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Welcome to a new kind of tension…

In the “old” days, The Joint Commission’s FAQ page would indicate the date on which the individual FAQs had been updated, but now that feature seems to be missing from the site (it may be that deluge of changes to the FAQs (past, present, and, presumably, future) makes that a more challenging task than previously (I will freely admit that there wasn’t a ton of activity with the FAQs until recently). That said, there does appear to be some indication when there is new material. For example, when you click on the link (or clink on the lick), a little short of halfway down the page you will see that there’s something new relative to the storage of needles and syringes (they have it listed under the “Medical Equipment” function—more on that in a moment), so I think that’s OK.

But in last week’s (dated May 31, 2017) Joint Commission e-Alert, they indicate that there is a just posted FAQ item relating to ligature risks, but the FAQ does not appear to be highlighted in the same manner as the needle and syringe storage FAQ (at least as of June 1, when I am penning this item). Now I don’t disagree that the appropriate storage (recognizing that appropriate is in the eye of the beholder) of needles and syringes is an important topic of consideration, I’m thinking that anything that TJC issues relative to the appropriate management of ligature risks (and yes, it appears that I am far from done covering this particular topic) is of pretty close to utmost importance, particularly for those of you likely to experience a TJC survey in the next little while. I would encourage you to take a few moments to take a peek at the details here.

So, parsing these updates a bit: I don’t know that I’ve ever considered needles and syringes “medical equipment,” but I suppose they are really not medications, so I guess medical equipment is the appropriate descriptor—it will be interesting to see where issues related to the storage of needles and syringes are cited. As usual (at least on the TJC front) it all revolves around the (wait for it…) risk assessment. It’s kind of interesting in that this particular FAQ deals somewhat less specifically with the topic at hand (storage of needles and syringes) and more about the general concepts of the risk assessment process, including mention of the model risk assessment that can be found in the introductory section of the Leadership chapter (Leadership, to my mind, is a very good place to highlight the risk assessment process). So no particularly new or brilliant illumination here, but perhaps an indicator of future survey focus.

As to the ligature risks, I think it is reasonable to believe that there will be very few instances in which every single possible ligature risk will be removed from the care environment, which means that everyone is going to have to come up with some sort of mitigation strategy to manage those risks that have not been removed. With the FAQ, TJC has provided some guidance relative to what would minimally be expected of that mitigation strategy; while I dare not indicate verbatim (you will have to do your own clicking on this one—sorry!), you might imagine that there would need to be: communication of current risks; process for assessing patient risk; implementation of appropriate interventions; ongoing assessments of at-risk behavior; training of staff relative to levels of risk and appropriate interventions; inclusion of reduction strategies in the QAPI program; and inclusion of equipment-related risks in patient assessments, with subsequent implementation of interventions.

I don’t see any of this as particularly unusual/foreign/daunting, though (as usual) the staff education piece is probably the most complicated aspect of the equation as that is the most variable output. I am not convinced that we are doing poorly in this realm, but I guess this one really has to be a zero-harm philosophy. No arguments from me, but perhaps some important work to do.

History shows again and again how standards (and EPs) point out the folly of men…

It’s beginning to look like the proofreaders in Chicago must be enduring some late nights watching the Cubs! I don’t know about you folks, but I rely rather heavily on the regular missives from The Joint Commission, collectively known as Joint Commission E-Alerts. The E-Alerts deliver regular packages of yummy goodness to my email box (okay, that may be a little hyperbolic) and yesterday’s missive was no exception. Well, actually, there was an exception—more on that in a moment.

While it did not get top billing in the Alert (which seems kind of odd given what’s been going on this year), the pre-publication changes to the Life Safety chapter of the accreditation manual have been revealed, including comparison tables between what we had in January 2016 and what we can expect in January 2017. Interestingly enough, the comparison tables include the Environment of Care (EC) chapter stuff as well (though the EC chapter did not merit a mention in the E-Alert), so there’s lots of information to consider (which we will be doing over the course of the next little while) and some subtle alterations to the standards/EP language. For example (and this is the first “change” that I noted in reviewing the 112 pages of standards/EPs), the note for EC.02.02.01, EP 9 (the management of risks associated with hazardous gases and vapors) expands the “reach” to specifically include waste anesthetic gas disposal and laboratory rooftop exhaust (yes, I know…very sexy stuff!). It does appear that at least some of the changes (tough to figure out the split between what is truly “new” and what is merely a clarification of existing stuff—check out the note under EC.02.03.05, EP 1 regarding supervisory signal devices because it provides a better sense of what could be included in the mix). Another interesting change occurs under EC.02.03.05 (and this applies to all the testing EPs) is that where previously the requirement was for the completion dates of the testing to be documented, now the requirement actually states that the results of the testing are to be documented in addition to the completion dates. Again, a subtle change in the language and certainly nothing that they haven’t been surveying to. Oh, and one addition to the canon is the annual inspection and testing of door assemblies “by individuals who can demonstrate knowledge and understanding of the operating components of the door being tested. Testing begins with a pre-test visual inspection; testing includes both sides of the opening.” At any rate, I will keep plowing through the comparison table. (Remember in the old days, it would be called a crosswalk. Has the 21st century moved so far ahead that folks don’t know what a crosswalk is anymore?)

The top billing in yesterday’s All Hallows Eve E-Alert (making it an Eve-Alert, I suppose) went to the latest installment in that peppiest of undertakings, the Physical Environment Portal. Where the proofreaders comment comes into play is that the Alert mentions the posting of the information relative to LS.02.01.30, (which happened back in August) but when you click on the link, it takes you to the update page, where the new material is identified as covering LS.02.01.35, so there is updated material, though you couldn’t really tell by the Alert. So, we have general compliance information for the physical environment folks, some kicky advice and information for organizational leadership, and (Bonus! Bonus! Bonus!) information regarding the clinical impact of appropriately maintaining fire suppression systems (there is mention of sprinkler systems, but also portable fire extinguishers). I’d be interested to see if anyone finds the clinical impact information to be of particular use/effectiveness. I don’t know that compliance out in the field (or, more appropriately, noncompliance) is based on how knowledgeable folks are about what to do and what not to do, though perhaps it is the importance of the fire suppression systems and the reasons for having such systems (Can you imagine having to evacuate every time the fire alarm activates? That would be very stinky.) that is getting lost in the translation. I have no reason to think that the number of findings is going to be decreasing in this area (if you’re particularly interested, the comparison table section on LS.02.01.35 begins on p. 80 of that document—any changes that I can see do appear likely to make compliance easier), so I guess we’ll have to keep an eye on the final pages of survey year 2016 and the opening of the 2017 survey season. Be still my beating heart!

Ah, the fresh (de)scent of hell…

Two relatively disparate topics of conversation this week; one that I suppose could be characterized as good news, the other not so much…

First, the good news: The Joint Commission is continuing in its review and revision of the various and sundry accreditation programs and has earmarked a number of EC performance elements for the scrap heap, one of which is kind of interesting (and none of which is what I had really hoped for—the management plans, like the monster in some horror flicks, just keep coming back for more). So the requirements that are either redundant or will be left up to the decision of each organization are as follows:

 

  • The requirement to monitor and report all incidents in which medical equipment is suspected in or attributed to the death, serious injury, or serious illness of any individual. Reason: All required by the Safe Medical Devices Act of 1990.
  • The requirement to have procedures that address how to obtain emergency repair services. Reason: Issue should be left to organization discretion.
  • The requirement to provide emergency access to all locked and occupied spaces. Reason: Should be left to organization discretion.
  • Requirement for staff and LIPs to describe or demonstrate methods for eliminating and minimizing physical risks in the environment of care. Reason: Left to organization discretion.
  • Requirement for staff and LIPs to describe or demonstrate how to report EC risks. Reason: Left to organization discretion.
  • Requirement for semiannual environmental tours in patient care areas. Reason: Left to organization discretion.
  • Requirement for annual environmental tours in non-patient care areas. Reason: Organization discretion.
  • Requirement to use environmental tours to identify environmental deficiencies, et al. Reason: (all together now!) Organization discretion.
  • Requirement for representatives from clinical, administrative, and support services to participate in the analysis of EC data. Reason: You guessed it!
  • Requirement to evaluate changes to determine if they resolved environmental safety issues. Reason: not quite what you might be thinking—It’s because this element is implicit in the requirement for your organization to take action on the identified opportunities to resolve environmental safety issues. But wait: How are we going to identify opportunities if we are wicked discreet about the environmental tours? Hmmm…

So we lose 10 performance elements that will now become “ghost” standards (don’t get any ectoplasm on you…icky!) Clearly the expectation that these elements are going to be present somehow and/or somewhere in your EC program is not going away and, to be honest, I’m not convinced (at least at the moment) that you’ll be able to risk assess your way out of a lot of this stuff. I’m most disappointed (after the management plans—I really, really, really don’t have a whole lot of use for them—they bring no intrinsic value to the process and are naught but an exercise in paperwork) in the removal of the specific requirements for staff to be able to describe or demonstrate methods for eliminating risks and to be able to report EC risks. I suppose you could decide that folks don’t have to know that stuff, but I have spent a lot of time and energy beating the drum for the “spread” of safety to point of care/point of service folks. Safety does not live on a committee; it does not live on a periodic survey process. Safety lives everywhere in your “house” every moment of every day. Somehow removal of those two EP’s makes me a little verklempt…

But not as verklempt as some of the folks in Chicago might be of late. Quick background: Periodically, CMS is charged with notifying Congress as to how the various and sundry accreditation organizations are faring when it comes to surveying to the Conditions of Participation, which is pretty much the fundamental task of the deemed status process. At any rate, the information that CMS shared with those pesky Congresspersons can be found here. Of particular interest to this conversation is the information beginning at the bottom of p. 38 of the document, where you will find a table that outlines the disparity rate between Condition-level findings identified by the accrediting organizations (referred to as AOs in the report) and those found by CMS during validation surveys. While (and I don’t think it’s much of a surprise) CMS does ferret out things that were missed during the regular accreditation survey, of the “big three” accreditors of hospitals (AOA/HFAP, DNV, TJC), only TJC did not improve its disparity score in FY 2014 (as the only accrediting agency for psychiatric and critical access hospitals, it didn’t do real well there, either—see pp. 39-40).

But where things get kind of ugly for us is the table (lucky #13) on p. 44, which lists the types of findings missed most frequently in hospitals by the accreditation organizations as compared to CMS. And the most frequently missed Condition of Participation? Why, it’s our old friend, the Physical Environment! The environment fares somewhat better in psychiatric hospitals (which, to be honest, surprises me a little, but it may be a question of a small sample size; unless, of course, your sample size is HUGE!) and about the same in critical access hospitals. At this point, I think I’ve probably yapped enough for one week, but I would encourage you to check out the analysis of the physical environment findings starting on p. 49. It doesn’t paint a particularly bright picture, particularly if there were any of you folks anticipating a return to the clinical side of things during surveys. All signs point to even more scrutiny (happy, happy, joy, joy!) of the physical environment…imagine that.

Batten down the hatches, mateys—we’re in for quite a blow!

So many FSAs, so little time…and all we get is MBW

Flexible Spending Account, Federal Student Aid, Food Services of America, Focused Standards Assessment.

So, I am forced to pick one. While I’m sure the lot of them is most estimable in many ways, I suppose the choice is clear: the freaking Focused Standards Assessment (kind of makes it an FFSA, or a double-F S A…what the…).

Just to refresh things a bit, the FSA is a requirement of the accreditation process in which a healthcare organization (I’m thinking that if you weren’t in healthcare, you probably would be choosing one of the other FSAs) reviews its compliance with a selected batch of Joint Commission accreditation requirements. The selections include elements from the National Patient Safety Goals, some direct and indirect impact standards and performance elements, high-risk areas, as well as the RFIs from your last survey—and I know you’ve continued to “work” those Measures of Success from your last survey. Ostensibly, this is very much an “open book” test, if you will—a test you get to grade for yourself and one for which there is no requirement to share the results with the teacher (in this case, The Joint Commission—I really don’t understand why folks submit their results to TJC, but some do—I guess some things are just beyond my ken…).

The overarching intent is to establish a process that enhances an organization’s continuous survey readiness activities (of course, as I see various and sundry survey results, I can’t help but think that the effectiveness of this process would be tough to quantify). I guess it’s somewhat less invasive than the DNV annual consultative visits, though you could certainly bring in consultants to fulfill the role of surveyor for this process if some fresh eyes are what your organization needs to keep things moving on the accreditation front.

I will freely admit to getting hung up a bit on the efficacy of this as a process; much like the required management plans (an exercise in compliance), this process doesn’t necessarily bring a lot of value to the table. Unless you actually conduct a thorough evaluation of the organization’s compliance with the 45 Environment of Care performance elements, 13 Emergency Management performance elements, 23 Life Safety performance elements (15 for healthcare occupancies, eight for ambulatory healthcare occupancies)—and who really has the time for all that—then does the process have any value beyond MBW (more busy work)? I throw the question out to you folks—the process is required by TJC, so I don’t want anyone to get in trouble for sharing—but if anyone has made good use of this process, I would be very interested in hearing all about it.

This is my last piece on the FSA process for the moment, unless folks are clamoring for something in particular. I had intended to list the EPs individually, but I think my best advice is for you to check them out for yourself. That said, I have a quick and dirty checklist of the required elements (minus the EP numbers, but those are kind of etched into my brain at this point). If you want a copy, just email me at smacarthur@greeley.com.

Plus ça change, plus c’est la même chose: Vive Le Joint Commission!

I apologize for not having gotten to this sooner, but sometimes the wind comes out of nowhere and you find yourself heading in a rather unexpected direction (I’ve never spent so much time in Texas!).

With the advent of each new year, our three-lettered friends in Chicago unveil the changes to the accreditation standards for the upcoming cycle. Most of the changes in the EC/LS/EM world (with a couple of fairly notable exceptions—more on those in a moment) have to do with a shift in focus for the Focused Standards Assessment (FSA) process as a function of the various specific risk areas (I will freely admit that this is a wee bit convoluted, but should not necessarily come as a surprise). At any rate, as part of the accreditation process, each organization is supposed to evaluate its compliance based on specific areas of concern/risk identified by The Joint Commission. Thus for 2016, some of the risks to be evaluated have gone away (at least for the moment) and other have been added to the mix:

Please remember: These are not going away entirely, they just don’t have to be included in your organization’s FSA process!

So, we bid adieu to specific analysis of the safety, hazardous materials, medical equipment, and utility systems management plans (leaving security and fire safety in the mix) and we say bonjour to the identification of safety and security risks (as you may have noted, I’m not indicating the specific standard and EP numbers—our friends get a little protective of their content, but if you really need to check out the numbers, please see your organization’s accreditation manual).

We say goodbye to implementing our hazardous material and waste spill/exposure procedures, the monitoring of gases and vapors, and proper routine storage and prompt disposal of trash; and say hello to the hazardous materials and waste inventory, the actual written hazmat and waste spill/exposure procedures, minimization of hazmat risks, ensuring that you have proper permits, licenses, etc., for hazardous materials, and labeling of hazardous materials.

We say howdy to a focused look at fire drills, including the critiques.

We greet a focus on the testing documentation relating to duct detectors, electromechanical releasing devices, heat detectors, manual fire alarm boxes and smoke detectors, as well as the documentation relating to fire dampers.

We say auf wiedersehen to focusing on the selection, etc., of medical equipment, the written inventory of medical equipment, SMDA reporting, inspection, testing and maintenance of non-high risk medical equipment, and performance testing of all sterilizers.

We say guten tag to the written utility components inventory, written frequencies for maintenance, inspection and testing of utility system components, written procedures for utility system disruptions, and minimization of pathogenic, biological agents in aerosolizing water systems.

We say konichiwa to a focus on the provision of safe and suitable interior spaces for patients and the maintenance of ventilation, temperature and humidity in all those other pesky areas (e.g., soiled utility rooms, clean utility rooms, etc.).

We say hola to a focus on whether or not staff (including LIPs) are familiar with their roles and responsibilities relative to the environment of care (I predict that this is one is going to start showing up on the top 10 list soon unless there is a dramatic shift in survey focus).

And we say “Hey-diddly-ho, good neighbor” to the use of hazard surveillance rounds to identify environmental deficiencies, hazards, and unsafe hazards, as well as ensuring that you have a good mix of participants in your EC Committee activities, particularly the analysis of data—clinical, administrative, and support services have to be represented.

Now, there are three standards changes that went into effect on January 1, 2016: one a shift to a different spot in the standards, one a fairly clarifying clarification, and one about which I am not quite sure what to make, though I somehow fear the worst…

The requirement for the results of staff dosimetry monitoring (CT, PET, nuclear medicine) to be reviewed at least quarterly shift from Safety to Hazardous Materials. The EP number remains the same (and I can give you 17 reasons for that…), but it’s only a shift in where it would be scored (another important reason for making sure that you have a solid relationship between your EOC Committee and your Radiation Safety Committee—I’m a great believer in having compliance information in a location where surveyors are more likely to encounter it: EOC Committee minutes).

The requirement for managing the risks associated with smoking activities was clarified to indicate that the risks have to be managed regardless of the smoking types (e-cigarettes and personal vaporizers are officially in the mix); I’m presuming that this is helpful to folks who have perhaps faced some resistance in this area.

And finally (we’ll cover the EM and LS changes next time—nothing particularly scary, but a little too voluminous for this rather dauntingly wordy blog post), the requirements based around the inspection, testing and maintenance of non-high-risk utility system equipment components has gone from a “C” Element of Performance (EP) to an “A” EP (they did remove the Method of Success requirement for a deficient finding in this area—I suspect that was as much for their own sanity as anything else. Plus, it never really made a great deal of sense to figure out how to monitor something over four months’ time that frequently occurs every six or 12 months). My sense is that they are making the change to increase the “cite-ability” of managing utility systems equipment; now they only need to find one instance of noncompliance for a finding. I don’t know that I’ve seen a ton of findings in this area, but I can’t honestly say that I’ve been doing a close count of the OFI section of the reports, so it may be that they’re seeing a trend with the non-high-risk utility equipment that makes them think we’re not doing as good a job managing as we should, but that is wholly and completely conjecture on my part. I will, of course, be keeping a close eye on this one; I have a sneaking suspicion that the focus on utility systems equipment is going to continue into the immediate future and this might just become another pressure point.

As a closing thought relative to the FSA and risk area discussion, I think we can reasonably intuit that (particularly since the FSA process, represents a process for self-reporting) the expectation is for folks to be looking very carefully at the requirements contained within the above-noted areas and that your compliance plans relative to those requirements will be well in hand come survey. For some reason, this shift “smells” like an approach that’s going to be that much more focused on organizational leadership when there are gaps (and ask anyone who’s had a bumpy survey these past couple of years—leadership gets dragged into the fray on a regular basis). The fact of the matter is that they will find something deficient in your facility—if they don’t, they didn’t look hard enough. It’s about having processes in place to recognize and manage those deficiencies appropriately (and yes, I recognize that I am running the risk of repeating myself). This is big-time crazy focus on this stuff—and we need to be continuously improving how we go about doing it (whatever “it” might be).

Back next week to cover the EM/LS stuff. Arrivederci for now!

More portal chortlings—under the god(s) of compliance

I guess one could say that it took them a wee bit to get around to the topic of the requirements (and survey vulnerabilities) relating to the built healthcare environment, but they’re really going full bore on EC.02.06.01, particularly as a function of making sure that the responsibility of organizational leadership is recognized as a (if not the) critical component of compliance. I know we’ve already covered the latest fireside chats from Messrs. Mills and Woodin, but if you have not already done so, I would encourage you to do two things (and part of me is a little anxious as this smacks a bit of endorsement, but I think this is important):

 

  • Include a viewing of the fireside chats at your EOC Committee meetings; I don’t know that I would do all of them at once, but they are certainly brief enough to do one a month. I think it’s crazy important for everyone on the Committee to review the contents of the videos and while I know that you could just furnish the links to the Committee members and have them view on their own, I suspect that there might be some very valuable discussions to be had if you watch it as a group (heck, you could even make some popcorn—multigrain, no butter, perhaps a light dusting of sea salt), with maybe 10 minutes of discussions. While there is not much in the way of epiphanies in the content of the videos (I think everyone kind of recognizes what needs to happen), again, I think you could have a pretty good discussion regarding some of the concepts covered and the practical application of those concepts in your organization. You might even invite folks from procedural environments that are not typically members of the Committee. This is a huge focus of the survey process at the moment and the closer we can get to an intimate understanding of the dynamics, the better off we’ll all be.
  • Share the video with your boss (and if you can do it, your boss’s boss); the fact of the matter is that findings in this area could very well (it’s almost a likelihood) result in a finding under the Leadership standards, which ostensibly ties this up (and back) to the governing board of your organization. I don’t think that you’ll have a very easy time of managing the built healthcare environment without the knowledge and support of your organization’s leaders. We can no longer act as though this stuff is the responsibility of a few folks in the “trenches”; the management of the physical environment extends from point of care/point of service all the way to the top of the organization. It’s all about stewardship and everyone’s role in that pursuit.

Now I’m sure some folks are getting tired of me harping on this dynamic, but until we start managing the physical environment in a proactive, risk-aware manner, the Top 10 is going to continue to be EC Corner—and I don’t think any of us want that.

To assist in providing information to leaders, the latest update to this part of the portal is a downloadable file of the contents of the videos and the posted materials (not quite a transcript). Hopefully you have a leadership team that’s on board with this stuff, but if not, you’ve got to keep hammering on it. Visit this link to get a refresher on the materials.

 

 

If anyone has some success stories in this regard, I (for one) would love to hear about them. We are a community of safety professionals; the success of one can be the success of all, so let’s make it happen!

 

Don’t be a Haz-been (or perhaps Haz-not would be more appropriate…)

I would like to take this opportunity to draw your attention to the two most recent issues of Perspectives, for a couple of reasons. First, as the articles (part 1 and part 2) deal with EC.02.02.01, which is on the top 10 list for most-cited standards during 2015, and Joint Commission interpretation relative to the wonderful world of hazardous materials (and it is, indeed, a wonderful world). Second, these articles introduce a new “voice” into the mix, Kathy Tolomeo, CHEM, CHSP, who is one of the engineers at The Joint Commission’s Standards Interpretation Group and is one of the folks in Chicago who reviews clarifications, ESC submittals, perhaps (presumably) PFIs, etc. In that context, I think it’s important to have a sense of how individual reviewers “see” the regulatory compliance landscape, and these articles provide some sense (I will stop short of saying insight) of compliance strategies.

As a starting point, those are good reasons to check out the articles. But I also found these articles particularly helpful in that compliance strategies are discussed in some detail (I mean the articles are only a couple of pages long, so there are limits to how much detail), including an example (in the December Perspectives) of a hazardous materials inventory form, which I think paints a very nice (and perhaps most importantly, clear) picture of what you need to have in place (I’ve encountered a lot of folks struggling with what is expected for the HazMat inventory). There are discussions of eyewash stations and lead PPE, ventilation, and risk assessments (imagine that!) in the December Perspectives; the January issue covers hazardous gases and vapors, permits, licenses, manifests, and other documentation, labeling, monitoring for radiation exposure, proper routine storage, and prompt disposal of trash.

I guess you could say it’s a bit of hodgepodge in terms of ground covered, but that is the wonderful world of hazardous materials and waste. Check out these articles and maybe, just maybe, you can keep yourself off this year’s (or next year’s, depending on when you’re going to be surveyed) Top 10 list.

A most excellent start…

Recently, the AORN Journal published an editorial penned by Kelly Putnam, the managing editor, highlighting the role nurses play in preventing surgical fires (see here for detail). The piece raises a lot of interesting points about some of the operational considerations that come into play when it comes to appropriately managing fire risks in the surgical environment. But what really caught my eye—and my imagination—was the conclusion, which goes a little something like this: “Perioperative nurses are integral to a team approach to fire safety. Nurses are responsible for performing preoperative risk assessments and informing other team members of the risks associated with each procedure, identifying potential fire hazards, helping to find system fixes that improve patient safety, and conveying the details of fire-related incidents to other stakeholders at the institution.”

Now those of you who’ve been following this space for a while will no doubt note the presence of one of my favorite (okay, pretty much #1 on the hit list) phrases: risk assessment. And not only does the risk assessment get a shout out, it’s within the framework of a team approach to managing fire safety in surgery. As I pondered this, I was thinking, wouldn’t it be cool if we could use this as a jumping off point for nursing involvement in a team approach to risk assessment that focuses on the management of the whole darn care environment? I’ve been yammering at just about every opportunity my “sense” that one of the desired end products of the current focus on the care environment by regulatory surveyors is the demolition of the “barrier” that exists (in smaller doses than formerly, to be sure, but not entirely gone) between the “clinical” and “non-clinical” functions of any healthcare organization. It is my firm belief that the organizations that will most effectively manage the survey process are those organizations that have developed a true collaboration of staff across the care continuum. In a very real sense, everyone in your organization is taking care of patients—directly or indirectly, everyone influences the “patient experience.” And at the end of the day (and yes, I recognize that the Urban Dictionary refers to that little turn of phrase as a “rubbish phrase used by many annoying people…”): CARING FOR THE PATIENT IS CARING FOR THE ENVIRONMENT!

Start printing up the t-shirts and bumper stickers…

Come together, right now over…more heavy breathing

Talk about your regulatory supergroups: it’s almost like the second coming of Crosby, Stills, Nash, Young and all manner of goodness or maybe the Fantastic Four (or in this case, the Spectacular Six)! Back on September 21, the modern healthcare environment equivalent of the Justice League (AAMI, ASHE, AORN, ASHRAE, APIC, and FGI) published a Joint Interim Guidance (JIG) on HVAC in the Operating Room and Sterile Processing Department. The intent of this JIG (sometimes acronyms can be fun) is to address what the Spectacular Six deem “the biggest challenge for owners and designers of health care facilities,” which is “to understand the purpose and scope of the various requirements” of the “conflicting and sometimes unclear” standards and guidelines for the management of heating, ventilation, and air-conditioning (HVAC) so “patient and staff safety and comfort can be managed.” You can check out the JIG document here.

Without spoiling too much of your interest in discovering all the particulars, the JIG speaks to the dichotomy inherent between the minimum design requirements and criteria that are used to construct an HVAC system (the FGI/ASHRAE/ASHE side of the equation) and the guidelines that “are intended to guide the daily operation of the HVAC system and clinical practice once the health care facility is occupied (this is where AAMI/AORN/APIC come in). As any number of you have experienced in real (and sometimes really painful) time, this dichotomy is very much at the heart of the regulatory survey process at the moment (somehow in my heart of hearts I knew that we could be continuing this conversation). But mayhap there is a light at the end of the tunnel (that is not an oncoming train!): the Spectacular Six have begun working towards a harmonization of the HVAC guidance in the various standards. They’ve been working on this since late April and the JIG is, for all intents and purposes, their first work product. I think it’s an excellent start and I hope that their work is allowed to continue with minimal interference from outsider influences (who that could be, I have no idea…).

An important part of the JIG is their advice to healthcare organizations (it’s on p. 2 of the document—I’ll let you reflect on it in your spare time) and those of you who’ve been following this space for a while will guess that my fave-o-rite topic is going to feature quite prominently in this movement: our old friend, the risk assessment! (Admit it, you knew it was going to go that route!) The goal of the assessment is to make a determination of HVAC operating parameters for critical areas that meet patient, personnel, and product storage needs, with an eye towards the identification of appropriate corrective measures to mitigate risk, etc. I think we’ve been honking this horn a bit as we’ve traversed this landscape, but I think the critical opportunity/challenge is going to be based on the Spectacular Six’s intent to communicate/advocate directly with the regulatory folks in this regard. I haven’t yet seen anything official from CMS in this regard, but based on its adoption of the tenets of the Joint Quality Advisory from January of this year (again, a number of web locales for info, including this one), I think we can reasonably anticipate some level of guidance to the surveyor corps in the not-too-distant future.

So perhaps we can work through this in relatively straightforward fashion; at the end of the day, our charge is to ensure that we are providing the safest possible environment for patients, staff, and visitors. But in meeting that charge, we also need to make sure that we are not writing checks that our building systems can’t cash. We should be able to identify appropriate, safe performance parameters that appropriately address all the risk factors and identify a response plan that we can effectively implement when we have conditions that increase the risk to unacceptable levels. If you ask me, that sounds like business as usual…

One score and no years ago: Guess who’s 20?

John Palmer, who edits Briefings on Hospital Safety, among other nifty periodicals, asked me to weigh in on the 20th anniversary of the EC chapter, with a particular emphasis on how (or where) things are now in comparison to the (oh so very dark) pre-EC days. And he did this in full recognition of my tendency to respond at length (imagine that!). At any rate, I decided that these thoughts would be good to share with all y’all (I can’t absolutely swear to all the dates; I think I’m pretty close on all of them, but if there are temporal errors, I take full responsibility…)

Prior to the “creation” of the Environment of Care as a chapter (you can trace the term Environment of Care back to 1989), The Joint Commission had a chapter in the accreditation manual known as Plant Technology and Safety Management (PTSM). The PTSM standards, while significantly more minimalistic than the present-day requirements, did cover the safety waterfront, as it were, but with the advent of Joint Commission’s Shared Visions/New Pathways marketing (you may assume that I am using “marketing” as the descriptor with a little bit of tongue in cheek) of their accreditation services, I guess the term I would use most is a modernization of the various standards chapters began, including the “birth” of the EC chapter in 1995. With that, things became a little more stratified, particularly with the “reveal” of the seven EC functions (safety, security, hazmat, emergency, life/fire, medical equipment, utility systems). This raised the profile of the physical environment a bit, but a true concerted focus on the EC really didn’t occur until 2007, when the Life Safety surveyor program was introduced, primarily in response to data gleaned by CMS from validation surveys. The Joint Commission survey process, prior to 2007, really didn’t have a reliable means of capturing life safety and related deficiencies. Since then, the survey focus on the physical environment has continued to grow, much to the point that now it very much eclipses the clinical component of the survey process, at least in terms of the number and types of findings.

Are things “better”? I suppose one could make the case that things have improved incrementally over time, but it’s tough to say how much direct influence the EC chapter has had on things (and the subsequent “peeling off” of the Life Safety and Emergency Management chapters). Clearly, the healthcare environment is significantly different than 20 years ago, both in terms of the inherent risks and the resources available to manage those risks. (Increased technology is pretty much a good thing, but reductions in spending, probably not so much. I’m sure you can come up with a pretty good list of pros and cons without too much difficulty.) You could also make the case (purely based on the number of findings…and I think TJC has a dog in that fight) that if hospitals are safer, it’s because of the level of scrutiny. I tend to think that the “true” answer resides on the development of the healthcare safety professional as a vocational endeavor, with the added thought that unsafe places tend not to stay in business for very long these days. So perhaps somewhere in the middle…

Better? Worse? Different…definitely! I will say that I firmly believe that the amount of survey jeopardy being generated at the moment leans towards the hyperbolic; there are certainly organizations that need to get their acts together a little more fully than they do at present. But not every organization that ends up in the manure is completely deserving of that status. I recognize that TJC has to be super-diligent in demonstrating their value to the accreditation process. But being accredited can’t become the be-all, end-all of the process. The responsibility of each healthcare organization (and, by extension, each caregiver) is to take care of patients in the safest possible manner and being attentive to the survey process can’t come at the expense of that responsibility. Sometimes, I fear, it does just that. I could probably say something pithy about job security, but…