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A hospital in trouble is a temporary thing: Post-survey blues!

As you might well imagine, based on the number of findings floating around, as well as CMS’ continuing scrutiny of the various and sundry accreditation organizations (the latest report card is out and it doesn’t look too lovely—more on that next week after I’ve had a chance to digest some of the details), there are a fair number of organizations facing survey jeopardy for perhaps the first time in their history. And a lot of that jeopardy is based on findings in the physical environment (ligature risks and procedural environment management being the primary drivers), which has resulted in no little chagrin on the part of safety and facility professionals (I don’t think anyone really thinks that it would or could in their facility, but that’s not the type of philosophy that will keep the survey wolves at bay). The fact of the matter is (I know I’ve said this before, though it’s possible that I’ve not yet bent your collective ears on this point) that there are no perfect buildings, particularly in the healthcare world. They are never more perfect than the moment before you put people in them—after that, it is a constant battle.

Unlike any other time in recorded history, the current survey epoch is all about generating findings and the imperfect nature of humans and their interactions with their environment create a “perfect storm” of opportunities to grow those numbers. And when you think about it, there is always something to find, so those days of minimal to no findings were really more aberrant than it probably seemed at the time.

The other piece of this is the dreaded adverse accreditation decision: preliminary denial of this, termination of that and on, and on. The important thing to remember when those things happen is that you will be given (well, hopefully it’s you and not your organization sailing off into the sunset without you) an opportunity to identify corrective action plans for all those pesky little findings. I can’t tell you it doesn’t suck to be in the thick of an adverse accreditation decision because it truly, truly does suck, but just keep in mind that it is a process with an end point. There may be some choppy seas in the harbor, but you have the craft (both figuratively and literally) to successfully make landfall, so don’t give up the ship.

Hyperbaric oxygen makes some noise. Also: Stop, in the name of…the law? Love? Sanity?

First off, a quick word for those of you with responsibilities relating to hyperbaric oxygen chambers: NFPA 99 (2012) states, “A source of breathable gas allowing unrestricted mobility shall be available outside a Class A or Class B chamber for use by personnel in the event that the air in the vicinity of the chamber is fouled by smoke or other combustion products of fire.” Soooooo, if you have not yet ordered a smoke hood with integral filter/air supply (or similar equipment) available for staff to use in case of a fire, then I would advise you to take very quick action on this, particularly if you are anticipating a survey sooner rather than later. Just as the recent medical equipment EP changes relative to oxygen equipment for hyperbaric oxygen environments came down from the mountain on composite-stone tablets, so too must the intricacies of Chapter 14 of NFPA 99-2012 be absorbed. Nothing like more new stuff to figure out…

Next up, a few random thoughts (more or less) about education and ensuring effectiveness (which might very well be a lost cause, yet I remain stubbornly hopeful).

The item that I keep coming up against is the thought/assumption (and yes, I know all about that last one) that the folks I see driving cars in various parts of the country are in fact licensed drivers. With the extended thought that in order to procure said license, there was some level of rudimentary testing of the budding licensee’s knowledge of the rules of the road. Now I will stipulate for all time that there is probably enough focus on simple driving etiquette and likely never will be. But, but, but, I am confident that there are certain elements that are universally covered in driver education and competency evaluation. So, I ask you this simple question: What is octagonal in shape, red in color, and provides what used to be a very specific command? (Hint: It’s a four letter word that, when reversed, describes cookware or perhaps earthenware.)

If you don’t know, it would seem that you are not alone…

It appears to me from my simple (but fairly voluminous at this point) observations that adherence to the octagonal has morphed into a corollary of the traffic signal (green means “go”; yellow means “speed up”; red means “it’s for the person behind me”). It’s gotten to the point where I’ve been honked at for actually coming to a full stop at these points and, to be honest, I’m not really sure how it all came to be widespread. I know it’s not because folks weren’t taught the expectation when encountering a stop sign (though I’m pretty sure that “yield” isn’t covered), but it does lead me to the question of how effectively do we “do” education?

Dragging this out into the hospital realm, I’m sure you’ve all come up against those survey encounters in which you cringe because you can’t be certain that the proper (never mind correct!) response is hard-wired into staff (particularly entry-level). Every day you see people doing things they have been instructed time and time again not to do (parking equipment, etc., in front of fire extinguishers, pull stations—you know the drill). And with alarmingly increasing frequency, you see people acting in a freakishly unsafe manner (e.g., cell phone use while driving); it can’t be that they don’t know and it can’t be that they are not at least somewhat familiar with the consequences. As a boss once told me: “You can’t mandate intelligence” (Ron White made a gazillion dollars converting that to something a little more folksy), but if that’s the case, how big a “stick” do you need to carry? Does a stick even work effectively anymore?

One of the key elements of post-survey corrective action plans is an increasing focus on how we plan to keep whatever it was from happening again. And I look at a majority of the findings and I’m thinking how far does one have to go to resolve each and every little thing for all time? I believe we should always be working towards perfection, but I am not so crazy as to think we’re going to get there anytime soon…

The physics of compliance: If you have no friction, you likely have no traction

Or those wheels are going to be slipping all over the place…

This week’s offering is a little bit towards the random musings category, so hang on tight!

Friction vs. traction: I think that just about everyone in the safety community has experienced some level of pushback when they’ve tried to enact some change of process/expectation/behaviors to enhance the safety of their organization. And in so doing, you’ve discovered that the healthcare culture really does embrace change—it grabs change by the throat, throws it on the ground, and kicks it until it stops moving. This usually comes down to the classic “I’ve worked here for umpty-ump years and it’s never been a problem before,” etc., and while it doesn’t always seem so helpful in the moment, it does give you something in the way of useful feedback—they’ve actually noticed what you’re trying to do. For example, I can recall a time when the thought of physicians actually wearing ID badges seemed like a fantasy. And yet, as we speak, it is actually happening in a whole bunch of places (maybe not as much as we would like, but you’ve got to start somewhere). Now admittedly, a lot of the move towards the use of ID badges comes down to the proliferation of access control technology, the end result is that compliance became more convenient (in the ongoing battle between convenience and compliance, all too often convenience kicks compliance’s tailbone).

I would ask you to think about those stubborn deficiencies/behaviors that are perennially on your “needs attention” list and look at whether compliance is sufficiently convenient or has the operationalization of a compliance activity, say, the segregation of full and not full compressed gas cylinders, resulted in a process so complicated that it does not encourage compliance. In this case, I would say that more than 50% of the instances in which I find partially full or empty cylinders in the rack designated for full cylinders is because the racks for the “not full” cylinders were jammed with empties or partials and the only place left to safely store (remember, we’ve been nagging folks for about a decade on the proper storage of cylinders) the partial or empty cylinder is in the full rack. Perhaps the question that needs to be asked is whether there is enough space for the partial/empty cylinders; you can usually control the number of full cylinders being provided, but the number of partial/empties can ebb and flow over the course of a shift, a day, even over a week. I know it’s tough to get folks to own up to having put a cylinder in the wrong place (or damaged a wall, but that’s for another day), but I am fascinated by the action that results in someone doing something that they know they are not supposed to do. By the way, this is based on my firm belief that we’ve done enough education on this subject—and I would like to believe that the education that we’ve provided is sufficiently effective to at least get the message across. In looking at the misfiled cylinder as a failure mode—what happened in the process to result in the cylinder being in the wrong place. I can’t imagine that it’s being done purposely (it happens way too often—if it’s purposeful, we might just as well give up), but there has to be something we can discern from these instances/practices that we can use to encourage compliance—make it more convenient, as it were. So, don’t be afraid of a little friction as you pull these stubborn compliance issues apart. If things go too smoothly, there’s probably a workaround lurking somewhere in the background. Remember, it’s taking the path of “least resistance,” not “no resistance.”

The other random musing for the week is for those of you that may be in the middle of your post-survey process; be very judicious when you are creating your corrective actions plans. All too often, I see folks that have way overcommitted on their corrective action plans. Look very carefully at what the standard or performance element is actually requiring you to do and try to pick the route to compliance that work best operationally (meaning choose strategies that encourage compliance without overwhelming the participants—this is an analogue of the eternal question of how to eat an elephant). Don’t commit to daily activities if you can get where you need to be by doing it weekly; don’t commit to weekly if you can get where you need to be by doing it every other week; and so on. Also, I would advise trying to stay away from activities that don’t make sense—operationally, logically, etc. I tend to say that logic doesn’t always prevail, but I reserve that for direct dealings with regulatory surveyors. Once the surveyors are on their way, take the compliance results as data to make improvements—and focus on determining how you’ll measure those improvements. It puts you in a much better position to avoid those findings in the future (and at some point, the regulatory folks are no doubt going to get ugly when it comes to repeat offenses). As with so many things in the safety and compliance realm: this is a journey, not a destination. And on that quasi-Zen note, I bid you a safe week!