All Entries Tagged With: "joint commission"

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?

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…

I need to know

Another challenge that’s been rearing it’s ugly little head is the requirement for staff and licensed independent practitioners (LIP) to describe or demonstrate actions to be taken in the event of an environment of care incident, as well as knowing how to report an environment of care risk. I will freely admit that this one can be most tricky to pull off).

The tricky piece, at least in my estimation, is that any data that would be gathered during survey would be the result of direct interaction with staff in the care environment. For staff, one strategy would be for them to contact their immediate supervisor to report a risk, or to be able to articulate the use of a work order system to notify facilities, biomedical, safety, and/or environmental services of conditions needing resolution. Alternatively, some hospitals have a single phone number for reporting unsafe conditions. Presumably, staff can also speak to their specific roles in emergency response activations such as fire, security, disaster, etc.

As to the LIPs, this task can be exponentially more difficult as, strictly speaking, the expectations of this group are pretty much the same as the rest of the house. I’m presuming that you have an emergency phone number to report codes and fire events. An LIP who is able to articulate familiarity with those codes and events would be useful toward a finding of compliance. They really ought to be able to articulate past the point of ignoring something and to at least be able to put in motion some sort of reasonably attainable resolution.

Again, I’ve not seen this come up a great deal with the LIPs, though certainly the rest of the cadre of front line staff would be considered targets during a survey. I think the key approach is to very clearly and very simply define what constitutes appropriate responses of staff and practitioners. When The Joint Commission doesn’t specifically define what they mean in a standard, it behooves us to define how compliance works in our organizations.

If they don’t know by now…you must be remarkably emergency-free

Lately, I’ve encountered some consternation relative to emergency management, specifically EM.02.02.07, for communicating in writing to each licensed independent practitioners their role in an emergency and to whom they would report in an emergency.

From my experiences, there are any number of ways to demonstrate compliance with this performance element, and to be honest, I’ve not heard of any Joint Commission surveyors “pushing” on this issue, but it could certainly be a vulnerability. One way folks comply with this standard is through credentialing and/or re-credentialing, making use of a process that is already in place. I’m presuming that you have e-mail access for your medical staff members, in which case a simple summary of their duties/roles in an emergency response activation would suffice. Another thought would be handouts at your regularly scheduled medical staff meetings, though, depending on attendance, this might be a tough one to sell if you have a particularly picky surveyor. Anything along these lines would be quite adequate as a demonstration of compliance with this standard.

By the way, the standard does not specify a frequency, so–at least for the moment—you need only document one communication of this nature. It would certainly be appropriate to inform medical staff of substantive changes in their roles, etc., but that would not be considered a standards-based requirement.

And now for something completely…the same

Time for a quick roundup of some recent survey trends:

• We’ve talked about the overarching issues with weekly testing of plumbed eyewash stations any number of times over the years and I am always happy to respond to direct questions. The key element here is that if your organization is not conducting an at least weekly testing regimen for your plumbed eyewash stations and has not documented a risk assessment indicating that a lesser frequency is appropriate, it will likely be cited. My consultative advice: If you’re not testing at least weekly, please do so, or do the risk assessment homework.
• With the extra life safety surveyor time during survey, the likelihood of encounters with frontline staff is on the rise. And apparently, it is not enough for folks to know what they are doing, but there is also an expectation that they will understand why they do what they do, primarily in the context of supporting patient care (which we all do—everything that happens in a hospital can trace back to the patient). I guess it won’t be enough for folks to be able to respond appropriately when asked how they would respond to a fire. They also need to understand how their response fits into the grand scheme of things. I really believe that folks understand why their jobs are important; we just need to prepare them for the question. Probably more on this as it develops.
• 96 bottles of beer on the wall, 96 bottles of beer—but will that be enough beer to last 96 hours (I guess it depends on how thirsty you are)? So the question becomes this: If a surveyor asks to see your 96-hour capability assessment, what would you do, and perhaps most importantly, can you account for it in your Emergency Operations Plan? My general thought in this regard is that the 96-hour benchmark would be something that one would re-visit periodically, just as you would your hazard vulnerability assessment, in response to changing conditions, both internal and external.
• As a final thought for this installment, please make sure that you (that would be the royal “you) are conducting annual fire drills in all those lovely little off-site locations listed as business occupancies on your Statement of Conditions. And make very sure that staff is aware that you are conducting those fire drills. There’s been a wee bit of an upsurge in fire drill findings based on the on-site staff not being able to “remember” any fire drills, in some instances, for several years. The requirement is annual and I don’t think any of us wishes to get tagged for something as incidental as this one.

Your mother should know…but what if she doesn’t?

I’ve noticed a little word popping up in recent survey reports, a word that strikes fear in my heart. I don’t know how widespread this might be, so if you folks have an opportunity to weigh in on this conversation, I’d be really interested in what you all are seeing out there. And so, today’s word of the day is “should.” Now scream real loud!

I think we are all pretty familiar with those things that are legitimately (perhaps specifically is a better descriptor) required by the standards. I like to refer to those requirements as “have to’s” – we have to test certain fire alarm components at certain frequencies, we have to conduct quarterly fire drills, etc. Now I’m certainly not someone who is going to complain when a regulator (of any stripe) provides us with concrete strategies (this is where we move from the “have to’s” to the “how’s,” inching ever closer to “should”) for achieving or maintaining compliance.

But the question I keep coming back to is how are we supposed to know about these unwritten requirements (we used to call them ghost standards—boo!) if they are, as noted, unwritten. And the reason I keep coming back to this question is because I’ve been seeing a number of findings lately that revolve around what an organization “should” do. And please, I am not necessarily disagreeing with the wisdom engendered in many, if not most of these findings (we’ll mention a couple of examples in a moment), but there is a point at which the line between what is consultative advice and what is actually required blurs so completely that any tipping point, compliance-wise, is almost completely subjective.

As an example (and remember, I’m not disagreeing with the concept), a recent survey report included a finding because the “clean” side of central sterile was negative to the adjacent corridor, with the qualifier “air flow should always be positive from clean areas to less clean areas”. Concept-wise, I’m down with that (I’m not loving the use of “always” in this type of context—how long is always, or maybe it should be how frequently is always, but I digress), but where in the Joint Commission standard does it say that, apart from the all-encompassing appropriate provision of pressure relationships, etc. That “should” really undercuts the whole statement. Is this something we “must” do within the context of the standard or are we trying to leverage behaviors by acting like something is deficient when it is not necessarily the case?

Another “should” that came up recently involved the results of a vendor’s testing of the medical gas system. Now you and I both know that our vendors are not always the most efficient when it comes to providing written documentation of their activities. In this particular instance, the testing had been done in June, and the report had been delivered in August, mere moments before the survey started. Within the report, there were some issues with master alarms that required repair work—repair work that had not yet been completed. Now, as near as I can tell, each organization still gets to prioritize the expenditure of resources, etc., presumably based on some sort of risk assessment (that’s a “should” for all you folks keeping track), but the finding in question ends with a resounding statement that the facility “should” have required the vendor to provide a deficiency report at the time of the inspection. Conceptually, you’ll get no argument from me, and as consultative advice I will tell you that it is a positively stupendous idea to know what problems are out there before your testing vendors leave the premises. Remember, you “own” the fixes as soon as they are identified, and if there are delays, you’d best have a pretty gosh-darn good reason for it. In fact, I would have to consider that strategy as a best practice in managing maintenance and testing activities, but where does it say that in the standards?

Reasons (not) to be cheerful, part 3

Or perhaps it should be “hit me with your Joint Commission stick”?

What follows is a compendium of recent survey findings, some from The Joint Commission (TJC), some from me. So in no particular order:

• Rooftop isolation exhaust fans and other “biohazard” areas should be appropriately labeled to identify the hazard. I’d expand this a little to include soiled utility rooms (particularly in outpatient settings) in which medical waste is collected and stored.
• If you have key utility components (e.g., emergency generators and the like) outside your building, make sure that they are appropriately secured from unauthorized entry. And once you’ve determined what “appropriately secured” means for your organization, document the risk assessment, so if a surveyor just happens to disagree with how you are managing things, you have the basis for a clarification of the finding. Same goes for your solid waste compactors—make sure nobody can monkey with them (all due respect to monkeys).
• Make sure everyone in the kitchen can locate and explain the operation of the fire suppression system. This is kind of a follow up from an earlier blog post outlining the monthly inspection of the kitchen fire suppression system. TJC recognizes that we, the primary stakeholders in the management of the care environment, have our act together. More and more, the focus has gone to the point of care/point of service staff. Safety lives in the trenches. We need to keep those folks in the loop.
• Make sure your main supply shutoff valves, including your main oxygen valve, are appropriately labeled. And if you should choose to decide that, for reasons of security, that is not an appropriate strategy, make sure you document the risk assessment that led you to that determination.
• Make sure you know where you need to have eyewash stations and where you don’t and why. Not every potential exposure requires an eyewash station—OSHA is very specific in that regard—potential exposure to corrosive materials is the determining factor. If you want to adopt a slightly stricter standard, the American National Standards Institute expands things to include corrosive and caustic materials. Beyond that, including blood and other potentially infectious material, you don’t “have to” have eyewash stations for exposure response. As a related aside, try to convince the folks in environmental services (and by extension, infection control) to promote the use of cleaning products that are not corrosive or caustic—that will help you identify an appropriate response capability.
• Don’t forget those pesky compressed gas cylinders—other than penetrations and doors not latching, I think the most frequently cited specific condition is the unsecured cylinder. And please promise me you won’t say that you have to do additional education. Folks know they’re not supposed to leave the cylinders hither and thither. Find out the root cause of why they can’t do the right thing. And if you find out anything useful in that regard, please let the rest of us know.

Th-th-th-that’s all folks. For now…

Veterans of policy wars

A client I was working with recently had a really good Joint Commission survey from an EC/LS/EM standpoint, but had identified some opportunities buried in some policies that prompted them to earmark an in-depth policy review to prepare for the next survey. Upon hearing this, I thought of some advice that I think could be useful in a general sense, so if you don’t mind a little pontificating, here goes nothing…

First ask whether the policy is really necessary. Some policies are vestiges of that bygone era when Joint Commission preparation meant shining up the policy books, including having a policy for everything. Don’t be afraid to retire a policy if it doesn’t make operational sense.

If a policy reflects management of a key, or widespread process, once you have determined what is actually “required” (which is when you have the answer to the question—where in the regulations does it say that we have to do this); make sure that the policy reflects the process to the extent allowed by regulation. All too frequently, organizations craft these beautiful policies and procedures that make absolutely no operational sense whatsoever. We need to know that the policy enhances the practical implementation of the policy, otherwise you get workarounds (not that that would ever happen in healthcare, but I digress…).

The more you can introduce common sense (which, I will freely admit, ain’t as common as it once was) into the conversation, and get it to stay in the front of the discussion, you are much more likely to come up with a product that will work in the real world. Analogous to that, it’s also important to remember that sometimes you have to birth the thing to see if it can work in the real world. All too often I see folks torturing themselves trying to make a “perfect” policy and never really deliver anything. Don’t be afraid to launch the boat—just don’t do it in the middle of the harbor—if it’s going to leak, it will leak just as nicely (though perhaps not as dramatically) in shallow water as it will in the deep.

If you need an external eye to look at something, or indeed if you are having difficulty gaining traction on an issue, I am happy to act as a sounding board. My second favorite consulting duty is to play the role of devil’s advocate, which helps favorite #1, the problem solving thing. So please feel free to shoot up a flare if you get stuck on something.

How soon is now, how safe is safe enough?

During a recent Joint Commission survey, a concern was raised because the hospital’s pediatrics and OB units were not “equipped” with the same security system, etc. I’m not certain whether the result was a specific finding, but the question, in and of itself, is instructive when it comes to the science of assessment.

First off, I’ve never actually seen the areas in question, so I will engage in a little bit of conjecture, but I think the general themes can be applied in your house, particularly if you don’t have a whole lot of pediatric patient volume. Now certainly, the historical focus on abduction prevention has been primarily on the security of newborns, which I think we can all agree is a vulnerable patient population. That said, there are certainly risks involved in providing for the security of pediatric patients (and maybe some adult patients as well—it’s getting kind of crazy out there in the world), risks that would have to include abduction.

From a regulatory standpoint, there is very little specific guidance beyond the caveat of ensuring that you are not compromising life safety concerns as you install security systems. Locking doors in egress paths can be tricky and, in virtually every instance I can think of, the process was much more complicated than was originally presumed, but that’s a story for another day. We know what the result will be if our security efforts are not sufficient/appropriate, etc.: something will happen and that something will not be good. But that raises the somewhat rhetorical question of whether you can “rest” based on nothing bad happening. Is that a legitimate conclusion to make? Variations on this theme have become very noticeable during surveys this year. Maybe it’s something identified by a vendor that you haven’t gotten around to fixing, maybe it’s a new piece of technology that you have budgeted for next year, but that’s going to take time to purchase, install, educate staff, etc. Maybe (as is more or less the case in the recent survey mentioned above) from an operational standpoint, your pediatrics unit is in a small part of a regular medical/surgical unit and the geography of the space does not lend itself to the same security measures as you have on your OB unit.

These are all real life occurrences and each has its own security or EC implications that need to be managed. But (and this is a sizable one), you have to be able to articulate where you are in the process and how you are making sure that any elevated risks that are the result of not being able to do something right now are being appropriately managed. I hate to say this, but it’s been coming up far too often in surveys this year for this to be ignored: you absolutely need to discuss and document the management of these types of risks, including those all-important interim measures (if they are needed). Otherwise, you leave yourself vulnerable to a survey finding for which it is very difficult to negotiate a “settlement” either during survey or as part of the clarification process.

There are no standards that specify a time frame for completion, a technology enhancement, etc. That’s the responsibility of each organization to manage. But with that responsibility comes the obligation to manage any associated risks in fairly transparent fashion (I think I’ve managed to avoid invoking the transparency card until now): frontline point of care/point of service staff need to be able to articulate how we are managing risk until such time as solutions can be implemented. If they can’t, the risk of a survey finding rises exponentially. It’s no longer enough for leadership to know what’s going on, the folks in the field have to know, too. Pediatrics staff need to articulate how they are managing abduction risks for their patients. And if you have pediatrics in the ED, there needs to be some competency there as well. We can’t always do what we want when we want to do it, which is the reality of healthcare. But we do need to understand and share the risk implications of all those decisions and non-decisions.

What is a nonpatient care area?

Catching up on some recent e-mail questions, there was one regarding hazard surveillance activities and the oversight of off-site buildings (not identified under the hospital’s license) where there are no patient services provided. So the question became whether these locations had to be included in the hazard surveillance program and whether they would be subject to a Joint Commission visit during survey.

So, taking a look at the Joint Commission “role,” while it is most unlikely that the survey team would visit an off-site location with no patient services (not quite 0%, but something very close to that), a pain-in-the-butt surveyor might check the hazard surveillance round documentation vs. the list of hospital departments. Now the standard/elements in question, EC.04.01.01, EPs 12 and 13, only refers to patient and nonpatient care areas, so I think the thing to do is to be very specific in identifying locations in the scope of your management plans (I mean, what exactly is a nonpatient care area? A nonpatient area—got that; a patient care area—got that. But this hybrid is a little vague). Ultimately, the whole process sets up based on what you’ve identified as the appropriate inclusions, etc., so you can certainly make the determination of what would rule in to the program, or indeed rule out of the program.

That said, I have a concern in the event that OSHA were to rear its ever so lovely head. It would be of critical importance to demonstrate some sort of oversight; one strategy that comes to mind would be to develop a self-inspection process for those areas and fold that into the formal surveillance process. As a safety professional, I’m having a hard time saying that these “other” locations can be culled out of the main process (in my experience, it is never a good thing for people to think that they are somehow being ignored or not appropriately tended). I think the thing to do is to set up a less-invasive process that will allow some sort of feedback loop if environmental issues crop up in these other locations. Better you find out about issues than to have somebody drop a dime to the big “O.”