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Do you know the way to TIA?

Last week we touched upon the official adoption of a handful of the Tentative Interim Agreements (TIA) issued through NFPA as a function of the ongoing evolution of the 2012 edition of the Life Safety Code® (LSC). At this point, it is really difficult to figure out what is going to be important relative to compliance survey activities and what is not, so I think a brief description of each makes (almost too much) sense. So, in no particular order (other than numerical…):

  • TIA #1 basically updates the table that provides the specifications for the Minimum Fire Protection Ratings for Opening Protectives in Fire Resistance-Rated Assemblies and Fire-Rated Glazing Markings (you can find the TIA here). I think it’s worth studying up on the specific elements—and perhaps worth sharing with the folks “managing” your life safety drawings if you’ve contracted with somebody external to the organization. I can tell you from personal experience that architects are sometimes not as familiar with the intricacies of the LSC—particularly the stuff that can cause heartburn during surveys. I think we can reasonably anticipate a little more attention being paid to the opening protectives and the like (what, you thought it couldn’t get any worse?), and I suspect that this is going to be valuable information to have in your pocket.
  • TIA #2 mostly covers cooking facilities that are open to the corridor; there are a lot of interesting elements and I think a lot of you will have every reason to be thankful that this doesn’t apply to staff break rooms and lounges, though it could potentially be a source of angst around the holidays, depending on where folks are preparing food. If you get a literalist surveyor, those pesky slow cookers, portable grills, and other buffet equipment could become a point of contention unless they are in a space off the corridor. You can find the whole chapter and verse here.
  • Finally, TIA #4 (there are other TIAs for the 2012 LSC, but these are the three specific to healthcare) appears to provide a little bit of flexibility relative to special locking arrangements based on protective safety measures for patients as a function of protection throughout the building by an approved, supervised automatic sprinkler system in accordance with Originally, this section of the LSC referenced which doesn’t provide much in the way of consideration for those instances (in Type I and Type II construction) where an AHJ has prohibited sprinklers. In that case, approved alternative protection measures shall be permitted to be substituted for sprinkler protection in specified areas without causing a building to be classified as non-sprinklered. You can find the details of the TIA here.


I suppose before I move on, I should note that you’re probably going to want to dig out your copy of the 2012 LSC when looking these over.

As a quick wrap-up, last week The Joint Commission issued Sentinel Event Alert #57 regarding the essential role of leadership in developing a safety culture (some initial info can be found here). While I would be the last person to accuse anyone of belaboring the obvious (being a virtual Rhodes Scholar in that type of endeavor myself), I cannot help but think that this might not be quite as earth-shattering an issuance as might be supposed by the folks in Chicago. At the very least, I guess this represents at least one more opportunity to drag organizational leadership into the safety fray. So, my question for you today (and I suspect I will have more to say on this subject over the next little while—especially as we start to see this issue monitored/validated during survey) is what steps has your organization taken to reduce intimidation and punitive aspects of the culture. I’m reasonably certain that everyone is working on this to one degree or another, but I am curious as to what type of stuff is being experienced in the field. Again, more to come, I’m sure…

The end of hordes of portal exhortals: Getting hep to the PEP!

Lots of information to cover this week, so let’s get started.

Effective July 1, 2016, there are a few EC performance elements that will be ushered into the archives; in looking at the provided information, which includes rationales for the removal of each EP: the decision-making process pretty much sorted out into four categories; 1) the EP is implicit in another EP in the standard; 2) the EP is duplicative of another EP in the standard; 3) the EP reflects an issue that should be left to the discretion of the organization, or, 4) the EP is considered part of regular operations and is reflected elsewhere in the standards. So that all seems pretty rational (which is a most excellent starting point for a rationale), but there have been instances in the past when the removal of an EP has ended up complicating compliance (the most prominent example being the removal of the EP requiring the triennial review of safety-related policies and procedures, which was “replaced” with the expectation that the annual evaluation process for each EC management plan would be inclusive of a review of policies and procedures), so this latest revelation may end up being something of the proverbial double-edged sword.

That said, I don’t see anything that I would consider particularly problematic: interventionary powers for immediate threats to life and/or health; managing the risks inherent with allowing patients to smoke; self-determination when it comes to soliciting input to aid the process for selecting and acquiring medical equipment; interim measures and re-testing of emergency power system components when there are failures; a little more flexibility regarding the practical administration of your improvement activities relative to EC. These all seem fairly benign. It does make me wonder if this is as much the result of these EPs not being surveyed to the same extent as other in the EC chapter, but wondering doesn’t necessarily get us very far. At any rate, if folks have some thoughts they’d care to share, I’m all ears!

Next up, we encounter our latest acronym PEP—short for Physical Environment Portal. As I noted to my friend and colleague Jay Kumar, there are many more rhyming opportunities for PEP than for portal, so I’m down with this.

This month’s update focuses on the some of the problematic aspects of LS.02.01.10, which mostly deals with the requirements revolving around your fire-rated barriers. Interestingly enough, it appears that the compliance gaps relate to managing rated doors and rated barrier walls (I’m sure you are all just as shocked as I am with that information). There are a couple of click-through links to Joint Commission Resources, which are basically reprints of some Clarification & Expectations columns from the June and July 2012 editions of EC News. I’m thinking you may already have those in hand, but if not, they are offered free of charge (you just have to register). The example of improved compliance is kind of interesting in a rather non-illuminative way, but that may just be me. So (and this may be a function of having to come up with compelling content every month), a not particularly peppy PEP this month, but what can you do?

As a final bit of info this week, I don’t know if you saw the marketing for the July Environment of Care Base Camp session, but I found it interesting that they’re really playing up the “you can’t get this information anywhere else” card, with a further indication that any other EC educational programs are based on findings from last year. Basically, they’re saying that if you pony up the dough, you can find out what the focus of the physical environment survey is this year (presumably based on the first few months of 2016), which sounds just a little bit extortionate to me. If memory serves, the purpose of the whole Physical Environment Portal was to provide healthcare facilities and safety professionals insight to the process and allow for more effective preparation, etc. Which I guess only serves to indicate that you get what you pay for…but should you have to pay for information regarding the expectations of regulatory inspectors/AHJs? It’s like having to go to a conference to have access to all this great content, etc., and no really useful way to determine if what you missed was of critical importance. I’m thinking that our budgetary focus would be more towards making operational improvements as opposed to spending time away at a conference, but perhaps I’m just a wee bit crazy…

Thanks to Jay Kumar for the “hep to PEP” line! See you next week…

Steak tips, turkey tips, and compliance tips—such a deal!

I’m not entirely certain what to make of this, but I always try to share anything I come across that might prove useful to you folks in the field. Back in July (yes, I know we are now edging towards the wintry portion of our year—we’ve had a lot of stuff to discuss), in one of the regular editions of Joint Commission Online, there was a list of compliance tips for the most frequently cited Life Safety standards.

Nothing wrong with that, as a going concern, but where I kind of got bogged down when I looked at the tips is that they weren’t necessarily in reference to stuff I’ve seen most in the field. All code compliance tidbits, to be sure, but again, not necessarily the type of stuff with which I’ve seen folks struggle.

As an example, the first tip deals with the required clear width of doors to sleeping rooms, egress doors, and doors to diagnostic treatment areas (existing construction must have at least 32 inches of clear width; new construction must have at least 41½ inches of clear width). Now I can think of a few instances in which I’ve encountered doors that were a might on the narrow side, but I’m also thinking door width is driving this particular standard (LS.02.01.20—egress requirements) to be among the most cited in all of survey land? I don’t know, which is why I’m not sure what to make of this. At any rate, make of it what you will—just make sure you grill those tips to your liking.

Alien invasion: Take me to your (Emergency Management) leader!

It’s been a fairly busy year when it comes to updates of standards and such (short of the anticipated adoption of the 2012 Life Safety Code®…as Tom Petty once noted, the waiting is the hardest part, but I digress) and this week we’ll take a look at the new requirements relative to leadership and oversight of the Emergency Management (EM) function. I’m still not entirely certain what we’re gaining by this, unless as a means of ensuring that organizational leadership is inclined to provide sufficient resources to the task of being appropriately prepared for emergencies, but I’m sure it will all be made clear in the fullness of time.

So, we start with LD.04.01.05 which (in EP 5) mandates hospital leaders to identify an individual (and it does say “individual,” not the usual “individual(s)”—sounds like only one person’s going to be on the hook for this) to be accountable for matters of EM that are not within the responsibilities of the incident commander role. This includes such processes as staff implementation of the four phases of EM (mitigation, preparedness, response, and recovery); staff implementation of EM across the six critical areas (communications, resources and assets, safety and security, staff roles and responsibilities, utilities, and patient clinical and support activities); collaboration across clinical and operational areas relative to EM; and collaboration with the community relative to EM stuff. I think that’s pretty straightforward and, to be honest, I can’t say that I’ve run into any organizations that have not taken things to this level.

Next up we have LD.04.04.01. EP 25, which ties hospital senior leadership in as the drivers of EM improvements across the organization, including prioritization of improvement opportunities, as well as a specific review of EM planning reviews (a review of the review, if you will) and a review of the emergency response plan (exercises and real events) evaluations. So this speaks to a very specific communications process from the “boots on the ground” EM resources up to senior leadership. This one is very doable and even “done-able” if you’ve been including consideration of EM program evaluations as a function of your annual evaluation of the Environment of Care Management program. Lots of folks are doing this, so this one’s not so much of a stretch.

Finally, we have EM.03.01.03, EPs 13 and 15, which basically establish the requirement to have a specific process for the evaluation of EM exercises and actual response activities. You’re doing this, I am quite certain, but what you might not be succinctly documenting is the multidisciplinary aspect of the evaluation process (don’t forget to include those licensed independent practitioners—we want them at the table). It goes on to the process for reporting the results of the exercise/event evaluations to the EOC committee. Again, I’m pretty confident that this is in place for many (probably most, maybe even all) folks.

That’s the scoop on this. The changes are effective January 1, 2014 and I don’t think this is going to present much of a problem for folks, though please feel free to disagree (if you are so inclined). Certainly what’s being required fits into the framework of processes and activities that are already in place, so less fraught with peril than other changes that could have been made. (I’m still waiting for the influx exercise requirement to be changed to an evacuation exercise requirement. I think we do influx pretty well; evacuation, that’s a whole other kettle of fish.)

Well, while I don’t think that you’d have to include alien invasion on your HVA, if such a thing were to occur, at least we’ll know who to take them to when they ask…

Clinical alarms: Getting the word out

All things being equal, I suspect that folks are wrestling with the very expansive elements of the Sentinel Event Alert regarding the management of medical device alarms (Sentinel Event Alert #50). I think the important thing to do is to first document a risk assessment that takes into account the various clinical alarm systems, identifying those that might legitimately be considered critical and use that as the starting point. I think it would behoove you to involve the folks in clinical engineering as they probably have performance data that would be very useful (equipment that they find during preventive maintenance activities that perhaps are not appropriately configured for audibility, etc.), it would also be important to include any potential occurrence reporting data that might indicate that there have been issues involving audibility of clinical alarms, etc. To be honest, I am not so sure that any one organization’s approach will be sufficiently universal to be used across the board beyond a simple “these are the specific risks involved with the clinical alarms you’ll be using” (in recognition that this may vary based on clinical location/service) and “these are the specific strategies we are using to appropriately eliminate/mitigate those risks.” I know that may sound like an overly simple approach, but if you do a good job on the risk assessment groundwork, you will have everything you need to manage the education process. As a further enticement, the Sentinel Event Alert web page noted above also includes links to a couple of podcasts that discuss the Alert in pretty fair detail. I don’t know that I’d recommend listening to it on the treadmill, but it’s probably a good way to combine work and exercise…

We are the champions

Now there may be some folks out there who are thinking that there are certain topics to which I have administered beatings akin to the deceased equine, but sometimes there are other folks who appear to share at least some of my “wacky” perspectives on how to manage safety in the healthcare environment.

So, I encourage you to contact the individual in your organization responsible for coordinating Joint Commission accreditation and ask them to share with you the February 2013 issue of Joint Commission Perspectives. And, if you turn to p. 9, you will find the latest column penned by George Mills entitled “Safety Champions—Making Health Care Safety Everyone’s Business.” And to this, I say hallelujah! Those of you who’ve been with me since we started this little space (it’s been years and years, I tell you, years and years) will recognize this as a common theme (I think I’ve twisted it every which way, over time, but you should recognize the basic form) and still one that I believe holds a key to compliance success ( I refrain from referring to it as “the” key, because the education “key” is pretty gosh-darn important as well).

And, interestingly enough, Mr. Mills’ column in the March 2013 issue of Perspectives focused on, wait for it…


Can I get an A(ssess)MEN(ts)! Stay tuned: You know I’ll have something to add to that conversation…

Finders and fixers: Can we get them to say something if they see something?

One of things that continuously comes up on my pondering list is how to enlist the eyes, ears, noses, and fingers of frontline staff in the pursuit of the early identification of risks in the physical environment. Unless one of the facilities maintenance folks happens to be in the right place at the right time, in all likelihood, an aberrant condition is going to manifest itself to somebody working out at the point of care/point of service. And my firm belief is that the organizations that manage environmental risks most effectively (including the “risks” associated with unannounced regulatory survey visits) are the organizations that have most effectively harnessed these hundreds, if not thousands, of agents in the field 24/7.

So, my latest take on this is that we can subdivide the totality of every (and, really, any) organization into two main constituencies—finders and fixers. The key is to get the finders mobilized, so the fixers (who, truth be told, in most organizers are currently finder-fixers) can focus on actually repairing/replacing stuff. I’m at a loss to explain why this can be such a difficult undertaking, so I’ll ask you, dear reader: What do you think? Or if you’ve found a way to really mobilize the “finders” in your organization, how did you make it happen? Did you have to guilt them into it, did you establish a “bounty” system for reporting conditions, etc.? I am firmly convinced that if we can enlist these folks in the identification of hazards, we can really move towards a process for ensuring constant readiness.

It’s up to you to heed the call out

If you’re reading this, then in all likelihood you’re a regular subscriber to this august publication (august in February—what kind of crazy talk is that, but I digress). In which case, I’m sure you read with some interest the article a couple of weeks ago in which one Mr. George Mills (of the Joint Commission Mills) called out facilities professionals for something akin to dereliction of duty (okay, that might be a wee bit hyperbolic, but this topic, and Mr. Mills stance on said topic, are as serious as all get out), based on the continued frequency of findings in the EC/LS part of the survey process.

At any rate, back in October 2012, Mr. Mills addressed a group of facility managers during a webinar sponsored by ASHE. During the webinar, there was much discussion of the persistence of  EC/LS findings during surveys, including attribution of many of those findings to what was characterized as a “lack of management.”  I think we can agree that, as characterizations go, that is a very strongly worded characterization indeed.  So what types of things are resulting in this level of unhappiness in Chicago? Stay tuned and we’ll find out (by the way, be prepared not to be surprised about much, or even any, of the sticking points during surveys. If you’ve been following this space for any period of time, you are already intimately familiar with the foibles and follies of the modern-day survey process.

Ride the lightning…tales from the survey wars!

Just a quick little list of recent survey findings – not necessarily having anything to do with the Top 20 most frequently cited standards. That said, I do think that this provides ample indication that the survey process is intent on identifying any EC/LS/EM deficiency that could be lurking in the furthest (farthest?) regions of your facility. So, how about:

Have you included (those of you who have them) lightning protection systems in your Utility Management inventory – or completed a risk assessment that indicates inclusion in the inventory is not appropriate?

Do you still maintain (at least) one hard copy of your organization’s Material Safety Data Sheets? If not, what’s your backup and how do you know it’s effective?

What about those rooftop exhausts for isolation rooms—have they been labeled? The biohazard symbol on your rooftop exhausts (or any isolation exhausts) makes quite a statement – and never goes out of style.

What about those flexible and rigid endoscopes? Have you included them in your medical equipment inventory or completed a risk assessment that indicates inclusion in the inventory is not appropriate?

How about those electrical receptacles in locations within 6 feet of sinks and other water sources—are they on GFCI protection? Could be the outlet, could be at the panel, but you need to know, ‘cause if you don’t…

Those of you who are performing manual disinfection of patient care devices / instruments, most frequently using an OPA product: Have you evaluated the process as a function of what is actually required by the manufacturer? This is a very complicated process (with lots of steps to go awry) and perfection is not merely the goal, it must be attained at every step, every time. Perfect, perfect, perfect…

What about those open floor plan areas (frequently ED’s, ICU’s, PACU’s, OR’s) where staff have all manner of equipment and stuff parked outside the rooms (hopefully not obstructing access to the zone shutoff valves) – have you officially designated those areas as suites, and updated the life safety drawings to reflect that designation? If you haven’t, that’s a survey slam dunk for an RFI – better get on it!

I know we’ve spoken of this in the past (or at least I think we have), you have to pay very close attention to the ins and outs of LS.02.01.30 EP #2, which has to deal with combustible storage areas greater than 50 square feet in area. (Storage room = door that self or auto-closes and latches.) And if there’s a “former” patient room (including procedure rooms in the OR, etc.) that’s been converted to storage (particularly if the conversion occurred after March, 2003), then you are looking at the requirements for “new” healthcare, which means sprinklers, one-hour walls, with a 45 minute fire-rated door. I know folks are trying to minimize corridor clutter, but you get right into a whole ‘nother pickle if you don’t watch for these kinds of transformations.

Anything ring any bells for anyone? Might be worth a little mental checklist to make sure you’ve got these areas covered.

And who do you think gave you permission to do that, mister man?

One of the interesting dynamics that can come into play relative to code compliance is the concept of getting permission for this, that, or the other thing, from our old friend the Authority Having Jurisdiction (AHJ).

For instance, there are probably a number of you who work in facilities of a certain vintage that indicated the installation of “occupant hoses”—you know, those canvas-y things that used to be coiled up in lovely cabinets. And many, if not most, of you who had such hoses were able to get the permission of the local fire folks to remove them. I mean, really—you’re not going to use them, your staff is not going to use them, and the fire department sure isn’t going to use them, so it’s not a difficult thing to imagine. In some instances, you may have to wait until your facility is fully sprinkled, but generally you can get the locals to sign off on it.

Likewise, you may have a fire pump that, for whatever reason, can’t undergo the annual test at a flow of 150% of the rating for the fire pump. Or you may have a medical gas system component that is not quite up to code, but is allowed by the AHJ as long as you agree to correct the condition when you renovate the applicable space. A common condition is the placement of medical gas zone shutoff valves in the same space as the outlets being controlled—no intervening wall to separate the valve from the outlet (I see this a lot in PACU’s of a certain vintage) and the condition poses no significant risk to occupants, etc. These are both examples of conditions that you wouldn’t have to fix as long as you had the permission of the AHJ.

So, you might ask, what’s the point of this? Well, an interesting phenomenon has been popping up periodically this survey year and it revolves around reliance on the permission of the local AHJ to defer correction of certain items like those noted above. And the sticking point is this – if you have not, upon receipt of this “permission” from the AHJ, then submitted that permission to TJC as a request for a traditional equivalency (you can submit the request on-line through the e-SOC portal – I think you’re going to find you’re using this portal more and more frequently in the future).

To be honest, the process of submitting equivalency requests with TJC has long been in the mix, but it appears that it is becoming a focus in survey year 2012. So, if you’ve been given permission from your AHJ for whatever little condition it might be, you better make sure you’ve submitted the equivalency request to TJC. I have no reason to think that these requests wouldn’t be approved, so long as they are reasonable (i.e.,not indicative of a significant risk). After all, I think one of the key elements in the relationships we have with the folks in Chicago is to let them know what’s going on in an open and forthright manner. I suspect it’s what we would all want if the roles were reversed.