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Hanging on in quiet desperation is the safety way

Thought I’d something more to say…

Beware the alligator roll: One quick item for your consideration (I’ve been “sitting” on this one for a little bit). When one considers ligature risks in the environment (as with all risks), one of the evergreen truisms is that risks are very often in the eye of the beholder. So, the question then becomes at what height does a ligature point become a risk that transcends what might be considered a minimal risk. There is certainly information from various sources that self-harm (mostly asphyxiation) can occur at any height—individuals have fixed a ligature to a low pipe and around their neck and then spun their body to twist the ligature until they were asphyxiated, often described as an “alligator roll” or “crocodile roll” (depending on your reptilian preferences). Our friends in Chicago recently updated one of their FAQs on the subject to reinforce consideration of the potential for at-risk patients to harm themselves. If there’s one thing I’ve learned over the years, it’s that persons wishing to harm themselves are often quite creative in how they make use of elements in the physical environment. That said, as creative as folks might be, they usually are not able to “create” while someone is watching; for example, I’m not aware of anyone using the alligator roll to harm themselves while someone was watching them. To me, this pinpoints the criticality of the assessment process and ensuring that folks who are at serious risk for self-harm are put under observation. There is no such thing as a completely risk-free environment and we need to make sure that the assessment process takes into account that “reality.”

As a closing thought for this Thanksgiving week, while the fall is probably my favorite time of year, there always seems to be a component of melancholy to experience (i.e., endure), usually in the form of reflection. There’s also the element of missing folks near and dear who are no longer with us in the corporeal sense (I rely a great deal on the memories of the dearly departed), but I try to remember to be thankful for all that has come before, as well as what we have now. It’s hard not to think of it all as a continuum, but that may just be me. So, as we close in on the end of Year 2 of the Time of COVID, I want to thank each and every one of you for your support and interest in the safety profession as well as this little slice of whatever it is. I appreciate everything you folks do, day in and day out, and my hope is for us all to get through this together. A most joyous and restful Thanksgiving to you and your families—enjoy the spirit of community to the extent that you can!

Everybody’s talking: I can’t hear a word they’re saying…

Something of a mixed bag of stuff this week, which is sometimes the case, particularly with the ever-shifting compliance landscape. First up, an update to one of TJC’s safety alerts dealing with the management of behavioral health patients in the ED, mostly as it relates to strategies of keeping things moving, and if they’re not moving, keeping things on a (relatively) even keel when inpatients beds are limited supply (which is pretty much all the time, though the degree to which that impacts ED patient flow is distinctly variable). If you’ve not had a discussion relative to the management of behavioral health patients in your ED (and I would certainly understand that pandemic response might just have caused a re-prioritization of discussions and conversations of all manner and variety), it’s probably worth checking out the updated materials with a small group and seeing if there are any improvement opportunities to be had. As with all such things, it’s never really about a “one size fits all” approach, but, in recognition that interpretations of compliance on the part of surveyors is often based on published content, at the very least it puts you in a better position having had the conversation about the “suggestions.” There are no magic bullets for any of this stuff and what works in some areas, works not so well in others, but it never hurts to see what’s in the minds of others (so to speak).

Closing out the week with a couple of COVID-related resources for your consideration. One of the hallmarks of the last 15-18 months of pandemic response has been the modification of existing facilities to support the medical management of infectious patients, etc. While there may have been some “casting about” for answers at the outset/onset of the pandemic, adjustments were made and life went on. But what if you had a facility that was specifically designed for such an event? I don’t know that anyone was sitting that “pretty,” but there’s been a lot of thought put into the design of the next iteration of healthcare facilities. For a glimpse of where things could be headed, there was an article in Health Facilities Management in July that discusses a lot of design considerations. My thought is that some of these might be useful in planning how to manage things in the shorter term (I somehow suspect that we are not all going to get new facilities any time soon) and if you’ve got some renovations in the not-too-distant future, you might find something useful to discuss with the architecture planning folks. For good or ill, we’ve never had so much practical experience as it relates to the management of pandemics, so let’s put it to good use. And just as I finished typing this post, the October 2021 issue of Health Facilities Management showed up in my inbox, featuring an article entitled “Designing The Post-Pandemic Hospital,” so there’s more information to consider. Much of it I suspect you already know, but it’s always good to see that you are not alone in thinking about this stuff.

Another component of pandemic response is the management of medical waste in the time of COVID; as with all such things, guidance is very fluid, but it’s worth bookmarking the Healthcare Environmental Resource Centers COVID medical waste page. There’s some state-specific information on the page as well as a link to a page where you can check on regulations in your home state. I suspect that the information contained therein will be in a near-constant state of update, so checking in on a regular basis is probably a good idea.

And now a brief word from…

The source of any number of potential nightmares…

Sorry for the extraordinarily late notice on this, but our friends at the Occupational Safety & Health Administration (OSHA) are hosting a healthcare symposium on August 31, but hopefully there are spots left. It’s a day-long event, so perhaps you can jump in and out depending on the presenters, etc. I suspect it would be nice to be able to take in the whole of it, but competing priorities might dictate otherwise. I am curious as to what they may have to say about suicide prevention (one of the planned topics), but alas I will be competing with my own priorities.

Recognizing that the “elephant in the room” at the moment remains responding to the pandemic (unless you are on the Gulf Coast and are dealing with Hurricane Ida and the storm’s aftermath—thoughts and prayers going out in that direction), I suspect that it will be topic that is covered rather extensively during the program.

A couple of items of note; the initial OSHA enforcement response plan has been archived in anticipation of OSHA completing a review of guidance from the Centers for Disease Control and Prevention (CDC) relative to precautions for fully-vaccinated folks, so we’ll have to keep an eye out to see what might be in the works on that count, which can be found (as well as the latest and the greatest) here.

And for those keen on partaking of some legalese as the summer begins its (all too rapid) wind-down, you can view the sum and substance of the Emergency Temporary Standard as it was initially published. Certainly, there are going to be some differences between the original and whatever comes out of the current (and perhaps future) review sessions, it’s tough to think that the whole thing is going to get tossed, so there may be one or two pointers lurking in the verbiage.

Again, my apologies for the late notice on the seminar/webinar/symposium; not quite sure how it slipped past me, but there is a lot of material out there. Hopefully you can “attend.”

Best wishes for a productive week and (with all luck) a restful Labor Day holiday. I suspect we’re looking at a busy autumn into winter stretch. Rest those weary bones for what I think we all hope will be the (finally!) home stretch of this event.

Night time in the switching yard: Listen to the train(ing) whistle whine…

I suspect that, amongst all the other things that have been pounding on the metaphorical rooftops, you saw the updated guidance from OSHA relating to the Emergency Temporary Standard. I don’t know that there’s a great deal in play that would be particularly problematic, but I think the training requirements might be worth a little bit of work to ensure that the required elements are readily discernible to a regulatory surveyor. That said, I wouldn’t necessarily consider these “new” requirements, as with so many of the post-pandemic “requirements,” it’s all kind of based on what you would do if you were facing whatever event was coming down the pike. I really don’t think this is anything about which you should be concerned, but I figure it can’t hurt to get the list out and make sure that your program speaks eloquently to the individual components.

Here they are:

1910.502(n)

Training.

1910.502(n)(1)

The employer must ensure that each employee receives training, in a language and at a literacy level the employee understands, and so that the employee comprehends at least the following:

1910.502(n)(1)(i)

COVID–19, including how the disease is transmitted (including pre-symptomatic and asymptomatic transmission), the importance of hand hygiene to reduce the risk of spreading COVID–19 infections, ways to reduce the risk of spreading COVID–19 through the proper covering of the nose and mouth, the signs and symptoms of the disease, risk factors for severe illness, and when to seek medical attention;

1910.502(n)(1)(ii)

Employer-specific policies and procedures on patient screening and management;

1910.502(n)(1)(iii)

Tasks and situations in the workplace that could result in COVID–19 infection;

1910.502(n)(1)(iv)

Workplace-specific policies and procedures to prevent the spread of COVID–19 that are applicable to the employee’s duties (e.g., policies on Standard and Transmission-Based Precautions, physical distancing, physical barriers, ventilation, aerosol generating procedures);

1910.502(n)(1)(v)

Employer-specific multi-employer workplace agreements related to infection control policies and procedures, the use of common areas, and the use of shared equipment that affect employees at the workplace;

1910.502(n)(1)(vi)

Employer-specific policies and procedures for PPE worn to comply with this section, including:

1910.502(n)(1)(vi)(A)

When PPE is required for protection against COVID–19;

1910.502(n)(1)(vi)(B)

Limitations of PPE for protection against COVID–19;

1910.502(n)(1)(vi)(C)

How to properly put on, wear, and take off PPE;

1910.502(n)(1)(vi)(D)

How to properly care for, store, clean, maintain, and dispose of PPE; and

1910.502(n)(1)(vi)(E)

Any modifications to donning, doffing, cleaning, storage, maintenance, and disposal procedures needed to address COVID–19 when PPE is worn to address workplace hazards other than COVID–19;

1910.502(n)(1)(vii)

Workplace-specific policies and procedures for cleaning and disinfection;

1910.502(n)(1)(viii)

Employer-specific policies and procedures on health screening and medical management;

1910.502(n)(1)(ix)

Available sick leave policies, any COVID–19-related benefits to which the employee may be entitled under applicable federal, state, or local laws, and other supportive policies and practices (e.g., telework, flexible hours);

1910.502(n)(1)(x)

The identity of the safety coordinator(s) specified in the COVID–19 plan;

1910.502(n)(1)(xi)

The requirements of this section; and

1910.502(n)(1)(xii)

How the employee can obtain copies of this section and any employer specific policies and procedures developed under this section, including the employer’s written COVID–19 plan, if required.

Note to paragraph (n)(1). Employers may rely on training completed prior to the effective date of this section to the extent that it meets the relevant training requirements under this paragraph.

1910.502(n)(2)

The employer must ensure that each employee receives additional training whenever:

1910.502(n)(2)(i)

Changes occur that affect the employee’s risk of contracting COVID–19 at work (e.g., new job tasks);

1910.502(n)(2)(ii)

Policies or procedures are changed; or

1910.502(n)(2)(iii)

There is an indication that the employee has not retained the necessary understanding or skill.

1910.502(n)(3)

The employer must ensure that the training is overseen or conducted by a person knowledgeable in the covered subject matter as it relates to the employee’s job duties.

1910.502(n)(4)

The employer must ensure that the training provides an opportunity for interactive questions and answers with a person knowledgeable in the covered subject matter as it relates to the employee’s job duties.

Again, I feel pretty confident that these elements have been in place in most instances (PPE, risks associated with COVID, health screening, any changes to procedures, etc.) and (presumably) the effectiveness of the education process supported by data of COVID-related illnesses amongst the workforce. But it might be a good idea to “pull” these elements out as a syllabus (if that makes sense) to be able to walk a surveyor through the elements.

Folks back home surely have called off the search…

We knew it was going to happen eventually, but our friends in Chicago have made it official (just in time for the implementation of Daylight Savings Time—for those of you participating), the return of the (more or less) completely unannounced surveys by The Joint Commission (see the first article in the March 10 edition of Joint Commission Online). To be honest (and I try never to be anything but), I really can’t say how far behind they are on the survey front. I can’t imagine that there’s not going to be some serious catching up to do, and, since the public health emergency is still in play, I’m not sure how much time they’ll be given by the feds to reach some sort of survey plateau.

Presumably, they will continue to rely on the CMS COVID data (we talked about that a little while back; if you’ve somehow managed to misplace that link, you can find it here) to determine where the trouble spots might be (if you look at the latest data, the results are promising; hopefully we won’t be remembering the beginning of March as the—yet another—calm before the storm), so if you’re in a “red” county, that may be enough to avoid being in the first wave. I suppose the other dynamic is how survey teams will they be able to field—it sounds like this is going to be a busy week for folks, so if they show up on your front door step, please know that this community is standing by with best wishes for success.

As an adjunct to the return of the survey, TJC unveiled the 2021 Survey Activity Guide, which, among other things, formally speaks to the elimination of the Environment of Care interview session, indicating that topics previously covered in the session will find their way into the EC/LS tracer activities. Thus, effectively giving the LS surveyors another hour or so to wander the halls, with the implication being that they may go to/get to places in your house where they’ve not previously been. I’m not entirely certain, though I suppose if you have a fair amount of square footage there may be one or two spots that might not have been ransacked before, but I’m guessing you have a pretty decent idea of where they’ve not been, so it might be worth kicking those tires, so to speak. We know for a pretty fair certainty that they will be visiting the kitchen (after all, there’s a checklist and far be it for a checklist to go unchecked…).

They’ve also updated/revised the list of documents, including the return (don’t call it a comeback!) of the Statement of Conditions and Basic Building Information, something of a focus on water management programs (make sure you have your ASHRAE and CDC ducks in a row) and the management of line isolation monitors (if you have them). And, of course, the perennial attentions to the Management Plans (I’m not going to say anything more about those for a bit…) and annual evaluation process. Oddly enough, it appears that the document list also includes things that are not required to be documented, but rather are in place to remind you and the surveyors of some specific expectations like, oh, how ’bout, managing safety risks. I almost forgot about that…

So, hopefully the survey process will be less lion and more lamb as we get things rolling again. I think most organizations are experiencing some variation of PTSD and I don’t think that kicking folks in the head is going to be very helpful. The fact that healthcare has managed to keep things going over the past 12 months is a testament to the effectiveness of our processes, etc. I’m not expecting pats on the back (as deserved as they may be), but I do expect some reason in the administration of the survey process—or at least, that’s my hope—especially for everyone that’s in the barrel for this coming few weeks.

Please be well and stay safe—and keep doing what you’re doing. You folks are amazing, and don’t forget it!

When you’ve done all you can do, what do you do?

As I start this, I’m thinking it will be kind of brief, but you and I have both been at the receiving end of my brevity, so we’ll see what happens.

As I ponder the various and sundry processes that make up an effective program for managing the physical environment, I cast my mind back to some instances in which self-identified corrective actions were not completed before our friends from the regulatory world parachuted out of their black helicopters to conduct accreditation surveys (I will freely admit that sometimes those black helicopters look exactly like commercial airliners—I’m not sure how the technology works, but it looks to be pretty seamless…) and the questions are inevitably raised as to (more or less) “How come it’s taking so long?”

There’s also the possibility (it may even be a likelihood, but I shy away from pronouncements based on a small data sample) that when there are findings relating to the physical environment, the general concept of the organization’s responsibility vs. just the Environment of Care (EC) folks sometimes flies out the window. Only you folks know what kind of culture you have in your organization and how much acknowledgement of shared responsibility is going to occur post-survey. But, in response to that “knowledge,” I would ask you to think carefully about how the EC program escalates issues that are difficult, if not impossible, to resolve within the EC program. Sometimes I get the sense that folks are less inclined to “air their dirty laundry” in the direction of organizational leadership, but (in my mind) one of the most important capabilities of any management process is knowing when to ask for help. Clearly, you don’t to “cry wolf” too often, but sometimes you just have to raise your paw…

By way of providing context, as this is generally the time of the annual evaluation (as opposed to the time of the season, though they may coexist), I would encourage you, in your “look back” over the year, to consider whether there were issues identified for which resolution has not been forthcoming. Part of this (OK, perhaps quite a lot of this) may have to do with all things COVID—if the effectiveness of our “product” is based on the juggling of (at times competing) priorities. Much as September 11, 2001 shifted the safety/preparedness world in an unanticipated direction, likewise COVID has pushed things around rather a lot. I suspect that everyone is going to have a COVID list of things that either didn’t get done or didn’t get done as well as one would like. Now is a good time (as we start to close on the birthday of the declared emergency) to quantify the impact of those “things.” I don’t know that it needs to be the sole focus of the annual evaluation process, but if you were to do so, I think you (and your organization) might be well-served for it.

As we rocket through January, I hope this finds you well and staying safe—we will get through this!

Remote control: Don’t forget to close the loop

It would seem that the likelihood of ongoing remote surveys is growing in relation to the number of organizations awaiting survey. To be honest, I’ve not seen an official accounting of where the various accreditation organizations (AO) are falling relative to survey delays. That said, I can’t imagine that there must be a fairly significant backlog of surveys to be conducted, so I suppose we’d best be prepared for at least some of that process to occur remotely—particularly document review. To that end, if you missed this news item, I think it will help provide an understanding of how the process is evolving (mutating?!?); the focus of the piece is how DNV is administering the process, but there are certainly some clues as to how the process in general is likely to “exist” over the next little while.

One thing I hadn’t encountered before (or if I had, it was lost in the slipstream of last year) is the COVID data being provided by CMS. It appears that the information is updated on a regular basis (at this writing, the most recent information was for the period ending December 23, 2020) and while it is labeled as Nursing Home Data, CMS feels that the data is applicable to survey planning for hospitals. It appears that unless you are in a “green” county (you’ll see what I mean when you download the spreadsheet), then you probably won’t be seeing a “live” survey team (will we have to face zombie survey teams?). In traveling the past few months and living in a state that requires a negative test before returning or self-quarantining, I can tell you that those green windows sometimes don’t stay open for very long. Fortunately, I have not yet been in a position where I have tested positive away from home—probably my second worst fear; the worst fear being to bring this stuff back home to share with my family.

That said, my own practice has been very much “out in the field,” with a mix of some remote document review. I really do miss the interaction of document review with the folks who are actually responsible for the critical processes. It’s very difficult to have an appreciation for the process when you can’t discuss the operational challenges, the process for making corrections, etc. One of the “common” themes I’ve noted is that the documentation provided remotely tends not to include evidence of corrective actions; certainly this is something I’m accustomed to asking for when I’m doing onsite document review, but I don’t know of too many surveyors that wouldn’t be looking to “close the loop” on any identified deficiencies as soon as they find them in the documentation and it’s tough to really hold someone’s feet to the fire relative to producing corrective action documentation when you are not “in the building” with a specific ending point for the survey. There are certainly any number of surveyors who will cite an organization for failing to provide evidence of corrective actions and I think remote document review only increases the potential for missing pieces of the puzzle.

So my consultative recommendation is this: Make sure that you attach evidence of corrective actions to any documentation you might provide remotely to a survey team. You know you’re going to be asked for it anyways, so you might as well get ahead of the “ask.”

That’s it for this week. I hope you continue to be well and stay safe—we will get through this!

As I look out the window, it’s snowing, which reminds me that we’ve got to keep turning with the world, so I will let you get back to it. Until next time, hope you are well and staying safe. For those of you who are in the process of receiving the vaccine, thank you for your service!

We’re only immortal for a limited time…

Just taking a quick cruise the FAQ pages and came across one or two items of interest; commentary as applicable…

Our friends in Chicago have given the thumbs up to using the current pandemic response to meet the emergency management exercise(s) requirements. Make sure you document the evaluation in accordance with the six critical areas of response:

  • Communications—what worked well and what did not
  • Resources and assets—what resources were abundant, adequate or lacking
  • Safety and security—what issues arose and how were they resolved
  • Staff responsibilities—what issues arose and how were they resolved
  • Utilities—what issues arose and how were they resolved
  • Patient clinical and support activities—what was abundant, adequate or lacking.

There is an indication that they may be “leaning” on EM when the survey process returns in earnest (and we all know how important that is…).

Moving on to the world of equipment management, specifically diagnostic imaging equipment, there is some relief relative to the completion of performance evaluations for certain systems (CT, MRI, NM, PET, but not mammography) for the duration of the declared state of emergency. I’d be curious as to how folks have been managing this in general; I suspect that some folks had these on the schedule before things came to a screeching halt, but we’re rounding the corner on a year’s worth of pandemic delight so probably want to keep an eye on where things stand. As with many things, the clock will be ticking once the state of emergency is discontinued, at which point you’ll have 60 days to get things scheduled. I bet there will be a lot of competition for external resources at that point…

We’ll close out this week’s edition with some fodder for the HVAC-heads in the crowd. I have to admit that the question being asked and the response don’t seem to match up particularly well and I do think there probably ought to be some mention of the manufacturers’ instructions for use (nothing like a little IFU to make one’s day). The question seems more along the line of “what should we be doing now,” but the response seems to focus a little more on “here’s what you do when this is all over,” when it comes to maintaining HVAC equipment being used to support COVID units. Again, I suspect the IFUs have a big part of where we should be at the moment. Hopefully, you’ve had enough ebb and flow of patients to be able to attend to something close to a normal preventive maintenance schedule and it probably couldn’t hurt to reach out to equipment manufacturers’ if we have significantly modified the use of existing systems and equipment. That said, I would certainly recommend including the bulleted items noted in the FAQ once we’re in a position to start returning things to “normal.”

Won’t you be glad when normal doesn’t have to be in quotation marks?

Hope you all remain safe and well!

Masking Tape/Taping Masks: Essential PPE is still in the mix…

As 2020 continues to roll along with no apparent respite from dealing with COVID on the horizon, it’s probably not a bad idea to share some PPE-related resources with folks. I suspect that pretty much no one out there in the studio audience has the time to bolt down the rabbit holes of the interweb, but here are a few links to some (hopefully) useful resources:

When it comes to PPE, it’s always important to keep an eye on the folks at the Occupational Safety & Health Administration, who have provided some guidance relative to the use of PAPRs for personal protection. It has the appearances of being somewhat flexible in certain instances, but enforcement is still enforcement, so if you’ve got PAPRs in the mix, worth checking out.

Next up, the good folks at ECRI have pulled together a number of PPE-related resources to ensure that we’re providing appropriate/effective PPE to those folks on the front lines who are at the greatest risks of occupational exposure. If you think all this stuff kind of sounds like a risk assessment opportunity, I would be inclined to agree. At some point (hopefully sooner rather than later), when move on to the new “new” normal, our regulatory friends are going to be curious to find out how we “knew” that we were adequately protecting folks and, since they’ve been rather reluctant to accept performance data without some sort of assessment framework, these should work well within the confines of the documented risk assessment process.

Here they are:

While shoe covers don’t really fall under the PPE category in general (though sometimes they can), for anyone who has ever struggled with putting on shoe covers before “bunnying up” to go in the OR, I thought this might be a good for the end-of-the-year holiday wish list (I know it’s on mine—as soon as they make one that’s portable), check out the Bootie Butler. I’ve only seen this item in a pharmacy clean ante room, but I found it intriguing.

As always, I hope this finds you well and staying safe. I figure every day brings us closer to the end of this (and I suppose there’s a certain inescapable logic to that). I hope…

Punching above your weight: Virtual inspections are coming!

As we continue the endurance test that is 2020, one of the general concepts that keeps cropping up relates to external folks (I hesitate to characterize them as “agencies” because of the potential for this to extend well beyond intrinsically compliance or regulatory-related processes) wanting to “visit” with you while minimizing the potential for physical “exposure” to your organization. For example, those of you who have been able to complete construction and/or renovation projects that require oversight from various folks, including your contractors, as a function of the punch list process before one can “close out” the project—in full recognition that the closing out of a project tends to represent a process under which as much of the “to-do” list is handed over to the onsite facilities folks by the contractor. And, yes, I suspect that statement reveals something in the way of a bias regarding the close-out process—but it’s a shoe that fits far more often than I would like, based on my experience.

Be that as it may, virtual inspections can be very much a double-edged sword (once again mixing far too many metaphors) in that, in some instances, the less that is found, the better (think the regulatory compliance angle), and, in other instances, the more that is found, the more “real” the assignment of responsibility for repair, etc. (i.e., the project close-out process). A little bit ago, I was chatting with a facilities director who was bemoaning the fact that his contractor had elected to conduct the punch list inspection virtually (not exactly sure how the process was administered, but it sounds like the facilities folks did not have representation in that process until after the punch list was received). An internal review of the space revealed a number of items that were not otherwise complete that (for whatever reason; you might be able to guess one or two) did not make it to the virtual punch list.

Ideally, the virtual inspection process would be an effective means of ensuring that everything in your building is “up to snuff,” but is the technology at a reliable point? Particularly if you’re the one left “holding the bag” if conditions, etc., get missed during the process and show up sometime in the future. I know some of the tech solutions are more than fascinating at first blush, but how do you folks feel is the appropriate level of trust for the results of the virtual survey? Please weigh in as you see fit. I’m really curious about folks’ experiences.

As we head towards the inevitability of autumn, I hope this finds you in good health and safe. Please keep it that way!