As I get a little longer in the tooth, I find that I need to create reminders for myself of subjects to cover during our weekly visits. Typically, I will capture an idea as a draft email and return to it as time permits. At any rate, as you are very much aware, there’s been a lot of material in recent weeks that have precluded the need to dig into my archives, but in the interest of keeping my draft emails at a manageable level, as well as making sure that I cover all the discussion points that I wanted to share, over the next little bit (unless something breaks big or bad in the compliance world) I’m going to set the wayback machine for stun and run a few timeless classics (at least I think they’re timeless—please feel free to disagree). Let’s hark back to July to revisit a concept that occupies a lot of my waking time: stewardship and accountability for the management of the physical environment.
As I was lurking about Joint Commission’s Physical Environment Portal (PEP) to see if there were any updates to be found, I stumbled upon a missive in TJC’s leadership blog that I did not recall seeing. This dates back to October 2015 in those halcyon days of the early chortlings of the portal… (insert going back in time sound effects here).
In looking at this particular missive (penned by one G. Mills, Director, Department of Engineering—you can find the whole magillah here), there is some ground covered that is among my most favoritest of topics: the universality of the responsibilities when it comes to the management of the physical environment (and for those you who are keeping count, I have no idea how many times I’ve discussed this particular topic, but I’m going to guess it’s well into double digits. And that’s not even counting the number of times I’ve had variations of this conversation with clients). In the blog, Mr. Mills notes that “…the patient care environment is not owned by one group in the healthcare setting.” I couldn’t agree more and yet I still (still, still, still!) encounter organizations that have not fully embraced that concept—which results in very little surprise on my part that eight of the 10 most frequently cited standards are in the physical environment. Mr. Mills goes on to say, “(W)e cannot look to one group to keep the area clean, another to keep the area warm/cool, and then another group to treat patients independently.” But organizations continue to do just that, get bounced around during surveys, and still (still, still, still!) fail to grasp the team concept of managing the environment.
Now it’s certainly not every organization that has these issues, but until every organization gets “down” with this as a way of conducting the business of healthcare, the EC/LS findings will continue to pile up. The silos of clinical and non-clinical functions in healthcare organizations are no longer a tenable model—I’ve said it before and I will (no doubt) say it again—every individual working at every level in every healthcare organization is a caregiver. I’ll give you the direct/indirect split, but taking care of the patient in the bed is the role and responsibility of everyone. It is past time for a new paradigm. Let’s make it happen—even without updates to the PEP!
As a closing thought, I was rather remiss in my discussion of the final CMS emergency preparedness rule. I neglected to indicate that the new regulations are effective 60 days after publication in the Federal Register (which plunks us into November 2016—you can make a reference to turkeys if you like) and implementation must be completed by November 15, 2017 (again, I will stand by my stand that this is not going to be a very big deal for hospitals—I have yet to find anything that is well and truly new and/or different in what is actually required. As with all things, I suspect that the worm will turn on the interpretive dances of the surveyors).
At any rate, if you don’t have plans for next Tuesday at 1:30 pm EDT, you might want to check out the public call to discuss the new rule, hosted by CMS’ Medicare Learning Network. The call is scheduled to last 90 minutes and you can register here. I will be doing client work that day, but I suspect that there might one or two folks from the editorial world that may tune in, so I am looking forward to finding out what the “skinny” might be on all this stuff. Much ado about nothing or something wicked this way comes? I guess we’ll find out soon enough…
And so, the flying fickle finger of compliance finally points portally (via The Joint Commission’s Physical Environment Portal) in the direction of that most troublesome of standards, EC.02.03.05, and we return once again to the fireside of our intrepid duo, Messrs. George Mills of The Joint Commission and Dale Woodin of ASHE. There are two videos, one for the facilities audience and one for leadership (does anyone else find it fascinating that the duo dons neckwear for the leadership video?).
While I don’t want to engage in revealing any spoilers, in the video, EC.02.03.05 is described as being “most prescriptive” and “frustrating” and also notes that Mr. Mills has taken some pains to “tear apart” the standard in past “Clarifications and Expectations” columns in Joint Commission Perspectives. Yet, yet, yet, approximately 40% of hospitals continue to get cited for deficiencies relative to the myriad components represented in this standard. I personally would love to see how this actually breaks down in terms of which of the 20+ performance elements are the most problematic (I can’t imagine that there are some that “float” to the top more than any others), but the video does seem to indicate what the “problems” are:
- You have to have an inventory, by location, of each device class, meaning smoke detectors, heat detectors, pull stations, HVAC shutdown devices, water flows, tamper switches, fire extinguishers, etc. It seems to me that back in the day, there was a reluctance on the part of our Chicagoan friends to actually say the words that would indicate the need for an inventory. But it all comes down (or back—I think I’ve beaten this particular breathless equine once or twice in the past) to knowing that you inspected, tested, maintained, each device in the fire alarm system. So if you (or your vendor’s documentation) do not specifically indicate that each device was demonstrably inspected, tested, maintained, then (buzzer sound): you lose!
- The documentation has to be available “upon request”, so really, if you can’t produce the current documentation PDQ, then (buzzer sound): you lose! You can only get credit for those inspection, testing and maintenance activities for which you have available documentation—if you didn’t document it, you didn’t do it. Period. End of story.
Now I certainly recognize that a combination of findings under EC.02.03.05 would drive a finding under the Leadership standards (to be exact, LD.04.01.05 EP 4), based on past survey reports. But apparently there is indeed a magic number of EC.02.03.05 EP findings that will result in the Leadership finding—three or more EPs out of compliance, then (bell rings): you win a discussion with your boss as to how you allowed (and I’m using that term in its most pejorative sense) such a thing to happen. At that point, for example, it is way too late to admit that the fire alarm and sprinkler testing vendors have not given you very useful reports (and something tells me that that particular conversation is not as rare as it ought to be). From watching the video (and in providing a neckwear-enhanced video specifically for your organization’ s leaders and Mr. Mills indicates he had to edumacate his bosses too—we are not alone), there is a very clear expectation that you, the facility/safety professional, will make the effort to proactive communicate with your boss, particularly if you are experiencing service issues, etc., in getting these activities under control. You can certainly make the case that the protection of the entire organization can be compromised if your fire alarm and sprinkler systems are not appropriately maintained, so, really, any infrastructure concerns should be communicated in a timely fashion to the leadership of each organization to ensure that appropriate resources are allocated on an ongoing basis to make sure everything stays on an even keel.
At any rate, our duo takes great pains to point out that none of this stuff is new (the “seed” documents from NFPA 72, 25 and the like having been penned way back in the 20th century), but I do feel that the methodology for surveying has evolved/mutated over time. I mean, if it were really that simple, wouldn’t this go away? They also point out that ASHE has a fair amount of information to assist you in your compliance efforts (ASHE Focus on Compliance: you can be especially warm for their forms) and there’s even a PowerPoint presentation that The Joint Commission uses at the EC Base Camp presentations (you can link to the presentation on the left hand side of the portal page), which gives it the power of the Quadruple P—Portal PowerPoint Presentation! Ultimately, you’ve got to keep a really close eye on this stuff, aside from product expiration dates, the management of the various and sundry elements of EC.02.03.05 is among the most voluminous in sheer numbers—that’s a lot of spheres to keep up in the air—and you only have to drop a couple to earn that lovely chat with your boss. I am absolutely convinced we can make it happen, so let’s see what we can do to retire EC.02.03.05 from the top 10. (Or 20…wouldn’t that be a fine thing?)
I know that this is typically characterized as a season of giving, but I have somewhat of a huge favor to ask of you folks out there in the depths of the blogosphere, so I hope you will bear with me.
With an almost astonishing regularity, the first of each month continues to bring with it a new module being posted in the Environment of Care portal. For the month of December 2015, the featured topic is the Built Environment, inclusive of elements covered under EC.02.06.01, which (as you may recall) was the #1 most frequently cited standard during the first six months (Freudian typo: When I first typed this passage, I came up with “first sux months”—make of that what you will…).
Since I know a lot of folks have been tapped on this one (both as a function of the published data and my own experiences), I was keen to look over the new material—including the latest fireside chat from our partners in compliance George Mills, director of engineering at TJC and Dale Woodin, executive director at ASHE, which covers EP 1 and EP 13 (in separate episodes). One of the interesting things I noticed was, in describing the many and varied findings that are generated under EP 1, a direct comparison was made to OSHA’s General Duty Clause as a function of how this particular EP is being used. Now, the GDC concept as a part of TJC’s survey efforts is certainly not unknown to us (in the “old” days, EC.02.01.01 used to be the catch-all for general safety findings) and basically it comes down to pretty much anything that isn’t quite as it should be (what I have taken to euphemistically describing as imperfections). Could be stained ceiling tiles, could be non-intact flooring, wall, or horizontal surfaces. Could be nurse call cords that are not properly configured (too long, too short, too wrapped around restroom grab bars), could be improperly segregated compressed gas cylinders. The list of possibilities is pretty much infinite.
The second video episode talks about maintaining temperature, humidity, and air-pressure relationships in the “other” locations (pretty much everywhere that isn’t an invasive procedure area or an area that supports invasive procedure areas). I know that there’s been some consternation from findings relating to issues such as pressure relationships in clean utility and soiled utility rooms (clean rooms have to blow and soiled rooms have to suck, so to speak), pressure relationships in pharmacies (positive), laboratories (negative) and so on. There’s some discussion about how these types of conditions might manifest themselves in the environment and the importance of staying on top of these things, particularly during surveys (personal note: my consultative advice is to have an action plan for checking all these various areas that have pressure relationship requirements the moment you learn that “Elvis,” my code name for TJC, is in the building). It is very, very clear that the Life Safety surveyor is going to be checking pressure relationships early on in the survey process—you want to have a very, very good idea of where you stand in the applicable areas.
At any rate, the favor I have to ask (and I’m sure I’ve gone on long enough that the favor is blissfully in the past) is for those of you who’ve viewed the contents of the portal (according to TJC figures, there were 48,000 views of the first two modules; I know I account for a couple of those, but clearly others have checked things out, though it might be interesting to see how many of that number are TJC surveyors…), particularly those of you who have been surveyed in the last few months: Has the material actually been helpful? Part of me feels that the materials are presented in such a general fashion that it makes them less useful from a practical standpoint (perhaps the better part of me), but since I don’t have to worry so much about day-to-day stuff anymore, I will freely admit that I’m too far away from it to be able to say. That said, I am really keen to hear if you think they’ve done a good job, not-so-good job, or somewhere in between. Pretty much any sense of whether the material has been helpful (of course, I could ask the same question about this space, as well, so feel free to weigh in—I always like feedback).
As a final note for this week’s epistle, you may be curious to read about what TJC’s leadership thinks about the portal. You may recall a bit of hand-wringing at the beginning of the year, by Mark Pelletier, the COO of accreditation and certification operations at TJC, regarding the recent “spike” in EC/LS findings (you can find my comments, including a link to Mr. Pelletier’s comments from January, here). As we all know very well, the torture in the EC/LS world has continued (presumably until morale is restored), but the EC Portal is being looked upon as “a light at the end” (at the end of what, I’m not sure, as it isn’t specifically indicated). The thing I keep coming back to in my mind’s eye, is that the typical list of findings is what (again, my “imperfections”) are the types of conditions and practices that, while not perfect (yes, we are imperfect) are not conditions that significantly increase the risks to patients, staff, visitors, etc. If these imperfections are not managed correctly, they could indeed become something unmanageable, but I’m just not convinced that the environment is the big boogie man when it comes to healthcare-acquired infections, which is pretty much the raison d’etre for this whole focus. I keep telling myself that it’s job security, but it frustrates the bejeezus out of me…
Mr. Pelletier’s latest can be found here.
And on that note, I wish you a most joyous holiday season and a safe and inspiring New Year! I may find the urge to put fingers to keys twixt now and the end of the year, but if I do not, please know that it’s taking every ounce of my self-control not to pontificate about something. Consider the silence my gift to you!
Be well and stay in touch as you can!
I suspect that the conversations regarding the number of EC and LS findings are likely to continue for the foreseeable future, for all the reasons we’ve discussed in the past and probably some that haven’t occurred to me yet, but surely will. At any rate, I want to encourage you to grab a copy of the February 2015 issue of Joint Commission Perspectives and turn directly to p. 10, on which begins a discussion of the use of dashboards as a means of keeping EC/LS compliance on the front burner. The article (part of George Mills’ ongoing series of Clarifications and Expectations) shows some dashboard examples, as well as providing links to some tools on the Joint Commission Resources website (including a blank form suitable for use in your very own organization). Heck, it even outlines a six-step process for setting up your own dashboard if the one from JCR doesn’t quite fit the bill. All in all (as much because it pretty much reiterates what I’ve been preaching almost since the beginning of time, but I digress), a most worthy addition to the safety canon and a resource that you would be well-advised to consult as you start to formulate your calendar year 2015/fiscal year 2016 activities.
All that said, I would encourage you, particularly as any number of you are embroiled in your annual evaluation process, to look over the information and make a (very, very) good faith effort to adopt at least the dashboard concept, if not an outright adaptation of the formats included in the article. One of the truisms of the compliance game is that anything that shows up in Perspectives is potentially surveyable/enforceable as a standards-based requirement, so there is a pretty fair likelihood that the surveyors are going to start looking for something along these lines when they next stop by your place for a visit. But please don’t look at this as one more thing to do; if you set this up and operationalize this properly, you will gain a great deal of information on where your organization stands on the compliance continuum, plus you will have data that you can use to clarify findings that may come up (okay, probably will come up) during survey. As always, it goes back to the management of imperfections in the environment—you know they’re there, I know they’re there, TJC knows they’re there. Our best “safety net” is to be able to demonstrate an ongoing process for managing those imperfections. Identify those pesky vulnerabilities and you are on your way!
One bit of caveat emptor, p. 13 includes a sample “In-Depth Data Analysis Worksheet,” which in this case is being used to collect data on the Daily Verification of Appropriate Air Pressures for In-Use Rooms. And you might well note that there is no specific requirement for the daily verification of appropriate air pressures for in-use (or indeed any other) rooms. For some strange reason, this one is giving me a bit of the willies as I can certainly see an instance in which a surveyor might interpret this to mean that there is such a requirement. It may be much ado about nothing (and I, for one, hope that is indeed the case), but probably something worth keeping an eye on.
In what is clearly one of the busiest years for regulatory upheaval in the healthcare safety world (at least in recent memory), CMS has, yet again, turned things on their ear—and to what all appearances seems to be a most positive potential outcome—in its ongoing series of categorical waivers. And this on a topic that has caused a ton of gnashed teeth and much sorrowful wailing: the use of relocatable power taps.
You will recall (it seems no more than minutes ago) that back in June (2014), George Mills, director of The Joint Commission’s Department of Engineering, was tasked with the dubious honor of announcing to the world that, basically, the use of relocatable power taps to power medical equipment in patient care areas was on the no-no list. Since then, many (okay, probably just about everyone to one degree or another) facilities and safety folks have been spending countless hours trying to figure out how to make this happen. So I guess this means that CMS has decided that Mr. Mills doesn’t have to get painted with the “bad guy” brush any longer as they have issued a categorical waiver that provides a fair amount of flexibility for the presence of RPTs in the patient care environment.
Now history has taught us, if nothing else, that that flexibility is going to vary quite a bit depending on your facility and the results of the inevitable risk assessment; but presumably you’ve already started the risk assessment process like good little girls and boys, yes? There is a lot of fairly useful (at least at first blush—we also have learned how useful can become useless in the blink of an eye) information to be had in the memo, which you can find here. If you have not yet had a chance to look this over, I would encourage you to do so before you make any “big” decisions on how you’re going to manage these pesky little items (hopefully, this “relief” is not coming too late to avoid having undo sweeping seizures of power strips, etc.).
Maybe it’s Christmas come a bit early (or maybe we just power-shifted into winter), but I would encourage you to unwrap this present very carefully (some assembly required) and try not to break it on the first day…
No doubt there will be questions, so please use this forum as you wish.
In what has turned out to be one of the busier periods when it comes to changes in regulatory oversight of the physical environment, we have George Mills, senior engineer at The Joint Commission, announcing a considerable shift relative to the use of power strips/relocatable power taps with medical equipment in patient care areas. According to the press release from the Association for the Advancement of Medical Instrumentation (AAMI)’s 2014 annual conference (at which Mr. Mills was a featured speaker), we should consider the following areas as being included in “patient care areas”: operating rooms, patient rooms, and “areas devoted to recovery, exams, and diagnostic procedures.” That looks like a pretty inclusive list from where I’m sitting. What say you? BTW, if you want to see the whole press release, you can find it courtesy of the AAMI.
At any rate, from wherever you’re sitting, this is going to be a pretty big freaking deal for way more organizations than not. All that said, at least at the moment (as of June 13, 2014), I’ve not seen anything in writing from CMS (generally, when a change of this magnitude comes down the pike, they’ll send out a letter to inform their surveyors how to enforce new requirements); my hope is that perhaps things will have smoothed out a bit when that missive arrives.
A couple other items from the AAMI conference include the announcement that CMS has made the determination that ultrasound equipment is considered radiologic equipment and can’t be included in any alternative equipment management program. The long and short of that is that ultrasound devices will have to be inspected, tested, and maintained in accordance with manufacturer recommendations. Not sure how many folks have strayed from that path, but if you have, you need to stray back.
The final bit of word from the conference (and feel free to make your own determination as to whether its good news or bad news) is that, effective July 1, 2014, all hospitals that use TJC for accreditation must maintain a written inventory of all medical equipment and identify “high-risk” medical equipment, which would include (as you would probably be able to guess), but is not limited to, life support equipment. And by way if revisiting the whole alternative equipment management program concept, if you are indeed managing any of the equipment in your inventory through the graces of an alternative equipment management program, then those devices must be identified as such. As we’ve seen in the past, requirements for written information/documentation can result in a fair amount of scrutiny, so I think we can expect the same thing to happen with these changes.
Is this evidence of a refocusing of the survey process on all things medical equipment (don’t forget to keep clinical alarm safety on the front burner too!) during the survey process? Tough to say, but past practices would seem to indicate perhaps, yes. Beyond that, only time will tell…
In the June 2013 edition of The Joint Commission’s Perspectives, George Mills covers the thorny topic of the Environment of Care management plans. Within his dissertation, he makes note that he doesn’t recommend inclusion of the Joint Commission standards and Elements of Performance (EP) in the management plans (see p. 6 of the article “Environment of Care Management Plans” for the skinny). The reasons include the caution not to “merely” restate the EPs and standards (I’ve seen management plans that consist of nothing but a reiteration of the standards and performance elements, verbatim, with no supporting description of the organization’s strategies for complying with each of the required elements—not a good thing at all), as well as to avoid the “tedious” task of making sure that minor changes to the standards (which happen periodically, but I don’t know that I’d get to the point where I’d call it tedious to review the standards from year to year) don’t trip you up during a survey. He finishes with the statement that surveyors know the standards and EPs, so they don’t need to be repeated in the management plans.
Now I don’t necessarily disagree with any of those statements, but I don’t know that there isn’t a benefit to indicating the specific performance elements as a function of the management plans, if only to ensure that it is very clear to everyone (internal reviewer, regulatory surveyor, etc.) how your organization manages compliance with each of those elements and standards. My personal experience (and those of folks with whom I have worked with on their management plans) has been that the easier it is for the surveyor to tie a standard or an EP to a specific portion of your management plan, the greater the likelihood that they will “tick” that element off and move on to other things. To be honest, when I’m looking at management plans, I tend to focus as much on what has changed recently as anything—it provides evidence that the folks charged with managing the EC program are making sure that they’re staying on top of changes to the standards.
As a further enticement to you folks who’ve not yet added Perspectives to your monthly reading list, p. 8 of the June issue also includes a rubric for evaluating the “quality” (my interpretation) of your management plans. It’s an interesting exercise that you might even consider covering as a group exercise with your EC committee. One of the most important aspects of this whole magillah is for your committee to have a comprehensive sense of how risk is managed in the physical environment—from the identification of opportunities through the strategies developed to make good on those opportunities through the monitoring and evaluation of performance relative to those opportunities. While there will always be content experts in the mix, it is of critical importance to a highly performing committee for the committee as a whole to be able to speak to what’s going on. If you can get to that point, you have really got something powerful upon which to sustain your program.
Now there may be some folks out there who are thinking that there are certain topics to which I have administered beatings akin to the deceased equine, but sometimes there are other folks who appear to share at least some of my “wacky” perspectives on how to manage safety in the healthcare environment.
So, I encourage you to contact the individual in your organization responsible for coordinating Joint Commission accreditation and ask them to share with you the February 2013 issue of Joint Commission Perspectives. And, if you turn to p. 9, you will find the latest column penned by George Mills entitled “Safety Champions—Making Health Care Safety Everyone’s Business.” And to this, I say hallelujah! Those of you who’ve been with me since we started this little space (it’s been years and years, I tell you, years and years) will recognize this as a common theme (I think I’ve twisted it every which way, over time, but you should recognize the basic form) and still one that I believe holds a key to compliance success ( I refrain from referring to it as “the” key, because the education “key” is pretty gosh-darn important as well).
And, interestingly enough, Mr. Mills’ column in the March 2013 issue of Perspectives focused on, wait for it…
Can I get an A(ssess)MEN(ts)! Stay tuned: You know I’ll have something to add to that conversation…
Another perpetually sticky wicket in the survey process (and we’ve discussed this, oh, once or twice before) is the timeliness of documentation from maintenance and testing vendors and the expectations of how that process has to be managed. During an ASHE-sponsored webinar last fall, George Mills posited the scenario in which there is a delay (delay times can vary, but you probably have a pretty good idea of how long you have to wait for reports to come back from your vendors) in receiving a report for fire alarm testing in which a handful of devices failed during routine testing. If you don’t receive the failure information immediately upon its identification by the vendor, what you are saying, in effect, is that it’s okay for me not to “know” (there’s that word again) how reliable my fire alarm system is for a month while I’m waiting for the report. If any of you think that it is indeed “okay” not to know might want to think about another line of work. From an empirical standpoint, a failed fire alarm device puts the building occupants (patients, staff—you know, those folks) at a greater risk, which is never, never, never a good idea. And what if you don’t get the report for six weeks, the failed devices haven’t been replaced, and now you’re looking at the possibility for having to manage the deficiency with a PFI, ILSM assessment—the whole magillah. Truthfully, you have better things to do with your time.
Mr. Mills’ suggestion (and I think it’s a good one, having made the suggestion at least once or twice in the past) is to ensure (either contractually or otherwise) that any deficiencies identified are in your possession before they “complete” their work. You can set it up so they let you know at the end of each testing day (that would be my preference) or at the end of the engagement. But you have got to have that information in your possession as soon as it can be made available to you. The occupants of your building depend on each and every element of your systems—fire alarm, fire extinguishment, medical gas and vacuum, emergency power—you know that list by heart and it’s your responsibility that they are managed appropriately.
For our next topic of conversation regarding George Mills’ address to the folks in ASHE last year, we take up the ever-vexing task of managing penetrations. Now, there’s certainly been a lot of ire pointed towards the folks who run cabling in healthcare—IT, cabling contractors, etc. But this represents something of a sea change in the public face of this problem—while there certainly any number of “perps” when it comes to making holes in rated barriers, there is a very clear sense that appropriate management of the process results in the buck stopping at a single destination: the desk of the facilities management professional.
So, a quick show of hands: How many folks are using an above the ceiling work permitting process? That many? That’s a pretty good number. But how are you administering that process? Have you told the entire organization about the process? Maybe established a bounty for finding folks working in the ceiling without a permit? You have tens of thousands, if not hundreds of thousands, of square feet in which mischief can occur above the ceiling. If you establish the condition that anyone (and that means folks employed by the hospital—everyone is equal in the eyes of a penetrated rated barrier) working above ceiling must display a permit on the ladder or lift—and get folks to call in when someone is working without a permit, then you can start to manage the process. By the way, I’m a great believer in rewarding folks who drop a dime for this and don’t be cheap; at least buy ’em lunch somewhere nice. And if you find you’re spending too much money feeding your dime-droppers, then that means that your permit process is not working very effectively!
When you find someone working above the ceiling without a permit, throw the bum out! Nothing draws attention to a process like a good swift kick in the pocketbook. If someone does not want to work by our rules, then they can work elsewhere, pure and simple. Then they can explain to their boss why they couldn’t finish a job, as opposed to you having to explain to your boss why you’re getting an RFI for rated barrier penetrations. I know which scenario I’d prefer…
One last thought: As for “existing” penetrations, Mr. Mills clearly indicated the expectation that facilities will undertake an above-the-ceiling inspection at least once per year to catch any deficiencies that were not captured by the normal process. Then you either fix them properly or manage them as a PFI (with applicable ILSM assessment—please don’t forget that piece of the puzzle). It’s really just that simple.