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Déjà vu all over again: A new ligature resistant FAQ!

Using the Hospital FAQ page as the baseline, I reckon we’ve got about a dozen FAQs dealing with ligature resistance with this latest offering. For some reason, the “visual” I get from all of this FAQing is the difference between looking at something from a distance (for example, a celestial body) and seeing that same thing up close and personal. What started out as a sphere of incomprehensibility has become (slowly, ever so slowly, over time) a much more nuanced endeavor—an endeavor that continues to represent survey vulnerabilities for accredited organizations.

One of the interesting things to me is how the narrative has evolved over the last couple of years relative to how hospitals are to deal with all the intricacies of managing ligature risks as a survey vulnerability (which is different than managing the risks to patients, but more on that in a moment). This FAQ reveals some specifics as to what you are required to include in the mitigation strategy for those risks that are not yet removed/resolved/corrected/adjudicated, etc. Now, I don’t know that this is truly ground-breaking stuff, but I think this is cray-cray important because this is what the surveyors are going to be looking for, both in terms of structure, but also as a function of an ongoing process. I’m not going to quote verbatim from the FAQ. I know youse guys are excellent readers and such, so a quick summary:

  • Leaders and staff have to know what risks are currently in the mix and somebody has to be responsible for telling them (and documenting that they were told…)
  • Identification of patients at risk for suicide/self-harm, with appropriate risk-based interventions
  • A process for ongoing assessments and reassessments of organization-defined at-risk behavior
  • Staff education re: management of patient risk and implementation of appropriate interventions
  • Ensuring this whole program/process is integrated into the organization’s quality assurance/performance improvement (QAPI) program (sounds like it might be a good time to include this as a standing agenda item at your QAPI committee meetings)
  • Making sure that any equipment that poses a risk, but is necessary for safe treatment of behavioral health patients (the example given is medical beds with siderails on a geriatric unit), is considered, as a risk, in the patients’ overall suicide/self-harm risk assessments, with appropriate interventions to minimize the identified risks

As I reflect over the seemingly endless amount of survey angst that this topic has wrought over the past couple of years, I keep coming back to the reality that while we can always do better (would we have done as much as quickly without enduring survey bludgeoning?), there is minimal data to support that, while not perfect, hospitals were not doing a good job in managing these at-risk patients. Purely from a risk management perspective, this would be a subject of great interest and concern to any healthcare organization as the burden of managing these patients has shifted over time. I suppose it ultimately gets filed under the “abdication of responsibility” that comes with the disenfranchising of difficult patient demographics and the subsequent “arrival” of those patients in the acute care settings, but it seems to me that (and yes, I recognize that this is part of doing business in healthcare) a little more collaboration during this process (as opposed to pointing fingers and assigning “blame”) might have yielded a better end-product. Hopefully, at some point, we will be given credit for the good work that has been done (and quantified), but I don’t think we are quite there yet.

Making stock, taking stock: Emergency inventory madness!

In trolling The Joint Commission’s FAQ page for interesting tidbits to share, I came across the entry regarding the thought process around the establishment of an emergency inventory. Some interesting takes on certain aspects of the emergency inventory concept—it doesn’t “have” to be centralized, in recognition of “just in time” purchasing and the importance of being able to use stock with a shelf-life (it would not be good to have your EM supplies expire because they were earmarked solely for emergency response).

The FAQ goes on to recommend tracking assets and inventory for a year to ascertain what your organization’s capabilities and needs might be. But I’m trying to figure out how that “recommendation” (recognizing that the FAQs can be invoked at the level of standards-based requirement) dovetails with the “requirement” for an annual “review” (I remain stymied by the use of “review” as opposed to evaluation; it may just be me, but a review doesn’t have the same action level as an evaluation but perhaps they are to be considered synonymous) of the inventory of resources and assets needed during an emergency. My thought would be that you would be looking at how resources and assets are managed on an ongoing basis and that information used to ensure that the organization has what it needs and has the ability to procure additional resources and assets should it experience a prolonged emergency.

I think the key thing to keep in mind (as when one is addressing each of the TJC-anointed critical functions) is to ensure that for each exercise or actual implementation, there is a process in place for evaluating performance in each of those areas. Someone should be looking at:

  • Communications
  • Staff roles and responsibilities
  • Safety/security
  • Utilities
  • Patient care activities
  • The management of resources and assets

And those someones (whoever they may be) need to be particularly forthcoming because (as we have learned over the years) it is not so much about what went right as it is about what opportunities can be identified to make the next time better. Too many times I’ve encountered folks that are reluctant to “air out the dirty laundry.” Identifying potential vulnerabilities is never a bad thing (true, it can make for some difficult discussions), it is the only thing.

Secret Club for Members Only: Some FAQing for your reading pleasure

This week finds us (once again) visiting with our friends from Chicago as they stand astride the accreditation world like some ancient colossus. (I am hopeful that my purple prose will subside at this point, but sometimes the fingers take me in odd directions.)

First up, we have some additional guidance relative to how one might go about managing compressed gas cylinders, particularly those pesky oxygen cylinders that can cause so much grief during survey. So now we have a Joint Commission performance element that establishes the expectation that each organization will have a policy regarding the storage of oxygen and other compressed gas cylinders, said policy is to include the amount of gas at which segregation of full and empty cylinders would take place. You may recall that the initial “take” required full cylinders to be segregated from empty and partially full cylinders, but that “interpretation” of NFPA 99 has shifted a bit to allow for the storage of partially full cylinders in the company of full cylinders.

And now, we have a new FAQ that provides some guidance relative to how one might go about determining the amounts representative of full/partial/empty, depending on whether the cylinder(s) you are using have an integral pressure gauge. The FAQ also introduces the concept of “depleted volume content,” which ( as near as I can tell), is the amount of gas left in the cylinder that requires storage with the empty (as opposed to the full) cylinders. There is also a (maybe) handy table that walks you through the various segregatory considerations—I’ll let you parse those in your spare time.

My takeaway is that you need to make sure that if your current policy (if you don’t have one, it is a standards-based requirement, so best get on it) doesn’t pretty closely mirror how things shake out in this FAQ, you should consider modification of current policy/practice or be prepared to discuss how what you’re doing to be in compliance with the NFPA 99-2012 requirements. The other “thing” I noticed is the discussion of the labeling of empty cylinders as a function of the segregation process—if you have the empties in a separate rack that is labeled as such, then you should be fine. But if you have a single rack with full and empty cylinders cohabitating, then the empty cylinders have to be labeled; unfortunately, this does not appear to allow for the marking of the rack itself (I’ve seen red tape and red paint to identify the empty “slots”), so if that’s your practice you might get some pushback from a literalist surveyor looking for the empty cylinders to be labeled.

Next up, we have some information relative to the management of behavioral health patients, in this case, discussions of the various methodologies for determining the risks of each patient to be managed. I do believe that the regulatory focus on environmental considerations will start to diminish somewhat as we kick into the “next” survey cycle,  but I believe that the focus on the management of at-risk patient populations will continue as a function of: now that we have a “safer” environment, how are we making sure that the patients are being appropriately cared for, which is driven by the assessment process. Assessment stuff can be found here.

As an additional piece of the puzzle (I guess time will tell whether it is more piece than puzzle or the reverse…), TJC has established an information portal to assist organizations in compliance with the July 1, 2019 changes to the National Patient Safety Goal on Suicide Prevention, including links to the issues of Perspectives in which the initial (and ongoing) guidance, etc. can be found. As a one-stop-shop, it looks like a pretty useful thing to have in your back pocket. As I’ve noted any number of times (and I think once or twice in this forum), a lot of the TJC surveyor knowledge comes to them the same way it comes to you, so I think it a positively splendid idea to take a gander at the links contained herein.

Keeping an eye on things: Managing behavioral health patients

What, again?!?

Recently, our friends in Chicago added a new FAQ to the canon, this time reflecting on the use of video monitoring/electronic sitters for patients at high risk for suicide (you can find the details here). For those of you paying attention over the years—and I think that’s everybody within the sound of my “voice”—the situational requirements are based on a clear invocation of the “it depends” metric. I think it is pretty clear (and pretty much the standard “problem” relative to the management of behavioral health patients at serious risk for suicide) that providing sufficient flexibility of staffing to be able to provide 1:1 observation of these patients is where folks are looking for that flexibility in technological monitoring and the FAQ pretty much puts a big stop on that front. I think the quote that comes into focus for this aspect is, “The use of video monitoring or ‘electronic-sitters’ would not be acceptable in this situation because staff would not be immediately available to intervene.” So, as a general practice, a 1:1 observation means that somebody (a human somebody) is “immediately available to intervene,” which means all the time, at any time.

At this point in the discussion, I think the important piece of this is (and is likely to remain so) the clinical assessment of the patient, inclusive of the identification of the risk level for suicide. I don’t think that the “reality” of having to deal with way more of these patients than we would prefer is going to change any time soon, and with it, the complete unpredictability of that patient volume as a function of staffing (full moons notwithstanding).

The FAQ goes on to discuss the use of video monitoring in those instances in which it is not safe for staff to be physically located in the patient’s room, but the use of video monitoring has to result in the same level of observation, immediacy of response, etc. It also indicates that video monitoring for patients that are not at high risk for suicide is at the discretion of the organization, indicating that there are no “leading practices” in this regard. I guess that means that you’re really going to have to make your own way if you chose the video monitoring route, which should include (as also noted in the FAQ) provisions for reassessment of the patient(s). Interesting times, my friends, interesting times…

As a final (and almost completely unrelated) note, I wanted to bring to your attention some discussion over at the Motor & Generator Institute (MGI) relating to recent CMS guidance regarding expected temperatures in the care environment during normal power outages and how, if you have a long-term care facility in your mix, a risk assessment might not be enough. You can find the details here and the folks at MGI are encouraging feedback, so I think it might be worth checking out and weighing in.

 

A quiet week in Lake Forgoneconclusion: Safety Shorts and Sandals!

But hopefully no open-toed sandals—maybe steel toed sandals…

Just a couple of quick items as we head out of the Independence Day holiday and into the heat of the summah (and so far, scorching has been the primary directive up here in the Northeast—hope it’s cooler where you are, but I also hope it didn’t snow where you are either…but I guess if you were in Labrador last week, all bets are off).

When last week’s musings on the ligature risk stuff in the July Perspectives went to press (or when I finished my scribbling), the new materials had not yet made their way to TJC’s Frequently Asked Questions page, though I thought that they might—and that’s exactly what has happened. To the tune of 17 new FAQs for hospitals, so if you haven’t yet laid eyes on the July Perspectives, head on over to the FAQ page and immerse yourself in the bounty (that’s a somewhat weird turn of phrase, but I’m going to stick with it).

While you’re there, you should definitely poke around at some of the other stuff on the FAQ page. There are lots and lots of recommendations for risk assessment types of activities, so if you’re looking for some risk minimization opportunities, you might find some useful thoughts. Of particular note in this regard is the practical application of safety practices in those organizational spaces for which your oversight is somewhat more intermittent; I’m thinking offsite physician practices or medical office buildings and similar care locations. Depending on where you are and where they are, it might not be quite so easy to keep a really close eye on what they’re doing. And while I tend to favor scheduling surveillance rounds with folks in general, I also know that if you don’t stop by from time to time, you might not catch any lurking opportunities (and they do tend to be lurksome when they know you’re coming for a visit). In a lot of the survey results I’ve seen over the last 18 months or so, there’s still a pretty good chunk of survey findings generated during the ambulatory care part of the survey process. Safety “lives” at the point of care/service, wherever that may be—definitely more ground to cover now that in the past. At any rate, I think you could use the FAQ stuff as a jumping off point to increase the safety awareness of folks throughout—and you can do that independently of anyone’s vacation schedule (including your own).

Hope you and yours had a most festive 4th!

Cylindrical musings and nudging as a compliance strategy

Howdy, folks. After surviving the battering of this past weekend’s tumultuous weather in the Northeast (I got to experience it twice—once in Indiana and again back home), I’m going to be (relatively) brief for this week’s missive.

First up, hopefully most of you are familiar with the TED Talks concept (all the info you need about that you can find here) and NPR has a weekly program that kind of crystallizes some of the TED offerings in their TED Radio Hour. This past weekend (no TV, so we had to huddle around the radio, just like in olden times), the program revolved around the use of gentle pushes or nudges to change behaviors (you can hear that broadcast here). As safety professionals, I think we are all acquainted with the various attempts to get folks to do our bidding when it comes to safe practice (that sounds a little authoritarian, but it’s kinda what we’re up against) and I thought the entire program really gave me some food for thought in how we might come at compliance from a slightly different perspective. I thought some of the ideas were fascinating and definitely worth sharing, so if you have a spare 55 minutes or so (the webpage above does break it out into the individual sections of the broadcast—I think it’s all good, but whatever description seems most interesting to you would be a good starting point), you might give it a whirl…

I also want to bring you some hopeful news on the cylinder storage segregation front; when this whole focus started, quite a few folks were cited for storing non-full (empty or partial) cylinders in the same location as full cylinders. I don’t know when The Joint Commission posted the updated FAQ on cylinder storage, but, and I quote, “Full and partially full cylinders are permitted to be stored together, unless the organization’s policy requires further segregation.” I know this whole thing was the bane of a lot of folks’ existence, particularly after we had to work so diligently to get folks to secure the cylinders properly, only to have this little paradigm shift towards the edge of darkness. I believe that this will make things somewhat simpler in the execution (make sure your policy reflects the allowance for full and partials to be stored together—they’ll be looking to review that policy).

As a final, non-safety note, I just flew cross-country and was able to watch Gary Oldman’s performance as Winston Churchill in Darkest Hour. I’ve always been something of a history buff, with World War II as a central theme and must tell you that I thought it was a really great performance and a fine movie (or is it a film?). It really points out the power of consensus and the use of the spoken word to galvanize folks (which kind of ties back to the nudging—though Sir Winston’s nudge packed a lot of wallop). At any rate, I thought it was very well done (no surprise about the Best Actor Oscar) and probably my favorite since Lincoln (the movie, not the car or President…though Lincoln in the Bardo was a very interesting book…).

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.

That’s the FAQ, Jack!

It may be that I am covering one topic of conversation more than necessary (it’s getting to the point where this might eclipse the discussion of eyewash stations—yow!), but I cannot help but be very concerned about the amount of play that the management of the environment in which we place behavioral health patients is receiving in the annals of The Joint Commission. April 24 saw an electronic update announcing the “birth” of a new standards FAQ regarding ligature risks that appears to be aimed at dovetailing with Sentinel Event Alert #56 and includes mention of a “Suicide Risk Booster” (who comes up with these names?!?). As we have discussed before, FAQs, Sentinel Event Alerts, and stuff that finds its way into Perspectives all take on the weight of standards when applied in the field, so clearly organizations need to have all their ducks in a row. (And this is starting to look like a whole mess o’ ducks to be “rowed”, which brings new meaning to that Willie Nelson classic “On The Rowed Again,” but I digress—and who wouldn’t?) The question I keep coming back to is whether there’s been an uptick in actual events in which patients have come to harm as the result of poorly or inappropriately managed ligature risks. Or is this the result of surveyors in the field citing organizations for having ligature risks and not being able to produce a risk assessment of the existing conditions and the identification (and communication to staff—key point, that one) of mitigation strategies to manage the identified risks?

Part of the challenge with this particular issue (and this is true of a great many things in the physical environment) is that it is virtually impossible to provide an environment that is entirely, absolutely (please insert your favorite qualifier here) impossible to provide a completely risk-free environment—at least on this planet (perhaps there are safer planets in the Federation, but I couldn’t say for sure), so there’s always going to be something with which patients intent on hurting themselves might use to that end. Now I know that not every healthcare setting is set up to deal with behavioral health patients (and somehow, I do think that for any hospital that has not come face-to-face with the management of BH patients in areas not designed for that purpose, it is just a matter of time) and I also know that the BH patient volumes can be very mercurial. Even if you have one “safe” room, there are no guarantees that, at any given moment, that will be enough to handle however many patients you have in the queue—and you really can’t leave these folks out in the waiting room. Again, I’m not convinced that the issue here is that there is data to support that folks are not managing things appropriately, but rather more along the lines of not being able to consistently communicate the process for assessing and identifying risks, educating staff to be able to speak to the mitigation strategies being used to manage the identified risks, etc. I would (as I have been for a while now) encourage you to really take this topic and do a deep dive into the particulars of your organization. I firmly believe that this is not going to be one of those “one and done” instances of risk assessment and that you will be well-served by periodically revisiting the initial assessment (if it has been completed) to ensure that the conditions upon which you based your initial assessment have not changed (and that includes the volume and acuity of the patients). There is every indication that TJC is going to be hammering on this for some time to come (remembering that EC.02.06.01 was the most frequently cited standard in 2016; the ligature risk findings tend to show up there when cited) and, much as issues with the surgical environment and interim life safety measures, process gaps can get you in a heap of trouble. A little extra work on this (and those others) can only increase your chances for a successful survey (or at least a not spectacularly ugly survey).

As a closing note, after a dinner discussion with my wife (who happens to be a nurse), I’ve been contemplating how the role of the safety professional has changed over the last 10-15 years, including my surprise when I encounter evidence of “old school” approaches to safety. To my mind (such as it is), where safety compliance was once the result of (more or less) coercion, sustained compliance can truly only come as the result of collaboration with the folks who have to manage the environment on a day to day basis—pretty much everyone at point of care/point of service. It is not enough for a safety professional to periodically stroll through an area and point out deficiencies, there has to be a conversation and there has to be problem-solving. I think the old coercive style was based on something approaching a lack of faith in the folks out in the environment to be able (or willing) to “do the right thing.” But in this era of “just” culture and empowerment, etc., safety has to happen all the time and that, my friends, can only come with an atmosphere of collaboration. If people hide stuff or behave more appropriately when they hear you are coming, then it makes the surveillance process less useful. And if you don’t work with folks to figure out how to resolve the issues that you “keep finding,” the likelihood of it fixing itself on its own is pretty remote. I freely admit that problem-solving is my favorite part of my safety consulting work (meeting folks is also a fave); there is nothing better than talking through a problem and achieving some sort of consensus on how to proceed. It’s not always easy, but it is worth every moment you put into it!

Before you a-Q’s me, take a look for yourself…

As we await new content on the PEP (aka the newly-popular Joint Commission offering, the Physical Environment Portal), I want to draw your attention to an interesting development on another part of the Joint Commission’s website: the ever-popular (such popularity and minimal polarity…) Frequently Asked Questions page (now re-imagined as Standards Interpretations—really, check it out). And let me tell you, there is a ton of newly configured information to be found. If I were really attentive to such things (I usually am, but in this case I wasn’t expecting such a sweeping re-imagination of this part of the TJC website), I would be able to tell you how much more information there is to be had, but I think I can safely say that, at least in terms of the numbers of entries, the amount has easily doubled in relation to the “old” FAQ page. Some of the material appears to be derived from information that had been previously shared through George Mills’ Clarifications and Expectations column in Joint Commission Perspectives; other bits and pieces seem to be derived from information shared on the PEP. There also seems to be some stuff that hinges on the practical application of the now-expiring CMS categorical waivers (which I guess means there will be some updating of content in the not-too-distant future) and some other stuff that appears to have been developed specifically for this new page. (Dare we call it the Standards Interpretation Portal? We’ll be able to engage in regular SIP-ing!)

At any rate, I’m going to be poring over these entries with great interest and I would recommend that you keep a close eye on the SIP as well. Remember, the interpretations published on the SIP (I really do like that!) are “enforceable” as standards, and there’s no reason to think that TJC surveyors aren’t going to be checking out these materials as well. One interesting note: I don’t recall seeing any official announcement regarding the re-birthing of the FAQs (I won’t claim that I track every utterance from the folks in Chicago), so I may be pre-empting the grand unveiling (if you have a standards question, don’t forget to SIP!).

One item that really caught my fancy (and this was in response to a client question) was the entry regarding oxygen storage, which I know has plagued a number of organizations, particularly as a function of the segregation requirements. My thoughts on this have been that the simplest means of separation is to focus on full and not-full as the segregation metric; most folks do not have sufficient space to be able to reasonably pull off the full/in use/empty trifecta and NFPA 99 really only requires that the full cylinders be separated from everything else. So, if you use the full/not full designations, it’s not only a simpler decision-making process in the moment, it appears to be in keeping with the information shared on the SIP.

I’ll let you be the judge of what’s going to work in your organization, but I do believe that the fewer complications in the mix, the greater the likelihood of compliance.

I recommend you starting SIP-ing right away and maintain your compliance hydration throughout the hot summer months!