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Can we count painful survey findings and new requirements as blessings?

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:

Who:

Leadership Involvement:

What:

When:

How:

Preventive Analysis:

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!

Pauline’s Preposterously Perilous Permutations

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!

A toast(er) to all that have gone…

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:

  1. 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)
  2. 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.
  3. 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.
  4. 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.
  5. 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.
  6. 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.

Ah, the fresh (de)scent of hell…

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!

Oh, what fresh hell is this?

Much as 2016 has laid waste to the pantheon of pop culture, so has it decimated the status quo in the realm of facilities and safety management. While this year has brought “pleasures” expected (adoption of the 2012 edition of the Life Safety Code®) and unexpected (the demise of the Plan for Improvement process), it appears that the wheels (gears?) that drive this regulatory machine are not yet done churning out new stuff for us to ponder.

As you’ve probably heard by now, last week CMS finally dropped the mike on the federal requirements relating to emergency management and the healthcare world. (Press release can be found here; link to the final rule–the hospital requirements start on p. 584 of this oh so fabulous 651-page document. Monsieur Needle, please meet Monsieur Haystack…zut alors!)

Let’s do a quick run-through of the four primary components:

  • You have to have an emergency preparedness plan that must be reviewed and updated at least annually.
    • The plan must be based on, and include, a documented facility-based and community-based risk assessment, utilizing an all-hazards approach.
    • The plan must include strategies for addressing emergency events identified by the risk assessment, utilizing an all-hazards approach.
    • The plan must address patient population, including, but not limited to, persons at-risk; the type of services the hospital has ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.
    • The plan must include a process for cooperation with the various AHJs’ efforts to maintain an integrated response during a disaster or emergency situation, including documentation of the hospital’s efforts to contact such officials, and when applicable, its participation in collaborative and cooperative planning efforts.
  • Develop emergency preparedness policies and procedures that must be reviewed and updated at least annually. The policies and procedures must address the following:
    • The provision of subsistence needs for staff and patients, whether they evacuate or shelter in place, include, but are not limited to the following:
      • Food, water, medical, and pharmaceutical supplies.
      • Alternate sources of energy to maintain the following:
        • Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions.
        • Emergency lighting.
        • Fire detection, extinguishing, and alarm systems.
        • Sewage and waste disposal.
        • A system to track the location of on-duty staff and sheltered patients in the hospital’s care during an emergency. If on-duty staff and sheltered patients are relocated during the emergency, the hospital must document the specific name and location of the receiving facility or other location.
        • Safe evacuation from the hospital, which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s); and primary and alternate means of communication with external sources of assistance.
        • A means to shelter in place for patients, staff, and volunteers who remain in the facility.
        • A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains the availability of records.
        • The use of volunteers in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated healthcare professionals to address surge needs during an emergency.
        • The development of arrangements with other hospitals and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to hospital patients.
        • The role of the hospital under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials.
      • Develop and maintain an emergency preparedness communication plan that must be reviewed and updated at least annually, which includes names and contact information for the following:
        • Staff
        • Entities providing services under arrangement
        • Patients’ physicians
        • Other hospitals and CAHs
        • Volunteers
      • The communications plan must also include contact information for the following:
        • Federal, state, tribal, regional, and local emergency preparedness staff
        • Other sources of assistance
      • The communications plan must identify primary and alternate means for communicating with the following:
        • Hospital’s staff
        • Federal, state, tribal, regional, and local emergency management agencies
      • The communications plan must provide a method for sharing information and medical documentation for patients under the hospital’s care, as necessary, with other healthcare providers to maintain the continuity of care.
      • The communications plan must provide a means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii).
      • The communications plan must provide a means of providing information about the general condition and location of patients under the facility’s care as permitted under 45 CFR 164.510(b)(4).
      • The communications plan must provide a means of providing information about the hospital’s occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee.
    • Develop and maintain an emergency preparedness training and testing program that is reviewed and updated at least annually.
      • The training program must provide for:
        • Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role
        • Emergency preparedness training at least annually
        • Maintenance of documentation of the training
        • Demonstration of staff knowledge of emergency procedures
      • The testing program must provide for:
        • Participation in a full-scale exercise that is community-based or when a community-based exercise is not accessible, an individual, facility-based. If the hospital experiences an actual natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in a community-based or individual, facility-based full-scale exercise for one year following the onset of the actual event.
      • Conduction of an additional exercise that may include, but is not limited to the following:
        • A second full-scale exercise that is community-based or individual, facility-based
        • A tabletop exercise that includes a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan
      • Analysis of the hospital’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the hospital’s emergency plan, as needed.

To be honest, at first blush, I don’t see anything of particularly dire consequence (feel free to disagree; I’m always up for some civil—or uncivil—discourse) unless you’ve done a less-than-complete job of documenting your communications with the various and sundry AHJs (“The plan must include a process for cooperation with the various AHJs’ efforts to maintain an integrated response during a disaster or emergency situation, including documentation of the hospital’s efforts to contact such officials, and when applicable, its participation in collaborative and cooperative planning efforts.”). In fact, it will be interesting to see if TJC backs off of their caveat that tabletops don’t count towards the annual exercise requirement though, as you can see, the tabletop must include some very specific elements.

There is some additional language relating to provisions for stand-by and emergency power that includes providing for generator locations when you build new or renovate (who wants an emergency generator that could end up under water?); maintaining fuel sources during an emergency; testing components in accordance with requirements, etc., but, again, I’m not seeing a lot of indigestion-inciting language. I suppose it is possible that, at the end of all this (I mean, what’s left to tweak), there will be enough certainty in the regulatory fabric to promote a consistent application of the standards, etc. during surveys. Wouldn’t that be nice…

And to the surprise of absolutely no one…

Last week, the good folks at The Joint Commission announced the list of the five most challenging standards for hospitals surveyed during the first six months of 2016 (for those of you remaining reluctant to subscribe to the email updates, you can find the details for all accreditation programs here. For the purpose of this discussion, the focus will be on the hospital accreditation program—but if you want to talk detail specific to your organization—and you are not a hospital, just drop a line).

While there has been some jockeying for position (the once insurmountable Integrity of Egress is starting to fade a wee bit—kind of like an aging heavyweight champion), I think we can place this little grouping squarely in the realm of the management of the physical environment:

 

  • 02.06.01—safe environment
  • 02.02.01—reducing the risk of infections associate with medical equipment, devices and supplies
  • 02.05.01—utility systems risks
  • 02.01.20—integrity of egress
  • 02.01.35—provision and maintenance of fire extinguishing systems

I suspect that these will be a topic of conversation at the various and sundry TJC Executive Briefings sessions to be held over the next couple of weeks or so, though it is interesting to note that about while project REFRESH (the survey process’s new makeover) has (more or less) star billing (we covered this a little bit back in May) , they are devoting the afternoon to the physical environment, both as a straight ahead session helmed by George Mills, but also as a function of the management of infection control risks, with a crossover that includes Mr. Mills. I shan’t be a fly on the wall for these sessions (sometimes it’s better to keep one’s head down in the witless protection program), but I know some folks who know some folks, so I’m sure I’ll get at least a little bit of the skinny…

I don’t think we need to discuss the details of the top five; we’ve been rassling with them for a couple of years now and PEP or no PEP (more on the Physical Environment Portal in a moment), I don’t believe that there’s much in the way or surprises lurking within these most challenging of quintuplets (if you have a pleasant or unpleasant surprise to share, please feel free to do so). And therein, I think, lies a bit of a conundrum/enigma/riddle. As near as I can tell, TJC and ASHE have devoted a fair amount of resources to populating the PEP with stuff. LS.02.01.35 has not had its day in the port-ular sunshine yet,  but it’s next on the list for publication…perhaps even this month; not sure about IC.02.02.01, though I believe that there is enough crossover into the physical environment world, that I think it might be even be the most valuable portal upon which they might chortle. And it does not appear to have had a substantial impact on how often these standards are being cited (I still long for the days of the list of the 20 most frequently cited standards—I suspect that that list is well-populated with EC/LS/IC/maybe EM findings). As I look at a lot of the content, I am not entirely certain that there’s a lot of information contained therein that was not very close to common knowledge—meaning, I don’t know that additional education is going to improve thing. Folks know what they’re not supposed to do. And with the elimination of “C” performance elements and the Plans for Improvement process, how difficult is it going to be to find a single

  • penetration
  • door that doesn’t latch
  • sprinkler head with dust or paint on it
  • fire extinguisher that is not quite mounted or inspected correctly
  • soiled utility room that is not demonstrably negative
  • day in which temperature or humidity was out of range
  • day of refrigerator temperature out of range with no documented action
  • missing crash cart check
  • infusion pump with an expired inspection sticker
  • lead apron in your offsite imaging center that dodged its annual fluoroscopy
  • missed eyewash station check
  • mis- or unlabeled spray bottle
  • open junction box

 

I think you understand what we’re looking at here.

At any rate, I look at this and I think about this (probably more than is of benefit, but what can one do…), even if you have the most robust ownership and accountability at point of care/point of service, I don’t see how it is possible to have a reasonably thorough survey (and I do recognize that there is still some fair variability in the survey “experience”) and not get tapped for a lot of this stuff. This may be the new survey reality. And while I don’t disagree that the management of the physical environment is deserving of focus during the survey process, I think it’s going to generate a lot of angst in the world of the folks charged with managing the many imperfections endemic to spaces occupied by people. I guess we can hope that at some point, the performance elements can be rewritten to push towards a systematic management of the physical environment as a performance improvement approach. The framework is certainly there, but doesn’t necessarily tie across as a function of the survey process (at least no demonstrably so). I guess the best thing for us to do is to focus very closely on the types of deficiencies/imperfections noted above and start to manage them as data, but only to the extent that the data can teach us something we don’t know. I’ve run into a lot of organizations that are rounding, rounding, rounding and collecting scads of information about stuff that is broken, needs correction, etc., but they never seem to get ahead. Often, this is a function of DRIP (Data Rich, Information Poor) at this point, I firmly believe that if we do not focus on making improvements that are aimed at preventing/mitigating these conditions (again, check out that list above—I don’t think there’s anything that should come as a surprise), the process is doomed to failure.

As I tell folks all the time, it is the easiest thing in the world to fix something (and we still need to keep the faith with that strategy), but it is the hardest thing in the world to keep it fixed. But that latter “thing” is exactly where the treasure is buried in this whole big mess. There is never going to be a time when we can round and not find anything—what we want to find is something new, something different. If we are rounding, rounding, rounding and finding the same thing time after time after time, then we are not improving anything. We’re just validating that we’re doing exactly the opposite. And that doesn’t seem like a very useful thing at all…

If accredited you wish to be, you must answer these questions three!

And other tales: If you thought the dervishes were whirling last week…you ain’t seen nothing!

Hortal hears a chortle from the portal: The much-anticipated (you tell me how hyperbolic that characterization might be…) return of updated content for the Joint Commission (oops, THE Joint Commission)’s Physical Environment Portal (PEP) has finally reached these shores. O frabjous day! Callooh! Callay! He chortled in his joy (from Jabberwocky by Lewis Carroll; see, chortling has been around for a while…).

The new content breaks down into three sections: one for facilities and safety folks, one for leadership, and one for clinical folks, lending further emphasis to the ongoing melding  of the management of the physical environment into a tripod-like structure (tripods having more stability and strength than a one- or two-legged structure—think about that one for a moment). At any rate, interestingly enough, the suggested solutions for both the clinical and leadership “legs” of the tripod are aimed at “supporting” the facilities “leg” through endorsement of the key process(es) as well as keeping smoke doors closed, not compromising closing devices (how may doors can a doorstop stop if a doorstop could stop doors?), and participation during construction activities. So, if you visit the noted URLs, you will find a whole bunch of stuff, some of it downloadable, to share with the other “legs” in your organization. It seems pretty evident to me, that at least part of the intent of the information shared, particularly the stuff earmarked for leadership and clinical folks, is to ratchet up the “investment” of those two groups in the management of the physical environment. On the face of it, nobody in healthcare has “time” to shoulder this burden on their own, hence the practical application of the tripod (sort of: that may be a bit of a reach on my part, but there’s some truth lurking around somewhere—and we will ferret it out).

Also breaking recently was the information (funneled from our fine friends at ASHE) that TJC is going to be including a set of three questions in the pre-building tour portion of the survey process (I think this is in addition to other questions that might be asked, including whether you have any identified Life Safety Code® (LSC) deficiencies). The intent, as described by Jim Kendig, TJC’s field director for surveyor management and development (I worked with Jim, like, a million years ago. Hi, Jim!), is to gather some pertinent/useful information before setting out to tour your facility.

Question 1: What type of firestopping is used in the facility?

Question 2: What is your organization’s policy regarding accessing interstitial spaces and ceiling panel removal?

Question 3: Which materials are used for high-level disinfection or sterilization?

On the face of it, I’m thinking the response to Question 1 might very well be the most challenging as I can’t recall too many facilities that have just one manufacturer’s product protecting their rated barriers. My consultative advice is you would be well-served to have some sort of document that identifies the various products in use, where they “live” in your organization, perhaps even color pictures of the products in situ so the surveyors will know what they are looking for (and please don’t try to pass off that yellow expanding foam stuff as an appropriate product—no point in getting into a urination competition with a surveyor over that). As to the other questions, as near as I can tell they’re pretty straightforward; the surveyor is going to have plan for extra time if a containment has to be erected/constructed for every ceiling tile removal or perhaps they will identify specific locations for inspections and just run through those one after the other. As to high-level disinfection and sterilization, lots of environmental and infection control opportunities for bungles there (BTW, it’s probably a very good idea to have a very good idea where those processes are occurring; it can be more widespread than you would prefer).

As a final thought for this week, I would encourage you to participate in ASHE’s survey of the potential impact of CMS’s requirement for all hospital outpatient surgery departments to be classified as Ambulatory Surgical occupancies under chapters 20 and 21 of the 2012 LSC. There is a fair amount of potential that this requirement is going to have an impact on facilities in which dental or oral surgery is being performed, plastic surgery, endoscopy, laser surgeries, etc. To help with the assessment of the impact of this change, ASHE is asking folks to complete a survey for each of the facilities you oversee that will be affected; you can find the survey here. https://app.smartsheet.com/b/form?EQBCT=c66f01e829184b648b4b0db3fd2cc552

I think it’s probably well worth your time to at least see what they’re asking about; I’m beginning to think that we are going to look back on 2016 as a really ugly year (compliance, popular culture, you name it!). Where’s that fast-forward button…or do we talk to Mr. Peabody and Sherman about that Wayback Machine…

Maybe these maps and legends have been misunderstood…

I don’t know about you folks, but The Joint Commission’s discontinuation of the PFI process has left me in a rather unsettled state. Heretofore, I think many of us (and I will include myself among that number) relied on TJC to provide some level of illumination into the inner workings of compliance as a function of what CMS is requiring. As I think I noted earlier, I was fully cognizant that CMS has been no particular fan of the PFI process as a means of ensuring compliance with the Life Safety Code®, but (presumably) there was always a tacit understanding—falling somewhat short of acceptance—that the PFI process wasn’t causing enough of a ripple in the fabric of compliance to warrant any direct intervention.

And now we find ourselves officially in August and still awaiting the arrival of the latest modular addition to The Joint Commission’s Physical Environment Portal (PEP), which was “scheduled” for a July release (at least that’s been the info posted on the portal site). At this point, I’m starting to think that the life safety modules may be on hold until the updated Life Safety chapter is unveiled later this year (presumably sometime ’twixt now and November). But the greater concern I have (and hopefully this is just a hyperbolic response to the deluge of changes) is whether the information contained in the PEP (and, to some degree, the physical environment FAQs) is as valuable (Useful? Reliable?) when it comes to keeping in line with CMS’ expectations. I think to one extent or another, we all relied on TJC as an arbiter/translator of how the physical environment Conditions of Participation could be interpreted/implemented from a practical/operational standpoint, but now I can’t help but wonder if that status has been torn asunder along with the PFI process. I’m probably over-thinking this, but I don’t have a feeling of comfort with the current state of things. I guess we shall see what we shall see—I, as always, remain optimistic, but, for whatever reason, it seems to be more of a struggle at the moment. But enough of that, for the moment…

As I was checking to see if there was an update to be found, I stumbled upon a missive in TJC’s leadership blog that I do not recall having seen before. So let me take you back about 10 months to those halcyon days of the early chortlings of the portal… (insert going back in time sound effects here).

In looking at this particular missive (penned by one G. Mills, Director, Department of Engineering—you can find the whole magillah here), there is some ground covered that is among my most favoritest of topics: the universality of the responsibilities when it comes to the management of the physical environment (and for those you who are keeping count, I have no idea how many times I’ve discussed this particular topic, but I’m going to guess it’s well into double digits. And that’s not even counting the number of times I’ve had variations of this conversation with clients…). In the blog, Mr. Mills notes that “…the patient care environment is not owned by one group in the healthcare setting.” I couldn’t agree more and yet I still (still, still, still!) encounter organizations that have not fully embraced that concept—which results in very little surprise on my part that eight of the 10 most frequently cited standards are in the physical environment. Mr. Mills goes on to say, “(W)e cannot look to one group to keep the area clean, another to keep the area warm/cool and then another group to treat patients independently.” But organizations continue to do just that, get bounced around during surveys, and still (still, still, still!) fail to grasp the team concept of managing the environment.

Now it’s certainly not every organization that has these issues, but until every organization gets “down” with this as a way of conducting the business of healthcare, the EC/LS findings will continue to pile up. The silos of clinical and non-clinical functions in healthcare organizations are no longer a tenable model—I’ve said it before and I will (no doubt) say it again—every individual working at every level in every healthcare organization is a caregiver. I’ll give you the direct/indirect split, but taking care of the patient in the bed is the role and responsibility of everyone. It is past time for a new paradigm—let’s make it happen—even without updates to the PEP!

Regardless of what happens in regards to the TJC/CMS dynamic, I think that healthcare as an industry needs to embrace this model for management of the physical environment. I know on an individual basis, everyone is wicked busy, but the success or failure of the management of the physical environment is a function of how ingrained the “see something, say something” philosophy is at point of care/point of service. You and I both know that I could say that I will speak of this no more, but you and I also know that the chances of my avoiding this topic are somewhere between slim and none…

Blame it on Cain…

We’ll see how long this particular screed goes on when we get to the end…

In my mind (okay, what’s left of it), the “marketing” of safety and the management of the physical environment is an important component of your program. I have also learned over time that it is very rare indeed when one can “force” compliance onto an organization. Rather, I think you have to coax them into seeing things your way. At this point, I think we can all agree that compliance comes in many shapes, colors, sizes, etc., with the ideal “state” of compliance representing what it is easiest (or most convenient) for staff to do. If we make compliance too difficult (both from a practical standpoint, as well as the conceptual), we tend to lose folks right out of the gate—and believe you me—we need everybody on board for the duration of the compliance ride.

For instance, I believe one of the cornerstone processes/undertakings on the compliance ride is the effectiveness of the reporting of imperfections in the physical environment (ideally, that report is generated in the same moment—or just after—the imperfection “occurs”). There are few things that frustrate me more than a wall that was absolutely pristine the day before, and is suddenly in possession of a 2- to 3-inch hole! There’s no evidence that something bored out of the wall (no debris on the floor under the hole), so the source of the hole must have been something external to the hole (imagine that!). So you go to check and see if some sort of notification had occurred and you find out, not so much. Somebody had to be there when it happened and who knows how many folks had walked by since its “creation,” but it’s almost like the hole is invisible to the naked eye or perhaps there’s some sort of temporal/spatial disruption going on—but I’m thinking probably not.

I’m reasonably certain that one can (and does) develop an eye/sense for some of the more esoteric elements of compliance (e.g., the surveyor who opens a cabinet drawer, reaches in, and pulls out the one expired item in the drawer), but do we need to educate folks to recognize holes in the wall as something that might need a wee bit of fixing? It would seem so…

At any rate, in trying to come up with some sort of catch phrase/mantra, etc., to promote safety, I came up with something that I wanted to share with the studio audience. I’d appreciate any feedback you’d be inclined to share:

WE MUST BE ABLE:

CAPABLE

RELIABLE

ACCOUNTABLE

SUSTAINABLE

I’m a great believer in the power of the silly/hokey concept when you’re trying to inspire folks; when you think of the most memorable TV ads, the ones that are funny tend to be the most memorable in terms of concept and product (the truly weird ads are definitely memorable, but more often than not I couldn’t tell you what product was being advertised). I think that as a four-part vision, the above might be pretty workable. What do you think?

As plain as the nose on your emergency response plan…

Periodically, the whole concept of adopting plain language codes for emergency response plan activities/activations percolates to the top of somebody’s to-do list (I’d much rather embrace the concept of the to-don’t list, but that’s a discussion for another day). There was a little bit of that (more by inference than anything else) in the CMS follow-up report to the hospital response to Superstorm Sandy. Jeez Louise, that seems like eons ago…

This discussion always seems to engender a lot of back and forth, mostly regarding the balancing act of providing enough information to direct an appropriate response and not providing enough information to cause a panic. I recognize both sides of the argument, but I must say that I haven’t seen a lot of data to support a wholesale change, particularly as it would require a fair amount of education (and yes, I know that just because something requires education, etc., is not enough to forego adopting a new strategy, etc.). But I will also say that, depending on your organizational palette when it comes to emergency notification, all the different codes relative to workplace violence, active shooter, emergency assistance calls, etc., may well benefit from a more succinct announcement.

Recently, the Texas Hospital Association has weighed in with a recommendation to its members to adopt plain language codes, including a sample policy, an implementation timeline, and some examples (you can find that information here). It appears that there’s a move away from the (fairly standard, though not quite universal) Code Red designation for a fire alarm activation to the plainer language (though somehow not quite as sexy) “fire alarm activation.” It does appear that medical emergencies will remain as the (again, fairly standard, not quite universal) Code Blue (I guess that one’s gotten enough play on medically-oriented TV programs to have become part of the vernacular—where are the TV shows about safety in hospitals?!?), but there are some other terms that are worth of consideration. I don’t know that there’s necessarily a groundswell of support, but sometimes Texas can be something of a bellwether, so it may be a good opportunity to look at the possibilities, particularly if you haven’t in a while.

That said, I have two (relatively moderate) concerns. One being we are still waiting on the unveiling of the CMS final rule on all things emergency management; I had thought perhaps that pursuit had become somewhat dormant, but with the adoption of the 2012 edition of NFPA 99 excluding the chapter on emergency management, I think we have to believe that something regulatory this way comes. At any rate, will CMS push for some standardized notification language, particularly as a function of a focus on interoperable communications capabilities? I think that card has been dealt, I guess we’ll have to see how it gets played.

The other concern is the overarching concept of interoperable communication capabilities; I, for one, do not recommend you go about changing anything in terms of notification until you have some talk-time with the local emergency response authorities. They may or may not feel like they have a stake in this discussion, but you want to be absolutely certain that any modifications you might be entertaining will not somehow fly in the face of established protocols, language, etc. Isolationism, particularly when it comes to emergency management, is not likely to be a winning strategy as it usually requires the cooperation of disparate resources. So don’t forget to keep the community folks in the loop—you never know when they might come in handy!