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As we relive our lives in what we tell you…

While it is always my intent to be amazingly timely in posting things, sometimes items that I’ve earmarked for sharing end up languishing in my draft emails folder. And, as I was poking around trying to decide what to run with this week, I came upon an item that, while a little long in the tooth in terms of when it was published, should still provide some food for thought (and action) as we navigate the waters of preparedness. There are always things to do and events to plan for, but you’ll probably want to review the document to look over the updates.

As usual, there’s nothing that I see that makes me crazy, but I also know that, in the hands of some surveyors, what looks like flexibility to folks with practical experience can become “the only way.” So you might want to check out the review tool being used in a certain Midwest state very close (so close they are the same) to our friends from Chicago. At some point, I suspect that the conversations during survey are going to turn to “What about the next one?” (as we venture further into the realm of emerging infectious diseases, or EID), so it’s probably a good idea to start planning along those lines. Hopefully the next one doesn’t get here for a very, very long time, but…

A couple of general thoughts regarding some of the changes:

Play nicely with others: collaboration versus isolation. In one of those ever-shifting dualities brought on by the pandemic, there’s been a lot of “distancing” (social or otherwise) that has only (at least to my mind—feel free to disagree) increased the degree of difficulty when it comes to meaningful collaboration. At least now we can get folks to “visit” from time to time, but a lot of the most difficult situations, conditions, etc., over the last year or so were very much accomplished “on the fly.” I think we all try to live by the “stronger together” ethic, but I guess it just proves the point that the whole 96-hour thang is very dependent on the event(s). That said, if you are accredited by our friends in Chicago, be very certain that you have met the requirements for evaluating emergency response activities, have a documented review of your emergency inventory, reviewed your HVA, evaluated your emergency response plan/emergency management plan/emergency operations plan. It doesn’t have to be complicated, but there is some indication that shortfalls will be cited. Please take an hour this week and make sure all those little duckies are in neat rows.

The umbrella can provide protection for a lot of different events: we did touch on this earlier in the year, but I’m glad to see that guidance is being provided to surveyors that it is not necessary to have response plans/protocols for every possible event. That said, you want to make sure that you have a good cross-section of folks participating in the planning process, particularly with the whole EID issue. Infection control and prevention folks are amazingly important when it comes to planning for emergencies (but after the last 12 months or so, you really didn’t need me to tell you that), but there are other folks in your organization that have a part to play in the planning. I think one of the critical performance metrics going forward will be the general concept of continuity as it impacts operations across the continuum of care. Your planning must key on how the place stays in business over the long haul (recognizing we’re still “hauling” to a fair degree…) and you really want to include consideration of continuity as a specific evaluation element. We now know that we can appropriately to a really long event, but the hows and whys are going to be key as we move out of response into recovery mode.

I think you folks “got this,” but it never hurts to look preparedness in the eye from time to time.

Take me to your leaders…

I believe that we’ll be able to wrap up the emergency management stuff next week—though I have one or two ideas percolating that I might move to the front of the queue, but certainly before May gives way to June (unless something really interesting pops up out of nowhere…).

With our friends from Chicago returning to the playing field, there was some discussion of a modification to the session with organizational leadership, primarily involving moving the session to the opening of the survey and to have that session focus on leadership’s involvement with response to the pandemic over the last little while. The exact rationale for this strategy (which has since, more or less, gone away) kind of escapes me because I really don’t think the last 12-15 months could have been successfully navigated without some level of interest/action/participation, etc., on the part of hospital leadership teams pretty much everywhere on the globe. That said, I do suspect that the level of interest in all things emergency preparedness have probably not been as widely appreciated as they are right now (soon we will chat about making the most of this moment—but that’s for another day).

At any rate, with the unveiling of the new guidance (I don’t know that there’s necessarily anything “new” that’s going to come out of any of this, but I guess we’ll have to see, but this seems more like a recapitulation or codification than it does a significant change), there continues to be a concerted aim towards clarifying the necessity of organizational leadership participating in the emergency preparedness activities as a baseline expectation (an expectation I think we’ve all shared, yes?). Again, from a practical standpoint, your hospital, in all likelihood, would not have endured the last little while without the active participation/interest/whatever you care to call it from your leadership group. If someone managed to do so (and that doesn’t mean in spite of their participation), I’m keen to hear that story. But in the infinite wisdom of the regulatory monarchy, the following topics of conversation could be raised during any survey event in which leaders are queried about their EM roles:

  • How did the organization encourage collaborations with the available coalitions (local/regional/state: remembering that community partners are defined by each organization)?
  • How did the organization prepare for and manage staffing?
  • How did the organization prepare for and manage evacuation (including planning for the evacuation of patients that do not wish to be evacuated)?
  • How did the organization ensure that communications are collaborative and align with the methods/structures, etc., of the AHJs in the mix?
  • How did the organization promote participation in exercises and engage in the after action report process?
  • How did the organization ensure ongoing preparedness in the face of changes/shifts in community or other partners?
  • How did the organization identify what services would be provided under what circumstances?
  • How did the organization align continuity of operations and business continuity (we’ve had plenty of opportunity to look at this, I would think)?
  • How did the organization effectively manage the delegation of authority, including succession planning considerations?

In almost any other point in modern history, it might have proven to be somewhat burdensome to bring leaders up to speed in advance of a survey, but I can’t imagine that there are too many leadership groups out there that wouldn’t have more than enough practical experience (even if they never completed IS-100 and IS-200). Going forward, I think it’s going to be really helpful to keep the last year in everyone’s heads as a function of how we manage preparedness. It’s not just about regulatory compliance—it’s ensuring that providing care in a safe setting continues to be the number one priority of emergency response.

Hope you all are healthy and staying safe. Somehow I get the sense that we’re not quite done with this (though I would be more than happy to be proven incorrect in that sense), but we will prevail! See you next week!

The impossible year continues: Emergency response in 2020

Interestingly enough, I don’t believe that I have a great deal of yammering to do this week; not sure if it’s just a case of mental fatigue with all that continues to transpire (or I daresay, escalate) in terms of community emergencies of virtually every and any imaginable kind. Just between COVID-19 and a typical hurricane season, it would have been an adventure of epic proportions, but perhaps a wee bit more manageable than the various forces assailing the planet. But no, what in the past had tended to be rather transient in nature has now turned towards an aggregation of conditions that rivals…certainly nothing in recent memory and perhaps not ever (the Dark Ages, maybe).

One of the positive byproducts of such a year as this is the ongoing development and promulgation of resources – I have maintained, and will continue to do so, that hospitals are generally pretty well prepared to deal with “stuff.” As I see it, the whole point of preparedness is to be able to manage circumstances (be they singular or plural) without “breaking” (by breaking, I mean a catastrophic failure of response such that folks are actually placed in unprotected risk because of the break, as opposed to facing a situation in which hospital operations would need to be altered, moved, etc.). There are no perfect organizations when it comes to this, which is as it should be—but that doesn’t mean that folks are content to rest on past experiences, but rather to build on those experiences and make improvements. The magnitude of events this year has tested the healthcare industry in ways that would only have been predicted as a hyperbolic planning exercise (this year has been a whole lot of “and then this happens”). As has been the case any number of times in the past, hospitals and other healthcare organizations have had to manage things on their own and/or with community partners as the upper levels of the response infrastructure have been less effective than might have been desired (not pointing any fingers—this is not the first time, nor is it likely to be the last time that the most effective response happens at the local level).

At any rate, there are a few resources that I’ve noted over the past couple of weeks that I wanted to share. I somehow doubt that you’ll have a lot of spare time with which to review written materials, but I’m thinking that at least the links to these materials will be in a place you can “find” again. Lots of stuff here, a lot of it coming out of the response to wildfires in California, but as a primer for relocation, establishing alternative care sites, etc., there is much that is applicable to any untenable emergency condition:

As always, I hope this finds you safe and in reasonable sanity. I would like to think that we’ve got more of this behind us than in front of us, but the numbers are frowning at me, so I will just hold that hope…until next time!

Emergency management in (you guessed it) ambulatory healthcare

I was really, really, really thinking that I’d be able to glom on to some other subject matter this week (which I suppose it partially true), but it would seem that I’m going to be mining this particular vein of compliance (recognizing that “vein” rhymes with “bane”—make of that what you will…) for at least a bit longer.

At any rate, our friends in Chicago recently indicated some changes relative to the requirements for emergency exercises, but it does seem to be that the changes are intended to reflect CMS reducing the number of required exercises, as referenced in the Emergency Preparedness final rule, to one exercise per year and you only have to conduct a “big” (for lack of a better descriptor) exercise every other year. By big, that would be either a community-based, full-scale exercise (if available) or a facility-based functional exercise.

You may, of course, conduct as many “big” exercises as you like, but in the opposite years, you can even run with a tabletop exercise (though there is a fairly specific setup for the tabletop, so make sure each of the elements is accounted for before you try to take credit). Also, if your organization experiences an actual emergency that requires activation of the emergency plan, you can count that as your activation for the year (and it’s beginning to look a lot like COVID-19 is going to populate a lot of folks’ 2020-2021 emergency management program events).

As a somewhat related aside, this reduces the number of performance elements relating to exercises from three to one, so I think we can count this as a victory for the downtrodden, etc.

I know a lot of folks sometimes struggle with how to involve the ambulatory healthcare locations in exercises, so I think this provides a simpler framework to consider when identifying potential compliance gaps/shortfalls.

I think next week we’re probably going to have a little chat regarding fire drills; the July 2020 issue of The Joint Commission Perspectives has some “clarifying” thoughts on the topic that are probably worth kicking around.

Until next time, hope all is well and you’re staying safe!

It’s a lot like you: The dangerous type of emergency risks!

I know we chatted just last week about emergency management concerns, but once again, there’s more news stuff relating to the management of utility systems (it’s not just about water features) during emergencies and it does appear that the consequences of inadequately managed risks can get you into trouble with more than just the usual regulatory suspects.

A USA Today story from a couple of weeks ago outlined the charges/arrests resulting from the deaths of a number of nursing home patients in the aftermath of hurricane Irma, back in 2017. The sticking point, as it were, was the failure of the facility to evacuate once they lost the ability to effectively cool the facility. The news story paints a bleak picture of negligence, failure to call 911, etc., but also provides some indication that 911 calls from the facility received no response. I imagine that some details will emerge during trials as to what may or may not actually have transpired, including the existence of a “fully functional hospital across the street” to which (apparently) evacuation was not an option. I still maintain the most important part of any emergency response plan (and if not the most important, one of the very, very most important) is having a very clear understanding of what the trigger points are that would result in a need to evacuate. The worst thing that can happen with evacuation is to wait so long that a safe evacuation is not possible. I guess we’ll (hopefully) see what circumstances led up to this circumstance.

On a related (somewhat) note, our friends at the CDC have collaborated with the American Water Works Association to develop an Emergency Water Supply Planning Guide to assist healthcare facilities in their efforts to prepare for, respond to, and recover from, a total or partial water supply interruption. The Guide is designed to help folks assess water usage, response capabilities, and water supply alternatives. I suspect that this might be especially useful to folks in areas that tend to experience drought conditions, so if you want to check out the CDC Guide, you can find it here, along with links to some other preparedness resources.

Closing out things for this week, I’d like to share with you folks an article that I found to be of interest; while I don’t personally have managerial oversight in my current role, I saw enough parallels to “back in the day” to prompt the thought that “I wish there was something like this available when I was starting out.” So, in case you’re starting out in the amazing field of management or are interested in what’s going on in management theory, I think this would be worth your while. There’s a quote from Warren Buffett that I think really captures the essence of the compliance wars: “What the human being is best at doing is interpreting all new information so that their prior conclusions remain intact.” I bet that everyone reading this knows at least one human being like that…

You can find the whole article here.

If you don’t signal, how will I know where you want to go? Emergency management and its discontents (Just What You Needed)!

Kind of a mixed bag this week, though it all fits under the heading of emergency management, so here goes nothing…

A few weeks ago, USA Today did a story on the preparedness levels of the United States based on an analysis of state-by-state metrics. The story was based on a study, the National Health Security Preparedness Index, prepared by the Robert Wood Johnson Foundation and covers a lot of ground relative to trends in preparedness, including governmental spending on preparedness and some other stuff. The reason I “noticed” this was the indication that my home state was “best prepared” for disasters, etc., but the overarching message was that, even in the face of some setbacks in individual regions, the nation continues to improve emergency preparedness. Of course, it being USA Today, there are color slides indicating where each state ranks among the fabulous 50, so if you thought there was no scorekeeping on this front…

OK, maybe not keeping score, but a certain accreditation agency is keeping an eye on all things relating to preparedness. In this blog post, Jim Kendig (field director for the Life Safety Code® surveyors at The Joint Commission, and a very knowledgeable fellow when it comes to this stuff) provides a really good overview of the Preparedness Index and describes it in terms of how the various pieces can (and do) fit together and provide the foundation for an effective emergency management program. I see no reason why we can’t expect something more of a deep dive in the coming survey cycle and I think you’ll find the information Jim shares to be really helpful.

As a final thought for this week, it is always the case that what constitutes a mass casualty incident varies from organization to organization, but if you want to catch a glimpse of how this gets framed within the context of one of the largest metropolitan areas on the planet, the Greater New York Hospital Association developed a Mass Casualty Incident Response Toolkit that you might find worth checking out. There’s a ton of information, tools/forms, and links to more tools/forms, etc., to review in this space, but I encourage you to give the materials a look-see. It does appear that the nature of what we can expect to show up at our collective front doors is shifting and anything that facilitates better positioning to deal with an emergency is worth our time and energies.

Wagering on a sewer thing: How are you managing wastes during an emergency?

Burn, bury, or dump it—apparently there is madness in the method—and your plan needs to reflect the methodologies.

I recognize that, particularly with newly introduced requirements, guidelines, etc., the rarified elements that we collectively (if not quite lovingly) refer to as “surveyor interpretation” are at their most diverse, maddening, arbitrary, capricious, and on and on and on. That said, there is one element relating to the recent CMS update relative to emergency preparedness that I touched upon in the blog a couple of weeks ago , but did not devote a lot of discussion time to it. And that element relates to waste management during an emergency response.

During CMS surveys as recent as March 2019, there has been much discussion about the particulars of how folks are poised to manage the various and sundry waste products generated by/through normal hospital operations, particularly during a prolonged emergency response condition. And while I can’t say I saw this coming (at least not in the first wave of scrutiny), it does appear that the CMSers (or at least some of ’em) are looking for fairly detailed planning in this regard: collection, holding/storage, short-term disposal, long-term disposal, pharmaceutical wastes, chemical wastes, etc. , inclusive of second and third-level backup plans. I suppose, like with just about anything and everything you could name, there is always the potential for external disruption that constricts the ability to remove waste materials from our campuses. And, while I think we tend to focus our preparatory activities on sustaining normal operations, it would seem that there might be some vulnerability relating getting rid of the stuffs that are the result of those normal operations.

At this point, I’m not entirely certain if the focus is more to the consultative than the compliance-related approach—the topic was discussed during survey, but no report has been issued as of this writing (if I hear more, I will certainly let you know), so it’s anybody’s guess. But I do know that these things tend to spread pretty quickly in the field, so it certainly wouldn’t hurt to kick the tires of your waste processes during your next emergency response exercise.

Waste not, want not: The rest of the CMS Emergency Preparedness picture

Moving on to the rest of the guidance document (it still lives here), I did want to note one last item relative to emergency power: There is an expectation that “as part of the cooperation and collaboration with emergency preparedness officials,” organizations should confer with health department and emergency management officials, as well as healthcare coalitions to “determine the types and duration of energy sources that could be available to assist them in providing care to their patient population. As part of the risk assessment planning, facilities should determine the feasibility of relying on these sources and plan accordingly.

“NOTE: Hospitals, CAHs and LTC facilities are required to base their emergency power and stand-by systems on their emergency plans and risk assessments and including the policies and procedures for hospitals. The determination of the appropriate alternate energy source should be made through the development of the facility’s risk assessment and emergency plan. If these facilities determine that a permanent generator is not required to meet the emergency power and stand-by systems requirements for this emergency preparedness regulation, then §§482.15(e)(1) and (2), §483.73(e)(1) and (2),

  • 485.625(e)(1) and (2), would not apply. However, these facility types must continue to meet the existing emergency power provisions and requirements for their provider/supplier types under physical environment CoPs or any existing LSC guidance.”

“If a Hospital, CAH or LTC facility determines that the use of a portable and mobile generator would be the best way to accommodate for additional electrical loads necessary to meet subsistence needs required by emergency preparedness plans, policies and procedures, then NFPA requirements on emergency and standby power systems such as generator installation, location, inspection and testing, and fuel would not be applicable to the portable generator and associated distribution system, except for NFPA 70 – National Electrical Code.”

I think it is very clear that hospitals, et al., are going to be able to plot their own course relative to providing power during emergency conditions, but what’s not so clear is to what depth surveyors will be looking for you to “take” the risk assessment. I suspect that most folks would run with their permanently installed emergency generators and call it a day, but as healthcare organizations become healthcare networks become healthcare systems, the degree of complexity is going to drive some level of flexibility that can’t always be attained using fixed generator equipment. If anyone has any stories to share on this front (either recent or future), I hope you’re inclined to share (and you can reach out directly to me and I will anonymize your story, if you like).

Wrapping up the rest of the changes/additions, you’ll be pleased to hear that you are not required to provide on-site treatment of sewage or waste, but you need to have provisions for maintaining “necessary services.” Of course, the memo indicates that they are not specifying what “necessary services for sewage or waste management” might be, so a little self-definition would appear to be in order.

If your organization has a home health agency, then you need to make sure that the communication plan includes all the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. I think that one’s pretty self-evident but may be worth a little verification.

Next up are some thoughts about providing education to folks working as contracted staff who provide services in multiple surrounding areas; the guidance indicates that it may not be feasible for these folks to receive formal training for each of the facilities emergency response plan/program. The expectation is that each individual (and this applies equally to everyone else in the mix) knows the emergency response program and their role during emergencies, but each organization can determine how that happens, including what constitutes appropriate evidence that the training was completed. Additionally, if a surveyor asks one of these folks what their role is during a disaster, then the expectation would be for them to be able to describe the plan and their role(s). No big surprise there (I suspect that validating the competency of point-of-care/service staff is going to be playing a greater role in the survey process—how many folks would they have to ask before somebody “fumbles”?)

The last item relates to the use of real emergency response events in place of the required exercises; I would have thought that this was (relatively) self-evident, but I guess there were enough questions from the field for them to specify that you can indeed use a real event in place of an exercise. Just make sure you have the documentation in order (I know I didn’t “have” to say that, but I figure if it’s important enough for CMS to say it, then who am I…). The timing would be one year from the actual response activation, so make sure you keep a close eye on those calendars (unless, of course, you have numerous real-life opportunities…).

I do think the overarching sense of this is positive, at least in terms of limiting the prescriptive elements. As is sometimes the case, the “responsibility” falls to each organization to be prepared to educate the surveyors as to what preparedness looks like—it has many similar components, but how things integrate can have great variability. Don’t be afraid to do a little hand-holding if the surveyors are looking for something to be done a certain or to look a certain way. You know what works best in your “house,” better than any surveyor!

And the wind blew the echoes of long faded voices: Some Emergency Management thoughts…

While the year seemed to start out relatively quietly on the emergency front (relative being a completely relative and arbitrary term—and perhaps never more so than at the moment), it appears that the various and sundry forces of nature (and un-nature) are conspiring to send 2018 out with a bang. From wildfires out West to curiously damp weather patterns in the East to some funky temperature swings in the middle, it seems preparedness levels are as critical an undertaking as ever (and frequently coming nowhere close to being over-resourced, but I guess there’s no reason that the “do more with less” mantra wouldn’t extend to the EM world), with a likely follow-up of focus by the accreditation preparedness panjandrums (more this than this, but I’m fine with either). And one area of vulnerability that I see if the regulatory noggins should swivel in this direction relates to improvements in educating folks on an ongoing basis (the Final Rule says annual, so that determines a baseline for frequency), including some sort of evidence that what you’re doing is effective. (I see lots and lots of annual evaluations that track activities/widgets without getting down to a means of determining effectiveness—another improvement opportunity!) The other “shoe” that I fear might drop is the inclusion of all those care sites you have out in the community. There are very (very, very) few healthcare organizations that are comprised of a single standalone facility; over time, acquisitions of physician practices and other community-based healthcare delivery settings have increased the complexity of physical environment compliance, including emergency management stuff. I don’t know that I’ve run into anyone who couldn’t somehow, to one degree or another, point to participation of the offsite care locations. But it typically comes as, if not quite an afterthought, then a scenario that kind of “grafts” the offsites into the exercise. And, much as I wish community exercises would include testing of response activities in which the hospital acts in a diminished or non-capacity (there’s always this sense that we’ll just keep bringing folks to the local ED), some of the events of this year have really impacted ready access to hospital services for communities. At any rate, if you have thoughts on how you are (or could be) doing a good/better job at testing preparedness across your whole healthcare network, I am all ears and I suspect that there might be some other attentive ears as well.

In closing for this week (a little late, but this truly shouldn’t be tied to just one day or week), my thanks to all that have served in the armed forces: past, present, and future. Your sacrifices continue to mean so much to our lives and I cannot thank you enough (but with the annual Day of Thanks coming up next week, I will surely try)!

Odds and Sods: Clearing out the Safety Brain

Once again, I come face-to-face with my depository for blog postings and the like, so we have something of a mixed bag this week, with very little in the way of a common theme…

I’m sure folks saw the news story regarding the dead woman found in a stairwell of a hospital power plant and it got me to thinking about the increasing importance of ensuring that all your unmonitored perimeter points are as secure as they can be. It appears that the woman was able to gain access to the stairwell and was either too confused or otherwise compromised to make her way back out. The hospital has since hardened the perimeter of the power plant, but I think this points out that you really need to encourage folks to be on the lookout (security rounds can really only go so far) for unusual circumstances/ folks in their environments. It may be that there was nothing that could be done to prevent this tragedy, but I think it serves as a reminder that you really can’t be too secure.

As something of a parallel pursuit, HCPro recently re-aired a webinar presented my good friend and colleague Ken Rohde on the topic of occurrence reporting and its impact on operations, including the safety realm. Ken is an awesome presenter with a completely useful take on how safety operations impact, and are impacted, by how we manage occurrence reporting, particularly as a source of data for making improvements. If you have some monies in your budget for education, I really encourage you to check out the On-Demand presentation and let Ken help you improve your safety program.

In other parts of my noggin, I was looking at the crosswalk that TJC provides in the online version of their accreditation manual and was contemplating what is referenced as the applicable CMS requirement that “drives” the documentation requirements under EC.02.03.05 EP #28. In all candor, what prompted me to look was this nagging feeling that there are a lot of other required process documentation elements in other parts of the Environment of Care standards and whether there is a likelihood of those documentation requirements being carried over to things like generator testing, medical gas and vacuum system testing, etc. (for you pop culture enthusiasts, I consulted the magic 8 ball and it says “signs point to yes”; for those of you not yet familiar with the amazing technology that is the Magic 8 Ball, find more here). And when I looked at the TJC/CMS crosswalk, I noted that not only is the Life Safety Code® invoked as a referenced requirement, but also the Emergency Preparedness Condition as a function of the provision of alternate sources of energy for maintaining fire detection, extinguishing, and alarm systems. It may not be an imminent shift, but I think you would do well to consider adopting the documentation format outlined under EC.02.03.05 EP #28—it will help organize compliance and maybe, just maybe, keep you a half-step ahead of the sheriff…

On a closing note, I have (yet another) summer reading recommendation for folks: I think we can all agree that the use of effective communications is one of the most powerful tools that we can bring to our safety practices. As you all know every well (I’ve been inflicting this on you all for many, many…), I do tend towards more florid descriptors (that’s one there; I mean who uses “florid” anymore?), which can make comprehension difficult across a multi-faceted audience if you do not take into consideration the entirety of the audience. At any rate, I recently finished Alan Alda’s latest If I Understood You, Would I Have This Look on My Face?, which deals with the science of communications and provides a lot of thought-provoking suggestions on how we might improve the effectiveness of interpersonal communications at every level of life. For me, the most compelling insight was the notion that is the responsibility of the person doing the communicating to make sure that the audience is comprehending what is being communicated. That prompted me to reflect on any number of conversations I’ve had over the years, more or less revolving around the frustration with an audience that “just doesn’t get it” and the thought that perhaps the audience (in all its parameters) merits more consideration when things don’t work out in the way it was planned. At any rate, I found a lot of interesting perspectives on communications and (it’s a pretty quick read) I think you might find a nugget or two for your own use.