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If you set things up correctly…they will still find stuff!

Those of you who are frequent readers of this little space are probably getting tired of me harping on this subject. And while I will admit that I find the whole thing a tad disconcerting, I guess this gives me something to write about (the toughest thing about doing the blog is coming up with stuff I think you folks would find of interest). And so, there is an extraordinary likelihood that you will have multiple EC/LS findings during your next triennial Joint Commission visit—and I’m not entirely convinced that there’s a whole lot you can do to prevent that from happening (you are not powerless in the process, but more in that in a moment).

Look at this way: Do you really think that you can have a regulatory surveyor run through your place for two or three days and at the end “admit” that they couldn’t find any deficiencies? I’ve worked in healthcare long enough to remember when a “no finding” survey was possible, but the odds are definitely stacked against the healthcare professionals when it comes to this “game.” And what amazes me even more than that is when folks are surprised when it happens! Think about, CMS has been taking free kicks on TJC’s noggin for almost 10 years at this point—because they weren’t finding enough issues during the triennial survey process. BTW, I’m not saying that there’s a quota system in place; although there are certainly instances in which surveyors over-interpret standards and performance elements, I can honestly say that I don’t find too many findings that were not (more or less) legitimate. But we’re really and truly not talking about big-ticket scary, immediate jeopardy kind of conditions. We are definitely talking mostly about the minutiae of the safety world—the imperfections, if you will—the slings and arrows of outrageous fortune that one must endure when one allows humans to enter one’s hallowed halls. People mess stuff up. They usually don’t mean to (though there are some mistakes, and I think you can probably think of some examples in your own halls), but as one is wont to say, feces occurs. And there’s a whole segment of each healthcare organization charged with cleaning up that feces—wherever and however it occurs.

So what it all comes down to is this: you have to know what’s going on in your building and you have to know where you stand as a function of compliance, with the subset of that being that you have to have a robust process for identifying conditions soon enough and far enough “upstream” to be able to manage them appropriately. We’ve discussed the finder/fixer dynamic in the past (here’s a refresher), so I won’t belabor that point, but we need to use that process to generate compliance data. Strictly speaking, you really, really, really need to acquaint yourselves with the “C” Elements of Performance; compliance is determined as a rate and if you can demonstrate that your historical compliance rate is 90% or better, then you are in compliance with that standard/EP. But if you’re not using the surveillance process, the finder/fixer process, the tracer process, the work order process, the above the ceiling permitting process, ad nauseum, to generate data that can be used to determine compliance, then you are potentially looking at a very long survey process. Again, it goes back to my opening salvo; they are going to find “stuff” and if you are paying good attention to what goes on in your organization, then they shouldn’t be able to find anything that you don’t already know about.

The management of the physical environment is, at its heart, a performance improvement undertaking. As a support process for hardwiring ongoing sustained improvement, a process for the proactive risk assessment of conditions in the physical environment is essential. As an example, the next assessment would use the slate of findings from your most recent surveillance rounds to extrapolate the identification of additional risks in the physical environment. For all intents and purposes, it is impossible to provide a physical environment that is completely risk free, so the key focus becomes one of identification of risks, prioritizing the resolution of those risks that can be resolved (immediate and long-term), and to develop strategies for managing those risks that are going to require resource planning and allocation over an extended period of time. The goal of the process is to ensure that the organization can articulate the appropriate management of these risks and to be able to provide data (occurrence reporting, etc.) to support the determination of that level of safety. By establishing a feedback loop for the management of risk, it allows the organization to fully integrate past actions into the improvement continuum. If you think of the improvement continuum as a football field (it is, after all, the season for such metaphors) or indeed any game “environment,” you need to know where you are in order to figure out where you need to go/be. The scrutiny of the physical environment has never been greater and there’s no reason to think that that is going to change any time soon. Your “power” is in preparing for the survey by being prepared to make full use of the post-survey clarification process—yup, they found a couple of doors that didn’t close and latch, a fire extinguisher that missed a monthly inspection or two, and on and on. Anticipate what they’ll find based on what you see every time you “look” (again, it’s nothing “new” to you—or shouldn’t be) and start figuring out where you are on the grid. That way, they can find what they want (which they will; no point in fighting it anymore) and you can say, thanks for pointing that out, but I know that my compliance rate for doors/fire extinguishers/etc. is 90%, 91%, 92%, etc. We want them to work very hard to find stuff, but find stuff they will (that’s a little Yoda-esque). We just have to know what do “aftah.”

And then came the last days of May…

This year has brought a lot of CMS work this year, both in preparation for impending visits and in response to endured visits. There’s just nothing particularly pleasant about the process, but I guess there’s naught that can be done for it.

One of the interesting, and extra not-pleasant developments in this realm is the use of the Plan for Improvement (PFI) process during CMS surveys to bludgeon facilities professionals into pretty much abandoning any pretense of being able to plan/prioritize the resolution of existing Life Safety Code® (LSC) deficiencies. As I think we’ve discussed, one of the changes in the Joint Commission final report is that (if your surveyor remembers to accept them) it includes a listing of all your PFIs, which gives the CMS LSC surveyors a ready-made starting point for their report (CMS has really never bought in to the whole PFI process for managing LSC deficiencies, which is very unfortunate). Recently, I worked with a client who had to complete all their damper repairs that were being managed through the PFI process and I started thinking about a number of folks who are managing their inaccessible dampers, etc., through the PFI process and then I start thinking, “Wouldn’t that suck a ton of eggs if the PFI report becomes a roadmap for CMS to have their way with folks?”

I guess this is all part of having to deal with the various authorities having jurisdiction (AHJ) and while I suppose not every AHJ is going to be prickly about this stuff, I am reasonably certain that there are those would who be more than happy to give folks a good regulatory thumping. We are in a time of great uncertainty and chaos as we are held to standards that are increasingly best noted as antiquities. But until we can get can somehow suborn a more rapid cycle of code/standard adoption, I guess we’re just going to have to spend far too much time and energy on things other than taking care of our patients.

Opinions are like…

Over time, I’ve developed certain thoughts relative to the management of the survey process, one of which relates to the ever-changing (maybe evolution, maybe mutation) regulatory survey process and I think it boils down to a couple of basic expectations (at least on my part):

  • You always run the risk of having a surveyor disagree with any (and every) decision you’ve ever made relative to the operational management of risk, particularly as a function of standards-based compliance
  • Your (or indeed any) Authority Having Jurisdiction always reserves the right to disagree with anything they, or anyone else, has ever told you was “okay” to put into place (and this includes plan review for new or renovated spaces)

Recent survey experiences are littered with the remains of practices and conditions that were never cited in the past, but in the latest go-round have become representative of a substandard approach to managing whatever risk might be in question. For example, just consider how the survey of the surgical environment has changed (and changed very rapidly, if you ask me) from what was typically a fairly non-impactful experience (there were any number of instances in which the Life Safety surveyor didn’t even dress out to go into the OR proper) to the area generating the top three most frequently cited standards during TJC surveys in 2014. That, my friends, is a whole lot of schwing in the survey process.

The bottom line message is, more or less, based on the adage “Future expectations are not necessarily indicative of past experiences.” You have to look at everything you are doing as a function of how your practices/conditions actually comply with the standards. Just as there are many ways to skin the proverbial catfish (skinning a catfish makes more sense to me in this modern era than skinning a feline), there are many ways to comply with what are typically rather open-ended compliance standards. As long as you can “trace” the practice or condition back to compliance with the standards/performance elements, then, even if you have a surveyor who disagrees with your approach to things, you can feel comfortable that you can “go to the mat” post-survey, using the clarification process to demonstrate how your organization achieves compliance relative to the finding. As a somewhat related aside, it is important to remember that you are only required to respond to what is actually written in the finding. Very often I run into folks who want to respond to more than what is actually in the report, usually because they remember what the surveyor “said” during the survey. Surveyors, like everyone, have opinions about how and what and where, etc., and they certainly have every right to hold those opinions (sometimes in higher regard than is warranted, but I digress). Opinions are rarely based on an absolute standards-based requirement. So, the tip-off comes in different forms: Maybe they say you “should” do something in a certain way or something similarly non-definitive. They typically stay away from things that you “must” or “have to” do. You “have to” comply with the standards and you “have to” comply with your organization’s policies and procedures, but beyond those points, you have to chart your course of compliance. You know best what will work to effectively ensure that you have an appropriately managed care environment (and, presumably, the performance data to back up that knowledge).

Hair Plugs? Heck, No! Shameless Plugs? That’s another story!

While I would never want to be accused of overusing my little bully pulpit, I did want to bend your ears a bit by way of encouraging you to really consider signing on for next week’s webinar, Surgical Environment Compliance: Meet CMS and Joint Commission Requirements. The program is on Friday, May 8 @ 1 p.m. EDT (you can register here). Plus (and this may really sweeten the pot), I’m not the only speaker, so you won’t have to listen to me yap for the whole program. Sounds like a win to me…

To catch up a bit, I haven’t yet given you a rundown on the most frequently standards during TJC surveys in 2014 as there were some other pretty compelling topics (at least in my mind)—mostly because the year-end tally looked so very much like the mid-term results I figured the sense of urgency might not be quite as acute as it could be. But an interesting thing is happening in 2015 and it keys very much on the top three most-cited standards: EC.02.06.01, EC.02.05.01, and IC.02.02.01, all of which figure in the management of environmental conditions in (you guessed it!) in surgery (and other procedural areas). By the way, as a quick aside, who would ever have guessed that the EC-related standard to go to #1 on the charts wouldn’t have been Integrity of Egress (LS.02.01.20), which sits at a lowly #4. It’s almost like a boy band past its sell-by date, but I digress.

TJC is still looking at the issues related to the surgical/procedural environment and, doggone it, they’re still finding stuff that’s getting folks into trouble (that is, if you think, as I do, that having to endure a second visit from the Joint is rather more troublesome than not). I won’t tell you that I have a magic bullet for this, but my colleague Jorge Sosa and I will be discussing how this issue fits into the grand scheme of things as well as hopefully helping identify the potential pitfalls. And, perhaps most useful of all, you’ll have the opportunity to ask questions that may be the difference between sailing through your next survey or getting hung up because one portal in your OR isn’t pressurized in the right direction (and believe me, it happens way more than you probably think). Lots of stuff to consider and the time and place to consider it.

Be there or be somewhere else that won’t be nearly as entertaining (unless you’re not at work…)

Join me on May 8 for the live webcast Surgical Environment Compliance!

My colleague Jorge Sosa and I wanted to take a moment of your time to remind you of our upcoming live webcast Surgical Environment Compliance: Meet CMS and Joint Commission Requirements to be held on Friday May 8 at 1 p.m. EDT. What a way to start the weekend! The 90-minute program will include a presentation of approximately 60 minutes with a 30-minute Q & A session to cover any questions you might have about the program content, or indeed anything else that strikes your fancy.

I really think you’ll find this program of great interest. The Joint Commission just unveiled the most frequently cited standards during 2014 surveys and the top three are all in the mix when it comes to managing conditions in the surgical environment (and beyond…we’ll cover that as well). We’ll be covering steps you can implement to avoid survey findings, as well as strategies for managing the process if you find yourself with some survey deficiencies.

At any rate, I’d like to invite you to join Jorge and me for a discussion of what is probably the most “dangerous” topic in the Environment of Care in maybe ever (this makes the management of Interim Life Safety Measures look like a walk in the park)!

Hope to “see” you on May 8. You can register for the program here.

An interesting security development: To arm or not to arm?

In a February 18 Joint Commission leadership blog post, Mark Crafton, TJC’s executive director of communications and external relations, focuses on the benefits of investigating different approaches for mitigating violence in hospitals. At least that’s where the conversation starts, but it ends up in kind of an interesting (and to my eyes, unexpected) direction: the question of whether hospital security officers are a more effective deterrent/mitigation strategy when they are armed. (N.B.: In Crafton’s post, he refers to security “guards”; call me whatever you like, but I think the term “guard” just doesn’t ring well with me. I’m okay with the terms “security staff” or “security officers,” but “guards” just gives me the vapors—metaphorically speaking, of course.)

In the course of the posting, Crafton points to an article in the Chattanooga Time Free Press that will likely generate some debate among healthcare security professionals, and I tend to agree with that thought. Apparently the article was the result of a healthcare system’s decision to disarm their security staff and adopt the “soft” uniform look (e.g., blazers, etc.) to more effectively emphasize the security officer’s role as a more customer-oriented (my description) countenance. Now we’ve touched on the subject of arming security officers in the past (it’s been a really long time) and it’s probably way past the time for looking at this topic, particularly as the good folks at CMS have some rather strong thoughts on the subject:

CMS does not consider the use of weapons in the application of restraint or seclusion as a safe, appropriate health care intervention. For the purposes of this regulation, the term  “weapon” includes, but is not limited to, pepper spray, mace, nightsticks, tazers, cattle prods, stun guns, and pistols. Security staff may carry weapons as allowed by hospital policy, and State and Federal law. However, the use of weapons by security staff is considered a law enforcement action, not a health care intervention. CMS does not support the use of weapons by any hospital staff as a means of subduing a patient in order to place that patient in restraint or seclusion. If a weapon is used by security or law enforcement personnel on a person in a hospital (patient, staff, or visitor) to protect people or hospital property from harm, we would expect the situation to be handled as a criminal activity and the perpetrator be placed in the custody of local law enforcement.

The use of handcuffs, manacles, shackles, other chain-type restraint devices, or other restrictive devices applied by non-hospital employed or contracted law enforcement officials for custody, detention, and public safety reasons are not governed by this rule. The use of such devices are considered law enforcement restraint devices and would not be considered safe, appropriate health care restraint interventions for use by hospital staff to restrain patients. The law enforcement officers who maintain custody and direct supervision of their prisoner (the hospital’s patient) are responsible for the use, application, and monitoring of these restrictive devices in accordance with Federal and State law. However, the hospital is still responsible for an appropriate patient assessment and the provision of safe, appropriate care to its patient (the law enforcement officer’s prisoner).

As you can well imagine, equipping security staff with weapons of almost any stripe can result in the classic slippery slope. My personal practice was to have a clear delineation between security staff and law enforcement responders. Security staff were provided ongoing crisis management education and worked closely with clinical staff to proactively manage at-risk situations. Law enforcement response was summoned when appropriate and the use of weapons was solely at the discretion of those responders. I know those lines can get pretty blurry in the heat of the moment, but specific roles are, I think, the best starting point for an effective security program.

At any rate, Crafton goes on to discuss the following: the cases for armed/not armed security staff; armed staff as authority figures vs. armed staff as a potential for raised anxiety of patients who are already distressed/stressed; and how do you make patients and staff safe, etc. There are, of course, good arguments on both sides, but ultimately (and this is one of the common threads when it comes to TJC standards and expectations), it is the responsibility of each organization to determine how best to manage, in this case, security risks. It doesn’t seem likely that peace, love, and understanding are going to be breaking out any time soon; the role of the security officer has never been more important.

I guess it really doesn’t matter where you set your humidity…

Because someone else will come along and move it—and it’s always been the same…

Returning to the Adding Insult to Injury desk here at the Safety Space plaza (with apologies to the Magliozzi clan), last week we learned of a delightful new development in the ongoing saga of the management of environmental conditions in surgery. You can find the opening salvo in this little skirmish here. To recap, back in January, AHA/ASHE/AHRMM issued a Joint Quality Advisory indicating that there may be supplies and equipment that are not/were not manufactured to tolerate the lower humidity levels (down to 20% relative humidity) that could be in place based on the Categorical Waiver issued back in 2013 (details here). In the Quality Advisory, there was a recommendation for a risk assessment, etc., to ensure that any risks associated with equipment/supplies and the lower humidity levels are being appropriately managed.

But apparently, that was not enough tumult to introduce into the mix (it almost makes me long for those halcyon first days of the relocatable power tap dictum). To wit, CMS (in its way beyond infinite wisdom) has weighed in on the topic of supplies and equipment that may not tolerate the lower temperature and humidity levels allowed by the categorical waiver. The sum and substance of the CMS position echoes the risk assessment process outlined by AHA/ASHE/AHRMM, but does it one step further by indicating that until the assessment has been completed and you know all your “stuff” can appropriately tolerate the lower humidity levels, you have to go back to the pre-waiver humidity levels. By the way, that could mean either the 30% low point indicated by ASHRAE or the 35% low point indicated by NFPA 99-1999. You can find links to the memorandum issued by CMS here.  By the way, this memorandum is also notable for the appearance of a kicky new term—IFU (instructions for use)—to add to the pantheon of acronymic stardom. Welcome IFU!

Now, I think we can all agree that looking at all the supplies and equipment being stored in these sensitive areas is going to be a fairly labor-intensive pursuit (Can you say pain in the gluteus maximus? I knew you could!) and it makes me wonder if there’s a way to push back at our vendors to help in at least reducing the number and type of materials we would need to evaluate. The Joint Quality Advisory makes note of some examples of materials that could be in the mix—EKG electrodes are noted—but I can’t help but hope that someone, somewhere is starting to parse this into a more manageable pursuit. I fully recognize that this is probably something of which everyone should already be aware; the CMS memo is rather pointed in mentioning just that: “The CMS expects hospitals, CAHs, and ASCs to follow the current IFUs for supplies and equipment used in their ORs. Failure to adhere to the IFUs must be cited, even if the facility has opted to use the categorical waiver of the [Life Safety Code] RH requirements.”

Sometimes doing the right thing ain’t so easy…

(P.S. If you’re interested in learning more about this topic, Jorge Sosa and I will host a webcast, “Surgical Environment Compliance: Meet Joint Commission and CMS Requirements,” on Friday, May 8 at 1 p.m. Eastern. Find out more and register online here.)

 

And to further complicate matters… (aka: Adding insult to injury)

On January 21, 2015, the American Society of Healthcare Engineering (ASHE), in coordination with the American Hospital Association (AHA) and the Association for Healthcare Resource & Materials Management (ASHRMM), issued a Joint Quality Advisory, offering new guidance on humidity levels in the OR. The short version is that the CMS waiver allowing hospitals to maintain humidity levels in operating rooms at a level down to 20% relative humidity (RH) is presenting some conflicts relative to the care and feeding of certain sterile supplies and surgical equipment that were designed to be in surgical environments with a humidity level of no less than 30% RH. Can I get an “Oh yeah!”?

One of the conversations I’ve bene having with greater frequency with clients relates to the storage of sterile supplies as a function of ASHRAE 170 Standard for Ventilation of Health Care Facilities, which has very clear design specifications for sterile storage (must have positive pressure, a minimum of two outdoor air exchanges, a minimum of four total air exchanges, a maximum of 60% RH (no identified minimum) and a temperature between 72 and 78 degrees F). The conversations generally grow out of thinking about all the areas in a hospital where sterile supplies can be found and whether all of those locations constitute “sterile storage” and thus would have to adhere to the design specifications listed in ASHRAE 170.

The upshot of those conversations is typically the need for a risk assessment of what supplies are being stored where (so to speak) and determining what locations and products need to be considered in the mix for “protection” in accordance with the ASHRAE standard. For all intents and purposes, the ASHE Joint Quality Advisory is recommending the same type of process (with the “net” being cast a little further afield to include equipment stored in these locations).

As we have learned over the past little while (and reinforced through TJC surveys pretty much everywhere), there is a concerted effort on the part of regulators to scrutinize the management of special environments with an ever-broadening list of locations to be included in those ranks. I believe that I have recommended using the table in ASHRAE 170 as a starting point for conducting a risk assessment of all the potentially applicable locations in each organization, so I’m just going to put it back out there—if you haven’t looked closely at how you are maintaining compliance with this stuff, I can only encourage you to do so. But please know that any lack of preparedness on this count can lead only to survey peril.

Be prepared!

Now that Superstorm Sandy has taken on the rosy hue of nostalgia…you mean it hasn’t?!?

By now I’m sure you’ve seen information regarding the CMS report that weighs in on hospital response during Superstorm Sandy and the challenges faced by hospitals during that October 2012 event.

Now, some of the media reports covering this particular issuance from CMS have painted kind of a bleak picture, but I don’t know if that is strictly the case. Certainly, there were, and likely will continue to be, challenges relating to response to any emergencies, but in looking at the data contained in the report, I ultimately can’t help but think the response efforts on the part of the hospitals in the New York metropolitan area and adjacent areas were pretty darn good.

Again, some of the coverage seems to highlight the 89% of hospitals that “reported experiencing critical challenges during Sandy, such as breakdowns in infrastructure and community collaboration” and equate “experiencing critical challenges” with “not being prepared.” Now I will freely admit that I have not exercised operational responsibilities in a hospital for about 13 or so years, but my recollection about such things is that one of the things that makes emergencies, like, emergencies, is that you experience critical challenges that could include breakdowns in infrastructure, etc. For me, the most important nuggets that are presented in the report are that:

  • Only 7% of the hospitals involved had to fully or partially evacuate (and yes, I do indeed recognize that evacuation is an entirely acceptable and appropriate response if the conditions dictate)
  • Only one hospital indicated that its emergency plan was not useful
  • No patient perished as the result of a hospital’s inability to appropriately respond to the disaster

Of course, there were a number of instances of flooding out of infrastructure components and some challenges relating to the whole idea of clinical folks not being able to use powered equipment to deliver IV fluids, etc., (I think it’s probably a good idea to look at those pesky clinical interventions in the case of utility systems or medical equipment failures; something tells me that this might become a wee bit more of a focus during your next TJC visit), but I will direct you back to #3. To me, this means that there was definitely some rough sledding as Sandy came and went, but the folks on the ground were able to keep things together, which is a pretty good measure of preparedness. If nothing happens, how do you know for sure you really were prepared?

Again, if you haven’t had a chance to read through the report, it’s a pretty interesting read (even for the Feds) and I think that some of the stories regarding somewhat rocky interactions with the community might sound at least a little familiar to folks. As with any emergency, there are lessons to be learned and there is much in this report to think on for just about everyone involved with hospital emergency management.

But perhaps the most instructive thing of all is the “tenor” of the conclusion and recommendations section, which doesn’t really point any fingers at the hospitals involved in responding to Sandy. Sure, there are some rather generic references to findings during previous Joint Commission surveys that could have had an impact on response capabilities, but to me it appears nothing more than a classic case of post hoc ergo propter hoc (for those of you not “down” with Latin, that translates roughly as “after this, therefore because of this”). They really don’t seem to be able to tie any survey findings to what happened, but I guess they have to tie the survey process in somehow—such is life.

A curiosity from the (left) coast

This is another plucked from the oblivion of the mailbag…

Back towards the end of September, I received an email from an acquaintance out in California who had attended The Joint Commission’s Executive Briefings conference, which included a session on CMS compliance, presented (or so it would seem) jointly by TJC and Joint Commission Resources. In their never-ending pursuit of encouraging customer participation, the audience (or learners as they are identified on the slide sheet) got to submit some questions to the faculty (who shall remain nameless … primarily because I don’t have that information), for which responses were prepared and shared with the group (there were 6 questions asked, based on the document I’ve seen).

At any rate, there are two questions asked for which the responses were somewhat illuminating, albeit in a rather frightening way:

Q. Does temperature and humidity need to be done/recorded daily in procedural areas even if they are closed (i.e., operating room closed on a Sunday or holiday)?

A. Indoor air quality testing that includes directional air flow, humidity, and temperatures should be done daily when in use, however, it is only recommended monthly when the rooms are not in use. So if the rooms are closed they need not be tested unless they are closed for more than one month, but tested when they are put back in use.

The question I have for the studio audience is this (and it’s not like we’ve had this conversation before in various permutations): Where in the regulations does it require daily performance of “indoor air quality testing that includes (which by extension can be interpreted as “not limited to”) directional air flow, humidity and temperatures”? Now it may very well be that this is an extension of the whole magillah regarding the maintenance and testing of critical utility systems components in accordance with manufacturer recommendations (and I don’t have nearly enough knowledge of the OEM guidance on the various and sundry HVAC systems there are out in TV land to be able to speak to that piece of it). Maybe this is destined to show up on TJC’s FAQ page (I see we’re getting a little acronym-heavy here, so I will try to refrain from further acronymization), but this one seems a little beyond the pale. My advice for the moment is that you really ought to look at this as a risk assessment and make the determination of frequencies, etc. for this kind of stuff. Which brings me to the other question of note, but let’s leave that for next time…