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Everybody here comes from somewhere else…

First off, just wanted to wrap up on the missives coming forth from our compadres at The Joint Commission and ASHE relative to the adoption of the 2012 Life Safety Code® (LSC) by CMS. The word on the street would seem to be rather more positive than not, which is generally a good thing. Check out the statements from TJC and ASHE; also, it is useful to note that the ASHE page includes links to additional materials, including a comparison of the 2000 and 2012 editions of the LSC, so worth checking out.

At this point, it’s tough to say how much fodder there will for future fireside chats. It does appear that the adoption of the 2012, while making things somewhat simpler in terms of the practical designation of sleeping and non-sleeping suites (Don’t you wish they had “bumped” up the allowable square footage of the non-sleeping suites? Wouldn’t that have been nice.), combustible decorations and some of the other areas covered by the previously issued CMS categorical waivers (If you need a refresher, these should do you pretty well: ASHE waiver chart and Joint Commission), isn’t necessarily going to result in a significant change in the numbers and types of findings being generated during Joint Commission surveys. From my careful observation of all the data I can lay hands on, the stuff that they’re finding is still going to be the stuff that they are likely to continue to find as they are the “deficiencies” most likely to occur (going back to the “no perfect buildings” concept—a lovely goal, but pretty much as unattainable as Neverland). I’m not entirely certain what will have to occur to actually bring about a change in EC/LS concerns predominance on the Top 10 list; it’s the stuff I can pretty much always find (and folks usually know when I’m coming, so I’ve pretty much lost the element of surprise on the consulting trail). Now, it may be that the new matrix scoring methodology will reduce the amount of trouble you can get into as the result of existing deficiencies—that’s the piece of this whole thing that interests me the most—but I see no reason to think that those vulnerabilities will somehow eradicate themselves. I suppose there is an analogy relative to the annual review of our hazard vulnerability analysis (HVA)—the vulnerabilities will always exist—what changes (or should change) is our preparedness to appropriately manager those vulnerabilities. Makes me wonder if it would be worth doing an EC/LS HVA kind of thing—perhaps some sage individual has already tackled that—sing out if you have. At any rate, I’ll be keeping a close eye on developments and will share anything I encounter, so please stay tuned.

Hopping over to the bully pulpit for a moment, I just want to rant a bit on what I think should be on the endangered species list—that most uncommon of beasties—the kind and decent person. I know that everyone is nice to folks they know (more or less), but there seems to be a run on a certain indifference to politeness, etc., that, to be honest, makes me see a little read from time to time. But then I think to myself that it is probably just as rude to overreact to someone else’s rudeness, so take some deep cleansing breaths and let it go. Now I would love to hear from folks that they haven’t noticed this shift and that their encounters with folks are graced with tolerance, kindness, etc.; it would do my heart good. Maybe it’s just me…but somehow I’m thinking maybe not.

Please enjoy your week responsibly and we’ll see what mischief we can get into next week.

He ain’t HVA, he’s my opportunity

An interesting topic came across my desk relative to a January 2013 survey, and it pertains to the use of your HVA process as a means of driving staff education initiatives.

During the Emergency Management interview session during this particular survey, the surveyor wanted to know about the organization’s hazard vulnerability analysis (HVA) process and how it worked. So, that’s pretty normal—there are lots of ways to administer the HVA process—I prefer the consensus route, but that’s me.

But then the follow-up question was “How do you use the HVA to educate staff and their actions to take?” Now, when I first looked at that, I was thinking that the HVA process is designed more as a means of prioritizing response activities, resource allocations, and communications to local, regional, and other emergency response agencies, etc., but staff education? Not really sure about that…

But the more I considered the more I thought to myself, if you’re going to look at vulnerability as a true function of preparedness, then you would have to include the education of staff to their roles and responsibilities during an emergency as a critical metric in evaluating that level of preparedness. The HVA not only should tell you where you are now, but also give you a sense of where you need to take things to make improvements and from those improvements, presumably there will be some element of staff education. A question I like to ask of folks is: “What is the emergency that you are most likely to experience for which you are least prepared?” Improvement does not usually reside in things you already do well/frequently. It’s generally the stuff that you don’t get to practice as often that can be problematic during real-life events. One example is the management of volunteer practitioners—this can be a fairly involved process. But if you haven’t practiced it during an exercise, there may be complexities that will get in the way of being able to appropriately respond during the emergency. Which is why I recommend if you haven’t practiced running a couple of folks through the volunteer process, what better time than during an exercise?

Infant abduction drills

There’s nothing I like more than questions from the studio audience, so this week I thought I’d field a question on one of those risks that never seems to go away completely, as much because there are not very many specific requirements. So, let’s consider abduction drills.

The current situation at this particular organization involves what I think is a pretty good cross-section of activities: campus-wide drills, suspicious person(s) on the unit drills, mother/baby-specific drills, as well as random quizzing of staff throughout the organization on their role(s) in the infant abduction policy (they have to answer 10 questions about the policy), and a monthly operational test of the infant security alarm system. Again, I think that’s a very good start to things. But it does sort of beg the question as to what requirements exist? Well, dear reader, I beg you, please read on.

Strictly speaking, The Joint Commission (TJC) does not have a great deal that could be characterized as requirements in this regard. EC.02.01.01 EP #9 requires hospitals to have written procedures that can be acted upon in the event the hospital experiences any security incident, including abductions of infants of pediatric patients. That’s pretty much all there is in the standards. I’m presuming that you have a written procedure for responding to an infant and/or pediatric abduction incident, so we’re off to a good start. [more]

From the muddy banks of compliance

Let’s break from form a little bit and start with a question:

How often are you (and by you, I mean your organization) screening contracted staff, including physicians, physician assistants, nurse practitioners, etc.?

A recent TJC survey resulted in a finding under the HR standards because the process was being administered on a biannual cycle. The finding vaguely referenced OSHA guidelines in identifying this deficiency, but the specific regulatory reference point was not provided (though apparently a call to Chicago validated that this was the case). Now, anyone who’s worked with me in real time knows that I have an exhaustive (and, at times, exhausting) curiosity about such matters. The deficiency “concepts” are usually sourced back to a “they;” as in, “they told me I had to do this” “they told me I had to that.” I am always, always, always curious as to who this “they” might be and whether “they” were good enough to provide the applicable chapter and verse. The answer, more often than not, is “no.” Perhaps someday we’ll discuss the whimsical nature of the” Authority Having Jurisdiction” (AHJ) concept, but we’ll save that for another day.

At any rate, I did a little bit of digging around to try and locate a regulatory source on this and in this instance, the source exists; however, the standard is not quite as mandatory as one might first presume (If you’re thinking that this is going to somehow wrap around another risk assessment conversation, you are not far from wrong). So, a wee bit of history:

Back in 1994, the CDC issued their Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Facilities, ( which, among other things, advises a risk-based approach to screening (Appendix C speaks to the screening requirements for all healthcare workers, regardless of who they work for. The guidance would be to include contract folks. The risk level is determined via a risk assessment (Appendix B of the Guidelines is a good start for that). So, for a medium exposure risk environment, CDC recommends annual screening, but for a low exposure risk environment, they recommend screening at time of hire, with no further screening required (unless your exposure risk increases, which should be part of the annual infection control risk assessment).

But, in 1996, OSHA issued a directive that indicates annual screening as the minimum requirement , even for low-risk exposure risks, and even while referencing the CDC guidance: ( with medium risk folks having semi-annual screening and high-risk folks being screened on a quarterly basis. So, friends, how are you managing folks in your environment, particularly the aforementioned contracted staff? Do you own them or is it the responsibility of their contracted employer? Does this stuff give you a headache when you think about it too much? It sure gives me one…occupational hazard, I guess. At any rate, it’s certainly worth checking to see whether a risk assessment for TB exposure has been conducted. The OSHA guidance document clearly indicates that if you haven’t, it’s the responsibility of the surveyor to conduct one for you, and I don’t know that I’d be really keen on having that happen.

Implementing workplace violence policies

Howdy, safety profs!

I’ve received a number of inquiries lately looking for workplace violence policies. I figured if a few might have questions, then that’s enough indication to me that there may be some other folks as well looking for these elusive policies.

With all that said, to be honest, I don’t know that I would advise pursuing policy development. It’s more than likely that any policies you would need to support the management of risks associated with workplace violence are already in existence. The key to compliance is to follow the risk assessment recommendations in the SEA and, for all intents and purposes, conduct a gap analysis based on the elements identified in the SEA.


Some risk assessment targets that you should aim at

Overall, risk assessments are really useful in two general instances:

  • When you have a risk that you cannot eliminate and you need help identifying the means of reducing that risk to the extent possible
  • When you have a risk for which there is no regulatory guidance or requirement and the “way” is not clear

With those thoughts in mind, there are plenty of situations that can benefit from a risk assessment, such as [more]

Despite bigger influences, Joint Commission wants emergency prep to stem from staff’s abilities

The surveyor cadre is not particularly knowledgeable about the practical application (and implications, for that matter) of  federal level emergency management activities.

There is a broad-based Joint Commission requirement for organizations to comply with applicable local, state, and federal laws and regulations, but even the National Incident Management System and Hospital Incident Command System only truly become “requirements” when [more]

Nurse firings during emergency response should trigger an HVA assessment on your end

Any of you been following the headlines regarding Washington (DC) Hospital Center firing a handful of staff for calling in to work during blizzards in February?

In a nutshell, the hospital has terminated 21 nurses and other essential personnel, saying they allegedly disregarded their duties and ignored attempts by the facility to offer [more]

Embrace the ebb and flow of emergency management planning

When it comes to Joint Commission emergency management strategies and your hazard vulnerability analysis, there is room for imperfections within the confines of preparedness.

This is a constantly fluid process for which assessment and re-assessment are the order of the day, and, to be honest, the process should reflect:

  • Improvements made in your planning activities
  • Improvement opportunities
  • Any shifting variables that would impact the organization’s response capabilities

By the way, when communicating to organizational leadership as a function of the annual evaluation of your HVA, I like to prepare a summary of the HVA results in narrative form to focus attention on the key programmatic elements, vulnerabilities, etc.