All Entries Tagged With: "Environment of care"

Taking care of business

Earlier today, I was conducting an EC/EM interview session with a very participative group and I was complimenting them on their ability to speak to improvement efforts in areas that are not necessarily in their scope of practice. Now, my experience has been that the folks most familiar/expert with the EC function being discussed tend to dominate the conversation (sometimes in a good way, sometimes not) and I thought it was cool that these folks were so familiar with what others in the group felt was important. To my compliment, the observation was made (and I thought this was absolutely the grandest definition of what a high-performance team can achieve) that they mind each other’s business. In that simple turn of phrase (not an exact quote – sometimes paraphrase is the best I can do), the whole concept of what the EC team can embrace and accomplish was crystallized: It’s not about what may or may not be “somebody else’s job” (or “not my job”); it’s actually using the team concept to make and sustain improvements. In the old days we used to call that type of organizational behavior “silos,” which is OK if you’re storing grains and such, but when the goal is organizational improvement, we want to be more like a snack mix with all sorts of nuts and fibrous bits.

And please keep in mind, it’s not necessarily about never having any issues to correct. As long as there are human beings in the mix, there will be corrections to make – be assured of that. But if you can harness the power of a group of committed individuals who accept responsibility, hold each other accountable, and care enough to “mind each other’s business,” you can accomplish so much. There’ll always be stuff to do, but think about the power of getting stuff done.

Brings a smile to my face – how ‘bout you?

Do you remember? Or even yesterday…

Way back in September of last year, we were chatting about the importance of appropriately managing conditions in the patient environment, primarily the surgical environment. For those wishing for a refresher, you can find that post here. (I talked about how I’ve noticed recent citation in surveys regarding the surgical environment, including the maintenance of temperature and humidity, ensuring appropriate air exchange rates, and making sure that your HVAC systems are appropriately maintaining pressure relationships, etc.)

One of the things I didn’t really cover back then was when you have documented out-of-range values. Could be temperature, could be humidity, could be those pesky air exchanges and/or pressure relationships. The fact of the matter is that we live in an imperfect world and, more often than not, our success comes down to how effectively we manage those imperfections. And that can, and does, come down to how well we’ve prepared staff at the point of care/service to be able to respond to conditions in the environment. But, in order to get there, you have to undertake a collaborative approach, involving your infection preventionist and the folks in the surgical environment.

The management of risk in the environment doesn’t happen because we have (or don’t have) nifty technology at our disposal; it’s because we can work collaboratively in ways that no building automation system or self-regulating HVAC equipment can. This idea has become an increasingly important part of the survey process. We know that more folks are harmed by hospital-acquired infections and other related conditions and I’ve seen it become a fairly significant survey vulnerability. So, let’s start talking about this stuff with the end users and make sure that we’re ahead of the curve on the matters of the care environment.

This ain’t the summer of love (but maybe it could be…)

One of the universal challenges facing Environment of Care/safety committees is the task of actually getting things done in the way of meaningful improvement, generally for the more controversial issues an organization might encounter. Sometimes it’s because opinions and interpretations are sufficiently diverse that common ground is tough to even imagine, or it could be that there is an agreement that a problem exists, but the solution resides within the more stratospheric pay grades.

One of the most useful means of breaking these deadlocks (I was going to say filibuster, but that sounds way too congressional—I don’t want to paint anyone with that brush) is by adopting a process for obtaining consensus from the group. Consensus provides a framework that allows for some disagreement (and ideally helps moderate those disagreements), but arrives at a work product that is acceptable to the group at large and allows things to move forward (you and I both know that every once in a while there will be a topic of conversation that never, ever goes anywhere—it just keeps burbling along in the minutes and frustrates the heck out of everyone in the room when the topic rears its ugly little head).

Now, consensus shouldn’t be confused with majority rule. In fact, majority rule, if you have strong personalities involved, can be a recipe for stalemate (the old saw regarding physicians: What do you call a medical staff vote of 99 to 1? A tie!) as can be impossible to move beyond those peculiar sticking points.

A nifty (that word doesn’t get used enough anymore, if you ask me) tool to help move towards this type of decision-making looks a little something like this:

+3   We must do this

+2   We should do this

+1   I support this

0    I’m neutral

-1    I don’t support this but won’t oppose it

-2    We should not do this

-3    We must not do this

So, for those thorny issues, everyone has a position, and in all likelihood, that position is represented somewhere on this continuum. As you can see the “decision point” for moving something forward is actually at -1, with everything below being clearly indicative of a stopping point. So, the process works like this: one person, one vote (I think the founding fathers would like that). My preference, but it is entirely up to you, would be for everyone to participate—and I do mean everyone—but that’s one of the ground rules you can (and, to my mind, should) establish. It’s not exactly like not going to bed angry, but it provides a framework (there’s that word again) for moving something forward or moving something off the board (you should also consider in the rules of engagement whether something is being moved off the board permanently or whether it can come back, given certain conditions).

I would encourage you to consider using this tool—and I would encourage you even more strongly to share with the safety community your successes (and failures—everything is a learning opportunity).

Try to keep cool!

That’s me in the corners…losing my infection (risks)

Not that long ago, I participated in a discussion regarding the terminal cleaning of surgical procedure rooms, particularly the recommended frequency of using wet vacuums and a liberal application of water to ensure appropriate results. As a function of that discussion, it appeared that the organization in question had adopted a weekly frequency for the use of wet vacs, and it also appeared that the OR rooms were noted to have a buildup of materials (you know what they are—no need to get graphic here) in the corners of the rooms. The overarching question was what the TJC survey risk might be given the current practice and conditions.

Now I honestly don’t know why people struggle so much with this, but here goes (and yes, for those of you keeping score, before we finish this conversation, I will invoke the mighty risk assessment).The Joint Commission standards do not specify any particular methodology for the cleaning of operating rooms, primarily (to my way of thinking) because there is far too much variability in the surgical environment for them to “require”  anything more than what they do now: EC.02.06.01, EP 20, which requires that “areas used by patients are clean and free of offensive odors.” And that, as they say, is that. (By the way, in case I have not previously noted this, this EP is now a Direct Impact finding and is showing up with far greater frequency in survey results. I characterize this as the “return of the white gloves.”)

Based on the conversation related above, if there is a buildup of nasty stuff in the corners, then clearly whatever frequency and/or method they are employing is not particularly effective—even if they are using a wet vac only once a week, they shouldn’t be getting a whole lot in the way of buildup in the corners, so putting my EVS hat on, there is at least some competency/education opportunities lurking in them thar corners. Will a water vac be enough? Read on…

Even the CDC, in its Guidelines for Environmental Infection Control points to other “published” guidance when it comes to the cleaning of OR’s , which, to my mind, points to the AORN recommendations (I don’t know if there is a more contemporary edition; this is from 2007, but I think the basic concepts still apply). Now there are a whole slew of things to do in the AORN guidance, including a process for before/between-case cleaning (which indicates the process would be in place even after the room is terminally cleaned). As a bit of consultative advice, I would be inclined to advise folks not to cherry-pick the “easy” pieces from the AORN guidance. If one were to consider the AORN guidance as a “best” practice, then we would need to look at is as a whole, at least as a starting point. As with all universal guidance documents, the “one size fits all” aim almost never results in universal applicability, but if we are going to adopt something along the lines of a hybrid kind of deal (wait for it!), we would need to have this framed within the context of a risk assessment.

So if, for instance, a surveyor were to cite a hospital for not following the AORN guidance (and there is not TJC standard that says you have to; good idea, yes, mandate, no),  without citing some level of failure relative to the cleaning process, then that would be an opportunity for clarification. But, if the organization can demonstrate that whatever methodology it is using is effective, based on data analysis, infection rates, etc., then who’s to say that its “strategy” is not every bit as valid as the recommendations of AORN? But, if the same hospital gets cited because it has sanitation opportunities in their OR’s, then it is dead in the water, so to speak. As something of an editorial comment, it has been a very long time since I’ve been in an OR that I would call clean; most are okay, but for instance, it is very rare indeed that the anesthesia machine does not have a buildup of dust. Now I know that the dust comes primarily from linen and the undoing of surgical packs, etc. in the room (that stuff does nothing but aerosolize lint—yuck!), which means pretty much every time an OR room gets used, we are introducing more stuff that will need to be cleaned.

In conclusion: Buildup in the corners will likely lead to a TJC or CMS finding and that is as it should be; folks who are experiencing less-than-ideal levels of cleanliness need to look at changing their process, but I don’t think it necessarily makes sense to tie your future to adopting anyone’s specific guidance, until you’ve figured out the reasons for having a deficient process in the first place. That way, if you should choose not to adopt what can legitimately be characterized as a best practice (the AORN guidance), then they better have a real good reason (which would include validation of the effectiveness of the alternative) for doing so.

This is just like the cardboard issue. There is no regulatory mandate in any direction on this, but it is a risk to be managed effectively. Nowadays, each organization’s responsibility, and, strangely enough, The Joint Commission’s expectations, is to know whether it is managing identified risks appropriately. There can truly be no more reliance on the “no news is good news” philosophy—reactive risk management will only cause trouble during survey. Improvement is a beautiful thing, but you need to understand how and why improvement occurred.

Mac’s Safety Space: Linens in the ENT clinic

Q: We have been having a discussion about the linens in our ear, nose, and throat (ENT) clinic. This clinic has an esthetician who uses spa wraps and smocks on the patients. Wouldn’t these linens have to be laundered the same as the hospital, as our clinics are under our hospital accreditation and license?

Steve MacArthur: I guess the question I’d have at this point is how are those items being laundered at the moment? It is possible to do a low-temperature wash (<160 degrees F) if appropriate chemicals are used. I’m thinking that we’re generally not dealing with an immune-compromised patient population in this context and maybe a risk assessment and a blessing from Infection Control would suffice.

The other thought I had is to either go with disposable wraps and smocks or perhaps the patients could keep their smocks, maybe as a marketing strategy. As I think about it, is the esthetician providing services under the auspices of the hospital’s accreditation or is it more like when they have hairdressers come in for patients in long-term care, which is sort of like a concession? I think the place to start is finding out what’s happening currently and working from there.

I think a credible risk assessment under the guidance of IC should be able to address any concerns that might come up during survey. Strictly speaking, this probably functions as an offshoot of palliative homeopathic care. I think as long as you approach the whole process in a thoughtful, methodical way, the surveyors will only be impressed at the level of service you are providing to patients. The IC standards all revolve around assessing risk and implementing prudent strategies for managing those risks, so why should this be any different. In fact, the acid test would be for you to submit the question to the SIG—and I bet you’ll get the same “figure it out for yourself” answer.

’tis the season…

As you prepare to don your Scrooge outfits and do battle with the holiday decorating season, I wanted to challenge the group to come up with your best practices for creative and compliant decorating tips.

Clearly, there is a therapeutic value to being able to brighten our facilities come the holiday season and I’m thinking that with our collective genius, we can devise a means of decorating without having to engage in the perennial urination competition over the “thou shall nots.”

This year, let’s strive to come up with a list of “yes you can” decorations for the holidays. Besides, the Scrooge outfits are getting just a little bit threadbare. We know the code. Let’s see how we can work within the confines of the code for a decorating season of unmatched splendor!

And no bah humbugs!

Mac’s Safety Space: Managing medical equipment in outpatient mini-clinics

Our hospital operates a number of outpatient mini-clinics in places like grocery stores and we’re trying to figure out how to manage medical equipment being used in those locations. Do we need specific medical equipment management plans for those locations? Also, do we need to include the equipment being used in our annual preventative maintenance program?

Thanks for your question – it’s always good to include medical equipment concerns in the discussion.

As to your question, the answer is: it depends.

If the organization that owns the clinics is operating them under the auspices of its Joint Commission accreditation, then you would need to make a determination as to whether management plans and/or scheduled preventative maintenance activities would be of benefit.

Some folks would write sites like this into their management plan, effectively treating the off-site locations as departments of the hospital. Others, because of the complex range of services provided off-site, would have a management plan dedicated to just the off-sites. When it comes to PM activities, I think you have to look at it from a risk management perspective as opposed to a solely accreditation compliance standpoint. I’m going to guess that most, if not all of the equipment used in these types of settings, would run more towards the low- or no-risk, with maybe the odd scale to calibrate.

But if they have things like AED’s, that might change the dynamic a little based on what model AED’s they have and what the manufacturer recommendations are.

In some ways, I’m probably making it sound more complicated than it really is. If there are enough commonalities in terms of equipment, then managing them monolithically should be just fine (I would document the decision process in the annual evaluation and periodically revisit the decision using the evaluation forum).

Does that make sense? Please let me know if you have any questions or concerns.