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

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

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

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

If it’s September, it’s time for Executive Briefings!

I suspect that, over the next few weeks, as I learn of stuff coming out of the various and sundry Joint Commission Executive Briefings sessions, I’ll be sharing some thoughts, etc., in those regards here in the ol’ blog.

The first thing to “pop” at me was some information regarding Chapter 15 (Features of Fire Protection) in NFPA 99 Health Facilities Code (2012 edition) relating to the management of surgical fire risks. If you’ve not had a chance to check out section 13 of said chapter, I think it will be worth your while as there are a couple of things that in the past one might have described as a best practice. But, with the official adoption of NFPA 99 by CMS, this has become (more or less, but definitely more than before) the law of the land. From a practical standpoint, I can absolutely get behind the concepts contained in this section (I’m pretty comfortable with the position that any surgical fire is at least one more than we should have), but from a strict compliance standpoint, I know that it can be very challenging to get the folks up in surgery to “play ball” with the physical environment rules and regulations.

As one might expect, the whole thing breaks down into a few components: hazard assessment; establishment of fire prevention procedures; management of germicides and antiseptics; establishment of emergency procedures; orientation and training. I think the piece of this that might benefit from some focused attention relates to the management of germicides and antiseptics, particularly as a function of the required “timeout” for the germicide/antiseptic application process. And yes my friends, I did say “required”; Section indicates (quite specifically) that a preoperative “timeout” period shall be conducted prior to the initiation of any surgical procedure using flammable liquid germicides or antiseptics to verify that:

  • Application site of flammable germicide or antiseptic is dry prior to draping and use of electrosurgery, cautery, or a laser
  • Pooling of solution has not occurred or has been corrected
  • Any solution-soaked materials have been removed from the operating room (OR) prior to draping and use of electrosurgery, cautery, or a laser

Now, I will freely and openly admit that I’ve not done a deep dive into the later chapters of NFPA 99 (though that’s on my to-do list), so I hadn’t bumped into this, but I can definitely see this being a potential vulnerability, particularly in light of the recent FDA scrutiny (and it goes to Linda B’s question in follow-up to a recent blog posting—I probably should have turtled to this at that point—mea maxima culpa). At any rate, nothing in this section of NFPA 99 is arguable unless you don’t have it in place and a surveyor “goes there,” so perhaps you should be sure that your OR folks are already “there” sooner rather than later.

Two closing items:

  • The good folks at the Facilities Guidelines Institute have provided a state-by-state resource identifying which states have adopted the FGI guidelines (completely, partially, not really). You can find that information here.
  • Also,  Triumvirate Environmental is presenting a couple of webinars over the next little while that might be of interest. The one this week (sorry for the short notice) deals with the recently established by EPA’s Hazardous Waste e-Manifest Program and then the week after next, there’s a program on Best Practices to Optimize Your Waste Documentation Program. While I can’t call these crazy risky survey vulnerabilities, EC.02.02.01 is still percolating around the top of the most frequently cited list, so it never hurts to obtain greater familiarity with this stuff.

Enjoy your week safely!

Can we count painful survey findings and new requirements as blessings?

First off, please accept my bestest wishes to you and yours for a most joyous and restful (or as restful as you want it to be) Thanksgiving holiday.

To paraphrase a certain musical ensemble, what a long, strange compliance year it’s been. Hopefully, 2016 will head off into the realm of history with a whimper (I think we’ve experienced enough “bangs” to take us well into 2017 and beyond). And so, a little casserole of safety stuff to tide you over ’til next week. First up, some risk assessment deliciousness, courtesy of NFPA 99.

I had intended to discuss this back a few weeks, but there has been a lot to discuss these past few weeks. At any rate, I was able to get a look at the CMS update portion of the Executive Briefings presentation and it appears that there was some discussion relating to the practical application of how a space is used to determine the risk category for the equipment and/or systems used to support that space. My sense of this is that it’s not so much the space itself as it is, but rather what processes, etc., exist within the space you are evaluating, using the definitions from NFPA 99. So, the methodology focuses on an analysis of facility systems and equipment based on the risks associated with failures of those systems:

Category 1—Facility systems in which failure of such equipment or system is likely to cause major injury or death of patients or caregivers

Category 2—Facility systems in which failure of such equipment or system is likely to cause minor injury to patients or caregivers

Category 3—Facility systems in which failure of such equipment is not likely to cause injury to patients or caregivers

Category 4—Facility systems in which failure of such equipment would have no impact on patient care.


So, moving to the definitions in NFPA 99, you sort the above concepts based on how the space is used:

  • Facility systems and equipment for critical care rooms would be Category 1
  • Facility systems and equipment for general care rooms would be Category 2
  • Facility systems and equipment for basic care rooms would be Category 3
  • Facility systems and equipment for support rooms would be Category 4

Each of the chapters in NFPA 99 (gas and vacuum systems, gas equipment, electrical systems, HVAC, etc.) have provisions for the different categories, as applicable, so it appears that the expectation (at least as it was presented at Exec Briefings) is that the organization of the facilities systems and equipment would reflect this methodology. To be honest, I think this may be more of an issue with re-packaging how things are equipped and maintained; maybe including the category designation on work orders, etc. I don’t know that this is going to extend to TJC’s activities, though with the bad marks it received on its CMS report card, it seems unlikely that TJC will become more reasonable…time, as they say, will tell.

Another potential complication for survey year 2017 (I’m pretty confident of this, but not yet certain about the timeline for implementation) is a broadening of the Evidence of Standards Compliance (ESC) process to include at least two more considerations. At the moment, the ESC process requires a response to the following categories: Who (is responsible for the correction); What (was done to correct the deficiency); When (the corrective action was completed); How (the corrective action was implemented and will be sustained), and Measure of Success (for those pesky “C” performance elements—to which we will bid a hearty “adieu” on January 1, 2017). I think we’re all pretty familiar with that part of the process (I can’t imagine that anyone’s had a survey with no findings in the physical environment, though I suppose the infamous “bell” curve might dictate otherwise), but there is indication that with the removal of the Measure of Success category, we will have two additional elements to document within the framework/context of the corrective action: Leadership Involvement and Preventive Analysis. At the moment, it appears that the sequence will look something like this:


Leadership Involvement:




Preventive Analysis:

I think being able to account for leadership involvement is a pretty straightforward response (I think probably the best way to frame this would be to identify the boss of whoever the “who” would be; and perhaps that boss’ boss, depending on the circumstance), but I suspect that the Preventive Analysis portion of the response could get quite complicated. As near as I can tell, it would be an amalgam of the root cause that resulted in the finding and the strategy for preventing future deficiencies, although minimizing the risk of recurrence might be a more useful viewpoint—as I like to tell folks, it’s the easiest thing in the world to fix something and the among the most difficult things to keep that something fixed. Hopefully, this will end up being no more than a little more water under the bridge, but I guess as long as findings in the physical environment remain a focus, the sustainment of corrective actions will be part of the conversation.

And on that note, I bid you a Thanksgiving to eclipse all yet experienced: gobble, gobble!

Coastal curiosities (Part deux)

At The Joint Commission’s Executive Briefings conference in September, another question that I found of some interest/horror (and please remember—that’s horror with a small “h”) continued the charge into the realms of environmental compliance.

Q: What areas need to be monitored for humidity and temperature? Does this include ICU patient rooms?

A: There are multiple areas in a hospital that require humidity and temperatures be monitored. Recovery rooms, Critical Intensive Care, and procedure rooms all require 30% to 60 % humidity and temperatures ranging from 70-75 degrees Fahrenheit. Other areas can have the same humidity levels but varied temps like the newborn nursery suite, which should have temperatures from 72-78 degrees Fahrenheit and Endoscopy would have temperatures from 68-73 degrees Fahrenheit. A very good reference is the AIA Guidelines for Design and Construction of Hospitals and Healthcare Facilities.

So I’ll ask you: How many folks out there are monitoring your Intensive Care Unit rooms for temperature and humidity? By the way, apparently the “faculty” in this instance were not quite familiar with the categorical waiver relating to humidity levels down to 20%. Actually, I suppose invocation of the American Institute of Architects Guidelines might be an indication that they were using an older edition of the Guidelines, since we all know that they’re the Facilities Guidelines Institute (FGI) Guidelines now.

I think minimally we can take this as further indication of an expansion of survey scrutiny into other areas of the hospital when it comes to the management of environmental conditions. I still think the best thing you can do is to get a copy of the 2010 FGI Guidelines, turn to the section at the end of this mighty tome that deals with the ventilation standards, start making a list, and check it twice.

We’ll cover the remaining questions and answers over the next little while; nothing quite as raucous as these first two, but nonetheless instructive.

A curiosity from the (left) coast

This is another plucked from the oblivion of the mailbag…

Back towards the end of September, I received an email from an acquaintance out in California who had attended The Joint Commission’s Executive Briefings conference, which included a session on CMS compliance, presented (or so it would seem) jointly by TJC and Joint Commission Resources. In their never-ending pursuit of encouraging customer participation, the audience (or learners as they are identified on the slide sheet) got to submit some questions to the faculty (who shall remain nameless … primarily because I don’t have that information), for which responses were prepared and shared with the group (there were 6 questions asked, based on the document I’ve seen).

At any rate, there are two questions asked for which the responses were somewhat illuminating, albeit in a rather frightening way:

Q. Does temperature and humidity need to be done/recorded daily in procedural areas even if they are closed (i.e., operating room closed on a Sunday or holiday)?

A. Indoor air quality testing that includes directional air flow, humidity, and temperatures should be done daily when in use, however, it is only recommended monthly when the rooms are not in use. So if the rooms are closed they need not be tested unless they are closed for more than one month, but tested when they are put back in use.

The question I have for the studio audience is this (and it’s not like we’ve had this conversation before in various permutations): Where in the regulations does it require daily performance of “indoor air quality testing that includes (which by extension can be interpreted as “not limited to”) directional air flow, humidity and temperatures”? Now it may very well be that this is an extension of the whole magillah regarding the maintenance and testing of critical utility systems components in accordance with manufacturer recommendations (and I don’t have nearly enough knowledge of the OEM guidance on the various and sundry HVAC systems there are out in TV land to be able to speak to that piece of it). Maybe this is destined to show up on TJC’s FAQ page (I see we’re getting a little acronym-heavy here, so I will try to refrain from further acronymization), but this one seems a little beyond the pale. My advice for the moment is that you really ought to look at this as a risk assessment and make the determination of frequencies, etc. for this kind of stuff. Which brings me to the other question of note, but let’s leave that for next time…