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Ground Control to Major Compliance: EOC, baby!

As September brings around the unwinding of summah, it also brings around The Joint Commission’s annual state of compliance sessions in locations across the country, better known as Executive Briefings. And, one of the cornerstone communications resulting from the Briefings is the current state of compliance as a function of which standards have proved to be most problematic from an individual findings standpoint.

Yet again (with one exception, more on that in a moment), EOC/Life Safety standards stand astride the Top 10 list like some mythical colossus (the Colossus of Chicago?), spreading fear in the hearts of all that behold its countenance (OK, maybe not so much fear as a nasty case of reflux…).

You can find the Top 5 most frequently cited standards across the various accreditation programs; you’ll have to check out the September issue of Perspectives for the bigger compliance picture, which I would encourage you to do.

At any rate, what this tells us is that (for the most part) the singular compliance items that are most likely to occur (for example, we’ve already discussed the loaded sprinkler head hiding somewhere in your facility—way back in April) are still the ones they are most likely to find. According to the data, of the 688 hospitals surveyed in the first six months of 2019, 91% of the hospitals surveyed (626 hospitals) were cited for issues with sprinkler/extinguishment equipment—and that, my friends, is a lot of sprinkler loading. I won’t bore you with the details (I think everyone recognizes where the likely imperfections “live” in any organization), but (at least to me) it still looks like the survey process works best as a means of generating findings, no matter how inconsequential they might be in relation to the general safety of any organization. I have no doubt that somewhere in the mix of the Top 10 list, there are safety issues of significance (that goes back to the “no perfect buildings” concept), particularly in older facilities in which mechanical systems, etc. are reaching the end of their service life—I always admired Disney for establishing a replacement schedule that resulted in implementation before they had to. It’s like buying a new car and having the old one still on the road: Are you going to replace the engine, knowing that the floor is going to rust through (and yes, I know that some of you would, but I mean in general)? But if the car dies on the way to the dealer to pick up the new one, you’re not going to do anything but tow it to the junkyard. But we can’t do that with hospitals and it’s usually such a battle to get funding/approval for funding/etc. that you can get “stuck” piecing something together in order to keep caring for your patients. It sure as heck is not an ideal situation, but it can (and does) happen. Maintaining the care environment is a thankless, unforgiving, and relentless pursuit—therein is a lot of satisfaction, but also lots of antacid…

One interesting shift (and I think we’ve been wondering when it would happen) is the appearance of a second infection control (IC) standard, which deals with implementation of an organization’s IC plan. I personally have always counted the IC findings relating to the storage, disinfection, etc. of equipment as being an EOC standard in all but name, but I think we may (finally) be seeing the shift to how appropriately organizations are managing infection risks. According to Perspectives, 64% of the hospitals surveyed in the first six months of 2019 were cited for issues relating to implementation, but not sure how the details are skewing. Certainly, to at least some degree, implementation is “walking the talk,” so it may relate to the effectiveness of rounding, etc. Or, it may relate to practice observed at point-of-care/point-of-service. I think we can agree that nosocomial infections are something to avoid and perhaps this is where that focus begins—but it all happens (or doesn’t) in the environment, so don’t think for an instant that findings in the environment/Life Safety will go gentle into that good night. I think we’re here for the long haul…

In the realm of possibility: More listening, less posturing!

An interesting anomaly that I encounter periodically is the time-honored “first opinion,” particularly when it exists outside of a second opinion. All too often I hear clients tell me that  “X told us we have to do something a particular way,” often with a wake of disruption because whatever strategy, etc., that was identified didn’t take into full consideration elements of organizational culture, resources, practice, etc. But what I don’t understand is when I look at Environment of Care committee minutes, etc., I don’t see any discussion about whether the recommendation(s) were useful, germane, etc., to appropriately manage whatever the condition might be. I think it is very important to use any survey activity (regulatory, consultative) as an opportunity to identify best practices and ensure that policy and practice are in alignment. That way, you’ll have some experience in being able to sort out what is truly required from a regulatory perspective and what is solely in the land of surveyor interpretation.

In all the years I’ve been involved in healthcare safety, the one defining truth I’ve found is that compliance is rarely a black and white endeavor. And while I absolutely understand that managing anything as a “black and white” is a whole lot easier to police, from an operational standpoint, absolutes (either positive or negative) are not always easily, or practically, implemented.

The other dynamic is (and this is very much the case with response to regulatory surveys) that often we “over-promise,” particularly in terms of frequency of monitoring. Don’t set yourself up for failure, for example, by indicating in a corrective action plan that there will be weekly inspections of electrical panels for inappropriately configured circuit breakers. Unless you know that folks are mucking around in the panels on a frequent basis, is there really a compelling reason to embrace an inspection frequency that is not a regulatory requirement? I would tend to think: Not so much.

As we have established beyond any reasonable doubt, there will always (always, always, always) be imperfections in the environment, but don’t go crazy trying to chase all these things yourself (or have your staff do the chasing). As I’ve said any number of times (before any number of audiences), all this stuff “lives” at the point of care/point of service and if you can’t get the folks that “live” in those areas to help feed the gaping maw of work order system, you are managing a process that is not as efficient as it might otherwise be. With the ongoing impact of the “do more with less” mantra, it’s not so much about working smarter (though there is certainly an element of that), but about working collaboratively. Everyone is caregiver—everyone is a steward of the environment—and by judicious application of only what is actually required by code and/or regulation, you can start to break down the barriers between mutually assured noncompliance and an environment that appropriately supports care. Compliance is the byproduct of consistently doing the right thing.

Ticking away the moments that make up a dull day: EOC orientation and ongoing education

Going to touch on a couple of things this week. First up? Ed-yoo-ma-cation!

A week or so back, I received an email encouraging me to list what educational competencies are most important relative to preparing for the survey process. Off the top of my head, the list (in no particular order) goes a little something like this (and I will stipulate that competency is the key focal point for these):

  • Fire response, including (and perhaps most importantly) department-level protocols
  • Emergency response, including how to summon assistance in an emergency
  • How to report an Environment of Care (EOC) problem or condition (I like to include “How to recognize an EOC problem or condition” as a subset of this one)
  • How to manage their own care environment (this is a bit of a stretch as it is not specifically mandated by code or regulation, but I will characterize this as something of a distillation of the general duty clause, kind of…)

After that, things get kind of gray, but if you look really closely at that last one, it comes down to everyone being able to demonstrate competency relative to what skills and knowledge are required for them to do their job appropriately (safely, timely, etc.). From knowing how long disinfectant has to keep a surface wet to appropriately disinfect whatever surface you’re disinfecting (say that 10 times fast!) to making sure that folks who are charged with providing on-to-one safety observation of at-risk patients are conversant with what to look for, how to summon assistance, when it is appropriate to intervene, etc. There does appear to be a growing focus on the processes involved in ensuring that folks are competent to administer their job responsibilities. While the list above gives you a sense of the “umbrella” under which organizationwide orientation provides a framework, the devil (as they say ) is in the details—and those details “live” at the department level.

To that end, it may be useful (if you are not already a participant in the department-level safety orientation) to “audit” some of the department programs to see if what folks are receiving matches up with what your expectations are of the entire orientation process. Most of the folks I’ve chatted with over time have found their “time” at orientation to be shrinking almost as quickly as those new pants in a hot water wash—it may be time to leverage some other opportunities to get the safety word out.

The other item for discussion relates to survey findings and the question of how much folks “expand” their surveillance in response to a survey finding. Minimally, you’re on the hook for resolving whatever the specific finding might be and now, with the submission of the corrective action plans to The Joint Commission (or whomever), there’s that whole concept of how you’re going to sustain the processes necessary to maintain compliance. Most of the action plans I’ve seen have a good framework for long-term monitoring, etc., but what about between right now and, say, next week? Or, even, next month? There seems to be a lot of follow-up surveying going on in the healthcare world and how far do you go to prepare for that potential “sooner than later” next visit. As with pretty much all of this stuff, there is very little in the way of guidance, but I was wondering if we could dig up some “best practices” in the name of (perhaps) introducing some non-EOC stuff into next year’s top 10 lists…just sayin’.

Have a most delightful week!

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).

One of your sprinkler heads is loaded: Can you find it before they do?

And now, to the recap of the 10 most frequently cited standards during all of 2018 (in hospitals; other programs are a little more varied), as chosen by somebody other than you (or me): the survey troops at TJC.

The top 10 are as follows:

  • EC 02.01.35—The hospital provides and maintains systems for extinguishing fires (88.9% noncompliance percentage).
  • EC 02.05.01—The hospital manages risks associated with its utility systems (78.7%).
  • EC 02.06.01—The hospital establishes and maintains a safe, functional environment (73.9%).
  • LS 02.01.30—The hospital provides and maintains building features to protect individuals from the hazards of fire and smoke (72.9%).
  • IC 02.02.01—The hospital reduces the risk of infections associated with medical equipment, devices, and supplies (70.9%)
  • LS 02.01.10—Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat (70.7%).
  • LS 02.01.20—The hospital maintains the integrity of the means of egress (67.4%).
  • EC 02.05.05—The hospital inspects, tests, and maintains utility systems (64.7%).
  • EC 02.02.01—The hospital manages risks related to hazardous materials and waste (62.3%).
  • EC 02.05.09—The hospital inspects, tests, and maintains medical gas and vacuum systems (62.1%).

The ongoing hegemony of the top 10’s EOC-centric focus (and I still consider IC.02.02.01 the point upon which infection control and the physical environment intersect—sometimes with spectacular results) leaves little to the imagination (both ours and the surveyors). While you can still get into some significant trouble with certain processes, etc. (more on that next week—I figure if they can have a Top 10 list, then so can I…), the reason that these particular standards continue to jockey for position is because they represent the kinds of conditions (to some degree, I hesitate to call them deficiencies) that you can find literally any (and every) day in your organization. Just think about LS.02.01.35 for a moment: How far would you have to go before you found schmutz on a sprinkler head, something within 18 inches of a sprinkler head, a missing escutcheon (or an escutcheon with a gap), or even something (likely network cabling) lying atop, wire-tied to, somehow “touching” sprinkler piping or supports? I’m going to intuit that you probably won’t have to range too far afield to find something that fits in that category. The only thing I can say is whoever was surveying the “other” 11.1 % of the hospitals in 2018 must not have felt like poking around too much.

At any rate, I don’t know that there is a lot to glean from the 2018 results (same as it ever was…), but if someone out there has a question or concern that they’d like to share, I’m all ears!

I’ve been there, I know the way: More Executive Briefings goodness

You’ve probably seen a smattering of stuff related to the (still ongoing as I write this) rollout of this year’s edition of Joint Commission Executive Briefings. As near as I can tell, during the survey period of June 1, 2017 to May 31, 2018, there were about 27 hospitals that did not “experience” a finding in the Environment of Care (EC) chapter (98% of hospitals surveyed got an EC finding) and a slightly larger number (97% with a Life Safety chapter finding) that had no LS findings. So, bravo to those folks who managed to escape unscathed—that is no small feat given the amount of survey time (and survey eyes) looking at the physical environment. Not sure what he secret is for those folks, but if there’s anyone out there in the studio audience that would like to share their recipe for success (even anonymously: I can be reached directly at stevemacsafetyspace@gmail.com), please do, my friends, please do.

Another interesting bit of information deals with the EC/LS findings that are “pushing” into the upper right-hand sectors of the SAFER matrix (findings with moderate or high likelihood of harm with a pattern or widespread level of occurrence). Now, I will freely admit that I am not convinced that the matrix setup works as well for findings in the physical environment, particularly since the numbers are so small (and yes, I understand that it’s a very small sample size). For example, if you have three dusty sprinkler heads in three locations, that gets you a spot in the “widespread” category. I don’t know, it just makes me grind my teeth a little more fiercely. And the EP cited most frequently in the high likelihood of harm category? EC.02.02.01 EP5—handling of hazardous materials! I am reasonably confident that a lot of those findings have to do with the placement/maintenance of eyewash stations (and I’ve seen a fair number of what I would characterize as draconian “reads” on all manner of considerations relating to eyewash stations, which reminds me: if you don’t have maintenance-free batteries for your emergency generators and you don’t have ready access to emergency eyewash equipment when those batteries are being inspected/serviced, then you may be vulnerable during your next survey).

At the end of the day, I suppose there is no end to what can be (and, clearly, is) found in the physical environment, and I absolutely “get” the recent focus on pressure relationships and ligature risks (and, soon enough, probably Legionella–it was a featured topic of coverage in the EC presentation), but a lot of the rest of this “stuff” seems a little like padding to me…

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.

Education < / = / > Achievement: Don’t Let Survey Prep Get in the Way of Good Sense

I’d like to start off this week with an interesting (and hopefully instructive) tale from the field:

I was doing some work recently at an organization that is facing down the final six months of its survey window. This was my first visit to the facility and I was working on getting a sense of the place as well as identifying the usual list of survey vulnerabilities. As we’ve discussed before, one of the things that’s always in the mix, particularly with the gang from Chicago, is the care and feeding of emergency eyewash stations. This particular organization has adopted the strategy of having folks at the department level perform the weekly testing (a sensible approach from my standpoint—I think the most important piece of the weekly testing is helping to ensure that folks who might actually need the eyewash in an emergency actually know how the darn thing works), but the documentation form had two columns: one for the date and one for the signature of the person doing the test. The sheet did not, however, have any instructions on it, which prompted me to inquire as to how folks would know what (and why) they are checking, since the purpose is not just to run the water. The response to my inquiry was rather noncommittal, which is not that unusual, so I continued to collect data relative to the process. So, over the course of the facility tour, we found a couple of eyewashes with missing caps and no clear indication on the testing form that this had been identified as an issue. OK, not crazily unusual, but pointing towards a process that could use some tweaking. A couple of eyewashes with obstructed access provided a little more data.

Then we made our way to the kitchen. No real compliance issues with the eyewash itself, but I noted that they were checking the eyewash station on a daily basis and recording the temperature at that same frequency. Now, the ANSI standard does not require daily verification of eyewash flushing fluid temperature, so I asked about this particular practice (BTW: Nowhere else had we seen this practice—at least not yet …) and was informed another hospital in the region had been cited for not doing the daily temp checks (I have not been able to verify that this was an actual survey finding, but sometimes believing is enough … to cause trouble). And then we headed over to the lab and ran into a similar practice (they were just verifying the temps during the weekly test) and the feedback there was that a College of American Pathologists (CAP) surveyor had told them a story about an individual that had suffered eye damage because the (low temperature) water from the eyewash interacted with a chemical. This was not written up as a finding, but was relayed as an anecdotal recommendation.

The “funny” thing about all this (actually, there are a couple of process gaps) is that each of the eyewash stations in question are equipped with mixing valves, which pretty much mitigates the need for daily or weekly temperature checks (you want to check the temp when you’re doing the annual preventive maintenance activity). But the more telling/unfortunate aspect of this is that (independent of each other) these folks had unilaterally adopted a process modification that was not in keeping with the rest of the organization (it has been said, and this is generally true, that you get more credit for being consistently wrong than inconsistently right). Now, one of the big truisms of the survey process is that is almost impossible to push back when you are not compliant with your own policy/practice. And while I absolutely appreciate (particularly when the survey window is closing) wanting to “do the right thing,” it is of critical importance to discuss any changes (never mind changes in the late innings) with the folks responsible for the EOC program. While I pride myself on not telling folks that they have to do something that is not specifically required by code or regulation, some of the regulatory survey folks don’t share that reticence. The other potential dynamic for these “mythical” requirements is when a surveyor tells an organization something that doesn’t show up in the actual report. I run into this all the time—they may “look” at the finding in the report, but what they sometimes react to is what the surveyor “said.” Compliance has way more than 50 shades of whatever color you care to designate and what works/worked somewhere else doesn’t always work everywhere, so folks make these changes without knowing what is actually required and end up increasing the potential for a survey finding.

And healthcare isn’t the only pursuit in which incomplete communications (or making sure that communications are as complete as they can be) can have an impact. At the moment, I am reading An Astronaut’s Guide to Life on Earth by Col. Chris Hadfield (this, apparently, is going to be the summer for reading astronaut memoirs, be that as it may) and I came across a passage in which Hadfield describes a debriefing following a practice spacewalk in which one of the instructors noted that while Hadfield has a “very clear and authoritative manner,” he encouraged the folks participating in the debrief to not be “lulled into a feeling of complete confidence that he’s right.” As soon as I saw that, I was able to tie it back to the management of surveyors who speak in a “very clear and authoritative manner” and sometimes turn out not to be worthy of complete confidence that the surveyor is correct. If you are doing something that, in good faith and the extent of your knowledge, is the “right thing” and somebody (even me!) comes along and says you’re not doing that right, never be afraid to ask to see where it says that in the code/regulation, etc. (BTW: I’m not giving you permission to be obnoxious about it!) Surveyors (same for consultants) see a lot of stuff and sometimes compliance becomes a fixed idea, or process, in their head, but that doesn’t mean it’s the only way. And if you hear something that makes you think you have a vulnerability (something you’ve heard through that pesky grapevine), talk it out before you make any changes. That gives everyone in your organization a fighting chance at compliance.

As a final note, if you’ve forgotten about Col. Hadfield’s most notable performance (beyond the astronaut thing), check it out:

Not enough rounding in the world: Compliance and readiness in the face of everyday chaos…

As I was engaged in my walk this morning (the sun just starting to cast its light on the Rockies!), I was pondering the complexities of the healthcare environment as a function of compliance. One of the truisms of my practice is that I am good at finding those points where things don’t quite gel. Sometimes (most times, to be honest), it’s relatively minor stuff (which we know is where most of the survey findings “live”) and every once in a while (mostly because my eyes are “fresh” and can pick out the stuff that’s happened over time; as I like to say, squalor happens incrementally), you find some bigger vulnerabilities (maybe it’s a gap in tracking code changes or a process that’s really not doing what you need it to do). So, after tooling around for a couple of days, folks will inevitably ask me “what do you look for?” and I will stumble through something like “I try to find things that are out of place” or something like that.

This morning, I had something of an epiphany in how that question actually informs what I do: it’s not so much what I look for, it’s what I look “at.” And that “at,” my friends, is everything in a space. One of the process element that gets drilled into housekeeping folks (I’m pretty sure this is still the case, it definitely was back in 1978 when I started this journey), is to check your work before you go on to the next thing, and that means going back over everything you were supposed to do. I’ve had conversations with folks about what tools I’ve seen that have been effective (and I do believe in the usefulness of tools for keeping track of certain problematic or high-risk conditions), but only in very rare circumstances have I “relied” on a tool because I have an abject fear of missing something critical because I had a set of queries, if you will. I would submit to you that, from a compliance standpoint, there are few more complex environments in which to provide oversight than healthcare. It is anything but static (almost everything except for the walls can move—and does!) and in that constant motion is the kernel of complication that makes the job of facilities safety professional infinitely frustrating and infinitely rewarding.

So, I guess what I’m advising is not to limit your vision to “for,” but strive for “at everything—and if you can impart that limitless vision to the folks who occupy your organization’s environment, you will have something quite powerful.

 

Why can’t we have anything nice? Hardwiring safety improvements: Finding fault vs. facilitation

It seems of late I’ve been encountering tales of much fingerpointing, heavy sighs, and the like in the lead-up to a date with our friends from Chicago. To my way of thinking, if there are outstanding/longstanding issues relating to compliance (and it can be just about anything relative to compliance), how much help can it be to keep pointing out the deficiency without working with folks to find some sort of rational/operational strategy for managing their environment? For example, where can one put stuff? I’ve been working the consulting beat for almost 17 years (as I wrap up my 40th year in healthcare—more on that as we approach that momentous July anniversary) and I can tell you with pretty much absolute certainty that there is not a single hospital anywhere that has enough (which would equate to too much) storage space. Clearly some of that deficit is a function of revenue generation potential as an algorithm for space allocation, but even your biggest money-makers tend to have more stuff than space. But I come back to the reality of kicking department managers for the same compliance concern(s) time and time again and (again, this is my interpretation) it just seems like a buck-passing exercise for the folks conducting the rounds— “well, I told them they couldn’t do that—and they keep doing it.” And try as I might, I can’t equate that type of process with anything that approaches performance improvement.

While I recognize (and observe in certain instances) that organizations have made, and continue to make, improvements over time, what is important is not to lose sight of the hardwiring of processes that are designed to sustain those improvements. As noted in the storage example, the physical plant is traditionally not considered a revenue generating concern, but the impact of ongoing maintenance of the physical environment on the delivery of excellent patient care has never been scrutinized more closely. It is of critical importance to develop and implement strategies that allow for those tasked with maintaining the physical environment to focus on those tasks, utilizing point-of-care/point-of-service staff to the fullest extent in the not just identifying, but facilitating management of “imperfections” in the environment.

Not to belabor the point, but the current level of focus on conditions in the physical environment, particularly as a function of the environment’s impact on infection control and prevention, calls for a greater degree of coordination amongst the primary stakeholders. While there is no specific dictate relating to the circumstances under which infection control risk assessments must be conducted; risk management strategies implemented (either through a hardwiring of basic risk reduction in standard operating procedures for certain activities, including repair and renovation activities on patient units), and a reliable process for notification of, and follow-up for, conditions that might nominally be described as “breaks” in the integrity of the environment. Certainly, the proliferation of leaks, stained ceiling tiles, damaged wall and flooring surfaces, etc., would indicate that the current management of this process does not provide enough of a “safety net” to serve the organization and its mission of continuous survey readiness. At this point, the administration of the survey process is clearly aimed at the removal of the “final” barriers between “clinical” and “non-clinical” functions in hospitals. The survey process is based on a clear sense/understanding that the entire hospital staff is engaged in patient care, regardless of their role in that care. The organizations that fare the best during survey are the organizations that have been able to grow the culture in a direction that results in a truly seamless management of the environment as the outer “ring” of the patient care continuum. Each staff member is a caregiver; each staff member is a steward of the physical environment.

I don’t think we can ever hope to be successful until we starting working towards a sheriff-less approach (based on that old saw “There’s a new sheriff in town”). One of the fundamentals of just culture is holding folks accountable, but not without working with them to achieve that nirvana state. I think if punishment (I consider reiteration of sins to be punishment) worked, we’d have a lot fewer findings in the physical environment. I can remember a time when you could get away with a more dictatorial approach to managing the environment, but I don’t think that time is coming back any time soon.

Unfortunately, the regulatory folks aren’t quite poised to embrace the facilitation/consultation model of accreditation surveying, which leads me to my closing thought/suggestion for this week. I am still “anxious” about the whole water management program issue as a function of the accreditation survey process and how it will play out. I’ve heard (but not seen) that TJC has cited folks for (presumably) inadequate water management programs, and I’ve learned over time that these types and numbers of findings tend to escalate before they de-escalate. Certainly, this is something we have to “do” very well, because to do otherwise puts people at risk. As I have in the past, I would encourage you to check out Matt Freije’s latest thoughts on all things water management programs. I suspect that everyone is a different point along the “curve” with this one, but I know one thing—you don’t want to have an outbreak relating to the management of waterborne pathogens. Talk about being “sheriffed”…