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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”…

And you may find yourself in another part of the survey process (more HazMat fun)

And you may ask yourself, well, how did I get here?

As is sometimes the case, I like to respond to questions from the “studio” audience and last week I received a question from the field that I think is worth a few inches of verbiage here. The question, as luck would have it, relates to the ascendancy of EC.02.02.01 (with 63% of the hospitals being surveyed taking hits), the management of hazardous materials and wastes.

While it may seem a little incongruous, with a side order of daunting, I think that the primary reason for the ascendance of EC.02.02.01 is that there are any number of things that can generate findings, particularly from the clinical surveyors (not that the LS surveyor couldn’t find stuff, but from what I’ve seen in recent survey reports, a lot of the HazMat findings are being generated during “regular” tracers). So, in no particular order:

  • emergency eyewash equipment (availability/accessibility/documentation of testing & maintenance)
  • availability and use of personal protective equipment (PPE) in accordance with product Safety Data Sheets (SDS)
  • management of hazardous energy sources, particularly as it relates to managing lead PPE;
  • labeling of secondary containers
  • management of hazardous gases and vapors (particularly as a function of ventilation, but also monitoring if you happen to have folks still using glutaraldehyde and/or cadmium-based products)
  • ensuring appropriate staff education is in place, particularly Department of Transportation education for staff signing manifests
  • with the odd issue relating to staff being able to competently access SDS

We’ve certainly spent our fair share of time talking about eyewash equipment (surveyors are as prone to over-interpretation as anyone, so you better have a clearly articulated risk assessment in your back pocket), and, interestingly enough, on May 31 (my birthday!), the folks at HCPro are hosting a webinar on the evergreen topic of eyewash stations, so you may want to give that look-see (listen-hear?).

I think the stuff surveyors are kicking folks on is pretty straightforward. I mean, just think about unlabeled or inappropriately labeled secondary containers—what’s the likelihood that you’ve got one out there somewhere in your organization? An unlabeled spray bottle; a biohazard container for which the label was washed off—lots of opportunities for the process to come up short.

At any rate, the list above is representative of what I’ve seen (in consulting practice and in actual survey reports). Anybody have any other potential findings that they’ve seen?

No one told you when to run: Closing out one year, embarking on another…

Every once in a while, I like to poke back through recent missives from our friends in Chicago and elsewhere to see if there was anything that I missed on first review or something that didn’t really “pop” out at me at the time. And, somewhat typically, the really pressing hard news stories are in rather shorter supply as we get closer to year’s end. Truth be told, the whole ligature picture has really held sway in recent weeks, almost to the exclusion of everything else.

At any rate, in looking at the most recent (I think) slate of pre-publication standards, I noticed a couple of “new” requirements that gave me a little bit of pause. Due to some editorial constraints, I won’t identify the standards and EP numbers, but I will try to give you a sense of where there “live”: they are identified as “new” on the webpage, so that may be enough for you to find them (you’re a pretty smaht bunch and I have every confidence in your detective-ing abilities). This week we’ll cover the Environment of Care changes and hit the Life Safety changes next week (where did the year go!?!):


  • The hospital has a library of information regarding inspection, testing, and maintenance of its equipment and systems. Note: This library includes manuals, procedures provided by manufacturers, technical bulletins, and other information. (Safety Management)
  • Management of smoking materials for patients receiving respiratory therapy. (Smoking Policy)
  • Periodic evaluations of fire hazards during surgical procedures (don’t forget to define that period!) (Fire Safety Management)
  • Process for reducing risks when flammable germicides or antiseptics are using during “hot” surgical procedures (electrosurgery, cautery, lasers) (Fire Safety Management)
  • The hospital meets all other Health Care Facilities Code fire protection requirements, as related to NFPA 99-2012: Chapter 15. (Fire Safety Management)
  • Elevators with firefighters’ emergency operations are tested monthly. The test completion dates and results are documented. (Inspection, Testing & Maintenance of Life Safety Systems equipment)
  • Hyperbaric facility safety, including labeling of equipment used in oxygen-enriched atmospheres (we covered this a couple of weeks ago, with a couple of folks weighing in with questions on how far to go with Chapter 14 of NFPA 99; if the past is any indicator of the future, I would be moving towards adoption of the whole thing and probably start to extend the labeling of equipment out to all oxygen equipment—this is where they start digging into this—we know the targets will move over the next survey years, so better to be ahead of the game than behind). (Medical Equipment Inspection, Testing & Maintenance)
  • Inspection, testing, and maintenance of anesthesia apparatus, including gas flow and oxygen concentration verification; no oil, grease or flammables for oxygen equipment. (Medical Equipment Inspection, Testing & Maintenance)
  • ORs are wet locations unless you have a risk assessment that says otherwise and has been approved by the governing body (it appears that risk assessments done in “isolation” will no longer meet the mark—organizational leadership has to be involved in the process. Written record of the risk assessment is available for survey review. We covered this before.  (Utility Systems Management)
  • Risk level identification of electrical distribution; we did this one before as well.  (Utility Systems Management)
  • Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered are tested after initial installation, replacement, or servicing. In pediatric locations, receptacles in patient rooms (other than nurseries), bathrooms, play rooms, and activity rooms are listed tamper-resistant or have a listed cover. Electrical receptacles or cover plates supplied from the life safety and critical branches have a distinctive color or marking.  Keep an eye on those pediatric locations, particularly areas that can “swing” – tamper-resistant receptacles could well become a moderate risk of harm during survey. (Utility Systems Management)
  • Power strips must be appropriately listed for use in patient care vicinity, patient care rooms, etc. Focus on this has already started, so you better start working with your IT folks to make sure everything is going in the right direction. (Utility Systems Management)
  • Extension cords are not used as a substitute for fixed wiring in a building. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was intended. I predict that this is going to keep this standard at the top of the most frequently cited standards list. (Utility Systems Management)
  • Areas designated for administration of general anesthesia using medical gases or vacuum are in accordance with NFPA 101-2012 and NFPA 99-2012 (Utility Systems Management)
  • Electrical system critical branch supplies power for specific needs (task illumination, fixed equipment, select receptacles, and select power circuits) in areas designated for administration of general anesthesia (specifically, inhaled anesthetics) using medical gases or vacuum. The EES equipment system supplies power to the ventilation system. (Utility Systems Management)
  • New buildings equipped with or requiring the use of life support systems (electro-mechanical or inhalation anesthetics) have illumination of means of egress, emergency lighting equipment, exit, and directional signs supplied by the life safety branch of the electrical system described in NFPA 99. (Utility Systems – Emergency Electrical Power Source)
  • Equipment designated to be powered by emergency power supply are energized by the hospital’s design. Staging of equipment startup is permissible. (Utility Systems – Emergency Electrical Power Source)
  • For deemed status hospitals, battery lamps and flashlights are available in areas not serviced by the emergency supply source. (Utility Systems – Emergency Electrical Power Source)
  • Line isolation monitors are tested in accordance with NFPA 99-2012. (Utility Systems Inspection, Testing & Maintenance)
  • Risk level identification of medical gas, medical air, surgical vacuum, waste anesthetic gas disposal (WAGD), and air supply systems. (Inspection, testing & maintenance of medical gas system components)
  • All master, area, and local alarm systems used for medical gas and vacuum systems comply with the category 1–3 warning system requirements. (Inspection, testing & maintenance of medical gas system components)
  • Containers, cylinders, and tanks are designed, fabricated, tested, and marked in accordance with NFPA 99-2012. (Inspection, testing & maintenance of medical gas system components)
  • Locations containing only oxygen or medical air have doors labeled “Medical Gases: NO Smoking or Open Flame.” Locations containing other gases have doors labeled “Positive Pressure Gases: NO Smoking or Open Flame. Room May Have Insufficient Oxygen. Open Door and Allow Room to Ventilate Before Opening.” (Inspection, testing & maintenance of medical gas system components)
  • A precautionary sign readable from 5 feet away is on each door or gate of a cylinder storage room, where the sign, at a minimum, includes the wording “CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING.” Storage is planned so cylinders are used in order of which they are received from the supplier. Only gas cylinders and reusable shipping containers and their accessories are permitted to be stored in rooms containing central supply systems or gas cylinders. (Inspection, testing & maintenance of medical gas system components)
  • More cylinder storage stuff (I suspect you know the drill)—NFPA 99-2012 has a great deal of detailed requirements—and I have no reason to think that they won’t be kicking the tires pretty diligently. (Inspection, testing & maintenance of medical gas system components)
  • Also, transfilling of liquid oxygen is a process with very, very specific requirements; if you’re not transfilling liquid oxygen in your facility, you could count yourself fortunate, but be on the lookout for any evidence of liquid oxygen being transferred inside your “house”; NFPA 99-2012 is your guide. (Inspection, testing & maintenance of medical gas system components)
  • Staff responsible for the maintenance, inspection, testing, and use of medical equipment, utility systems and equipment, fire safety systems and equipment, and safe handling of hazardous materials and waste are competent and receive continuing education and training. (Staff Competency & Education)

I know this is a lot of stuff to consider, but I wanted to put it out in front of you folks on the off chance that your bedtime reading hasn’t strayed into the realm of the 2018 standards changes. I have every reason to think that some of this stuff will show up again in this space (and what a space!), but if someone wants to start a particular conversation before we kick off (kick at?) 2018, please feel free.

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

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!