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Thank you for being round pegs in a square world…

As this is a somewhat shortened week (in complete recognition that safety never takes a holiday), I just wanted to briefly touch base to thank you all for hanging out (and hanging through) the various twists and turns of the last decade or so. Sometimes being the safety “cop” can be a frustrating endeavor, but this week I’d like to (and I’d like you to do so as well) focus on the folks I encounter who “get it right” all day, every day. That’s not to say that I’ve run into any perfect organizations (and I will count myself among the imperfectionists), but there are those (and I count you all among that number) who understand that the process of improving the safety of an organization is not so much about yesterday as it is about tomorrow (and the next day) and the commitment to those tomorrows is what sets us apart from (and sometimes in opposition to) other folks. It takes a unique set of skills to embrace all that is safety in healthcare (and elsewhere) and I am proud to be able to provide some level of service to your cause.

At any rate, please accept my sincerest wishes to you and your families for a most joyous Thanksgiving—and an enormously safe Friday after for those of you about to shop—I salute you!

More safety goodness next week!

Leave it better than you found it!

This past week (and this coming week as well), I’ve been on vacation in Maine (code name: A Beautiful Place by the Sea), which affords me the luxury of observing a lot of human behaviors, some interesting, some not so much. Some winning, and others that just grate.

There’s been a movement to reduce the amount of “invasive” plant species that have, in some instances, overtaken the natural landscape (and no, I’m pretty sure that this reduction is going to extend to tourists, though I bet there are moments…). So something of a reclamation project is underway, the result of which will (ideally) be a sustainable and less intrusive beautification. Where things go a little awry is in the areas somewhat off the more deliberately beauteous locales and offers what appears to be too many opportunities for the dark underside of human behavior to hold sway. Each morning, I make a circuit of the area and have noted beer and soda cans tossed into bushes, dirty diapers tossed under those same bushes and all matter of detritus left behind, presumably because the effort to properly dispose of these items was greater than what could be tolerated in the moment. My walk, at least partially, includes collecting some trash (I will admit that I’ve avoided the dirty diapers—I will have to prepare better in the future) along the way, but I have a pretty good sense of where the waste receptacles are along the way, so it’s not like I have to lug the stuff for miles.

At this point, you’re probably asking yourself: What does this have to do with healthcare safety and the myriad related conditions and practices that I might encounter during the workday? Well, the thought that keeps returning to the front of my head goes back to the age-old task of trying to “capture” these conditions at the point at which they occur, or at least when they are identified (yes, it’s another “see something, say something” tale). When we encounter unsafe conditions during rounds—damaged walls, unattended spills, etc.—we “know” that these things did not happen by themselves, so what prevented the originator of the condition from at least saying, “Oh poop, I need to tell somebody about that hole in the wall/spill on the floor so it can be remedied.” Not a particularly difficult thing conceptually, but human behavior-wise, it seems like it is an impossible task. I suppose you could look at it as job security (hahaha!), but having to manage all these little “dings” keeps us away from paying attention to the big and bigger dings that we know are out there. I suspect that I’m probably not supposed to be thinking about this stuff so much when on vacation, but I guess that’s part of my brain that never really shuts off. And don’t get me started about people who leave shopping carts out in the middle of the parking lot at the grocery store (yes, that’s me pushing a line of carts either to the cart corral or back to the store—it is a most consistent manifestation of my OCD). Hope your August is proving to be most splendid!

PFI – Pretty Freaking Important – you’d better believe it!

I’m reasonably certain that we’ve dealt with this before, but there’s been a wee bit of a bump in survey findings relative to the practical assessment of PFI’s as a function of Interim Life Safety Measures.

It’s really quite simple, when you come right down to it. The Joint Commission standards require us to assess for Interim Life Safety Measures, based on the criteria in our policy, any Life Safety Code® (LSC) deficiencies that cannot be immediately corrected (BTW – it’s a good idea to define immediately in your policy – the standard holds no specific definition, so it’s a bit of self-determination – but don’t go crazy trying to define immediately as something much more than the end of the shift/end of the day). Okay, that’s a pretty solid LSC deficiency that we can’t fix right away.

So, the next question in this little chain is this – what is the defining characteristic of a PFI? Why, it’s a Life Safety Code deficiency that is going to take some time to resolve (something very much less than immediately)! So, as a simple quid pro quo arrangement (or equation, if you like), we have:

PFI = ILSM Assessment

Where you have the first, you must also have the second, otherwise you could find yourself staring down the barrel of a Situational Decision and potential Joint Commission re-survey. Is there anyone in the studio and broadcast audience that has any desire to endure that fate?

I didn’t think so – so, make sure you have ILSM assessments for each of your PFI’s and you will avoid this particular world of hurt. You should go check right now…

A little more conversation

Another contractor-related “impression” that’s surfaced lately (and this is not just in hospitals – this can be in your own backyard) is that fascinating phenomenon of the contractors that show up not exactly when you were expecting them and before you got a chance to let your neighbors know that there will be a project going on.

Admittedly, this (hopefully) doesn’t happen too often in healthcare (it better not, at any rate), but I still run across instances when clinical and other staff in areas adjacent to construction/renovation projects feel that they haven’t received much in the way of effective communication prior to the onset of the crash, bang, boom.

Now I know sometimes this is a little bit of the “it’s easier to get forgiveness than it is to get permission” concept (and yes, I also understand that that is a frequent mantra when it comes to taped-over door latches, door wedges, and other sins upon the life safety components of the building), but it’s not like the work isn’t going to happen, so the bestest thing you can do is to reach out to the neighbors to enlist their advocacy on your behalf. Face it, there’s going to be commotion that’s going to reach the eyes/ears/noses of everyone in adjacent spaces – including patients (the reason we are here, n’est-ce pas?)

If we can get the folks managing care to act as advocates for our sawing and drilling and dropping stuff and (quietly) swearing and playing the radio, etc., then (as with so many things) patients might not feel as inclined to provide negative feedback (no guarantees, but it certainly increases the chances of heading a complaint off at the pass).

One of the truisms of modern healthcare is that we cannot communicate enough, but if we keep everyone in the loop, the likelihood of a successful, complaint-free project increases quite a bit (I was tempted to use the exponential qualifier here, but you don’t need me to go all hyperbolic on you at this late date). So, start talkin’!

One of our subs is missing (with apologies to T. Dolby)

In recent months, I’ve encountered a couple of instances in which some contractors doing various and sundry projects for hospitals did something (what follows is merely my opinion) incredibly boneheaded – namely leaving roof access doors unsecured and unmonitored.

I’ve also encountered some instances in which contractors had gone to lunch (yes – they really were out to lunch!) and left their “work” unattended on a patient care unit (thankfully not a behavioral health unit, but still) – electrical closets open/unsecured, open ceilings, the whole gamut.

Now, one of my favorite observations is that the human race has an enormous capacity for doing stupid stuff (insert whatever relevant current event you think might be apropos evidence of such a sweeping generalization). And while we generally have pretty good controls over the folks who are working for us (that still doesn’t mean nothing will happen, but that measure of control can really pay dividends over time), but—and this seems to be on the increase—when we bring in folks from the outside (nominally because we are a wee bit under-resourced on the home front), we have to relinquish at least some of that control.

So I ask: When it comes to orienting contractor staff, on what topics do you focus? Do you make a general “don’t do anything stupid” statement as well as more specific concerns? I sometimes think that contractors forget about the complexities of providing a safe environment for patients. I honestly don’t think it’s a lack of capacity on anyone’s part, but in the heat of the battle, so to speak, and we’re charging towards a project completion date, etc., sometimes…

Anyone out there want to share any interesting examples of close calls / near misses, or even a sense of what you’ve done/learned to keep things on an even keel during construction/renovation projects involving external contractors? I know I’m not alone on this one – how about a little sharing?

Living on a thin line…

One of the realities of modern healthcare has been the shift (not everywhere, but in a lot of places) from inpatient volume to outpatient volume, with the result being a number of facilities that close and re-open patient care units based on demand. Now, certainly an organization has to be able to allocate resources appropriately, so consolidation, etc. is a very viable strategy.

But there are some states that can get a bit testy when it comes to the discussion of licensed beds, etc. and pushing the focus back on hospitals to be able to quickly (there’s no hard and fast number; what’s your state say?) restore those rooms/bed positions to service in the event of an increase in census.

Recently, I chatted with an organization that was facing a real challenge because some of the vacated patient units had been converted to other uses (offices, etc.); they are maintaining all the systems that are needed to return these spaces to patient care (just covering over the utilities in the headwall, etc. with a removable panel), so they’re good on that count. But where things have kind of squirted out the sides of the bag is the management of all the patient room furniture that has been displaced – can’t leave all that stuff in the corridors, etc.

So, this organization is looking at establishing a relationship with a medical furnishings vendor who can provide them with patient room furnishings within 48 hours (that’s the state mandate in this particular instance). This is after investigating the potential for off-site warehousing of the furniture now in service, etc., but it was decided that to do so with be extremely labor/resource intensive and since it’s been a while since they’ve actually had to flex back up, they’ve decided to try and work this through an external source.

So I thought that was pretty cool, but then the question became – how would CMS / TJC look at the farming out of the furniture component of their flex plan?

My first thought was they generally wouldn’t have much to say about stuff concerning licensed beds, etc. (beyond the application process), but then I was thinking that this could be an important component of your Emergency Operations Plan, particularly as a function of having to manage an influx of patients in an emergency. In which case, you’d need to be able to evaluate this process as a function (potentially) of your 96-hour plan, etc. I guess ultimately everything relates to everything else and any substantive changes you might make from an operational standpoint can come under scrutiny during survey. Is anybody out there in the listening audience faced with anything similar—maybe seasonal ebb and flow?

Keeping things cool in the hot lab

In reviewing “stuff” from the past few months (September and October were pretty busy on the regulatory front), I wanted to mention (in case this hadn’t crossed your path) the Government Accountability Office’s (GAO) report on the security of radioactive materials in hospitals as a function of the Nuclear Regulatory Commission’s (NRC) existing requirements. The GAO found the NRC requirements to be somewhat lacking, based on a sample of 26 hospitals and medical facilities.

According to the highlights of the report (you can find the whole megillah at: www.gao.gov/products/GAO-12-925), the NRC did not agree or disagree with the findings of the report, feeling that existing security requirements are adequate. Some of the security lapses found during the GAO survey were such items as unsecured medical equipment containing radioactive material, unescorted access to radiological sources, even (darn it!) numerical keypad lock combinations inscribed on door frames.

Now I will tell you that this is all stuff I’ve encountered periodically during my consulting life (a boss of mine once told me “you can’t mandate intelligence”; then Ron White distilled that into “you can’t fix stupid”) and I will also tell you that sometimes all you can do is shake your head about this stuff. That said, I have no reason to think that the good folks at The Joint Commission (or indeed anybody else with a horse in the regulatory survey derby) are not abundantly aware of this report and it’s contents. So what follows is purely consultative in nature:

Read the report, look at the recommendations, perform a gap analysis at your facility, identify any improvement opportunities, present the risk assessment to your EOC committee and move forward. You may want to consider identifying the necessity for recurring review (which, natch, you should be doing as a function of your annual evaluation of the security management program), if you think you might lose track of this, but I think this should cover things quite nicely.

For those of you go-getters who’ve already run this race – what kind of stuff did you find? Any suggestions for the rest of the classes? Inquiring minds want to know!