have the time-honored concept of cluttah (that’s the New English version), which has gained some flexibility over time to include crash carts, wheeled equipment, including chemotherapy carts and isolation carts that are being used for current patients, transport equipment, including wheelchairs and stretchers/gurneys (whichever is the term you know and love), and patient lift equipment. There is also an exception for fixed (securely attached to the wall or floor) furnishings in corridors as long as here is full smoke detector coverage or the furniture is in direct supervision of staff.

Also, we’ll be seeing some additional granularity when it comes to exiting in general: each floor of a building having two remote exits; every corridor providing access to at least two approved exits without passing through any intervening rooms or spaces other than corridors or lobbies, etc. Nothing particularly earth-shattering on that count. We’ll also be dealing with some additional guidance relative to suites, particularly separations of the suites from other areas and subdividing the areas within the suite—jolly good fun!

Finally, Clarifications & Expectations covers the pesky subject of illumination, particularly as a function of reliability and visibility, so head on over to the June Perspectives for some proper illuminative ruminations.

A couple of weeks back (May 24, to be exact), TJC unveiled some clarifications. I think they’re of moderate interest as a group, with one being particularly useful, one being somewhat curious and the other two falling somewhere in the middle:

ED occupancy classifications: This has been out in the world for a bit and, presumably, any angst relating to how one might classify one’s ED has dissipated, unless, of course, one had the temerity to classify the ED as a business occupancy—the residual pain from that will probably linger for a bit. Also (and I freely confess that I’m not at all sure about this one), is there a benefit of maintaining a suite designation when the ED is an ambulatory healthcare occupancy? As suites do not feature in the Ambulatory Occupancy chapters of the LSC, is it even possible to do so? Hmmmm…

Annual inspection of fire and smoke doors: No surprise here, with the possible exception of not requiring corridor doors and office doors (no combustibles) to be included. Not sure how that will fly with the CMSers…

Rated fire doors in lesser or non-rated barriers: I know this occurs with a fair degree of frequency, but the amount of attention this is receiving makes me wonder if there is a “gotcha” lurking somewhere in the language of the, particularly the general concept of “existing fire protection features obvious to the public.” I’m not really sure how far that can go and, given the general level of obliviousness (obliviosity?) of the general public, this one just makes me shake my head…

Fire drill times: I think this one has some value because the “spread” of fire drill times has resulted in a fair number of findings, though the clarification language doesn’t necessarily get you all the way there (I think I would have provided an example just to be on the safe side). What the clarification says is that a fire drill conducted no closer than one hour apart would be acceptable…there should not be a pattern of drills being conducted one hour apart. Where this crops up during survey is, for example, say all your third shift drills in 2016 were conducted in the range of 5 a.m. to 6 a.m. (Q1 – 0520; Q2 – 0559; Q3 – 0530; Q4 – 0540), that would be a finding, based on the need for the drills to be conducted under varying circumstances. Now, I think that anyone who’s worked in healthcare and been responsible for scheduling fire drills would tell you (at least I certainly would) that nobody remembers from quarter to quarter what time the last fire drill was conducted (and if they think about it at all, they’re quite sure that you “just” did a fire drill, like last week and don’t you understand how disruptive this is, etc.) If you can’t tell, third shift fire drills were never my favorite thing to do, though it beats being responsible for snow removal…

So that’s the Joint Commission side of the equation (if you can truly call it an equation). Next time: CMS!

Come on, I Lean: Do you Lean?

As you are no doubt aware by now, there’s been a wee bit of a shift in this forum away from all things Joint Commission, as the CMSers seem more inclined to assert themselves in the accreditation market place. I personally have had a lot of work this year in follow-up activities relating to CMS visits and one of the structural/organizational vulnerabilities/opportunities that seem to be cropping with some regularity are those relating to the integration of the physical environment program into organizational Quality Assessment/Performance Improvement (hereafter referred to as QAPI, pronounced “Kwoppee”—I think you’re going to find that you’ll be hearing that term a lot in the coming years/decades) activities. This very much goes back to a topic we discussed back in January (it’s funny, when I started looking for the link to this story, I could have sworn that we had covered this within the last month) relative to making sure that organizational leadership is abundantly familiar with any issues that are (more or less) “stuck” in your safety committee. There is no “sin” in admitting that there are or may be improvement opportunities for which traction in making those improvements is a little slippery—you have to have a means of escalating things to point where reasonable traction is possible. So, from a regulatory standpoint, this all falls under §482.21 Condition of Participation: Quality Assessment and Performance Improvement, which includes the rejoinder: “The hospital must develop, implement, and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors.”

Now, I can tell you that this is a very big deal, particularly when it comes to the reporting up of data, occurrence reporting, etc.—even from the likes of our little world of physical environment safety and related topics. And sometimes you have to be willing to throw some light on those process areas that are not performing as you would want them to; improvement doesn’t typically happen in a vacuum and that absence of vacuum tends to require a fair amount of conversation/collaboration (with some resultant caterwauling) in order to make things happen/get things done.

One QAPI topic you will probably be hearing about (if you have not already) is Lean methodology, which pretty much embraces the general concept of reducing “waste” while still delivering positive service outcomes by focusing on what the customer wants (you can find some useful highlights here; the books are worth a look—perhaps your local library can hook you up). One organization that appears to be endorsing the Lean methodology is that kooky bunch in Chicago and while the article focuses on behavioral health, I think there is enough practical information to be worth a look. And, since we know from past experience that TJC tends to adopt a more pervasive stance when it comes to these types of things, I think it would be very useful (at the very least for those of you using TJC for accreditation) to be conversant in Lean. It’s probably going to rock your boat at some point—life preservers mandatory!

Or the light that never warms

Continuing in our somewhat CMS-centric trajectory, I did want to touch upon one last topic (for the moment) as it portends some angst in the field. A couple of weeks ago (April 14, 2017, to be exact), the friendly folks at CMS issued notice of a proposed regulation change focusing on how Accrediting Organizations (AO) communicate survey results to the general public (you can find the details of the notice here).

At present, the various AOs do not make survey results and subsequent corrective action plans available to the general public, but apparently the intent is for that to change. So, using the Joint Commission data from 2016 as test data, it seems that a lot of folks are going to be highlighted in a manner that is not going to paint the prettiest picture. As we covered last week, hospitals and other healthcare organizations are not CMS’ customers, so their interest is pretty much solely in making sure that their customers are able to obtain information that may be helpful in making healthcare decisions. Returning to the Joint Commission data from last year, pretty much at least 50% of the hospitals surveyed will be “portrayed” as having issues in the environment (I’m standing by my prediction that those numbers are going to increase before they decrease—a prediction about which I will be more than happy to be incorrect). Now, the stated goal of this whole magillah is to improve the quality and safety of services provided to patients (can’t argue with that as a general concept), but I’m not entirely certain how memorializing a missed fire extinguisher check at an outpatient clinic or a missed weekly eyewash station check is going to help patients figure out where they want to obtain healthcare. So, I guess the question becomes one of how the folks we hire to assist with accreditation services (the folks for whom we are the customers) are going to share this information in the name of transparency? (Though I suppose if you were really diligent, it might be a little easier to discern trends in survey findings if you’re of a mind to dig through all the survey results.) It will be interesting to see how this plays out; I can’t imagine that they’d be able to publish survey results particularly quickly (I would think they would have to wait until the corrective action plan/evidence of standards compliance process worked itself through).

As with so many things related to the survey process, I understand what they are trying to do (begging the question: Is transparency always helpful?), but I’m not quite catching how this is going to help the process. I absolutely believe that the CMS and the AOs (could be a band name!) have a duty and an obligation to step in when patients are being placed at risk, as the result of care, environment, abuse, whatever. But does that extend to the “potential” of a process gap that “could” result in something bad happening—even in the presence of evidence that the risk is being appropriately managed? There always have been, and always will be, imperfections in any organization—and interpretations of what those imperfections may or may not represent. Does this process make us better or more fearful?