Or, oh me of little faith…
Another somewhat hodgepodge-ish coverage of sundry and assorted niceties this week. For some reason, this week has resulted in a lot of ideas flying around in my noggin (I suspect you might have weeks like that too, from time to time), but I think there’s a sufficiently common theme for these to hang together. Hopefully some level of cogent thought will hold sway…
First up, a discussion about topics relating to cleaning, and by extension, cleanliness. Health Facilities Management recently published an article regarding a three-year study aimed at identifying ways of improving patient room cleaning (my philosophy on that is that we need to consider more than just the cleaning of patient rooms, but more on that in a bit). The article covers some of the process breakdowns observed during the study, and speaks to the inclusion of housekeeping staff in unit meetings, etc., to enhance the sense of the importance of their roles in the process of providing care to the patient by making sure the environment is clean. I think you folks know that my primary background is in the EVS (from the EVS world?) and I have never needed to be “sold” on the importance of the frontline housekeeping staff in supporting the care environment. I know from experience that it’s a tough job and I can tell you with absolute certainty that there is way more stuff in the typical patient room to clean than their used to be. (I only had to periodically dust off the abacus, etc.) The article provides some interesting data on the cleaning of various surfaces in the room, but I’ll let you see those for yourself. In looking at the data, it does make me ponder how much of a leap of faith it is to leave a restroom without having a paper towel (or some such) in hand to twist the ol’ door knob. I just can’t bring myself to stride right out without a thought in the world—but I see folks do that all the time and only about half of them wash their hands…
One of the things I’ve been seeing in survey country is a focus on what I will call the concept of the patient-ready room; this goes beyond the regimen of daily cleaning of surfaces, etc., and gets to the land of discharge cleaning, etc. I think one of the key conversations you can have in your organization is to figure out what a “patient-ready room” means and to start educating folks. Some things to consider: making sure the waste containers are empty; making sure that everything in the room works (just as you would yip if you had a hotel room where stuff wasn’t working properly—or at least I hope you would yip); making sure there are no stained ceiling tiles, etc. Again, this room is going to be somebody’s home—it may only be for a day or so—but think about someone flat on their back and only having the TV and that stain on the ceiling to look at. And they’re probably not going to say anything while they’re staying with you (I suspect that most folks are just to amped up about being there to speak up much), but they may very well remember that ceiling tile if they get a satisfaction survey. And don’t get me started about schmutz on the floor or on the bed rails; I see it happen far too often and I don’t know if too many organizations that can’t do a little better with that.
As a final thought in this realm, I know a lot of folks have secured the areas under sinks to prevent storage, etc. If your organization prohibits under-sink storage, it’s probably the simplest solution to keeping them (whoever “them” might) out. But I ask you this: how often are you opening up those areas to see what’s going on? It seems like lately I’ve been running into a fair number of conditions bordering on Roquefort—or perhaps a Gorgonzola or Stilton. Just because you can’t see it, doesn’t mean there isn’t something growing under those pesky sinks—and if the water intrusion isn’t enough to leak down below, you may have no reason to look. But I’m thinking you might want to think about thinking about setting that up as a process. Just sayin’…
Those of you who’ve followed this space for a while know that my first “life” in healthcare was working in various positions in what we now call Environmental Services (used to be Housekeeping and/or Building Services where I “grew up” in healthcare). So, in the spirit of “once a housekeeper, always a housekeeper,” I entreat you to join me in recognizing some of the folks in the trenches as we celebrate Environmental Services and Housekeeping Week from September 8-14. My stance has been that it is nigh on impossible to appropriately prevent infection if the environment is not properly maintained—and that process goal is frequently in the hands of the EVS folks. As with any frontline position, there are challenges galore (it takes a lot of diligence and pride to have to clean up after folks—I did it for a long time and truth be told, I still pick up stuff off the floor, etc.), so I think it an excellent opportunity to let these folks know how important they are in the management of the physical environment. And I will add my own thanks to the folks who wash the floors, clean the toilets, pick up the trash, and a myriad other tasks that, if left undone, would result in a much less tidy experience for our patients and our colleagues. Hip, hip, hooray!
Continuing on our recap of survey adventures, we finish out the Top 10:
EC.02.06.01 – Establishment and maintenance of a safe, functional environment (#9, with 32% of hospitals having been cited)
A couple of somewhat disparate conditions are coalescing under this particular standard:
- Safety and suitability of interior spaces – this apparently is where the unsecured compressed gas cylinders are ending up when they are found during survey. Not necessarily the place I would have picked (I’d run with EC.02.01.01 EP #3 – minimization of safety risk in the environment), but I can see where it would fit;
- Management of ventilation, temperature and humidity in the care environment – this is one that will cause you so much heartache, it’s not funny. Temperature and humidity logs? You better have ‘em (and yes, I know that they are not specifically required in the regulatory verbiage, but that doesn’t mean a (insert descriptor of your choice) thing. Trust me on this, if on nothing else, ever!) Make sure that you have extremely reliable pressure relationships in every spot where you’ve got clean/soiled environments cheek-to-jowl; clean/sterile; sterile/soiled, etc. The air has got to flow from the good to the bad (euphemistically speaking), if it flows from the bad to the good, you are going to get lit up like a Roman candle during survey, likely resulting in a CMS visit to boot – none of us want that, none of us at all.
- Finally, and I don’t know that this got a whole lot of play in the official version, but there is a universal opportunity relative to cleanliness in the patient environment. There are some that I’ve seen who do a pretty good job, but I also know that I’ve not encountered anything close to perfect. If you have a surveyor with a mind to find dust, etc. somewhere in the patient environment, it will be found and it will be cited. Tell me the EVS folks aren’t shoveling against the tide sometimes…
EC.02.02.01 – Management of Hazardous Materials Risks (#10, with 29% of hospitals having been cited)
Lots of funky conditions can reside here, to name just a couple:
- Management of eyewash stations – weekly checks, temperature, obstructions, where they are installed, etc.
- Labeling secondary containers – if the chemical leaves its home vessel and is placed in another vessel, the second vessel (spray bottle, basin, sink) needs to have the hazard identified, unless the second vessel is absolutely attended until it is used/properly disposed – and even then, I’d do the label;
- Access to the Hot Lab in Nuclear Medicine – you’ve got to have a policy that makes sense about access, particularly for couriers delivering the materials – and remember, they’re already driving around with the stuff – if they want to swipe the stuff, they’ll just keep driving – so keep an eye on your stuff (George Carlin would want you to). That said, you should track down the July 2012 edition of Perspectives – there’s a lovely article on just this subject – can you say risk assessment? Thought so.
OK, we’ll do one more for this week, breaking into the next 10
EC.02.05.01 – Managing risks associated with Utility Systems (#11, with 28% of hospitals having been cited)
For those of you with older buildings and/or older utility system components, this one may keep you up at night. The sort of overarching way this is popping up during surveys (other than temperature, humidity, and ventilation, about which we’ve already spoken and will, no doubt, speak of again) is the inability of the system (whichever system it might happen to be) to achieve required results. Now, the sticking point here relates very much to what constitutes a “required result”. In case you hadn’t noticed, CMS is pretty much calling the shots when it comes to enforcement and, with increasing frequency, the practice of grandfathering older, lesser-performing systems is going by the wayside. If you (or someone you love) has a utility system that is not performing up to modern standards, then you had best get going on a risk assessment and identify mitigation strategies for appropriately managing the risks associated with the current performance level of the systems (and, perhaps, a plan for how you’re going to get to where you need to be).
The other condition that has been popping up is the identification, in writing, of inspection and maintenance activities (and the appropriate intervals) for all operating components of utility systems on the utility management inventory (which is, of course, populated through an arduous risk assessment process). It’s my understanding that continuous monitoring through the good graces of a building automation system is an acceptable means of compliance with this requirement, but if you don’t have a building automation system, you’d best be prepared to produce, in writing, the activities and intervals as noted above (a computerized work order system might work – but it has to be a pretty robust platform).
And so we’ve reached the end of yet another batch of fun facts and figures – next week, we’ll wrap it all up – until next year!
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.
Q. I have a question regarding OR humidity. If OR humidity drops below the required range, can a portable reservoir type humidifier be used to bring the humidity back up within range? If not, what should the facility do? Should the facility stop surgeries?
I have been researching the World Wide Web to find additional information. What I have found is that reservoir type humidifiers should not be placed in duct work. Any additional help would be greatly appreciated.
A. The humidity levels are very much in the way of guidelines as opposed to strict regulations. Recently, ASHRAE (the American Society of Heating, Refrigeration and Air-Conditioning Engineers) dropped the lower control limit for humidity to 20%, basically because electrical systems and OR environments in general are much better designed and can safely tolerate a “drier” environment.
At the end of the day, it all comes down to the comfort of occupants, and as long as the OR rooms aren’t dripping condensation, the infection control risks are minimal. However, if you are dealing with humidity levels below 20%, I would contact your HVAC vendor and see what type of humidification is available.
You are correct in that reservoir-type humidifiers should not be placed in duct work, but there is humidification equipment that can be installed for those really dry days.
The safety of operating trash compactors and locking them when not in use is yet another opportunity for a risk assessment.
Strictly speaking, there are no specific regulatory or code requirements for trash compactors in healthcare organizations. But we have learned over the years that [more]
I was discussing “Wet Floor” signs with a risk management coordinator, and I told her this is yet another sterling example of the risk assessment process.
“Wet Floor” signs are a tripping hazard, but that hazard has been mitigated to a degree by [more]
As you might guess, I’m in favor of using the risk assessment process to look at the issue of power strip use in hospitals.
And I’d start with a determination of whether a power strip is the most appropriate strategy, with the recognition that once you start with the power strip as opposed to additional electrical outlets, you’ve increased [more]
I was asked about a clean utility room that is also an electrical storage closet, which contains electrical panels, many wires, and oxygen cylinder storage against the wires.
It sounds like the organization had to make use of the available space for its network cabling, and while this is not an optimal environment of care practice, there’s no real regulatory language that precludes it. That said, there are a couple of things I would cite as “other environmental concerns” to consider: [more]
My colleagues and I had a discussion recently about an OSHA reference for when material safety data sheets (MSDS) are not required when staff members use everyday consumer cleaning products.
This comes from OSHA’s hazard communications standard (1910.1200), in which [more]