All Entries Tagged With: "inspection/testing"
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?
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.)
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–
–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?
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…
In your eyes – the light, the heat … the chemicals?
A couple of weeks ago, a client was asking me about who should be performing the weekly checks of eyewash stations. A clinical surveyor consultant had given them the impression that this should be the responsibility of maintenance staff. Now, I’m not sure if this direction was framed as a “must” or a “would be a good idea,” but what I can tell you is that there is no specific regulatory guidance in any direction on this topic. I do, however, have a fairly succinct opinion on the topic—yeah, I know you’re surprised to hear that!—which I will now share with you.
Certainly we want to establish a process to ensure the checks will be done when they need to be done. I agree that maintenance folks are typically more diligent when it comes to such routine activities than clinical folks often are. However, from an end-user education standpoint, I think it is way more valuable for the folks who may have to use the device in the area to actually practice its operation. If they do have a splash exposure, they would have a moderately increased familiarity with the location, proper operation, etc., of the device. Ideally, the eyewash will never have to be used because all our engineering controls and PPE will prevent that splash (strictly speaking, the eyewash is a last resort for when all our other safeguards have failed or otherwise broken down.
I’m also a believer (not quite like Neil Diamond, maybe more like Smashmouth) that providing for the safety of an organization is a shared responsibility. Sure, we have folks who call ourselves safety professionals help guide the way. But real safety lives at the point of care/point of service, where everyone works. So it’s only appropriate that each one of us take a piece of the action.
One more from the mailbag
Q: Regarding patient/nonpatient care areas, what about performing site visits to off-site doctor offices run by the medical center? Once yearly or twice yearly?
A: That’s one that could go either way; strictly speaking, the two per year requirement is in the standards specific to hospitals and various assorted healthcare occupancies, but you could make the case that it’s best practice to extend that to physician office practices. What you could do is, if you decide to adopt the once a year, go at it as a function of a risk assessment and leave the option of increasing the frequency if conditions dictate, then wrap the whole thing up as part of the annual evaluation of the program scope. The other thing you could do (and this might be a good compromise) is to create a 10 to 15 item checklist (it can be less, I wouldn’t do more) that someone in the office can do and then do an “official” site visit to make the two per year. Generally speaking, physician office practices don’t endure a lot of variability, so the safety conditions, etc., while not exactly static, are of a much more manageable pace that the acute care setting, so it is entirely appropriate to administer the program accordingly.
Determining the need for a quality report on clinical alarms
Q: Is there a certain standard or EP that speaks specifically to alarms of medical equipment and the requirement for someone to do a report?
A: Years ago, there was a NPSG that related to clinical alarm audibility on the units and ensuring that they could be heard on all points on the unit, but this has been gone for some time now. For some reason, (relating to the focus of the NPSG, my opinion is that upon closer examination, it was not so much an equipment management failure mode as it was a function of the behaviors of clinicians) it’s somewhat notorious and exalted status has diminished over time (although, based on information provided at the recent Joint Commission Executive Briefings, there is a sense that concerns surrounding this may be on the rise).
Is there any leeway to not test automatic transfer switches monthly?
I was asked whether there was any flexibility to test transfer switches at intervals less than normally prescribed. For example, might you be able to test low-risk transfer switches, such as those serving the kitchen, less frequently?
Let’s start with Joint Commission environment of care standard EC.02.05.07. EP 6 requires that, “Twelve times a year at intervals of not less than 20 days and not more than 40 days, the hospital tests all automatic transfer switches. The completion date of the test is documented.”
The key word here is “all,” and the key pain in the posterior is that [more]
