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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!

I feel like we’ve crossed this bridge before…fire drills are all the RACE!

While the numbers are fairly small (though at almost 30% for a noncompliance rate during 2019 surveys, you could certainly make the case that almost any deficiencies in this area is too much), there remain a couple of common stumbling points when it comes to conducting fire drills. According to the August 2020 issue of Perspectives (get it at your newsstand now!), there continue to be issues with:

  • Not completing/documenting quarterly drills on every shift. I don’t know that there’s a whole lot of mystery here—sometimes you miss a drill. You don’t want to miss a drill; nobody wants to miss a drill! But sometimes the quarter expires so quickly that you don’t realize that a drill was missed until it’s too late. The links below will take you to The Joint Commission’s guidance on the topic, but my best advice is to set a reminder for March 10, June 10, September 10, and December 10 to check fire drill status. That way, you’ve got a couple of weeks if you need to get one in.

https://www.jointcommission.org/resources/news-and-multimedia/podcasts/take-5-the-environment-of-care-fire-drill-matrix-tool/

https://www.jointcommission.org/resources/patient-safety-topics/the-physical-environment/

  • The fire alarm signal was not transmitted on the third shift drills. I absolutely understand why this is still in the mix (as TJC has noted, the allowance for a coded signal for drills between 9P and 5A, does not preclude the transmission of the fire alarm signal). My best advice is to have a line item on your fire drill critique form that goes a little something like: Fire alarm signal transmitted – Yes   No. That way you are providing a surveyor documentation of the signal transmission where you know they’ll be looking.

https://www.jointcommission.org/standards/standard-faqs/hospital-and-hospital-clinics/environment-of-care-ec/000001235/

  • Not enough variation of times when fire drills are conducted; not too much more to say that hasn’t already been said—you have to mix it up—and make sure that the folks conducting the drills understand that once you’ve set up a fire drill schedule, it is to remain unchanged without approval. I know that sounds kind of draconian (and I suppose it is), but our surveyor friends have been rather inflexible on this count and you don’t want to get dinged for a measly 15 or 30 minutes of overlap in your drill times. In the words of the inimitable Moe Howard, when it comes to fire drills—SPREAD OUT! Or, if you’d rather use George Mills’ take on it, you can find that here (with some other Life Safety bon mots).

Now, at the moment, the survey process is not focusing on fire drills as a function of the 1135 Waivers in effect due to the COVID-19 maelstrom. So it would seem that we have a little bit of time to work on the finer points of fire drill compliance. I think the overarching focus is going to end up being (and I think this is likely to be the case with emergency management exercises) is how well you are doing relative to ensuring that “all staff” are participating. For the purposes of the education and training component, I would like to think that if we can demonstrate that everyone in the organization (including the folks in administration) participated, to some degree, over a two-year period, that will result in a finding of compliance during survey. Is it even possible for most places of size to get to everyone, every year? I’m thinking not, but feel free to disagree. I think it may end up going the route of hazard surveillance round frequency—you have to do as many as you have to do to cover the territory you need to cover. So, if in order to be effective, you have to do more than one fire drill per shift per quarter, then that becomes part of the algorithm used for your annual evaluation (or to use the annual evaluation as a place to ensure your clear assessment of the effectiveness of the program). There is always the potential for a surveyor to disagree with your fire drill schedule, as it relates to effective education of staff. Use the annual evaluation to document your assessment of the effectiveness—it may be the only way to keep the survey wolves away from the flock.

So, let’s get the flock out of here…

As always, hope you are well and staying safe. I’ve been traveling some over the past few weeks and, humans being humans, I think we’ve got a ways to go before we wrestle this thing to the ground, so keep those shields up!

We advance, masked!

In the topsy turvy world of Personal Protective Equipment (aka PPE), there are some developments on the decontamination/reprocessing of masks that I wanted to bring to your attention, if you’ve not already scoped them out.

First up, a little more information from our friends at the Occupational Safety & Health Administration, where we find that the guidance issues to surveyors is to be somewhat judicious in how they chase issues relating to PPE, but the basic expectations of employers look like this:

  • Make a good-faith effort to provide and ensure workers use the most appropriate respiratory protection available for the hazards against which workers need to be protected. Efforts should be consistent with flexibilities outlined in OSHA’s previous COVID-19 enforcement memoranda.
  • When respirators must be decontaminated to facilitate their reuse in ways consistent with OSHA’s previous COVID-19 enforcement memoranda and the U.S. Centers for Disease Control and Prevention (CDC) Strategies for Optimizing the Supply of N95 Respirators, ensure that decontamination is accomplished according to the methods described above and detailed in CDC’s Decontamination and Reuse of Filtering Facepiece Respirators using Contingency and Crisis Capacity Strategies.
  • Ensure users perform a user seal check each time they don a respirator. Employers should not permit use of a respirator on which the user cannot perform a successful user seal check. See 29 CFR § 1910.134, Appendix B-1, User Seal Check Procedures.[11]
  • Train employees to follow appropriate precautionary measures prior to using a decontaminated filtering facepiece respirator (FFR). See cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/decontamination-reuse-respirators.html.
  • Train employees using decontaminated respirators to understand that if the structural and functional integrity of any part of the respirator is compromised, it should not be used by that individual as respiratory protection. The inability to achieve a successful user seal check could be an indicator that the integrity of the respirator is compromised.
  • Visually inspect, or ensure that workers visually inspect, the FFRs to determine if the structural and functional integrity of the respirator has been compromised. Over time or as a result of the decontamination process, components such as the straps, nose bridge, and nose foam material may degrade, which can affect the quality of the fit and seal.
  • Train employees on the procedures for the sequence of donning/doffing to prevent self-contamination. See cdc.gov/niosh/npptl/pdfs/PPE-Sequence-508.pdf.
  • If no manufacturer or third-party guidance or procedures are available to support the specific decontamination method(s) employed, avoid the use of decontaminated FFRs when healthcare personnel perform surgical procedures on patients infected with, or potentially infected with, SARS-CoV-2 or perform or are present for procedures expected to generate aerosols or procedures where respiratory secretions are likely to be poorly controlled (e.g., cardiopulmonary resuscitation, intubation, extubation, bronchoscopy, nebulizer therapy, sputum induction). If decontamination methods degrade FFR performance, including filtration and fit, or otherwise affect structural integrity, the decontaminated FFR may not provide the level of protection needed or expected during aerosol-generating procedures.

I suspect that, in general, folks are being sufficiently attentive to their PPE (perhaps more than has ever been the case) that they are checking for integrity (though they may not be as familiar with the User Seal Check Procedure—could be a teachable moment). And the missive covers some decontamination methodologies that may be of interest, particularly in light of the FDA’s altered stance on decontamination and reprocessing of masks.

I guess the questions become those related to available supplies of PPE. I get the sense that some folks are still relying to a fair degree on the use of masks that are not NIOSH-approved and so this latest development could potentially mean that, in the absence of being able to decontaminate and reprocess, the supply chain is going to have to be considerably more robust in either providing more non-NIOSH masks or more NIOSH masks that can be appropriately decontaminated, etc. I’d be curious to hear of any experiences (good or not so) that you’ve had in this regard. It seems likely that, even as we try to get to the “new normal,” we’re going to be dealing with this for a while, so we might as well share the good, the bad, and the ugly.

Speaking of which (sort of), as a closing thought for this week, now that I am hanging out in airports again, one thing that I’ve noticed is the phenomenon of the smile that doesn’t reach someone’s eyes. Pre-mask, I don’t know that I analyzed transient interactions with folks, but I find myself responding to folks based on their “eye language” and I’ve found that it can turn what would typically be a (more or less) neutral transaction into a positive or negative. I suspect that most customer service training involves reminding folks to smile, but now that our smiles have been temporarily removed from the occasion, the eyes are all we have for first impressions. Don’t know if that’s useful to you, but something to ponder.

Be well and stay safe ’til next time!

A little mo’ from the Mighty O (ccupational Safety & Health Administration)

As they are wont to do, the folks at OSHA periodically issue safety alerts and it would seem that the ongoing challenges of managing the ongoing occupational health and safety aspects of COVID-19 is ripe for alerting. You can find the complete list of alerts on OSHA’s COVID-19 homepage.

Interestingly enough, OSHA has not (as of this writing) issued an alert specific to hospitals, but they did recently issue an alert aimed at nursing homes and long-term care facilities, the elements of which are, at the very least, instructive for other folks in the healthcare demographic; you can find the alert in its entirety here. I just wanted to plant a seed relative to a few of these:

  • Maintain at least 6 feet between workers, residents, and visitors, to the extent possible, including while workers perform their duties and during breaks.
  • Stagger break periods to avoid crowding in breakrooms.
  • Always follow good infection prevention and control practices. Consult OSHA’s COVID-19 guidance for healthcare workers and employers.
  • Provide handwashing facilities and alcohol-based hand sanitizer with at least 60% alcohol throughout facilities.
  • Regularly clean and disinfect shared equipment and frequently touched surfaces in resident rooms, staff work stations, and common areas.
  • Use hospital-grade cleaning chemicals approved by the Environmental Protection Agency (EPA) from List N or EPA-approved, hospital grade cleaning chemicals that have label claims against the coronavirus.
  • Ensure workers have and use any personal protective equipment (PPE) they need to perform their jobs safely.
  • Continually monitor PPE stocks, burn rate, and supply chains. Develop a process for decontamination and reuse of PPE, such as face shields and goggles, as appropriate. Follow CDC recommendations for optimization of PPE supplies.
  • Train workers about how to protect themselves and residents during the pandemic.
  • Encourage workers to report any safety and health concerns.

I don’t know that there’s anything on the list that doesn’t make sense, but I do think it might be useful/beneficial to keep an eye on these (and the other elements) to ensure you and your folks are not at elevated risk for exposure. Admittedly, there is still a lot we don’t know about the epidemiological aspects of COVID-19 and it may result in additional levels of guidance and/or protection (remember those halcyon days when masks were not required—seems like only months ago—oh, wait, I guess it was…). I also think it’s important to hear folks out if they voice frustrations with process, etc. A fair amount of this stuff is learning as we go—and making the best decisions we can based on the available information—in full recognition that being a leader in healthcare can mean having to put up with some unpleasant feedback. I think some folks in the field remain super concerned and super attentive to the decisions others are making on their behalf, so it’s important to keep things on an even keel.

Until next time, continue to stay safe—and keep rocking it!

Possibly making the impossible, possible…

As I look back over the years, particularly my time as a consultant, I continue to be fascinated by requests to safety/facility professionals to (channeling Jean-Luc Picard) “make it so,” even when the “so” they are requesting was not considered in the design of whatever system/process that is the target of the request. Just last week, I fielded a question from a facility manager who had been requested to make an OR procedure room negative for procedures on COVID patients. Unfortunately, it wasn’t a direct reach-out so I wasn’t able to dialogue with this individual, so I’m not sure of the particulars (availability of negative pressure procedure rooms in the facility, etc.), but it did get me to thinking about how many impossible things have been done over the last eight to 10 weeks in hospitals all over the country.

As of this writing, the first week in June is bringing about my first onsite client visit since mid-March and I am keen to see what’s been happening “in the field.” Fortunately, through the 1135 waiver process, there have been some instances in which we’ve been able to “bend” the regulatory statutes to some degree, but I think (hope?) we can all agree that there have been (and likely will continue to be) gray areas that are not (at least currently) covered by a waiver and may be so funky in the execution that you could never do more than ask forgiveness when this is all done (recognizing that directly targeted permission has not been abundant). My consultative advice is to keep track of some of the more ingenious (and you can read that as “a little crazy”) solutions to challenges you’ve experienced at your facility—the worst thing that could happen would be for all this stuff to get lost in the slipstream of “getting back to normal” and never get shared with the world at large.

I suspect you are all way too busy to be thinking about this now, but (as an amateur student of history) a response to an unprecedented event would make for an interesting and compelling story for future generations. I hope that we’re not bound for a repeat any time soon, but there are lessons (or, dare I say, teachable moments) for all of us. And with the slow decline of the oral storytelling medium, I want to make a case for capturing this…

Until next time, please stay well and safe—and keep rocking it!

The trouble with normal: Some things to consider as we ease back into recovery

I think we can all agree that there are a lot of stressors in motion as we navigate the unknowns of the pandemic; some of which one might not normally encounter and others are just an amped-up version of “business as usual.” As we near the end of May, it does seem like there is a little bit of movement towards a return to normalcy (recognizing that we’ve probably bid adieu to the “old” normal), which has prompted some consideration of the demands placed on our facilities’ systems and how best to position ourselves to safely engage the recovery phase of this historic emergency response.

Another point of agreement (hopefully) would be that elements relating to infection control are going to be scrutinized more than ever as the accrediting organizations get back to it. I suspect that at least part of that scrutiny will involve the overarching management of utility systems and their components. Fortunately, there is much to be learned from/shared by folks I consider to be excellent sources of information and insight.

As was the case before the onset of COVID-19, I think the management of building water systems is going to come into play and, particularly if you’ve had to reduce usage in some areas of your facility, bringing things back online represent some real challenges. Certainly, the focus on managing the risks associated with waterborne pathogens goes back more than just a few months, but the following should be enough for you to get ahead of the curve.

The first two articles, penned by Matt Freje from HCInfo, focus on some key planning/prevention considerations that, at the very least, should be a part of your planning risk assessment going forward. It’s all completely sensible and clear in direction, particularly as work towards appropriate management of environmental conditions for our most at-risk patient populations, and both articles are definitely work a look. They cover building water systems and Legionella concerns.

Finally, for this week, we have a webinar covering potential Legionella risks as we ramp our buildings up to normal speed, sponsored/presented by the good folks at the ScalingUp!H2O podcast. Lots of good information presented by Dr. Janet Stout of Special Pathogens Laboratory. There’s a slide presentation, hence its availability on YouTube, but (again) worth the 35 or so minutes of your time to check it out.

Please continue to stay safe and productive during the pandemic. Thank you for your hard work and dedication to keeping things on an even keel!

When you get to the end, you get to start all over again…

I know you folks have (more or less) been under a constant bombardment of facts, figures, strategies, etc., relating to COVID-19 and, as every day brings us a little closer to a return to some sort of normalcy (It will be interesting to look back on how things changed as the result of the current emergency), I wanted to chat this week about one of those “other” things that is likely to be on the to-do list when we get to the recovery phase of this emergency. Not that long ago (OK, two weeks ago), we covered the potential for an intensification of scrutiny in the outpatient setting. And, as it should turn out, one of those areas of potential is the management of behavioral health patients in that setting. Last month (March 2020) our friends in Chicago posted an FAQ aimed at “hospital and hospital clinic settings” that talks about expectations relative to risk assessments in non-psychiatric units/areas in general hospitals. Of particular interest to me is the invocation of competency as a function of conducting the risk assessment “in areas where staff do not have the training to do this independently” and referencing “on-site psychiatric professional” as a potential resource. To me, that likely means that (and this may be the case of any risk assessment upon which you’ve modified practice, the environment, etc.) there will be questions about the risk assessment process, including “How do you know that the folks involved with the assessment were competent?” or something akin to that. I don’t know that everyone who has to (at least periodically) manage behavioral health patients is going to be able to access “on-site psychiatric professional” assistance, in which case it’s probably a good idea to clearly establish the credentials of the team or individual crafting the assessment. You can see what elements you’ll want to include here.

To aid in ensuring an appropriate environment for behavioral health patients, you might find the information assembled by the Center For Health Design to be useful. There is (almost literally) a ton of resources, from interviews, webinars, and podcasts to discussions of design elements, etc. As we have seen over the past few years, the management of the behavioral health environment is very much a moving target and the more information we have at our disposal, the more (dare I say) competence we can obtain. Every one of us is a caregiver to one degree or another and this is another useful resource that will help provide the most healing environment possible.

Please stay safe and (reasonably) sane ’til next time!

Will it go ’round in circles? A couple more pieces of the COVID-19 pie

As I try to embrace brevity as the soul of wit (which is likely to be as close to Shakespearean as this space is ever likely to venture), I have just a couple of resources to share with you folks this week. I do hope this finds you settling in (at least somewhat) to the current reality and the “new” stressors have subsided a bit.

Clearly, there’s been a lot of discussion regarding the protection of healthcare workers, mostly as a function of providing essential personal protective equipment (and the struggles that folks have faced in procuring said PPE). What is somewhat sketchier at the moment it to how organizations/employers are going to be held accountable for worker protection in the aftermath of the pandemic condition. But you might be able to gain some sense of things by consulting our friends at the federal Occupational Safety & Health Administration. While the OSHA website does speak of “discretion” in enforcement activities when considering an employer’s “good faith” efforts, I think it will be of critical importance that we be able to speak to a risk assessment to determine where folks jobs/tasks fall on the exposure continuum. OSHA indicates a spread of low, medium, high, and very high as risk categories with the enjoinder “(u)ntil more is known about how COVID-19 spreads, OSHA recommends using a combination of standard precautions, contact precautions, airborne precautions, and eye protection (e.g., goggles, face shields) to protect healthcare workers with exposure to the virus.” They also encourage the use of the Centers for Disease Control & Prevention as the primary source of current strategies, etc., so we can all work from the same source.

One of the other common threads of discussion relates to the disinfection of surfaces, etc., for which I would encourage you to check out the Environmental Protection Agency’s list of approved disinfectants (hopefully whatever your organization is using is on the list; not necessarily a deal-breaker if it isn’t, but there are always risks when one goes off-list). I keep reflecting on the reality that, in all likelihood, we won’t know what worked/didn’t work, etc., until this is long past it’s point of criticality, so it’s important to make sure that we can evidence a thoughtful process in identifying strategies. As of this writing (April 21), there does seem to be a growing unrest to get things back to normal, with some states opting to employ less restrictive strategies for distancing (in all its many permutations—who knew?). I am hopeful that we won’t be having this same discussion a month (or two months) from now if there is a resurgence, but it does seem inopportune to try and short-circuit a process before we have enough data to support easing up on things. I guess it all goes back to what they say about time—it will tell!

Stay safe!

Why pay full price for the right thing…

…when you can get an approximation for a lot less money!

I’ve been sitting on this particular line of thought for quite some time—long enough for the world to get to a place where having to “make do” is not only the order of the day, but a philosophy that is being endorsed by the various and sundry regulatory folks as work to hold the line on PPE and other operational necessities. It seems almost daily, the hard lines that existed in the compliance world have blurred to the point of vanishing. And while we know that things will eventually return to whatever normal awaits us, there are some indications of what that world might look like (again, looking purely at regulatory compliance as a function of surveys).

While there has been no formal public announcement yet (though I am anticipating something or other in the not too distant future), it seems that something we chatted about almost a year ago is going to manifest itself during surveys conducted by our friends in Chicago to the tune of an additional scheduled survey day, with the intent being the opportunity to really kick the environmental tires (so to speak) in your outpatient locations. As we discussed last year, I believe that there’s the potential for any number of vulnerabilities in the outpatient settings that may not manifest themselves so readily in the hospital setting, but if you look at what has been driving the numbers when it comes to the survey of the physical environment, it is clear that a lot of the same potentials exist—loaded sprinkler heads, issues with door hardware, gaps in inspection, testing and maintenance activities, depending on the environment, even air pressure relationships, and the management of temperature and humidity can be in the mix. The cynic in me is quite certain that there is no surprise in moving further afield with the survey process when it comes to generating findings—think of how much stuff they found in hospitals, where we exercise the most “control”! At any rate, I’m sure we’ll be getting the official word soon, but I’ve been thinking about what this is all gonna look like post-COVID and I think this is an important piece to be thinking about in terms of preparation.

In closing for this week. I wanted to share a piece on inspirational quotes. I personally don’t hate inspirational quotes as a going concern, but I hadn’t run into to a few of these before, so I figure it can’t hurt to share with the group.

Hope you all are safe and (reasonably) sane—you’ve got this!

Rock on: Where do we go from here?

It would seem that the subtext to all we are experiencing/dealing with now is how long we can anticipate this “siege” to last, and (as is typical of these types of events) we probably won’t have a clear sense of the timing until the clouds break and the “sun” comes out. From a practical standpoint, the current situation is a very robust test of each organization’s continuity of operations plan (COOP), as well as the opportunity to witness the intricacies of the 1135 Waiver process as it unfolds. Of course, the other element that is unfolding is the number of COVID-19 cases worldwide (I’ve found the Johns Hopkins University case map of particular use in watching the spread of cases, both worldwide, but particularly in the United States; if you haven’t “found” it yet, it’s definitely worth a look).

At any rate, from a planning perspective, we’ve gotten to the point where some preparations need to be made to ensure sufficient capacity in the event regions are not successful in their attempts to “flatten the curve.” And those preparations will probably involve real-life/real-time actions to be ready to establish alternate care sites (to see what that looked like 100 years ago, you can scroll down this page to see my old stomping grounds at Brockton Hospital). To aid in that pursuit, just yesterday (March 30), CMS unveiled a number of regulatory changes to encourage thoughtful expansion of capacity, including provisions for what is described as “hospitals without walls.” I would encourage you to review these new materials as they do have some restrictions (mostly checking to make sure your planning dovetails with your state’s planning for alternate care sites).

From a practical standpoint, our friends at the American Society for Health Care Engineering have included with their COVID-19 resources some guidance (including links to other materials) on options for establishing/converting alternate care sites. Again, looking at the COVID-19 map, it is fairly easy to discern where bed capacities are likely to be in greatest demand and hopefully those most dire of conditions will not spread everywhere, but there’s no reason to delay consideration of what can be done in advance to be able to flex up capacity at your facility. I know there’s a lot going on right now and the struggle to attain some level of normalcy is all too real, but it is clear that we are in the process of redefining the magnitude of planning and preparation activities. Anything we can do to stay at least a couple of steps ahead is worth our time and energies.

Stay safe until next time!