One interesting thing to note during a recent CMS validation survey up here in the Northeast: there was a fair amount of interest on the part of the CMSers on life safety system testing documentation for patient care locations other than the main hospital sites. Fire alarm testing (and sprinkler testing for those locations having sprinkler protection) documentation for physician practices and other free-standing service locations was requested (and in some instances not quite produced in full). I know that generally speaking we tend to focus on stuff that occurs within the “four walls” of the hospital, but once you get outside those walls, you can encounter an increasingly complicated set of conditions. There may be patient care services being provided in leased space, in which case you may have to deal with a landlord to access testing the needed testing documentation (unless, of course, you have taken responsibility for managing that process, but I’m going to guess that folks with multiple sites may not have the “luxury” of taking complete responsibility for those types of activities). I don’t know if this signals a sea change in what documents might be expected, but it’s certainly something worth considering—and perhaps testing within your own sphere of influence. I know I’m going to be asking about these types of processes a little more frequently…
When it comes to the Life Safety document review, there is still a fair amount of survey risk exposure and (no surprise) a fair amount of survey findings. EC.02.03.05 is the 6th most frequently cited standard; 44% of the hospitals surveyed in the first six months of 2013 were cited under this standard!
Some of the findings have related to irregularities in the testing process. You have to make sure that your device inventory numbers match up; if you had 50 pull stations last year and 55 pull stations this year in the testing documentation, you had better know why and it better be because you added some pull stations, otherwise it could get ugly. But one thing I’ve seen in a couple of recent surveys (both TJC and in my own practice) is the documentation of fire alarm and sprinkler system testing and maintenance that is performed by in-house staff. A typical one is the weekly fire pump test—pretty much everyone does that one in house. Now, there’s nothing wrong with that, but you have to make sure that the documentation of in-house activities is in compliance with EP 25, which requires the inclusion of the following information:
- Name of the activity
- Date of the activity
- Required frequency of the activity
- Name and contact information, including affiliation, of the person who performed the activity
- NFPA standard(s) referenced for the activity
- Results of the activity
In my experience, most folks have the first three pretty well in hand, but sometimes those last three get lost a bit in the shuffle. It might be worth a review of your in-house documentation to make sure you have all the required elements in place.
Way back in September of last year, we were chatting about the importance of appropriately managing conditions in the patient environment, primarily the surgical environment. For those wishing for a refresher, you can find that post here. (I talked about how I’ve noticed recent citation in surveys regarding the surgical environment, including the maintenance of temperature and humidity, ensuring appropriate air exchange rates, and making sure that your HVAC systems are appropriately maintaining pressure relationships, etc.)
One of the things I didn’t really cover back then was when you have documented out-of-range values. Could be temperature, could be humidity, could be those pesky air exchanges and/or pressure relationships. The fact of the matter is that we live in an imperfect world and, more often than not, our success comes down to how effectively we manage those imperfections. And that can, and does, come down to how well we’ve prepared staff at the point of care/service to be able to respond to conditions in the environment. But, in order to get there, you have to undertake a collaborative approach, involving your infection preventionist and the folks in the surgical environment.
The management of risk in the environment doesn’t happen because we have (or don’t have) nifty technology at our disposal; it’s because we can work collaboratively in ways that no building automation system or self-regulating HVAC equipment can. This idea has become an increasingly important part of the survey process. We know that more folks are harmed by hospital-acquired infections and other related conditions and I’ve seen it become a fairly significant survey vulnerability. So, let’s start talking about this stuff with the end users and make sure that we’re ahead of the curve on the matters of the care environment.
I generally don’t single out any of the myriad potential demographics of this portion of the blogosphere, but the Joint Commission’s January 2012 Perspectives, has singled out of you good folks keeping the safety faith out in California, based on some state-level legislation promulgated back in 2010.
The focus of the legislation is those folks engaged in CT scanning activities, which I’m going to guess includes just about everyone (the standard applies to ambulatory, critical access, and hospital accreditation). I don’t see this as a particular nuisance for folks. I believe that everyone with a compliant radiation control program is on top of this, but if you’re not—even if outside of California—this new element of performance (EP) might be worthy of consideration moving forward.
EP #17 (an “A” EP) under EC.02.04.03 requires at least an annual measurement of the actual radiation dose produced by each CT imaging system, and further requires that the radiation dose displayed on the system is within 20% of the actual amount of radiation dose measured. Naturally, the dates of these verifications would be documented (and, by extension, made available during survey.)
(We’ll be chatting more about what documents and documentation could be considered “reviewable” during survey—it’s a long list.
Now, a 20% margin is a pretty wide range, I would say. In fact, if there’s anyone out there in Cali who’d care to weigh in, would you mind speaking to how you’re managing this process and what your experiences have been? I’m going to guess the 20% tag is fairly attainable on a regular basis, but maybe not. It’s not really something that I’ve focused on in the past. It does seem that legislation on the coasts tends to ripple across the compliance landscape, so maybe a future concern is best dealt with now.
At any rate, if you have stories to share, by all means, please include us.
Let’s break from form a little bit and start with a question:
How often are you (and by you, I mean your organization) screening contracted staff, including physicians, physician assistants, nurse practitioners, etc.?
A recent TJC survey resulted in a finding under the HR standards because the process was being administered on a biannual cycle. The finding vaguely referenced OSHA guidelines in identifying this deficiency, but the specific regulatory reference point was not provided (though apparently a call to Chicago validated that this was the case). Now, anyone who’s worked with me in real time knows that I have an exhaustive (and, at times, exhausting) curiosity about such matters. The deficiency “concepts” are usually sourced back to a “they;” as in, “they told me I had to do this” “they told me I had to that.” I am always, always, always curious as to who this “they” might be and whether “they” were good enough to provide the applicable chapter and verse. The answer, more often than not, is “no.” Perhaps someday we’ll discuss the whimsical nature of the” Authority Having Jurisdiction” (AHJ) concept, but we’ll save that for another day.
At any rate, I did a little bit of digging around to try and locate a regulatory source on this and in this instance, the source exists; however, the standard is not quite as mandatory as one might first presume (If you’re thinking that this is going to somehow wrap around another risk assessment conversation, you are not far from wrong). So, a wee bit of history:
Back in 1994, the CDC issued their Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Facilities, (http://www.cdc.gov/mmwr/pdf/rr/rr5417.pdf) which, among other things, advises a risk-based approach to screening (Appendix C speaks to the screening requirements for all healthcare workers, regardless of who they work for. The guidance would be to include contract folks. The risk level is determined via a risk assessment (Appendix B of the Guidelines is a good start for that). So, for a medium exposure risk environment, CDC recommends annual screening, but for a low exposure risk environment, they recommend screening at time of hire, with no further screening required (unless your exposure risk increases, which should be part of the annual infection control risk assessment).
But, in 1996, OSHA issued a directive that indicates annual screening as the minimum requirement , even for low-risk exposure risks, and even while referencing the CDC guidance: (http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=DIRECTIVES&p_id=1586) with medium risk folks having semi-annual screening and high-risk folks being screened on a quarterly basis. So, friends, how are you managing folks in your environment, particularly the aforementioned contracted staff? Do you own them or is it the responsibility of their contracted employer? Does this stuff give you a headache when you think about it too much? It sure gives me one…occupational hazard, I guess. At any rate, it’s certainly worth checking to see whether a risk assessment for TB exposure has been conducted. The OSHA guidance document clearly indicates that if you haven’t, it’s the responsibility of the surveyor to conduct one for you, and I don’t know that I’d be really keen on having that happen.
A quick thought about safety manuals, taken from my book, The Hospital Safety Director’s Handbook, Fourth Edition:
To be considered useful, your safety manual needs to strike a balance between the availability of information and [more]
Whenever organizations like the ECRI Institute, the American National Standards Institute, and The Joint Commission provide consultative advice that could be described as a best practice, organizations that choose to adopt some other guidance will need to demonstrate that the alternative strategy they’ve adopted is equivalent from a risk management perspective to the original best practice. [more]
The EPA put a new rule into effect in December that requires hospitals with ethylene oxide (EtO) sterilizers to run full loads.
Partial loads may be run if medically necessary, and in all cases, hospitals must document every sterilizer load and, when loads aren’t full, note the medical reasons. The EPA mandates initial notification of compliance status for existing sterilizers by June 27, 2009.
A safety officer at a healthcare system with 800 licensed independent practitioners (LIPs) asked me whether it was acceptable to The Joint Commission that instead of an annual safety test, physicians read material relative to risks in the environment and attest to their knowledge and by signing a form.
She specifically pointed to EC.03.01.01, which requires staff members and LIPs to be familiar with their roles in the EC.
First off, the language involved in establishing the expectations comes down to [more]
As a quick follow up to my post last week about The Joint Commission’s updated FAQs, I wanted to discuss related documentation.
Remember those nifty little “D” icons in the EC, emergency management, and life safety standards that tell us what has to be documented? I don’t see ‘em on the FAQ page. [more]