All Entries Tagged With: "hospital safety"

Can’t get no protection…

I’m not sure if you folks follow my HCPro colleague David LaHoda’s OSHA Healthcare Advisor e-newsletter and blog, but there’s an item this week that I think bears bringing to your attention in case you didn’t see it.

Now I think we can all agree that there is a great deal of attention being paid (and rightly so) to issues of workplace violence and how can we be assured that we are doing all we can to protect the front line folks from assaults, etc. And I think many, if not most, of us recognize that acts of violence by patients are definitely not diminishing over time. The variables are wide-ranging—the economy, the reduction of behavioral health resources, etc.—and endlessly complex.  We must manage these variables in as proactive a manner as possible.

So, how are you folks out in the safety community addressing these types of concerns? What education are you providing and to what staff demographic groups are you targeting with that education? Are you mandating education in certain areas, or are you letting folks participate as they feel necessary? Who has a program that’s working well, and what monitoring and measures have you put in place to ensure that the program you have is getting the desired results? I think this is a dialogue that’s going to be with us for a while, so please weigh in on what you’re doing/facing/dreading.

As a final thought, back in the day before we had “standard precautions,” there was the term “universal precautions” based on the concept that you can’t tell whether a person is an infection risk just by looking at them, so you have to manage everyone as if they had the potential. Is it time for a truly “universal” approach to the potential for violence when it comes to patient management? What do you think?

Gaining some Perspectives on The Doors of Perception

I’m going to guess that you all out in the audience do not necessarily place The Joint Commission’s Perspectives periodical on your list of must-reads, but for the May and June 2012 issues (and who knows beyond that), you really owe it to yourself to grab a copy and prepare for some hard-hitting door and barrier conversation with our esteemed colleague, one Mr. George Mills, Director of the Engineering Department at The Joint Commission.

At any rate, I think we can point to an increasing level of frustration on the part of the various and sundry regulatory agencies (and us, don’t forget us) relative to the number of findings in the life safety (LS) chapter and the omnipresence of these issues in the most frequently cited standards during surveys. How do we make this go away? The answer to that question, interestingly enough, is adopting a risk-based strategy for the ongoing inspection and maintenance of whatever building component is in play – this month its doors.

Now, those of you who’ve been hanging around the pea patch for one or two cycles will immediately recognize the concept as being almost eerily similar to the Building Maintenance Program of days gone by (OK, maybe not so gone by). That said, I think that I can safely say that if you can adopt the strategies contained in this month’s Perspectives (starting on page six), you will have the power (and data-driven power at that) to ensure that your organization will not have to endure another RFI for door issues on your final survey report (but remember that you may still have to use the post-survey clarification process to rid yourself of those pesky RFIs. Still, it is so worth it).

The article has recommendations, a lovely form to use, the philosophy and concept behind the whole thing – really, it’s the complete package. One word of caution: Stuff that appears in Perspectives is traditionally held to be equivalent to anything in the standards manuals and FAQs. For all intents and purposes it’s a requirement, so you’d better get to the adoption of this strategy or having a most compelling risk assessment to indicate that you are achieving an equivalent level of safety for your facility and its occupants. Failure to do so will make things very difficult when attempting post-survey clarifications.

As noted in the article (and this has been a frequent touchstone in my consulting practice), the stuff The Joint Commission is finding is mostly minor in nature: doors not latching, missing ratings labels, excessive gaps and undercuts, etc. These is not big ticket stuff by any stretch of the imagination. And, to my way of thinking—odd though it may be at times—there is no reason we should have to be burdened with having to clean up all these little survey messes (not that I’m advocating big messes as an alternative – no no no). I think we’ve been provided a very implementable strategy for keeping things on the side of compliance, which is never a bad thing.

What do you folks think?

Taking care of business

Earlier today, I was conducting an EC/EM interview session with a very participative group and I was complimenting them on their ability to speak to improvement efforts in areas that are not necessarily in their scope of practice. Now, my experience has been that the folks most familiar/expert with the EC function being discussed tend to dominate the conversation (sometimes in a good way, sometimes not) and I thought it was cool that these folks were so familiar with what others in the group felt was important. To my compliment, the observation was made (and I thought this was absolutely the grandest definition of what a high-performance team can achieve) that they mind each other’s business. In that simple turn of phrase (not an exact quote – sometimes paraphrase is the best I can do), the whole concept of what the EC team can embrace and accomplish was crystallized: It’s not about what may or may not be “somebody else’s job” (or “not my job”); it’s actually using the team concept to make and sustain improvements. In the old days we used to call that type of organizational behavior “silos,” which is OK if you’re storing grains and such, but when the goal is organizational improvement, we want to be more like a snack mix with all sorts of nuts and fibrous bits.

And please keep in mind, it’s not necessarily about never having any issues to correct. As long as there are human beings in the mix, there will be corrections to make – be assured of that. But if you can harness the power of a group of committed individuals who accept responsibility, hold each other accountable, and care enough to “mind each other’s business,” you can accomplish so much. There’ll always be stuff to do, but think about the power of getting stuff done.

Brings a smile to my face – how ‘bout you?

Dry your eyes – but don’t dry those wipes!

A quick note of interest from the survey world –

A recent survey resulted in a hospital being cited under the Infection Control standards (IC.02.02.01 on low-level disinfection, to be exact). In two instances, someone had the temerity to forget to close the cover on a container of disinfectant wipes. Can you believe such risky behavior still exists in our 24/7 world of infection prevention? It’s true, my friend, it is true!

The finding went on to say that, as the appropriate disinfection of a surface depends on wet contact with the surface being disinfected, leaving the cover open would partially dry out the next wipe, impairing the ability of the wipe to properly disinfect the surface. Now, I suspect that the person to use that next wipe might somehow intuit that the moisture content in the wipe was not quite where it needed to be and maybe, just maybe, go to the lengths of (wait for it) – pulling out an additional wipe (or two, or three). Now my experience has been that sometimes those wipes are not what I would call particularly well-endowed in the moisture department. And  the use instructions for these products usually indicate that you should use as many wipes as it takes to ensure that the surface to be disinfected stays wet long enough for disinfection to occur.

I’ve always been a pretty big fan of the slowly-becoming-less common sense, so I’m not quite sure how we’ll be dealing with this one – thoughts, anyone?

Panic in Detroit – Panic at the Disco – Panic at the Surgery Center…Fire in the Hole!

I’m presuming (and please don’t attempt to disabuse me of this notion) that you are all dutifully conducting security risk assessments on a regular basis. As you conduct them, I’m sure you find risks of some events that are greater than some other areas. So, I to ask: When you’ve completed your security risk assessment, do you identify specific strategies, including the use of technology, for minimizing those risks to the extent possible? If you’re not including that facet in the risk assessment process, you might want to consider doing so.

Recently, I was looking at a survey report in which an ambulatory surgery center was cited during a TJC survey because they had not installed a panic alarm “at the registrar’s desk in order to obtain immediate assistance in an emergent or hostile situation.” Now, as with so many things that have been popping up during surveys, I don’t disagree with the concept of having panic alarms at those customer service/interaction points where unhappy folks (or folks of any ilk) can experience the need to vent their frustrations, etc. But in that disagreement, I think I’d first be looking at what tools have been provided to staff to actively manage, if not de-escalate, these negative encounters. I would much prefer to avoid having to use a panic alarm by appropriately managing the encounter, much like I would just as soon not “need” to have an emergency eyewash station.

I’m a great believer in the proactive management of risk, but I’m also a great believer in implementing risk management and response strategies that make operational sense. So, the question to the studio audience is: Where have you installed panic alarms and where have you not installed panic alarms, and why? There’s always the risk that some surveyor will disagree with your strategy, but if that strategy was derived through thoughtful analysis of the involved risks, does that not meet the intent of all this?

I like the concept of best practice as much as anyone, but I also recognize that there is a tremendous amount of variability in the safety landscape. Just because something works in one place does not necessarily mean that it will work in all cases—that’s the mystical, magical, and ultimately mythical power of the panacea. One size doesn’t fit all—never has, never will. But if we’re going to be held to that type of an expectation, how does that help anyone? Ok, jumping down from soapbox for now, but rest assured, you’ll see me back up here before too long.

There’s a light, a certain kind of light – and it’s not an oncoming train!

This one has the potential to be the game-changer we’ve been hoping (waiting) for – the emergence of the 2012 edition of the Life Safety Code® as a CMS-sanctioned regulatory standard.

Once you lay your hands on this plucky little document -  the official CMS memorandum – you will see that it appears) to represent a fair degree of flexibility when it comes to, among other things, corridor storage, and the amount of combustible decorations that are allowed. One thing this likely means is that everyone’s going to be inundating NFPA for their own personal copy of the 2012 Life Safety Code® – this is going to become a go-to resource from here on out.

Now, the first thing you will notice is that there’s a lot of mention of nursing homes, and not so much of hospitals, particularly on Page 1. To that end, let me direct you toward the bottom of page 2 of the document (under the section titled “Effective Date”), which specifically indicates that the memorandum and all its components are “in effect for all applicable healthcare facilities such as Hospitals and Nursing Homes.”

The other caveat, at least for the moment, is that it appears that the changes are only “accessible” through the CMS waiver request process, which will, in turn, result in a process in which “each waiver request will have to be evaluated separately in the interest of fire safety and to ensure that the facility has followed all LSC requirements and the equipment has been installed properly by the facility.” I’m not entirely certain whether this would drive anything more than a review of the waiver request, but I’m not entirely certain how they’d be able to ensure compliance with LSC requirements, etc., without eyeballing a facility. That said, there’s a whole heck of a lot of hospitals that would be pursuing this, so maybe there’s a process in place, maybe based on past TJC/DNV/HFAP and/or CMS survey results.

So, what it looks like we have here is some room for stuff in the corridors, including fixed furniture; and the presence of combustible decorations on “walls, doors and ceilings.”

That’s enough yapping from me for the moment; I encourage you to check out the document and let us know what you think. I think it’s very interesting.

And your bird can sing…

One of the topics that resurfaces every once in a little while concerns those most critical documents– your life safety drawings – and what should be contained therein. If you are still uncertain about what those suckers oughta look like, I would direct your attentions to the February 2012 edition of The Joint Commission’s EC News in the “Asked and Answered” section. The laundry list of items to be included on your life safety drawings is not particularly surprising by those among us who have been advocating for a certain contingent of information. So, if you were going to air out your “dirty” life safety drawings, some items for consideration might include:

• a legend that clearly identifies fire safety features of your building
• identification of those areas of the building that are fully sprinkled (if your building it partially sprinkled – no need for such detail if you’re fully sprinkled)
• the location of all of your hazardous storage areas (if you’re not sure what that entails, check out EP #2 under LS.02.01.30 and/or NFPA 101-2000: 18/19.3.2.1);
• the locations of all your rated barriers (yes, all of them – don’t leave any out)
• locations of all your smoke barriers
• the boundaries of any areas that have been designated as suites – and don’t forget to include the square footage of the suites – both sleeping (maximum 5,000 square feet) and non-sleeping (maximum 10,000 square feet)
• locations of your smoke compartments
• the locations of any chutes and/or shafts (as opposed to chutes and ladders – that’s kids’ stuff)
• any approved waivers or equivalencies.

A quick word about waivers and equivalencies: It’s always nice to share those ahead of time with your various “Authorities Having Jurisdiction.” A proactive approach to communications, as with most proactive approaches, will yield much goodwill. This whole thing works best as a collaborative process. No surprise on either side and you’ve got yourself a pretty good survey experience.

Manufacturer recommendations?!? We don’t need no stinkin’ manufacturer recommendations…

As you’re no doubt aware, there is some movement afoot relative to the inclusion (or exclusion, depending on your preference and organizational experience) of the risk assessment concept when it comes to the establishment of preventative maintenance frequencies for medical equipment. The Joint Commission has historically encouraged the use of data and past performance to provide a backdrop for the most efficient utilization of clinical engineering resources. However, CMS has been pretty adamant and absolute in their preference for manufacturer recommendations for PM frequencies to be the “be all, end all” source for determining such things.

As we take on the next in our informal series—CMS – what up with them?—we bounce once again to the web–

https://www.cms.gov/SurveyCertificationGenInfo/PMSR/itemdetail.asp?filterType=none&filterByDID=-99&sortByDID=4&sortOrder=ascending&itemID=CMS1254595&intNumPerPage=10

–and find that, lo and behold, there has been some relaxation in terms of scheduled PM frequency. The caveat, at least for the moment, is that although we can judiciously schedule preventative maintenance activities to our heart’s content, we’d best not stray from the manufacturer recommendations for what those activities will include.

Now, off the top of my head, I can’t think of too many instances in which you would modify manufacturer recommendations for such activities, but maybe you can. I’m not sure how effective this will be; my gut says it helps in the long run; the fundamental change is toward a more flexible planning (they’d have been looking for us to follow manufacturer recommendations for the PM activities anyways, so this is really nothing new as near as I can tell – please feel free to disabuse me of that notion).

What say all you clinical engineers out there?

And I’ll return to claim your hand – as the King of California

I generally don’t single out any of the myriad potential demographics of this portion of the blogosphere, but the Joint Commission’s January 2012 Perspectives, has singled out of you good folks keeping the safety faith out in California, based on some state-level legislation promulgated back in 2010.

The focus of the legislation is those folks engaged in CT scanning activities, which I’m going to guess includes just about everyone (the standard applies to ambulatory, critical access, and hospital accreditation). I don’t see this as a particular nuisance for folks. I believe that everyone with a compliant radiation control program is on top of this, but if you’re not—even if outside of California—this new element of performance (EP) might be worthy of consideration moving forward.

EP #17 (an “A” EP) under EC.02.04.03 requires at least an annual measurement of the actual radiation dose produced by each CT imaging system, and further requires that the radiation dose displayed on the system is within 20% of the actual amount of radiation dose measured. Naturally, the dates of these verifications would be documented (and, by extension, made available during survey.)

(We’ll be chatting more about what documents and documentation could be considered “reviewable” during survey—it’s a long list.

Now, a 20% margin is a pretty wide range, I would say. In fact, if there’s anyone out there in Cali who’d care to weigh in, would you mind speaking to how you’re managing this process and what your experiences have been? I’m going to guess the 20% tag is fairly attainable on a regular basis, but maybe not. It’s not really something that I’ve focused on in the past. It does seem that legislation on the coasts tends to ripple across the compliance landscape, so maybe a future concern is best dealt with now.

At any rate, if you have stories to share, by all means, please include us.

Breaker, breaker…

Recently I received a question from a colleague regarding a survey finding an RFI under EC.02.05.01, performance element numero 7, which requires hospitals to map the distribution of its utility systems. The nature of the finding was that there was an electrical panel in which the panel schedule did not accurately reflect the status of the breakers contained therein.

My guess is that there was a breaker labeled as a “spare” that was in the “on” position, which is a pretty common finding if one should choose to look for such a condition. At any rate, the finding went on to outline that staff were unaware of the last time the mapping of the electrical distribution was verified. The question thus became: How often do we need to be verifying panel schedules, since the standard doesn’t specify and there is no supporting FAQ, etc., to provide guidance.

Now, first, I don’t know that this would be the most appropriate place to cite this condition; my preference would be for EP #8, which requires the labeling of utility systems controls to facilitate partial or complete emergency shutdowns, but I digress. Strictly speaking, any time any work is done in an electrical panel, the panel schedule should be verified for accuracy, which means that any breaker that is in the “on” position should be identified as such on the panel schedule. This is not specifically a Joint Commission requirement, but I think that we can agree that the concept, once one settles the matter as a function of logic and appropriate risk management behavior, “lives” in NFPA 70 the National Electrical Code®.

As I noted above, unfortunately, this is a very easy survey finding if the surveyor looks at enough panels; it is virtually impossible to not have at least one breaker in the “on” position that is identified on the panel schedule as a spare or not identified at all. That said, if you get cited for this, you are probably going to have to wrestle with this at some point and your facilities folks are going to have to come up with a process for managing this risk, as it’s really not safe to have inaccurately labeled electrical panels.

As to a desired frequency, without having any sense of how many panels are involved, which would be a key indicator for how often the folks would be able to reasonably assure compliance (a concept not very far away from the building maintenance program [BMP] concept), it’s tough to predict what would be sufficient. That said, the key compliance element remains who has access to the electrical panels. From my experience, the problem with the labeling of the breakers comes about when someone pops a breaker and tries to reset it without reaching out to the facilities folks. Someone just goes flipping things back and forth until the outlet is working again (floor buffing machine operators are frequent offenders in this regard).

From a practical standpoint, I think the thing to do in the immediate (if it’s not already occurred) is to condcut a survey of all the panels to establish a baseline and go from there, paying particular attention to the breakers that are not properly labeled in the initial survey. Those are the breakers I’d try to secure a little better, just to make sure that they are not accessible by folks who shouldn’t be monkeying around with them. Another unfortunate aspect of this problem is that both EP 7 and EP 8 are “A” performance elements, so it’s a one-strike-and-you’re-out scenario. Certainly worth a look-see, perhaps during hazard surveillance rounds.

So many panels, so little time…