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If you remember nothing else: Nothing happens in isolation…

With the (presumed) onset of regulatory surveys including a more thorough review of survey results past, I would imagine that everyone out there in the listening/reading audience can name at least a couple (if not more) instances of non-compliance that were (for want of a better term) “missed” during survey. Just to use a simple example (which we touched upon back in the wilds of winter), your most recent surveyor may have stopped looking for improperly labeled breakers (spares in the on position; breakers in the on position not labeled, etc.). But the question becomes: How many more are out there…and how carefully did someone look post-survey? Certainly, whatever was identified would have been corrected as part of the plan of correction—you can’t be telling regulators that you did something that you didn’t do, now can you? But what about other potential findings? Now, I recognize that using this particular example is (hopefully) a wee bit hyperbolic in that (again, hopefully), the low risk findings are going to get a mulligan if there are recurrences. If you have really crappy luck, you could have an exit sign burn out every time you have a survey or something similar (can anyone say “improperly segregated compressed gas cylinder”?) but I would think that the little stuff is not going to drive a seriously negative survey result, with perhaps one exception.

The exceptional item (or items) are those in which the management of the care environment crosses into the realm of infection control and prevention: damaged/non-intact surfaces, stained ceiling tiles, etc. The reason for my concern with this stuff is it is really hard to manifest a solid process for managing these incidental conditions without hard-wired participation of point-of-care/point-of-service folks. I don’t know, I’m just having a hard time wrapping my head around taking issue with findings/conditions similar to those found in previous surveys. Now, if we’re talking widespread versus isolated, I can see widespread issues maybe pushing a survey in the wrong direction, but I still think the severity has to come in to play to some degree, as well as the (ever-present) potential for recurrence. To my mind, the stuff that gets broken/damaged tends to be because those are the things that suffer the most “abuse” (and I use that in the most general of meanings). It’s like the fire doors near the loading dock—tell me they don’t have a significantly greater potential for damage, during a survey or not.

At any rate, I think the important thing is to work diligently to ensure that those isolated findings are not the tip of a widespread iceberg. I don’t think we can just stop with what was cited anymore.

Next week, we’ll spend a little time with the “new” expectations relating to the management of workplace violence; I’m still trying to figure out if there’s anything that is truly “new” (I tend to think no, but you never know what might be hiding in the nuances), but we should at least start the discussion of where things seem to be going.

Hope you had a safe and festive Independence Day!

Stop making sense: Normalizing abnormality…

A brief foray this week, though I hope that is very much in keeping with you all being able to grab a few moments for yourselves over the holiday weekend. It was rather dreary up here in the land of the New English, but the rain is much needed, so if there was a bit of dampening of the spirits, it should take the edge off any fire risks up this way. I would be happy to share with the more parched regions of the country, but it appears that rain (like many other things) is rather more capricious than not…

First up: If you have not had the opportunity to get back to the grind that is the hunt for expiring/expired product, please remember that a ton of products were purchased about a year ago and it does seem like I’ve been running into a bunch of stuff that is reaching the end of its (sometimes not so) useful life. Wipes and sanitizer proliferated quite extensively last spring into early summer, so make sure someone in your organization is worrying about that one.

Next up, the only EC-related item in the June edition of Perspectives (and it is a little bit of a stretch) deals with the Sentinel Event Alert on infusion pump safety. It seems somehow that improvements to medical equipment technology manage to create more challenges for the folks in clinical engineering. The more a device can do, the more stuff that can go wrong. This is not to say that these are in any way a problem in and of themselves, but it seems like there are always gaps in the education process when these things roll out, so best of luck on that front. Medication safety is clearly going to be a focus moving forward and if we have learned nothing over the last little while is that everything ties across the physical environment eventually.

As a closing reiteration (we did touch upon this a couple of weeks ago), just a reminder to try and capture as much of the last year as you can. Many (if not most) of the lessons learned are pretty hard-wired into our response protocols, etc., but it’s also important to take stock of what didn’t work particularly well so we can avoid repeats in the future. One of the consistent challenges I’ve noted over the years is when an organization learns of a process, etc., that has worked really well at another organization and adopts that process lock, stock, and barrel. And a lot of times, that “perfect” process involved a fair amount of stumbling around to get to the point of perfection—and for some reason, folks don’t always share the missteps. It reminds me of that oft-told aphorism regarding doom and repeating history, but let us leave doom to others…

Hope you all are well and making the most of the moment!

Risk assessments: Don’t leave home without one!

An interesting phenomenon I’ve been encountering of late relates to the whole notion of having to do environmental risk assessments in locations that are not specifically designated for the management of behavioral health patients. At this point, I don’t know of any healthcare organizations that would be able to say that they would not be managing behavioral health patients, even if they don’t have inpatient bed capacity, though I suppose you might be able to set up a transfer policy with another local organization that does have inpatient capacity. But those beds are typically in fairly sort supply and might well end up with having to “hold” a behavioral health patient for a prolonged period of time. Maybe you can manage that continuum in your ED, but what if you had a surge of, hmmm, let’s say infectious patients. Is there a possibility that a behavioral health patient could end up on an inpatient unit? And could you say absolutely in either direction without having a risk assessment in your back pocket?

So you could make the case that moving the environmental concerns relating to behavioral health patients from the Environment of Care standards to the National Patient Safety Goals section of the accreditation program has clarified (to a degree) the expectations relative to the management of at-risk patients, but that clarity brings with it some mandates. The mandate comes in three pieces (so to speak): a thoughtful evaluation of the environment; a plan; and available resources to guide staff when you have to put at-risk patients in an environment that is not designated for managing that type of patient.

To my eyes and ears, a thoughtful evaluation of the environment sounds an awful lot like a risk assessment; the FAQ goes on to describe some examples of resources that could be provided to staff, including the use of an on-site psych professional to complete the environmental risk assessment if staff are not sufficiently competent to do so. Which means that, if you do use in-house staff, you might be pushed to identify how you know that the folks doing the evaluation of the space immediately before a patient is placed are competent to do so. Though I suppose that also means you might have to demonstrate how you evaluated the on-site psych person… ah, it never really ends, does it?

At any rate, if you have not done a quick (but thoughtful—gotta be thoughtful!) risk assessment of your non-BH patient spaces, it’s almost certainly worth your time to do so. To my mind, the best risk assessment of all is the one they don’t ask for because the effectiveness of the process is in evidence. But sometimes we don’t get credit for “doing the math in your head,” so the possession of the risk assessment is your best bet.

Thanks for tuning in. Please be well and continue to stay safe. Until next time…

Identifying issues and finding solutions…

…versus identifying issues and pointing fingers.

I think we can all agree that (at least for the moment) our friends in the regulatory survey services world have misplaced the location of their customers and, as a result, have become significantly more punitive in administering the survey process. Of course, the accreditation survey team always tells organizations that, despite the umpty-ump number of findings, they are a quality organization and really, this was a good survey. I have yet to hear of any instances in which the survey team “supported” anything other than a positive vibe, but it seems that, in growing numbers, that vibe is not really translating past the point of the exit conference.

Now, I know that it is not the role of the accreditation organizations to do anything more than identify deficiencies (I have hopes that a more consultative approach will re-emerge before too long, but I am not holding my breath), but what I keep bumping into are instances in which the folks (internal and external to an organization) charged with preparing organizations for survey are almost as punitive in their administration of the survey prep process. The purpose of environmental rounding/touring, etc., is to help folks become as prepared as possible and to identify strategies for sustaining compliance. It is not about the “gotcha,” with follow-up paperwork. My personal philosophy (as a safety professional in general, but certainly as a consultant) is that my obligation to the process is to help get things going in the right direction, even to the point of cleaning up a spill or picking something up off the floor while touring. Certainly, I can (and do) identify lots of things that need attention, because there are always lots of things to find that need attention (this goes back to my “no perfect buildings” philosophy; probably too much philosophy for so early in the year, but so be it). But I go into this having suffered at the hands of consultants (and others) who are not as interested in helping work through an issue to achieve some sort of sustainable solution.

As an example, I recently heard about an instance in which the environment of care rounding team had identified a resolution to a pesky issue (in this case, ensuring that specimen containers were appropriately labeled) but did not share that resolution with the entire organization. So last time, a “sticky” label was affixed to the container, but the label didn’t stick so well; this “failure mode” was communicated to the folks in infection control, but there was no immediate follow-up. So, next rounding activity, a specimen container to which a “sticky” label had been affixed was, in the local parlance (not really), nekkid in terms of labeling. Well, after the labeling issue had been cited, it was “revealed” that, after some consideration (may have been careful consideration, but less careful in the communication), it was determined that the containers would be stenciled in more permanent fashion. Interesting thing, the “finding” still required response, etc. even though the “finding” was the result in a communications misfire.

At any rate, as I think I’ve noted here before, there’s no regulatory statute that requires us to shoot ourselves in the foot, or, indeed, to engage in friendly fire. To my way of thinking, internally punitive surveying is not helpful and since we know the “real thing” isn’t particularly helpful (to healthcare organizations, at any rate), doesn’t it make more sense to work together towards sustainable compliance?

Quick closing question: While I was having some lab work done today, I noticed that the emergency eyewash station in the sink area was covered with a clear plastic bag. Has anyone out there in blogland encountered this or are practicing it? I’m thinking that this adds a step to activation of the eyewash station, but perhaps there’s a risk assessment that supports it. Just asking for a friend…

Well that stinks! Or maybe it doesn’t…

I guess we can file this under the “You never know what’s going to pique someone’s interest” category.

In last week’s Joint Commission E-Alert publication, there is a featured set of links to an updated FAQ regarding “Aromatherapy & Essential Oils” (for example, this one). When I first saw it, I was thinking that maybe it was going to discuss some of the intricacies of dealing with all this smelly stuff that seems to crop up in offices and other spaces (everywhere looks like a good place for a stick-up). But when I clicked through the link, I found the question revolved around whether or not aromatherapy and/or essential oils needed to be managed as medications. As usual, the response was “it depends” (admittedly, that is a very much shortened version of their response, but please feel free to click through to embrace the majesty of this FAQ), with the slightly more involved response being “it depends on how you’re using it.” I have to say that I am not typically a fan of a lot of these scents; some of the them just seem like iffy attempts at covering other odors and some of them just seem wrong, but I digress. I know there are (perhaps more than) a few organizations that have adopted a fragrance-neutral/fragrance-free environment (these days, you just don’t know how someone is going to react to various scent-sations—allergies abound), but I can definitely see some folks interpreting this as something of an endorsement of using scents as a strategic intervention.

In other news, TJC also announced the publication of a new book of safety lists, which (based on my past experiences with their book products), may or may not be the answer to your sticky challenges (I pretty much live in the “not” camp, but someone wants to try and convince me that we have a winner, I’m game). Alternatively, you might consider the 2019 edition of the HCPro Hospital Safety Trainer Toolbox, which promises so much more than a bunch of checklists. I personally kind of ebb and flow on the whole concept of checklists, primarily because I find they try to do too much (or perhaps promise too much is the more appropriate descriptor). I see those checklists that go on and on for pages and pages and I’m thinking how in (insert deity of choice)’s name do you operationalize something that big? To that point, I am often asked what I look for when I’m doing consultant survey work and my (admittedly somewhat glib) response is that I don’t look for anything in particular, but rather I look at everything. I suspect it goes back to my EVS days when I looked at things from top to bottom in a (more or less) circular fashion—pretty much looking for stuff that didn’t look right (it is very rare indeed that I find an instance of noncompliance that looks “right,” if you know what I mean). The corollary to that is that a surveyor (and I count myself among that august assemblage) is never more dangerous than when they are standing still—that’s when the little funky detail stuff comes into focus. All the divots, loaded sprinkler heads, dust animals (bunnies, dinosaurs, the lot), become more visible. A moving surveyor (unlike the moving finger…) is a very good thing!

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!