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Walls and Bridges: Managing construction projects large and small

As you might guess, part of my approach when I’m doing onsite client work is to review the process for managing construction projects, inclusive of the risk assessment process (infection control, life safety). To my mind, there is no more risky business in the physical environment (the management of ligature risks notwithstanding) than undertaking construction or renovation projects, particularly when those projects are in spaces adjacent to occupied patient care (or indeed, any occupied) areas. And with the adoption of the 2012 Life Safety Code® (LSC) and the growing invocation of Chapter 43 Building Rehabilitation, it would seem that the tip of the regulatory spear is getting sharper by the moment.

One of the things that I encounter with some regularity is a fundamental flaw in how the risk assessment actually captures/identifies the risks to be managed as a function of what strategies are to be implemented to eliminate/mitigate the impact of those risks. For example, I can’t tell you how many times I’ve seen assessments of a project that is going to include construction barrier walls in a corridor for which the assessment indicates no impact on egress. Now, you can certainly indicate that, based on the implementation of X, Y, and Z, you have mitigated the impact on egress, but to indicate in the assessment that there was no impact on egress from a barrier wall that has encroached on the corridor, is inaccurate at best—and possibly could draw the ire of a literalist surveyor. As I like to tell folks when I encounter this: You don’t get credit for doing the math in your head; the assessment should indicate that there was an impact, but the impact was mitigated by the implementation of ILSM(s).

Similarly, if you remove the suspended ceiling in a project area, you have impaired the smoke detection/sprinkler protection in the area. Now it may be that the impairment is sufficiently minor in nature to not require implementation of ILSMs, based on your policy, but you still have to indicate that such is the case. You can’t say there was no impact or impairment, because the condition you have represents an impairment and so, there’s got to be some level of impact.

I think perhaps the way to look at this is much in the vain of our emergency management Hazard Vulnerability Analysis (HVA) process. There is no harm/no foul in identifying risks for which you would need to be prepared (you could make the case that there are few things as disruptive to an organization as a construction project) as long as you have a strategy for managing those risks. So, if you carry over the philosophy to construction/renovation, it makes it “easier” to frame the assessment as a proactive management of risks rather than trying to figure out how to do as little as possible (and I do see pre-construction risk assessments that seem to be aimed at a de minimis implementation strategy). But using the HVA algorithm (likelihood, impact, preparedness, response) you might find that your “packaging” is a little tidier than it was previously.

As a final note on this subject, I really think you need to get in the habit (if the habit has not already formed) of posting infection control permits, ILSM permits, etc., outside of construction/renovation areas so it is clear what the expected conditions and/or practices might be. You can’t be looking over the shoulder of the contractors every minute, so it helps to have some eyes in the field (with a reasonable knowledge base) keeping watch. There is definitely an expectation of regulatory surveyors that these will be posted in conspicuous locations (yeah, I know there’s no rule that says you have to, so chalk this up to a best practice invocation), so better to have visible postings.

Please let me close things out with best wishes for a joyous and restful (Can you combine those two? I think you can!) Thanksgiving to you and your families. 2018 whipped along at a pretty good clip and I suspect that the holidays will launch us into 2019 before too long, so take a few deep breaths and enjoy the day.

Don’t ask, don’t tell, don’t tell, don’t get in trouble…

Hope everyone is having a good week and that the rather stormy weather impacting so many parts of the country has not created too much of a challenge for you and your organizations.

This week is another (sort of) catch-all of topics, starting first with a little bit of CYA advice.

Lately there have been several instances (of which I am aware—can’t say for sure if this is an iceberg, but it “feels” like it might) of some very adverse accreditation/deemed status decisions based on insufficient documentation that organizational leadership had been effectively informed of conditions in the physical environment that required additional resources, etc. It’s not that organizational leadership was unaware of the conditions, but more that there was no trail of documented discussion (committee minutes, surveillance rounds, etc.) by which the organization could demonstrate to the surveyors that they had everything under control. In fact, the impression given because of the lack of a documented trail was exactly the opposite.

While nobody is really keen on telling their boss about problems of significance, especially problems for which the means of resolving them are elusive or beyond one’s resources (don’t want to look like you can’t do your job effectively), it is of critical importance to be able to escalate these types of issues to (or near) the top of the organization. Typically, this is about having to fund something (at least in my experience); maybe it’s a roof replacement; maybe it’s replacing some HVAC equipment—I’m sure most folks have a list of things for which it is a struggle to get traction. Let’s face it, unless it’s a new building, facilities infrastructure improvements, safety stuff, etc., is not particularly sexy, so when the capital improvement budgets come and go, it’s a tough sell. But sell it you must and you must keep pushing it—eventually those improvements (or lack thereof) are going to impact patient care and that’s when things can go south in a hurry. We always want to be respectful and not panicky, etc., but, please believe me, when the three- and four-letter regulatory folks knock on the door, you want to be in a position to describe how issues are brought to the attention of leadership. It may not be too pleasant in the moment (okay, in all likelihood, it won’t be pleasant at all), but it can save a whole lot of grief later on.

Next up (and this is something in the way of a commercial), The Joint Commission is hosting a webinar on Tuesday, February 7 to provide information on the new SAFER matrix, which is going to be an important feature of your survey report. We first covered it back in May, but now that they’ve been using it for the past few months (in behavioral health hospitals), it’s possible (I’m hoping likely, but I don’t want to get too amped up) that they will be sharing some useful information from the field. At any rate, particularly for those of you anticipating surveys in the next six to 12 months, I would try to make time for this one. I truly believe that every good intention is put into these survey changes, but I think we can all agree that those good intentions figure very prominently on a certain road…

Finally, this week, I would encourage you to look really, really, really closely at your interim life safety measures (ILSM) policy. TJC conducted a consultant conference last week and it is my understanding that the one significant shift in the survey of the physical environment is that there is going to be a lot of focus on the practical application of ILSMs as a function of Life Safety Code® deficiencies that cannot be immediately corrected. You have to make sure that your policy reflects an ongoing, robust process for that part of the equation. I think the conclusion has been drawn that folks generally have it together when I comes to ILSMs and construction, but are rather less skilled when it comes to those pesky LS deficiencies. We know they tend to focus on areas where they feel there are vulnerabilities (how else might one explain the proliferation of EC/LS/EM findings in recent years). This is a big one folks, so don’t hesitate to dial in with questions.