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No one told you when to run: Closing out one year, embarking on another…

Every once in a while, I like to poke back through recent missives from our friends in Chicago and elsewhere to see if there was anything that I missed on first review or something that didn’t really “pop” out at me at the time. And, somewhat typically, the really pressing hard news stories are in rather shorter supply as we get closer to year’s end. Truth be told, the whole ligature picture has really held sway in recent weeks, almost to the exclusion of everything else.

At any rate, in looking at the most recent (I think) slate of pre-publication standards, I noticed a couple of “new” requirements that gave me a little bit of pause. Due to some editorial constraints, I won’t identify the standards and EP numbers, but I will try to give you a sense of where there “live”: they are identified as “new” on the webpage, so that may be enough for you to find them (you’re a pretty smaht bunch and I have every confidence in your detective-ing abilities). This week we’ll cover the Environment of Care changes and hit the Life Safety changes next week (where did the year go!?!):

 

  • The hospital has a library of information regarding inspection, testing, and maintenance of its equipment and systems. Note: This library includes manuals, procedures provided by manufacturers, technical bulletins, and other information. (Safety Management)
  • Management of smoking materials for patients receiving respiratory therapy. (Smoking Policy)
  • Periodic evaluations of fire hazards during surgical procedures (don’t forget to define that period!) (Fire Safety Management)
  • Process for reducing risks when flammable germicides or antiseptics are using during “hot” surgical procedures (electrosurgery, cautery, lasers) (Fire Safety Management)
  • The hospital meets all other Health Care Facilities Code fire protection requirements, as related to NFPA 99-2012: Chapter 15. (Fire Safety Management)
  • Elevators with firefighters’ emergency operations are tested monthly. The test completion dates and results are documented. (Inspection, Testing & Maintenance of Life Safety Systems equipment)
  • Hyperbaric facility safety, including labeling of equipment used in oxygen-enriched atmospheres (we covered this a couple of weeks ago, with a couple of folks weighing in with questions on how far to go with Chapter 14 of NFPA 99; if the past is any indicator of the future, I would be moving towards adoption of the whole thing and probably start to extend the labeling of equipment out to all oxygen equipment—this is where they start digging into this—we know the targets will move over the next survey years, so better to be ahead of the game than behind). (Medical Equipment Inspection, Testing & Maintenance)
  • Inspection, testing, and maintenance of anesthesia apparatus, including gas flow and oxygen concentration verification; no oil, grease or flammables for oxygen equipment. (Medical Equipment Inspection, Testing & Maintenance)
  • ORs are wet locations unless you have a risk assessment that says otherwise and has been approved by the governing body (it appears that risk assessments done in “isolation” will no longer meet the mark—organizational leadership has to be involved in the process. Written record of the risk assessment is available for survey review. We covered this before.  (Utility Systems Management)
  • Risk level identification of electrical distribution; we did this one before as well.  (Utility Systems Management)
  • Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered are tested after initial installation, replacement, or servicing. In pediatric locations, receptacles in patient rooms (other than nurseries), bathrooms, play rooms, and activity rooms are listed tamper-resistant or have a listed cover. Electrical receptacles or cover plates supplied from the life safety and critical branches have a distinctive color or marking.  Keep an eye on those pediatric locations, particularly areas that can “swing” – tamper-resistant receptacles could well become a moderate risk of harm during survey. (Utility Systems Management)
  • Power strips must be appropriately listed for use in patient care vicinity, patient care rooms, etc. Focus on this has already started, so you better start working with your IT folks to make sure everything is going in the right direction. (Utility Systems Management)
  • Extension cords are not used as a substitute for fixed wiring in a building. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was intended. I predict that this is going to keep this standard at the top of the most frequently cited standards list. (Utility Systems Management)
  • Areas designated for administration of general anesthesia using medical gases or vacuum are in accordance with NFPA 101-2012 and NFPA 99-2012 (Utility Systems Management)
  • Electrical system critical branch supplies power for specific needs (task illumination, fixed equipment, select receptacles, and select power circuits) in areas designated for administration of general anesthesia (specifically, inhaled anesthetics) using medical gases or vacuum. The EES equipment system supplies power to the ventilation system. (Utility Systems Management)
  • New buildings equipped with or requiring the use of life support systems (electro-mechanical or inhalation anesthetics) have illumination of means of egress, emergency lighting equipment, exit, and directional signs supplied by the life safety branch of the electrical system described in NFPA 99. (Utility Systems – Emergency Electrical Power Source)
  • Equipment designated to be powered by emergency power supply are energized by the hospital’s design. Staging of equipment startup is permissible. (Utility Systems – Emergency Electrical Power Source)
  • For deemed status hospitals, battery lamps and flashlights are available in areas not serviced by the emergency supply source. (Utility Systems – Emergency Electrical Power Source)
  • Line isolation monitors are tested in accordance with NFPA 99-2012. (Utility Systems Inspection, Testing & Maintenance)
  • Risk level identification of medical gas, medical air, surgical vacuum, waste anesthetic gas disposal (WAGD), and air supply systems. (Inspection, testing & maintenance of medical gas system components)
  • All master, area, and local alarm systems used for medical gas and vacuum systems comply with the category 1–3 warning system requirements. (Inspection, testing & maintenance of medical gas system components)
  • Containers, cylinders, and tanks are designed, fabricated, tested, and marked in accordance with NFPA 99-2012. (Inspection, testing & maintenance of medical gas system components)
  • Locations containing only oxygen or medical air have doors labeled “Medical Gases: NO Smoking or Open Flame.” Locations containing other gases have doors labeled “Positive Pressure Gases: NO Smoking or Open Flame. Room May Have Insufficient Oxygen. Open Door and Allow Room to Ventilate Before Opening.” (Inspection, testing & maintenance of medical gas system components)
  • A precautionary sign readable from 5 feet away is on each door or gate of a cylinder storage room, where the sign, at a minimum, includes the wording “CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING.” Storage is planned so cylinders are used in order of which they are received from the supplier. Only gas cylinders and reusable shipping containers and their accessories are permitted to be stored in rooms containing central supply systems or gas cylinders. (Inspection, testing & maintenance of medical gas system components)
  • More cylinder storage stuff (I suspect you know the drill)—NFPA 99-2012 has a great deal of detailed requirements—and I have no reason to think that they won’t be kicking the tires pretty diligently. (Inspection, testing & maintenance of medical gas system components)
  • Also, transfilling of liquid oxygen is a process with very, very specific requirements; if you’re not transfilling liquid oxygen in your facility, you could count yourself fortunate, but be on the lookout for any evidence of liquid oxygen being transferred inside your “house”; NFPA 99-2012 is your guide. (Inspection, testing & maintenance of medical gas system components)
  • Staff responsible for the maintenance, inspection, testing, and use of medical equipment, utility systems and equipment, fire safety systems and equipment, and safe handling of hazardous materials and waste are competent and receive continuing education and training. (Staff Competency & Education)

I know this is a lot of stuff to consider, but I wanted to put it out in front of you folks on the off chance that your bedtime reading hasn’t strayed into the realm of the 2018 standards changes. I have every reason to think that some of this stuff will show up again in this space (and what a space!), but if someone wants to start a particular conversation before we kick off (kick at?) 2018, please feel free.

Temper Temper(ature)

In the continuing pursuit of every possible question that could ever be asked about eyewash stations, there’s been some chatter recently (as well as some field encounters) relative to what is involved with the weekly operational testing of emergency eyewash equipment, particularly whether or not you have to verify the temperature of the flushing fluid. The “good” news is that while there is a requirement to periodically verify the temperature of the flushing liquid, that period is one that is some 52 weeks in length, so we can put that down for an annual visitation. Having said that, I’m thinking this might be a fine opportunity to cover the basic goals of the weekly test (I find there is frequently a bit of a gap in terms of front-line staff’s understanding of the reasons behind the testing).

Let’s start with the ANSI standard. The intent of the weekly activation from the ANSI perspective is to ensure that there is a flushing fluid supply at the head of the device and to clear the supply line of any sediment buildup that could interfere with flow (that’s why you do the test with the caps on – if the pressure isn’t sufficient to “pop” the caps, then there may be some blockage). Running the water also helps to minimize any contamination due to stagnant water.

Another common question is, “How long should I run the water?” The answer is “It depends.” I think we’ve discussed this before, but once more unto the breach: You have to consider the amount of water contained in the eyewash itself, and the water which is in all the sections of piping that do not form part of a constant circulation (a “dead leg” in the plumbing, as it were). Since water tends to be stagnant in these sections until a flow is activated, you need to run the device long enough to flush out all the stagnant water. This may take a little bit of figuring, but once you’ve figured out the time period, you should be good to go.

You also want to make sure that the eyewash equipment is completely accessible, the protective caps are in place, and someone hasn’t installed a cabinet over the device close enough to result in a head injury if someone tries to use the eyewash (don’t laugh – I’ve whacked my head more than once trying to fit my noggin into a confined eyewash. Yes, I realize that head trauma probably explains a lot, but that is an entirely different topic of conversation). Ultimately, it’s about making sure that if someone gets some bad stuff in their eyes, they have an appropriate means of responding to that exposure. Hopefully, it’s not something we need to use very often, but if we have the eyewash stations, we have to properly maintain them.

96 Tears – 96 Hours – 96 Response Plans – You’re gonna cry – cry, cry, cry!

I was doing some work at a client facility recently and happened to be on site when these folks were entertaining the representative from their property insurer. While there was lots of discussion about processes for managing fire alarm and sprinkler system impairments (might be worth checking with your property insurer for their definition of an impairment – might be a little more restrictive than you might think, especially if you are using the 4-hour timeframe identified in the Life Safety Code / TJC standards), which I expected, there was a little more attention paid to emergency response plans, particularly in relation to utility systems failures, primarily as a function of business continuity.

The rep was really keen to see the organization’s detailed response plans for the normally-anticipated failures and it prompted the thought that, in these days of the (at least somewhat) monolithic 96-hour assessment/response plan dynamic, whether we’re best served by having really in-depth, specific response plans, or if we’re better off with what amounts to a bullet list of strategies for managing the risks and vulnerabilities inherent in a particular failure event. So my question to you is this: How “deep” do your response plans go? Are we talking lots of details or is it more or less a response framework that requires a little more intuition/familiarity on the part of your incident commander?

I know that the structure and content of response plans have evolved (mutated?) over the past 10 years or so, but I’d be hard pressed to be able to quantify the improvements (I’m certain that there have been improvements – but I can’t say how I “know” this). Or, in the vernacular of this year’s presidential race, if we are better off than we were 10 years ago – how can we “prove” that improvement?

What say you?

How long has this been going on?

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…

And where it’s going, no one knows

Continuing on our recap of survey adventures, we finish out the Top 10:
EC.02.06.01 – Establishment and maintenance of a safe, functional environment (#9, with 32% of hospitals having been cited)
A couple of somewhat disparate conditions are coalescing under this particular standard:

  • Safety and suitability of interior spaces – this apparently is where the unsecured compressed gas cylinders are ending up when they are found during survey. Not necessarily the place I would have picked (I’d run with EC.02.01.01 EP #3 – minimization of safety risk in the environment), but I can see where it would fit;
  • Management of ventilation, temperature and humidity in the care environment – this is one that will cause you so much heartache, it’s not funny. Temperature and humidity logs? You better have ‘em (and yes, I know that they are not specifically required in the regulatory verbiage, but that doesn’t mean a (insert descriptor of your choice) thing. Trust me on this, if on nothing else, ever!) Make sure that you have extremely reliable pressure relationships in every spot where you’ve got clean/soiled environments cheek-to-jowl; clean/sterile; sterile/soiled, etc. The air has got to flow from the good to the bad (euphemistically speaking), if it flows from the bad to the good, you are going to get lit up like a Roman candle during survey, likely resulting in a CMS visit to boot – none of us want that, none of us at all.
  • Finally, and I don’t know that this got a whole lot of play in the official version, but there is a universal opportunity relative to cleanliness in the patient environment. There are some that I’ve seen who do a pretty good job, but I also know that I’ve not encountered anything close to perfect. If you have a surveyor with a mind to find dust, etc. somewhere in the patient environment, it will be found and it will be cited. Tell me the EVS folks aren’t shoveling against the tide sometimes…

EC.02.02.01 – Management of Hazardous Materials Risks (#10, with 29% of hospitals having been cited)
Lots of funky conditions can reside here, to name just a couple:

  • Management of eyewash stations – weekly checks, temperature, obstructions, where they are installed, etc.
  • Labeling secondary containers – if the chemical leaves its home vessel and is placed in another vessel, the second vessel (spray bottle, basin, sink) needs to have the hazard identified, unless the second vessel is absolutely attended until it is used/properly disposed – and even then, I’d do the label;
  • Access to the Hot Lab in Nuclear Medicine – you’ve got to have a policy that makes sense about access, particularly for couriers delivering the materials – and remember, they’re already driving around with the stuff – if they want to swipe the stuff, they’ll just keep driving – so keep an eye on your stuff (George Carlin would want you to). That said, you should track down the July 2012 edition of Perspectives – there’s a lovely article on just this subject – can you say risk assessment? Thought so.

OK, we’ll do one more for this week, breaking into the next 10
EC.02.05.01 – Managing risks associated with Utility Systems (#11, with 28% of hospitals having been cited)

For those of you with older buildings and/or older utility system components, this one may keep you up at night. The sort of overarching way this is popping up during surveys (other than temperature, humidity, and ventilation, about which we’ve already spoken and will, no doubt, speak of again) is the inability of the system (whichever system it might happen to be) to achieve required results. Now, the sticking point here relates very much to what constitutes a “required result”. In case you hadn’t noticed, CMS is pretty much calling the shots when it comes to enforcement and, with increasing frequency, the practice of grandfathering older, lesser-performing systems is going by the wayside. If you (or someone you love) has a utility system that is not performing up to modern standards, then you had best get going on a risk assessment and identify mitigation strategies for appropriately managing the risks associated with the current performance level of the systems (and, perhaps, a plan for how you’re going to get to where you need to be).

The other condition that has been popping up is the identification, in writing, of inspection and maintenance activities (and the appropriate intervals) for all operating components of utility systems on the utility management inventory (which is, of course, populated through an arduous risk assessment process). It’s my understanding that continuous monitoring through the good graces of a building automation system is an acceptable means of compliance with this requirement, but if you don’t have a building automation system, you’d best be prepared to produce, in writing, the activities and intervals as noted above (a computerized work order system might work – but it has to be a pretty robust platform).

And so we’ve reached the end of yet another batch of fun facts and figures – next week, we’ll wrap it all up – until next year!

It’s so easy, it’s so easy, it’s so easy (repeat ad infinitum)–so doggone easy!

When you compare it to sustaining improvement, actually making the improvements to start with is rather like the proverbial piece of cake.

One of the common themes I’ve been running across (and sometimes running into) in my consulting work is the frustration that comes with encountering conditions and/or practices that the organization thought had been resolved. And it’s generally not big ticket stuff and it’s generally not the types of things for which additional education is going to be making a significant difference. [more]

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. [more]

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?

Do you remember? Or even yesterday…

Way back in September of last year, we were chatting about the importance of appropriately managing conditions in the patient environment, primarily the surgical environment. For those wishing for a refresher, you can find that post here. (I talked about how I’ve noticed recent citation in surveys regarding the surgical environment, including the maintenance of temperature and humidity, ensuring appropriate air exchange rates, and making sure that your HVAC systems are appropriately maintaining pressure relationships, etc.)

One of the things I didn’t really cover back then was when you have documented out-of-range values. Could be temperature, could be humidity, could be those pesky air exchanges and/or pressure relationships. The fact of the matter is that we live in an imperfect world and, more often than not, our success comes down to how effectively we manage those imperfections. And that can, and does, come down to how well we’ve prepared staff at the point of care/service to be able to respond to conditions in the environment. But, in order to get there, you have to undertake a collaborative approach, involving your infection preventionist and the folks in the surgical environment.

The management of risk in the environment doesn’t happen because we have (or don’t have) nifty technology at our disposal; it’s because we can work collaboratively in ways that no building automation system or self-regulating HVAC equipment can. This idea has become an increasingly important part of the survey process. We know that more folks are harmed by hospital-acquired infections and other related conditions and I’ve seen it become a fairly significant survey vulnerability. So, let’s start talking about this stuff with the end users and make sure that we’re ahead of the curve on the matters of the care environment.

Shock the monkey (part x + y to the 10th power) – here we go again…

OK, so now it appears that we’re going to have to rethink how we schedule preventative maintenance (PM) activities on our critical equipment, particularly if that criticality affects patient health and safety. I believe that we’ve already chatted a bit about the whole clarification of PM frequencies and where CMS stands on the issue (in case you hadn’t noticed, they’re pretty much standing on your head).

In issuing the clarification (and I will freely admit that I missed this at first – check it out at: https://www.cms.gov/Surveycertificationgeninfo/downloads/SCLetter12_07.pdf), the Feds have decided that, in the matter of critical equipment, the frequency will reflect manufacturer recommendations, AND NOTHING ELSE! Let me repeat that: AND NOTHING ELSE!

For example, PM’ing defibrillators on an annual basis (despite what your experience might indicate) is a big freaking no-no! Isn’t that special? Yeah, I thought so, too.

Maybe this isn’t anything to you folks, but I know of at least one hospital that got cited during a recent survey, so when there’s one, there’s usually others (these things almost never happen in isolation). So, if you think you may be taking advantage of logic and common sense approaches to the management of the risks associated with the use of medical equipment, think again (hopefully this won’t shift again, but if history tells us anything.)