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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!

He held his head in his hands: Outpatient/Offsite Vulnerabilities

Being something of a quiet week on the compliance front (as we embrace the “dog days” of summer—and spring’s got 10 or so days to go), I wanted to use a recent Joint Commission announcement relative to Environment of Care standards relating to fluoroscopy as they apply to outpatient/office-based surgery practices (which seems rather more logical than not, particularly when one reflects on the Conditions of Participation requirements relating to the management of imaging equipment). You can find the particulars here, but I don’t think that there’s anything that’s going to come as a surprise. To my mind, why would the expectations be any different based on where the equipment “lives”? Just as there must be continuity of care, there must also be continuity of compliance.

Now one could certainly disagree as to how much of a sea change this represents relative to the survey process, but (and I’m going out on a limb here, but it’s a very, very stout one) I think the next significant survey “beachhead” (mixing all sort of metaphors today) is going to be all those pesky little physician practices and clinics and such that dot the landscape and are covered by the “umbrella” of hospital operations (you know, offsite locations that have become “departments of the hospital”). If we accept the premise that the primary goal of the survey process is to generate as many findings as possible (and I accept that premise—the evidence doesn’t really point to much else), then the likelihood of the regulatory folks looking for areas with greater levels of vulnerability seems, again, rather more logical than not.

At any rate, my best advice to those of you with these types of sites is to really kick the tires when you’re rounding. As you are no doubt aware, there can be a lot of resistance when compliance comes to the hinterlands (think about how much angst fire drills can generate!), but the stakes for non-compliance have never been greater and, for the record, one can never be too safe…or too compliant!

I’d like to know, can you tell me, please don’t tell me: Behavioral health and egress

In response to last week’s modified Top 10 list (there’s been a request for another list regarding point-of-care/point-of-service staff knowledge of EC stuff—coming soon to a blog near you…), I received a question from the Lone Star state that I wanted to chat about with the group at large (I’m never quite sure if folks go back and revisit past questions and I thought this one might generate some comments from folks in general).

The question comes from the folks at a large hospital in east Texas who are in the process of designating a behavioral health “safe room” adjacent to their ER, where they’ll be holding patients for evaluation and eventual transportation to a local behavioral health hospital. The room in question is approximately 900 square feet (30 x 30) and the question raised relates to installing a second door in the space for use in the event of an emergency. The problem (or at least the stated problem, a little more pondering in a moment) is that this second egress door would lead into a major egress corridor. The question resulting from this “problem” is whether, due to the nature of what’s going on in the behavioral health room, having the door swing out into the egress route would be permitted, based on a risk assessment, etc.

First off (and you could certainly look at this as a bit of shameless self-promotion), it would be much more effective to be walking/talking this through in the present physical space, etc., but since I’m not scheduled to visit east Texas any time soon, I’m going to have to work this from afar. To that end, I have one question for the general audience: Do any of you have a behavioral health safe room with more than one “portal”? Since I saw this question, I’ve been racking my brain to recall an instance in which there was a room (as opposed to a designated space within an ER, or indeed, a behavioral health ER) that had a second egress door (and if I’ve visited your “house” and you have a two-door arrangement and I have somehow forgotten, please let me know). Even before I get to the door swinging into the egress corridor (and I think there are ways of being able to do this, but more on that in a moment—though it will require some homework), I start thinking about how you would secure that second door in such a way as to appropriately limit escape by the patient occupant and still provide sufficient access to staff removing themselves from a dangerous situation. Talk about a tightrope. But then I’m thinking, is there a way to configure the space that reduces the potential for a staff person to become “trapped” even with only one way out? I’m intuiting that the request for the second door is based on an actual occurrence in which an entrapment occurred, but I keep coming up against the “reality” that I can’t think of a behavioral health room with multiple ways out and that staff education of appropriate techniques for dealing with patients in a “confined” space would be the way to go.

As to the second egress door itself, while there are instances in which doors do swing out into an egress corridor, I think probably the best way forward, once you have completed the risk assessment, is to seek out the opinion of the authority having jurisdiction (AHJ), which in this instance would be the Texas Department of Health. Having had some experience with CMS surveys conducted by the state in that part of the world (and, truthfully, in most parts of the world) is to embark upon a field modification without providing the AHJ with an opportunity to review the proposed change(s). I think the primary reason that I would encourage this route is that this appears to be a somewhat unusual (if not quite rare, though it may be) arrangement; I understand the safety implications of the second door, but I also understand the implications such an arrangement can have on egress for adjacent occupants and I am not convinced that you’ll get carte blanche from the regulatory folks solely on the basis of a risk assessment in hand.

That said, I suppose you could also investigate a modification to the space that creates enough of an alcove on the egress side of the space to provide room for door swing, though that would certainly reduce the number of folks you could safely manage in the space. It may be that you folks are on the cutting edge of healthcare design, but sometimes the cutting edge “cuts” in the wrong direction. Given the attention being paid to the physical environment at the moment, it is unlikely that such a modification would escape notice (particularly with CMS).

The pendulum may swing back at some point, but I don’t see it happening any time soon—there are so many potential findings that they’d be hard-pressed to turn away. It’s very much like finding buried treasure and then leaving some for somebody else to find—it is not in line with human nature to walk away while there are still riches to be had.

We are hope, despite the times: Steve Mac’s top 10 most troublesome EC challenges

First a quick (moderately revelatory) story: While traveling last week, I had the opportunity to see Creed II on the plane (I found it very entertaining, though somewhat reminiscent of another film—but no spoilers here). Interestingly enough, the image that stayed with me was during a scene on a maternity unit in a hospital where I observed a nicely obstructed fire extinguisher (there was some sort of unattended cart parked in front of the extinguisher). I guess that means I can never turn “this” (and you can call it what you will) off… but enough digression.

About a month or so ago, an organization with whom I had not worked before (they’re on the upcoming schedule) asked for a top 10 list of what I’ve seen as the most challenging physical environment standards, etc. I will admit to having been taken off guard a wee bit (I usually depend on others for top 10 lists), but then I figured it was probably about time that I put a little structure to all the various and sundry things that I’ve seen over the last decade or so.

To that end, here are Steve Mac’s Top 10 Things that will get you in the most trouble in the quickest amount of time (I don’t think there are any surprises, but feel free to disagree…):

Top 10 Critical Process Vulnerabilities – Physical Environment

  1. Inadequately mitigated ligature/safety risks in behavioral health environments
  2. Management of surgical and other procedural environments (temperature, humidity, air pressure relationships)
  3. Construction management process—lack of coordination, inconsistent implementation of risk management strategies
  4. ILSM policy/assessment/implementation—including “regular” LS deficiencies
  5. Management of hazardous materials risks, particularly those relating to occupational exposure (eyewash stations, monitoring, etc.)
  6. Life safety drawings (accuracy, completeness, etc.)
  7. Management of infection control risks in the environment (non-intact surfaces, expired product, high, intermediate and low-level disinfection)
  8. Management of contractors/vendors (documentation, activities, etc.)
  9. Effectiveness of surveillance rounds; integration of work order system, etc., to address compliance concerns
  10. Stewardship of the environment—participation of point-of-care/point-of-service staff in management of the environment.

Now I don’t know that there’s anything here that we haven’t covered in the past, but if you folks would like a more in-depth analysis of anything in the list above (or, indeed, anything else), please let me know. I suspect that I will be returning to this list from time to time (particularly during slow news weeks).

How green is your dashboard? Using the annual evaluation process to make improvements

I was recently fielding a question about the required frequencies for hazard surveillance rounds (hint: there are no longer required frequencies—it is expected that each organization will determine how frequency of rounding and effective management of program complement each other) and it prompted me to look at what was left of the back end of the EC chapter (and there really isn’t a lot compared to what was once almost biblical in implication). I think we can agree that there has been a concerted effort over time to enhance/encourage the management of the physical environment as a performance improvement activity (it’s oft been said that the safety committee is among the most important non-medical staff committees in any organization—and even more so if you have physician participation) and there’s been a lot of work on dashboards and scorecards aimed at keeping the physical environment in the PI mix.

But in thinking back to some of the EC scorekeeping documents I’ve reviewed over the years (and this includes annual evaluations of the program), the overarching impression I have is one of a lot of green with a smattering of yellow, with a rather infrequent punctuation of red. Now I “get” that nobody wants to air their dirty laundry, or at least want to control how and where that type of information is disseminated, but I keep coming back to the list of most frequently cited standards and wonder how folks are actually managing the dichotomy of trying to manage an effective program and having a survey (aimed at those imperfections that make us crazy) that flies in the face of a mostly (if not entirely) green report card.

While it’s always a good thing to know where you stand relative to your daily compliance stuff, when it comes down to communication of PI data, it’s not so much about what you’re doing well, but where you need to make improvements. I venture to predict that the time will come when the survey process starts to focus on how improvement opportunities are communicated to leadership and how effective those communications are in actually facilitating improvement. It’s not so much about “blaming” barriers, but rather the facilitation of barrier removal. There will always be barriers to compliance in one form or another; our task is to move our organizations past those barriers. With the amount of data that needs to be managed by organizational leadership, you have to make the most of those opportunities when direct communications are possible/encouraged. And if there are considerations for which the assistance of organizational leadership is indicated, you have a pipeline in place to get that done with the annual evaluation process.

An invitation to the regulatory dance—and the band keeps playing faster…

About a year ago, we chatted a bit about the likely changes to the regulatory landscape under a new administration, most of which (at least those related to the changing of the guard) never really materialized to any great extent. But one thing held true—and continues as we embark upon the good ship 2018—the focus on management of the physical environment is very much at the forefront of preparatory activities.

We also chatted a bit about The Joint Commission’s previous exhortations to healthcare leaders to focus more attention on the management of the physical environment (I was going to provide a link to TJC’s leadership blog regarding our little world, but it appears that the page is not so easily found, though I’m sure it has nothing to do with revisionist history…). But it does appear that there’s no reason to think that the number (and probably types) of survey findings in the environment are going to be anything but steady, though hopefully not a steady increase. Remember, we still have two years in the survey cycle before everyone gets to have undergone their first survey with the loss of the rate-based performance elements.

Which brings us squarely to 2018 and our continuing storm of regulatory challenges; I had made a list of stuff that I believed would play some role of significance in 2017 and (strangely enough) appear to be poised to do the same in the coming year (or two…or three?!?):


  1. Physical environment standards remain among the most frequently cited during TJC surveys (Nine of the 10 most frequently cited standards for the period January through June 2017). Please check out the September 2017 issue of Joint Commission Perspectives for the details! Just so you know (and I do believe that I’ve mentioned this in the past), I “count” IC.02.02.01 as a physical environment standard. Yes, I know it’s under the Infection Control chapter, but disinfection, the management of equipment and supplies? That all happens in the environment!
  2. CMS, in its report card to Congress, identified the physical environment as the largest “gap” of oversight during all accreditation organization surveys
  3. Also in its report card to Congress, CMS singled out TJC as lagging behind its competition when it comes to improving identification of deficiencies relative to the Conditions of Participation. I firmly believe that the report card to Congress was the proverbial “spark” that fanned the flames of regulatory focus in the environment. I don’t know when we can expect an updated edition of the report card (I suspect that it may be a while), but knowing that CMS is “concerned” can only mean continued focus…
  4. CMS adoption of the 2012 Life Safety Code® (effective survey date of November 1, 2016) definitely did create some level of confusion and uncertainty that always accompanies “change.” And 2017 demonstrated very clearly that it’s not just “us” that have to learn the practical application of the new stuff—the surveyors have to catch up as well! I am definitely starting to see the impact of the adoption of the 2012 Health Facilities Code (NFPA 99)—if you don’t have a copy in your library, it might just be time.
  5. TJC is in the process of revising its Environment of Care and Life Safety chapters to more closely reflect CMS requirements. January 2018 continues the rollout of the standards/performance elements updates—and they’re still not done. As we’ve discussed over the last few weeks, there’s still a lot of shifting requirements (some we always knew were in place, others merely rumored).
  6. Recent TJC survey reports indicate an increasing focus (and resulting vulnerabilities) on outpatient locations, particularly those engaging in high-level disinfection and/or surgical procedures. The physical environment in all areas in which patients receive care, treatment, and services are generating up to 60% of the total physical environment findings in recent surveys. That was just as true in 2017 as in 2016—each care location in the organization has to be prepared for multi-day scrutiny.
  7. CMS published its final rule on Emergency Preparedness (including Interpretive Guidelines, effective November 2016, with full implementation of requirements due November 2017). While organizations in compliance with current TJC Emergency Management standards will be in substantial compliance with the new rule, there will be some potential vulnerabilities relative to some of the specific components of the rule. The key sticking points at the moment appear to relate to the Continuity of Operations Plan (COOP) and the processes for delegating authority and leadership succession planning during extended events.
  8. Introduction of TJC’s SAFER matrix, which did indeed result in every deficiency identified during the survey process being included in the final survey report. Formerly, there was a section called Opportunities For Improvement for the single findings that didn’t “roll up” into a Requirement For Improvement. With the SAFER matrix, everything they find goes into the report. And there did seem to be a preponderance of findings “clustered” (make of that descriptor what you will) in the high risk sections of the matrix.
  9. As a final “nail” in the survey process coffin, effective January 2017, TJC will no longer provide for the clarification of findings once the survey has been completed. While this didn’t result in quite the devastation in the process as it might have first appeared (mostly because I think it forced the issue of pushing back during the survey), it also appears that clarification only during survey was not the hard line in the sand it appeared to be when this first “dropped.” That said, there very definitely seems to be a reluctance on the part of the folks at the Standards Interpretation Group (SIG) to “reverse the call on the field” once the survey team has left the building; just as there is a reluctance to vacate physical environment findings once the LS surveyor has hit the bricks. If you feel that a finding is not valid, there is no time like the present when it comes to the pushback.
  10. One unexpected “change” during 2017: The focus on ligature risks in the various environments in which behavioral health patients receive care, treatment, and/or services. We’ve discussed the particulars fairly extensively in this space and while I didn’t see it “coming,” it has certainly leaped to the top of the concern pile. The recent guidance from the regulators has (perhaps) helped to some degree, but this one feels a lot like the focus on the procedural environment over the past couple of years. I don’t think they’re done with this by any stretch…


In my mind, still working from the perspective of CMS calling out the physical environment as an area of concern, the stuff noted above indicates the likely result that the next 12-24 survey months will show a continued focus on the physical environment by the entire survey team (not just the Life Safety surveyor) and a likely continued plateau or increase in findings relating to the physical environment. I still believe that eventually the regulatory focus will drift back more toward patient care-related issues, but right now the focus on the physical environment is generating a ton of findings. And since that appears to be their primary function (generating findings), there’s always lots to find in the environment.

As I like to tell folks (probably ad nauseum, truth be told), there are no perfect buildings/environments, so there’s always stuff to be found—mostly fairly small items on the risk scale, but they are all citable. The fact of the matter is that there will be findings in the physical environment during your next survey, so the focus will shift to include ensuring that the corrective action plans for those findings are not only appropriate, but also can demonstrate consideration of sustained compliance over time. Preparing for the survey of the physical environment must reflect an ongoing process for managing “imperfections”—not just every 36 (or so) months, but every day.

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!

The end of hordes of portal exhortals: Getting hep to the PEP!

Lots of information to cover this week, so let’s get started.

Effective July 1, 2016, there are a few EC performance elements that will be ushered into the archives; in looking at the provided information, which includes rationales for the removal of each EP: the decision-making process pretty much sorted out into four categories; 1) the EP is implicit in another EP in the standard; 2) the EP is duplicative of another EP in the standard; 3) the EP reflects an issue that should be left to the discretion of the organization, or, 4) the EP is considered part of regular operations and is reflected elsewhere in the standards. So that all seems pretty rational (which is a most excellent starting point for a rationale), but there have been instances in the past when the removal of an EP has ended up complicating compliance (the most prominent example being the removal of the EP requiring the triennial review of safety-related policies and procedures, which was “replaced” with the expectation that the annual evaluation process for each EC management plan would be inclusive of a review of policies and procedures), so this latest revelation may end up being something of the proverbial double-edged sword.

That said, I don’t see anything that I would consider particularly problematic: interventionary powers for immediate threats to life and/or health; managing the risks inherent with allowing patients to smoke; self-determination when it comes to soliciting input to aid the process for selecting and acquiring medical equipment; interim measures and re-testing of emergency power system components when there are failures; a little more flexibility regarding the practical administration of your improvement activities relative to EC. These all seem fairly benign. It does make me wonder if this is as much the result of these EPs not being surveyed to the same extent as other in the EC chapter, but wondering doesn’t necessarily get us very far. At any rate, if folks have some thoughts they’d care to share, I’m all ears!

Next up, we encounter our latest acronym PEP—short for Physical Environment Portal. As I noted to my friend and colleague Jay Kumar, there are many more rhyming opportunities for PEP than for portal, so I’m down with this.

This month’s update focuses on the some of the problematic aspects of LS.02.01.10, which mostly deals with the requirements revolving around your fire-rated barriers. Interestingly enough, it appears that the compliance gaps relate to managing rated doors and rated barrier walls (I’m sure you are all just as shocked as I am with that information). There are a couple of click-through links to Joint Commission Resources, which are basically reprints of some Clarification & Expectations columns from the June and July 2012 editions of EC News. I’m thinking you may already have those in hand, but if not, they are offered free of charge (you just have to register). The example of improved compliance is kind of interesting in a rather non-illuminative way, but that may just be me. So (and this may be a function of having to come up with compelling content every month), a not particularly peppy PEP this month, but what can you do?

As a final bit of info this week, I don’t know if you saw the marketing for the July Environment of Care Base Camp session, but I found it interesting that they’re really playing up the “you can’t get this information anywhere else” card, with a further indication that any other EC educational programs are based on findings from last year. Basically, they’re saying that if you pony up the dough, you can find out what the focus of the physical environment survey is this year (presumably based on the first few months of 2016), which sounds just a little bit extortionate to me. If memory serves, the purpose of the whole Physical Environment Portal was to provide healthcare facilities and safety professionals insight to the process and allow for more effective preparation, etc. Which I guess only serves to indicate that you get what you pay for…but should you have to pay for information regarding the expectations of regulatory inspectors/AHJs? It’s like having to go to a conference to have access to all this great content, etc., and no really useful way to determine if what you missed was of critical importance. I’m thinking that our budgetary focus would be more towards making operational improvements as opposed to spending time away at a conference, but perhaps I’m just a wee bit crazy…

Thanks to Jay Kumar for the “hep to PEP” line! See you next week…

If you set things up correctly…they will still find stuff!

Those of you who are frequent readers of this little space are probably getting tired of me harping on this subject. And while I will admit that I find the whole thing a tad disconcerting, I guess this gives me something to write about (the toughest thing about doing the blog is coming up with stuff I think you folks would find of interest). And so, there is an extraordinary likelihood that you will have multiple EC/LS findings during your next triennial Joint Commission visit—and I’m not entirely convinced that there’s a whole lot you can do to prevent that from happening (you are not powerless in the process, but more in that in a moment).

Look at this way: Do you really think that you can have a regulatory surveyor run through your place for two or three days and at the end “admit” that they couldn’t find any deficiencies? I’ve worked in healthcare long enough to remember when a “no finding” survey was possible, but the odds are definitely stacked against the healthcare professionals when it comes to this “game.” And what amazes me even more than that is when folks are surprised when it happens! Think about, CMS has been taking free kicks on TJC’s noggin for almost 10 years at this point—because they weren’t finding enough issues during the triennial survey process. BTW, I’m not saying that there’s a quota system in place; although there are certainly instances in which surveyors over-interpret standards and performance elements, I can honestly say that I don’t find too many findings that were not (more or less) legitimate. But we’re really and truly not talking about big-ticket scary, immediate jeopardy kind of conditions. We are definitely talking mostly about the minutiae of the safety world—the imperfections, if you will—the slings and arrows of outrageous fortune that one must endure when one allows humans to enter one’s hallowed halls. People mess stuff up. They usually don’t mean to (though there are some mistakes, and I think you can probably think of some examples in your own halls), but as one is wont to say, feces occurs. And there’s a whole segment of each healthcare organization charged with cleaning up that feces—wherever and however it occurs.

So what it all comes down to is this: you have to know what’s going on in your building and you have to know where you stand as a function of compliance, with the subset of that being that you have to have a robust process for identifying conditions soon enough and far enough “upstream” to be able to manage them appropriately. We’ve discussed the finder/fixer dynamic in the past (here’s a refresher), so I won’t belabor that point, but we need to use that process to generate compliance data. Strictly speaking, you really, really, really need to acquaint yourselves with the “C” Elements of Performance; compliance is determined as a rate and if you can demonstrate that your historical compliance rate is 90% or better, then you are in compliance with that standard/EP. But if you’re not using the surveillance process, the finder/fixer process, the tracer process, the work order process, the above the ceiling permitting process, ad nauseum, to generate data that can be used to determine compliance, then you are potentially looking at a very long survey process. Again, it goes back to my opening salvo; they are going to find “stuff” and if you are paying good attention to what goes on in your organization, then they shouldn’t be able to find anything that you don’t already know about.

The management of the physical environment is, at its heart, a performance improvement undertaking. As a support process for hardwiring ongoing sustained improvement, a process for the proactive risk assessment of conditions in the physical environment is essential. As an example, the next assessment would use the slate of findings from your most recent surveillance rounds to extrapolate the identification of additional risks in the physical environment. For all intents and purposes, it is impossible to provide a physical environment that is completely risk free, so the key focus becomes one of identification of risks, prioritizing the resolution of those risks that can be resolved (immediate and long-term), and to develop strategies for managing those risks that are going to require resource planning and allocation over an extended period of time. The goal of the process is to ensure that the organization can articulate the appropriate management of these risks and to be able to provide data (occurrence reporting, etc.) to support the determination of that level of safety. By establishing a feedback loop for the management of risk, it allows the organization to fully integrate past actions into the improvement continuum. If you think of the improvement continuum as a football field (it is, after all, the season for such metaphors) or indeed any game “environment,” you need to know where you are in order to figure out where you need to go/be. The scrutiny of the physical environment has never been greater and there’s no reason to think that that is going to change any time soon. Your “power” is in preparing for the survey by being prepared to make full use of the post-survey clarification process—yup, they found a couple of doors that didn’t close and latch, a fire extinguisher that missed a monthly inspection or two, and on and on. Anticipate what they’ll find based on what you see every time you “look” (again, it’s nothing “new” to you—or shouldn’t be) and start figuring out where you are on the grid. That way, they can find what they want (which they will; no point in fighting it anymore) and you can say, thanks for pointing that out, but I know that my compliance rate for doors/fire extinguishers/etc. is 90%, 91%, 92%, etc. We want them to work very hard to find stuff, but find stuff they will (that’s a little Yoda-esque). We just have to know what do “aftah.”

Underneath the accreditation manual last night!

And just when you thought you’d opened up all the presents under the tree, you see one way in the back and it’s another one from our friends at The Joint Commission (TJC)…but not just then, our friends at the American Society of Healthcare Engineering (ASHE) are also joining in this festive holiday season! Who needs the colds of December when such a bounty is available now!

TJC and ASHE have joined forces to create a portal to assist healthcare organizations in managing those pesky Environment of Care (EC)/Life Safety (LS) findings that have been (literally and figuratively) sweeping the nation. The stated purpose of the portal is to provide information to reduce findings of non-compliance with the eight EC/LS top findings (not sure if they’ll be coming up with a portal to address the IC findings under IC.02.02.01). They’ve broken things down to eight individual modules, one each for EC.02.05.01, LS.02.01.20, EC.02.06.01, EC.02.03.05, LS.02.01.10, LS.02.01.30, LS.02.01.35, and EC.02.02.01. These modules are being rolled out between now and October/November 2016, so this is going to be a gift that keeps on giving. We may have to rewrite the 12 Days of Christmas…

One thing that’s available right now is a Fireside Chat, featuring George Mills from TJC and Dale Woodin from ASHE (you’ll see the “screen” on the right hand side of the linked page noted above). The video takes about 20 minutes to watch, but it gives you a glimpse of the thought process behind the portal, the mission of the portal, a discussion of the portal itself, and ultimately, what the expectations are of organizations. It sounds like the portal is going to feature information that gets down to the EP level (I don’t know that there will be too many surprises for what EPs get the attention, particularly if you’ve been following this space) and, hopefully, will provide some practical (and I mean practical in a sustainable way) compliance solutions. I’m really interested to see what the sum and substance of the modules will be; I don’t know that there are that many “secrets” left, though I’m hoping that there’s a lot of good discussion about managing compliance data. I have yet to find a “perfect” building from a physical environment standpoint (buildings are never more perfect than the moment before you let the first person in), so it will be interesting to see how much focus is on recognizing those imperfections and “managing” them as a function of the all-important “high-reliability” benchmark. One last note, Messrs. Mills and Woodin indicate that all of the modules will be available throughout the rollout period (I’m glad they’re doing that, but it makes me wonder why they wouldn’t), though they don’t speak to the time beyond the end of the rollout. Maybe by then it won’t be necessary, but I’m thinking it would be nice if they could keep this going for at least the following (2017) year; that way, we’ll have gotten through an almost complete accreditation survey cycle.

At any rate, definitely check out the portal—and be sure to set aside some time for the Fireside Chat (sounds like the Chat will be a regular feature of the portal)—it’s definitely worth more than the 20 minutes it will take. And I don’t know that I wouldn’t make a point of sharing it with your boss (and maybe your boss’s boss); the greater the understanding of what is at stake, the greater the likelihood of appropriate levels of support when you have to go to the mat to make improvements in the physical environment.