As we mark the passing of yet another (couple of) pop culture icon(s), I’m feeling somewhat reflective as I place fingers to keyboard (but only somewhat). As I reflect on the potential import of Sentinel Event Alert #57 and the essential role of leadership, one of the common themes that I can conjure up in this regard has a lot to do with the willingness/freedom of the “generic” Environment of Care/Safety program to air the organization’s safety-related (for lack of a better term—if you have a better one that’s not really PC, send it on) dirty laundry (kick ’em when they’re up, kick ’em when they’re down). I’ve seen a spate of folks getting into difficulties with CMS because they were not able to demonstrate/document the management of safety shortfalls as a function of reporting those shortfalls up to the top of their organization in a truly meaningful way. As safety professionals, you really can’t shy away from those difficult conversations with leadership—leaky roofs that are literally putting patients and staff at risk (unless you are doing incredibly vigorous inspections above the ceiling—or even under those pesky sinks); HVAC systems that are being tasked with providing environmental conditions for which the equipment was never designed; charging folks with conducting risk assessments in their areas…perhaps the impact of reduced humidity on surgical equipment. There’s a lot of possibilities—and a lot of possibility for you to feel the jackboots of an unhappy surveyor. One of the responsibilities of leaders, particularly mid-level leaders—and ain’t that all of us—is to work things through to the extent possible and then to fearlessly (not recklessly) escalate whatever the issue might be, to the top of the organization.
I was recently having a conversation with my sister about an unrelated topic when we started discussing the subtle (OK, maybe not so subtle) differences between two of my favorite “C” words: commitment and convenience. My rule of thumb is that convenience can never enter the safety equation at the expense of commitment (I suppose compliance works as well for this) and all too often I see (and I suspect you do, too) instances in which somebody did something they shouldn’t have because to do the right thing was less convenient than doing the wrong (or incorrect) thing. Just last week, I was in an MRI suite in which there were three (count ’em: 1, 2, 3) unsecured oxygen cylinders standing (and I do mean standing) in the MRI control right across the (open) door from the MRI. There was nobody around at the moment and I thought if there was a tremor of any magnitude (and I will say that I was in a place that is no stranger to the gyrations of the earth’s crust) and those puppies hit the deck, well, let’s just say that there would have a pretty expensive equipment replacement process in the not-too-distant future. The question I keep coming back to is this: who thinks that that is a good idea? I know that recent times have been a struggle relative to segregation of full and not full cylinders, but I thought we had really turned a corner on properly securing cylinders. These are the times that try a person’s soul: tell Tchaikovsky the news! Compliance ≠ Convenience…most of the time.
Or mayhap a preschooler…
When it comes down to the usual arc of things, our reliance on technology often exceeds technology’s “ability” to do everything we would want it to do when we want it done. In this regard, I imagine technology as a really precocious toddler that frequently astounds, but also frustrates more often than we would like (imagine when technology becomes a surly teen!), resulting in various and sundry risks, hazards, etc. Well, this is a landscape that the good folks at ECRI tend to watch very carefully, with the end result being regular recommendations to the folks actually dealing with the ups and downs (hopefully more ups) of technology operations, as well as the bosses. Now I will say that not everything on the ECRI list has a direct impact on the hospital safety world (though one could submit that the pervasiveness of technology provides potential issues for all manner of stuff) as information with which to be familiar. At any rate, this year there are two offerings, one to provide information to the folks occupying the environs of the C-suite, the most interesting/applicable offerings being those related to UV disinfection technology and the application of technology in caring for patients with opioid addiction (that one is less directly tied to safety operations, but this has such wide-ranging implications, it can’t possibly hurt to have a little background info). And then for us non C-suiters, a report on the top Technology Hazards in healthcare for 2017 is also on offer, with infection control and prevention being somewhat of a common thread in the hazards, but clinical alarm safety is also represented. The links provided here will take you to access portals where, for a nominal offering of contact information, you can download these reports.
Now, in looking out my window, it appears that winter has finally put in an appearance on the East Coast (though I guess the rains out in California over the past few days is also representative of a winter weather pattern, albeit less snow-covered) and it reminded me of my past days of having (personal and professional) responsibility for (among any number of things) snow removal. Now, to my way of thinking, there is a certain zen that can be experienced when one is combatting the forces of nature one on one (preferably at night) that is probably one of my favorite OCD moments (and believe me, shoveling snow in the middle of the night brings with it a certain inescapable essence of OCD, but I digress). At any rate, one of the more important aspects of the snow removal game is that of ensuring that any and all nearby fire hydrants are well and truly accessible in the event they are needed in an emergency. Just as there is many a slip twixt cup and lip, any delay in accessing firefighting resources can yield catastrophic results, so, as a community service, I give you this information. Particularly in those areas experiencing a little more snow than usual, this might even be worth sharing with the rest of the folks in your organization. I figure if it helps even one person to be a little safer, then it’s worth the effort to spread the news.
Periodically, the whole concept of adopting plain language codes for emergency response plan activities/activations percolates to the top of somebody’s to-do list (I’d much rather embrace the concept of the to-don’t list, but that’s a discussion for another day). There was a little bit of that (more by inference than anything else) in the CMS follow-up report to the hospital response to Superstorm Sandy. Jeez Louise, that seems like eons ago…
This discussion always seems to engender a lot of back and forth, mostly regarding the balancing act of providing enough information to direct an appropriate response and not providing enough information to cause a panic. I recognize both sides of the argument, but I must say that I haven’t seen a lot of data to support a wholesale change, particularly as it would require a fair amount of education (and yes, I know that just because something requires education, etc., is not enough to forego adopting a new strategy, etc.). But I will also say that, depending on your organizational palette when it comes to emergency notification, all the different codes relative to workplace violence, active shooter, emergency assistance calls, etc., may well benefit from a more succinct announcement.
Recently, the Texas Hospital Association has weighed in with a recommendation to its members to adopt plain language codes, including a sample policy, an implementation timeline, and some examples (you can find that information here). It appears that there’s a move away from the (fairly standard, though not quite universal) Code Red designation for a fire alarm activation to the plainer language (though somehow not quite as sexy) “fire alarm activation.” It does appear that medical emergencies will remain as the (again, fairly standard, not quite universal) Code Blue (I guess that one’s gotten enough play on medically-oriented TV programs to have become part of the vernacular—where are the TV shows about safety in hospitals?!?), but there are some other terms that are worth of consideration. I don’t know that there’s necessarily a groundswell of support, but sometimes Texas can be something of a bellwether, so it may be a good opportunity to look at the possibilities, particularly if you haven’t in a while.
That said, I have two (relatively moderate) concerns. One being we are still waiting on the unveiling of the CMS final rule on all things emergency management; I had thought perhaps that pursuit had become somewhat dormant, but with the adoption of the 2012 edition of NFPA 99 excluding the chapter on emergency management, I think we have to believe that something regulatory this way comes. At any rate, will CMS push for some standardized notification language, particularly as a function of a focus on interoperable communications capabilities? I think that card has been dealt, I guess we’ll have to see how it gets played.
The other concern is the overarching concept of interoperable communication capabilities; I, for one, do not recommend you go about changing anything in terms of notification until you have some talk-time with the local emergency response authorities. They may or may not feel like they have a stake in this discussion, but you want to be absolutely certain that any modifications you might be entertaining will not somehow fly in the face of established protocols, language, etc. Isolationism, particularly when it comes to emergency management, is not likely to be a winning strategy as it usually requires the cooperation of disparate resources. So don’t forget to keep the community folks in the loop—you never know when they might come in handy!
Patients with high-risk behaviors pose a danger to healthcare staff and other patients and are difficult for healthcare employees to manage. In this live webcast, expert speakers Tony W. York, MS, MBA, CHPA, CPP, and Jeff Puttkammer, M.Ed., will discuss the patient factors that often lead to violent events in the workplace, provide a clear understanding of environmental influences and triggers that contribute to violence, and supply tools and resources to help you reduce the risk of a violent event in your facility. The program is scheduled for Wednesday, January 20 from 1 to 2:30 p.m. ET.
Employees have the power to influence their own safety, but they often lack the proper training. Give your staff the knowledge they need to deal with high-risk patients and keep themselves and their facility safe!
At the conclusion of this program, participants will be able to:
- Define high-risk patient behavior (more than just mental health patients)
- Explain how a balanced approach to patient-focused care and personal safety impacts patient satisfaction and work-related injuries
- Identify how workspace design and medical equipment placement can promote or reduce the safety of staff, patients, and visitors
- Define policies, procedures, and practices aimed at reducing safety risks associated with at-risk patients
- Understand the critical role staff education and training plays in helping provide the culture, tools, and competencies required to successfully reduce and manage patient-generated violence
In full recognition that the Internet (including, I daresay, this august space) is a constant barrage of information (okay, information may be a more generous descriptor than some of the Web is entitled to, but…), every once in a while something comes flying through the ether that captures my thoughts and/or imagination (next week I’m going to share with you the latest in fire suppression techniques) and I feel inclined (I never want to think of this as an obligation) to share with you.
Now, some of you may be “old” enough to have experienced the time when Dwight David Eisenhower was president of these United States (as opposed to the “other” United States) and while he is famous for having facilitated the creation of a lot of far-reaching programs (the interstate highway system and NASA, to name but two), there was one productivity initiative that bears his name: the Eisenhower box. This derives from Eisenhower’s observation that “what is important is seldom urgent and what is urgent is seldom important.” I think I was generally familiar with the quote, though I can’t say that I’d ever seen it attributed to him.
At any rate, yesterday’s Flipboard email brought with it (among other things—Flipboard is a very interesting app and provides kind of off-the beaten-path content) an article from the Huffington Post outlining the Eisenhower box concept. I can’t provide the image in this space, so I encourage you to give it a look-see. The “box” is pretty much a 2 x 2 matrix outlining four possible actions—do, decide, delegate, delete—based on the important/not important, urgent/not urgent metric. For those of you in the studio audience with operational responsibilities, I can see where this might be a very useful tool for sorting through the flood of information that is your “day” (and I can’t think of too many folks who are in the position of having to manage the exact right amount of information and tasks every day). So I’d ask you to give a whirl and let the rest of this community know if it helped at all.
Every once in a while (and I don’t think I abuse this privilege, but please feel free to disabuse me of that notion), I like to vent a little regarding those annoyances that can impact how the folks in the safety world carry out their duties. In this particular instance, I’d like to rant a bit about those members of the “safety committee” that seem only to attend meetings when there is an opportunity to stonewall/derail/obstruct, etc., the ongoing work of the committee.
Lately it seems a lot of folks are struggling to bring their active shooter response plans past the initial stages and move into the implementation phase. That struggle inevitably seems to revolve around those transient members that always seem to know when you’re committee is just about to “birth” a new policy or process and they glide into the action with reservations/objections/all manner of constipations to set things back, without having participated in the work leading up to that point.
In my heart of hearts, I know that this is not very collegial behavior, but the question I have for the community is: How are you managing these occasions? My philosophy (which can be sorely tested from time to time) is that you have to birth the policy before you can tell for sure how well it will (or won’t) work when you operationalize it. I guess the analog to that is that it is better to have a flawed policy that you can work to improve than it is to have no policy at all, particularly to manage critical functions or risks. It is very, very difficult (certainly bordering on impossible) to come up with perfection without doing some trialing in the real world (maybe it’s possible, but I can honestly say I’ve never encountered it). I suspect this has happened to many (if not most, and probably all) safety professionals. Anybody have any inventive solutions for organizational blockages? Please sing out—let the world in on your secret!
As you are all no doubt familiar, sometimes those educational topics surrounding safety can come across as a bit dry and that dryness all too frequently ends up being the focal point of safety presentations. Now, one of the fun little quirky things that you run into when flying is that every time you get on a plane, you have to go through orientation (if only we as healthcare safety professionals could “capture” an audience as frequently as the airlines do) and sometime those orientations are very much less than compelling. And so, I thought that you might find the following offerings from NPR and The Telegraph of some interest, entertainment, and perhaps some inspiration. As I like to say during my consulting visits, this stuff doesn’t have to be torture. At any rate, I hope you enjoy these, and maybe you’ve got some homegrown footage you’d want to share (or perhaps already have shared); there’s no reason we can’t all partake of such splendor.
We’re rounding the turn and headed for home – no squeeze play at the plate this time…I hope!
EC.02.05.09 – Inspection, testing and maintenance of medical gas and vacuum systems (#16, with 24% of hospitals having been cited)
It seems to me that we’ve discussed this in the past as well, but it appears that, in this survey year, everything bears repeating.
Anything that your medical gas and vacuum testing activities generate as deficiencies/recommendations/hints from Heloise/etc. needs to be accounted for somehow. Maybe your medical air intake is right next to an isolation exhaust, or it’s nothing more than a leaky outlet, or the issue is non-compliant construction (a favorite is the medical gas zone shutoff valve in the PACU with no intervening wall) that can wait until you do a remodel/renovation project. Whatever it is, you need to say, “This is what we’re doing about that, based on our assessment of the involved risks.” And don’t wait to get ahead of the curve on the fixes: As soon as the activity is completed you are on the hook for the fixes, so you need to know what’s on that list even before you get the pretty report. The clock starts ticking upon identification of the condition, so if you have to wait a month or 45 days for the report, you (and more importantly, your patients) are at some level of risk.
The other thing to do is make sure that your vendor is not using this process to drum up work; I can’t tell you how many times I look at multiple years of testing documentation and find the same “deficiency” over and over again – and then find out, well, it’s not really a deficiency at all. You will get slapped during a survey for this – if it’s a critical fix, then fix it, if it’s not a critical fix, then dot the “I’s” and cross the “t’s” and make sure they are accounted for.
Another component of this is obstructed access to zone shutoff valves, as well as making sure that the labeling of valves is accurate (areas served, contents of piping – labels have to be accurate, accurate, accurate). Also, make sure that what you are calling the area of coverage is in some sort of accordance with what the staff calls the area. I can’t tell you how many times that I’ve seen zone valves labeled in accordance with the architectural drawings and find out that front line staff really doesn’t know which areas are served by the valves. Knowledge is very powerful, and certain knowledge is an invaluable commodity during surveys.
EC.02.05.07 – Inspection, testing and maintenance of emergency power systems (#17, with 23% of hospitals having been cited)
Emergency generators and automatic transfer switches have to be tested in accordance with the requirements of EC.02.05.07 – if you need me to tell you what those are at this point, you may be in the wrong line of work. However, I am more than happy to answer any questions you might have regarding this most important subject. 30%, 30 minutes, no closer than 20, no greater than 40 between tests, run it for 4 hours at a minimum 30% load every 36 months – these are a few of my favorite things.
EC.02.03.01 – Management of fire risks (#20, with 19% of hospitals having been cited)
Breathing a sigh of relief, we’re near the end of our little journey through time and (interstitial) space.
This is another of those findings that it becomes a question of how far one must look before one can encounter enough deficiencies to drive an RFI (the answer in this case being 2). The question I have for you is this – how many junction boxes do you have in your facility. 100? 1,000? 10,000? So, the follow-up question is: How many would an individual (say, a Joint Commission Life Safety surveyor) have to look at before they found two that didn’t have a cover? There are so many opportunities to drop the ball on this one – mechanical spaces, comms closets (it’s very rare that I find an open j-box in an electrical closet – but not impossible). You know they’re going to look above the ceiling – and they’re not just looking for penetrations – and cabling on sprinkler piping – and, and…
You need to enlist the efforts of everyone who does work above the ceiling in your facility; they don’t necessarily have to fix it, but if you know where it is, then you have a shot at being able to address it before it gets ID’d during a survey. The proactive approach works unbelievably well for stuff like this.
And on the horizon looms the specter of a return to focus for the prevention of surgical fires – including the participation of physicians. Too many (and my stance is that one surgical fire is too many) surgical fires occur for my (or anyone’s) liking, so it’s time to kick this process into high gear. I know they’re busy, and may not always seem to be the most cooperative bunch on the planet, but this I see as a moral imperative (and it appears that TJC is similarly inclined – so if you won’t do it for me, do it for them). We can do a better job of educating folks about the risks of surgical fires – and so, we must do just that.
One other related thought is to make sure that you are appropriately managing amounts of compressed gas – don’t go over 12 e-cylinders in an unprotected area. And make sure that your gas storage rooms (for amounts greater than 300 cubic feet of gas) are appropriately fire-safe, etc.
This concludes our test of the emergency survey broadcasting system – this was only a test. We now return you to our regular programming, which is already in progress. If you have any questions or concerns about this or any other topic, you know where I am…
Just a thought relative to a finding from a recent survey – a quick show of hands, if you will. For those of you blessed (cursed?) with having a fire pump (or two, or three, or…), when your folks conduct the weekly churn test, are they documenting the pressures at the pump as required by NFPA 25-1998, 5-126.96.36.199?
It seems that there are some instances in which the run time for the test is all that is being documented, so if you think you might be among those who aren’t documenting the pump pressures, consider yourself informed. For those of you who don’t have fire pumps, well, one less thing to worry about, which leaves about 999,999 things to worry about. You take one down, pass it around…
Every once in a while, someone will “challenge” me relative to something I “know” is the real deal. Now, just so we’re clear on this, I absolutely encourage the respectful pursuit of knowledge, and it helps keep me on my toes, metaphorically speaking.
The issue in question during this recent survey was regarding the requirements for the placement of smoke detectors vis-à-vis the location. Or, in the vernacular, “Where does it say that it the code?” At this particular facility (as will happen from time to time), I noted that there were several smoke detectors that were located within three feet of air supply/return vents. I fully recognize that moving such devices around can represent a not-insignificant expense, so I was happy to respond to the “nobody’s ever said anything about that before” conversation, but had to admit that I was not certain as to the chapter and verse that governed this particular metric.
So, for the purposes of furthering the knowledge base, I give you NFPA 99 – 1999 edition, which is the edition of record referenced in the 2000 Life Safety Code®:
2-3.5.1*: In spaces served by air-handling systems, detectors shall not be located where airflow prevents operation of the detectors.
Now you may have noticed that there is no specific distance indicated, just a (not particularly useful) thou shalt not. So, how do we figure out where to go with this? Luckily, the little asterisk, points in a very useful direction. And so, to the Appendix!
A-2-3.5.1: Detectors should not be located in a direct airflow nor closer than 3 ft (1 m) from an air supply diffuser or return air opening. Supply or return sources larger than those commonly found in residential and small commercial establishments can require greater clearance to smoke detectors. Similarly, smoke detectors should be located farther away from high velocity air supplies.
Which provides us with a minimum distance of 3 feet (or 36 inches, for those of you inclined to such measures). While there is still a little wiggle room (not necessarily related to the little asterisk) relative to distance from larger and/or high velocity sources (in fact, you could make the interpretive case that supply and/or return sources in hospitals might indeed be larger than those commonly found in residential and small commercial establishments), this gives us the means of drawing a line in the sand beyond which we shouldn’t traverse. As a final thought, for those of you eagerly awaiting the opportunity to embrace the 2012 edition of The Life Safety Code®, the 2010 edition of NFPA 99 provides this little piece of the regulatory pie under 188.8.131.52.