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Never say never: The ligature risk conversation continues…

I truly was thinking that perhaps I could go a couple more weeks without coming back to the ligature risk topic, but continued percolation in this area dictates otherwise. So here’s one news item and one (all too consultative) recommendation.

If you took a gander at the September issue of Briefings on Accreditation and Quality, you will have noted that the Healthcare Facilities Accreditation Program (HFAP) isn’t revising their existing standards in the wake of the recent CMS memorandum indicating that The Joint Commission’s (TJC) focus work on the subject of managing physical environment risks and behavioral health patients is an acceptable starting point (and I am very serious about that descriptor—I don’t see this ending real soon, but more on that in a moment). I’m not sure if HFAP makes as much use of Frequently Asked Questions forums as TJC does (and with that use, the “weight” of standards), so it may be that they will start to pinpoint things (strategies, etc.) outside of revising their standards (which prompts the question—at least to me—as to whether TJC will eventually carve out the FAQs into specific elements of performance…only time will tell). At any rate, HFAP had done some updating prior (already approved by CMS) to the recent CMS memorandum, but, in using existing CMS guidance (which tends not to be too specific in terms of how you do things), should be in reasonable shape. You can see a little more detail as to where the applicable HFAP standards “live” by checking out this and this. I would imagine that the other accreditation organizations are looking at/planning on how to go after this stuff in the field and I suspect that everyone is going to get a taste of over-interpretation and all that fun stuff.

In the “dropping of the other shoe” department, recent survey results are pointing towards a more concerted look at the “back end” of this whole process—clear identification of mitigation strategies, education of applicable staff to the risks and mitigation strategies, and building this whole process into ongoing competency evaluation. You really have to look at the proactive risk assessment (and please, please, please make sure that you identify everything in the environment as a risk to be managed; I know it’s a pain in the butt to think so, but there continues to be survey findings relating to items the survey team feels are risks that were not specifically identified in the assessment) as the starting point and build a whole system/program around that assessment, inclusive of initial and ongoing education, ongoing competency evaluation, etc. Once again, I would seem that we are not going to be given credit for doing the math in our (collective) head; you have to be prepared to “show” all your work, because if you don’t, you’ll find yourself with a collection of survey findings in the orange/red sections of the ol’ SAFER matrix—and that is not a good thing at all. We are (likely) not perfect in the management of behavioral health patients and that is clearly the goal/end game of this, but right now anything short of that has to be considered a vulnerability. If you self-identify a risk that you have not yet resolved and you do not specifically indicate the mitigation strategy (in very nearly all circumstances, that’s going to be one-to-one observation), then you are at survey risk. I cannot stress enough that (at least for the now) less is not more, so plan accordingly!

It’s knowing (hoping) that this can’t go on forever: A little bit of regulatory mishegas…

It being only the third week of the New Year, it’s a little early for any trends to fully manifest themselves, so a couple of odds and ends to get you caught up on (or, upon which to get you caught up, for any hard-core grammarians in the crowd…).

The latest issue of Health Facilities Management has a couple of articles (and a risk assessment available to ASHE members—gotta love a new risk assessment) that should prove of some value/interest over the next little bit:

  •  ASHE issues update on CMS ligature-risk policy – this is basically a recap of the CMS memo issued in December (details here) but also includes mention of an environmental ligature risk tool (updated to include a worksheet for EDs) that is available to ASHE members. I’m not sure if the “hand in glove” relationship between ASHE and TJC will remain the same with the departure of George Mills, but there is every reason to feel that ASHE’s position as an advocacy group will continue. In that light, probably a good idea to check out the ligature risk tool and adopt any elements that you may not have yet considered. I still feel that you have to rule everything in as a risk until you can start ruling stuff out, but I also think that we should be checking out any and all available resources.
  • An interesting article on airflow in the OR; to be honest, I love this kind of digging around into the corners of what makes the surgical environment such a bear from a compliance standpoint and where regulatory scrutiny might be headed as a function of increasing attention to the infection control impact of the environment. I’m not suggesting you have to mimic the study, but it might help you anticipate some pointed survey questions or requests.
  • Also in the latest issue of HFM, there’s an update on the CMS interpretations relative to rolling latches and related concerns as well as a request for volunteers to assist in gathering information, policies, etc. on how folks are keeping things quiet at night.

Moving on to our friends from Chicago, in the continuing unfolding of information regarding the management of ligature risks, the latest issue of Joint Commission Online includes further guidance relating to “other” (my quotation marks) behavioral health environments such as residential treatment, partial hospitalization, intensive outpatient and outpatient treatment programs. The guidance indicates that these settings are not required to be ligature resistant, but then goes on to indicate that a risk assessment should be conducted in these environments, and then policies and procedures implemented to address how to manage patients in these settings that may experience and increase in symptoms that could result in self-harm or risk of suicide. The piece also indicates that the expert panel met again in December and there will be additional guidance relating to suicide risk assessment and safe monitoring of high-risk patients. And so the conversation continues…

On the nth day of Christmas, CMS gave to me: Ligature risks revisited

As you will no doubt recall, back at the beginning of November, The Joint Commission released guidance relative to survey expectations and ligature risks, splitting things into guidance for behavioral health units/hospitals and then some separate items for expectations in non-behavioral health settings (emergency departments, inpatient units). The information release indicated that there were some folks from CMS involved in the (what will apparently be ongoing) discussion on what healthcare organizations can expect over the next little while as the challenges of managing all variations of the behavioral health patient population. What wasn’t clear at the time (at least to me—and it’s still not) was whether CMS’ participation in that process could be interpreted as an at least tacit endorsement of the guidance statements.

And now (well, this past week), CMS issued its own thoughts relative to its expectations, including indication that more will be forthcoming (in approximately six months’ time, so let’s just say sometime next summer). The Survey & Certification memorandum outlines the current slate of expectations (yours and theirs), starting with the pretty much unassailable notion that: “Ligature risks compromise Psychiatric Patients’ right to receive care in a safe setting.” I think we can all agree that that is a reasonable assertion with which to start a conversation.

The memo also goes on to outline the CMS definition of a ligature risk: “(a) ligature risk (point) is defined as anything which could be used to attach a cord, rope, or other material for the purpose of hanging or strangulation. Ligature points include shower rails, coat hooks, pipes, and radiators, bedsteads, window and door frames, ceiling fittings, handles, hinges and closures.” For me, the only surprise was that the example list didn’t say “include, but are not limited to.” I’m used to the regulatory rapscallions leaving themselves an “out” when it comes to this kind of stuff. While the list is pretty comprehensive, I think it stops a little short of all-inclusive, but perhaps as a function of the designated behavioral health environment, it will do. Which leads to the next highlight: this particular guidance is “primarily aimed at Psychiatric units/hospitals.” I guess that means that guidance for non-BH areas like regular emergency departments and acute-care hospital inpatient units that might have to manage behavioral health patients—maybe in the summer, but not really clear on that. It will be interesting to see how future guidance will dovetail (or not) with the TJC stuff.

So, as we wait for the next installment, it appears that it will be left in the hands of the folks on the ground (CMS regional offices, state survey agencies, accreditation organizations) to “the identification of ligature and other safety risk deficiencies, the level of citation for those deficiencies, as well as the approval of the facility’s corrective action and mitigation plans to minimize risk to patient safety and remedy the identified deficiencies.” At least for the moment, we know how TJC is going after this issue, but everything else is somewhat in the land of gray.

A couple of other items covered include time frame for correction of deficiencies (you have to fix things in the time frame identified by the surveying body, unless it is determined that it is not reasonable to expect compliance within the designated time frame, then only CMS can grant additional time for correction); the specific direction that ligature risks do not qualify for Life Safety Code® (LSC) waivers (because ligature risks are not LSC deficiencies); and if you do get to take additional time for corrective actions, monthly electronic progress reports—including substantiating evidence of progress towards compliance—will be the task. It would seem that the monthly check-in, particularly as a function of providing “substantiating evidence of progress” will help to keep the fires of progress burning bright in the hearts and minds of folks charged with making the necessary corrections. As a function of that, I’ve heard of some anecdotal accounts of surveyors indicating that there is a six-month grace period for corrective actions as long as you can substantiate that the corrections will take that long, but the word from Chicago is that is not the case. I have certainly witnessed long lead times for procurement of ligature-resistant door hardware and such, but that’s not enough to delay the reporting of progress process.

The Survey & Certification memorandum includes an attachment that outlines the current guidance to surveying agencies/organizations. I would encourage you all to give that a thorough look-see (and perhaps a dramatic reading instead of the traditional “’Twas the night before Christmas”—bet it puts the kiddies to sleep PDQ). Doubtless, I will weigh on some of the particulars as they leap out at me (much like those leaping lords) in the coming weeks, but I think I’ve gone on long enough for the moment. That said, I will leave you with these two passages from the guidance attachment:

  •  “In order to provide care in a safe setting, hospitals must identify patients at risk for intentional harm to self or others, identify environmental safety risks for such patients, and provide education and training for staff and volunteers.”

 

  • “Although all risks cannot be eliminated, hospitals are expected to demonstrate how they identify patients at risk of self-harm or harm to others and steps they are taking to minimize those risks in accordance with nationally recognized standards and guidelines.”

Certainly nothing we haven’t talked about in the past in regards to an endless supply of subjects, but kind of interesting to see this included in a missive from the palace…

Thank you falletin me: Some survey-related (and otherwise random) thoughts

The first order of business is a word of thanks to anyone and everyone within the sound of my “voice” – I truly appreciate you (sometimes invisible) folks out there in the audience. It continues to be a rare treat having the opportunity to converse with you on a regular basis (the rarer treat is when I get to actually meet folks in the flesh—definitely a delightful happenstance when it occurs) and I hope that I’ve managed to carry on this little slice ‘o safety without being boring, pedantic, etc. Oftentimes, compliance stuff is rather more torturous than not, but what’s the point of doing something if you can’t have a little fun amidst the abject seriousness of it all…

Next up, a couple of items that have appeared during recent surveys that signal (in some instances) a clarification of intent and/or a change in the focus of the physical environment surveys. Some of this you will find endlessly aggravating, particularly if you get cited for it; some of it has the overpowering stench of inevitability as the regulatory folks find new and inventive ways to keep the numbers of findings at record levels. In no particular order:

 

  • In the wake of the clarifying information relative to the management of ligature risks, make sure that (and this is primarily in the ED/regular inpatient settings) for the risk items you have identified as being medically or clinically necessary/essential to the appropriate care of behavioral health patients, make sure that your risk assessment specifically identifies the inherent risks of the remaining risks. For example, if you need to have a medical bed (with side rails, etc.) in the room, make sure that all the specific risk elements of that (or “the”) medical bed are clearly enumerated in the risk assessment. Saw a survey result recently for which the finding was not that the bed was in the room (the finding specifically noted that the bed was medically necessary), but that the risk assessment did not clearly identify the individual components of the bed: side rails, electrical cord, etc. The survey finding indicated that the risk management strategy employed by the organization was appropriate (in this instance, using 1:1 staffing for the at-risk patients), the only “issue” was not identifying the component risks in the risk assessment. I think/hope that this is something of an overreach and if I find out that there is some clarifying information forthcoming, I will surely share it with you.
  • Those of you with older facilities (and perhaps some “younger” facilities as well) are often faced with the proliferation of electrical panels (and sometimes medical gas zone shutoff valves) that are located in spots for which it is almost impossible to ensure that equipment, etc., is not parked directly in front of the panel, etc. Sometimes the panels, etc., are located in the corridors (it really does make one appreciate electrical closets!); some of you may even have the abject misfortune of having electrical panels in your utility rooms (my condolences); and others have panels out in the operational area of busy locations like food services/kitchen areas. I wish that I had good news to impart, but there do seem to be at least a couple of surveyors heck-bent on citing each and every instance of obstructed access to electrical panels. And don’t get me started on corridor med gas shutoffs with electrical receptacles installed directly underneath. Sometimes I wonder if we would run into these types of conditions if the folks doing the design work actually had to live in the space once it is constructed…
  • Staying on the electrical side of things, I’ve also seen an increase in recent findings relating to the use (primarily in patient care areas) of relocatable power taps/power strips/etc. I know the appropriate management of these devices has been “hittable” for a little while now and perhaps there was an unspoken “honeymoon” period for the industry to get things going in the right direction. If that is the case, it appears that the honeymoon is over, so you (particularly if “you” are in the bucket for survey in the next little while) probably should focus a bit on power arrangements in the areas where equipment use and power needs tend to be exponential. I still think the resources provided by ASHE are worth checking out if you have not already done so. It just might save you a painful survey experience.

Closing out, I leave you with this thought/opportunity; I won’t pretend to have an answer for it, but perhaps someone out there in the audience might. Fortunately, it doesn’t happen very often to me personally, but as I get to visit and meet new folks all the time, I am always fascinated by a certain type of individual: they will pledge that they will do anything to help the cause, with the unspoken understanding that that help hinges on their not having to do anything. Sort of a “ask me anything and if it involves no effort on my part, I’ll be all over it.” Again, fortunately, there doesn’t appear to be a proliferation of these folks in healthcare, and if the sounds completely foreign to you, that’s great. But if anyone has any tips for managing the eager-to-pledge non-participant, I’m all ears.

A most joyous and restful Thanksgiving to you and yours!

Breaking good, breaking bad, breaking news: Ligature Risks Get Their Day in Court

As I pen this quick missive (sorry for the tardiness of posting—it was an unusually busy week), the final vestiges of summer appear to be receding into the distance and November makes itself felt with a bone-chilling greeting. Hopefully, that’s all the bone-chilling for the moment.

Late last month brought The Joint Commission’s publication of their recommendations for managing the behavioral health physical environment. The recommendations focus on three general areas: inpatient psychiatric units, general acute care inpatient settings, and emergency departments. The recommendations (there are a total of 13) were developed by an expert panel assembled by TJC and including participants from provider organizations, experts in suicide prevention and design of behavioral healthcare facilities, Joint Commission surveyors and staff, and (and this may very well be the most important piece of all) representatives from CMS. The panel had a couple of meetings over the summer, and then a third meeting a few weeks ago, just prior to publication of the recommendations, with the promise of further meetings and (presumably) further refinement of the recommendations. I was going to “cheat” and do a little cut and pasting of the recommendations, but there’s a fair amount if explanatory content on the TJC website vis-à-vis the recommendations, so I would encourage you to check them out in full.

Some of the critical things (at least at first blush—I suspect that we, as well as they, will be discussing this for some little while to come) include an altering of conceptual compliance from “ligature free” to “ligature resistant,” which, while not really changing how we’re going to be managing risks in the environment, at least acknowledge the practical reality that it is not always possible to provide a completely risk-free physical environment. But we can indeed appropriately manage the remaining risks by appropriate assessment, staff monitoring, etc. Another useful recommendation is one that backs off on the notion of having to install “alarms” at the tops of corridor doors to alert that someone might be trying to use the door as a ligature point. It seems that the usefulness of such devices is not supported by reported experience, so that’s a good thing, indeed.

At any rate, I will be looking at peeling these back over the next few weeks (I’ll probably “chunk” them by setting as opposed to taking the recommendations one at a time), but if anyone out there has a story or experience to share, I would be more than happy to facilitate that sharing.

As a final note for this week, a shout out to the veterans in the audience and a very warm round of thanks for your service: without your commitment and duty, we would all be the lesser for it. Salute!

 

Workplace Violence: One Can Never Have Too Much Info…

I will freely admit that sometimes it takes me a while to get to everything that I want to share with you folks and this is one of those instances…

Back in May (yes, I know—mea culpa, mea culpa, mea maxima culpa—it was even longer ago that I was an altar boy), ECRI Institute published some information on violence in healthcare facilities that includes a white paper, some guidance on how to share the risk landscape of your facility as it relates to workplace violence and some other information that is accessible upon enrolling in a membership program (they have quite a few different programs, this week’s stuff comes from the Healthcare Risk Control program). I suspect that the provided information may be representative of a loss-leader to drive traffic to their website and service programs (much as this blog is a labor of love and obsession, its function is rather much the same—I don’t know that they would put up with my yammering otherwise), but the information available through the above links are certainly worth checking out (there are also free newsletters; as noted in this week’s headline, information coming directly to you saves having to hunt it down).

Another item on my mental to-do list (and it may very well be that it is on my to-done list, but a little reiteration never hurt anyone) was to encourage you to keep an close eye on The Joint Commission’s standards FAQ page (you have to do a lot of scrolling to get to the Hospitals section—they’ve changed the formatting of this section of their website and it just feels quite clunky to me). At any rate, there are way more FAQs than there used to be (maybe more than there needs to be, but if you make the presumption that the characterization of these questions as being frequently asked, then it is what it is) and you can’t really tell which ones have changed (they do highlight new FAQs; lots of pain management stuff on there right now). They used to include a date so you could more or less keep track of stuff. I’m going to guess that there’s going to be a lot of following up relative to the whole management of ligature risks—and make sure you talk to your organization’s survey coordinator to make sure you access the Suicide Risk Booster (there just seems to be something odd about that as a descriptor). As much as any issue there’s ever been in the physical environment, the management of ligature risks is one for which you cannot be too well prepared (think an infinite number of Boy Scouts and you’ll be moving in the right direction).

 

Welcome to a new kind of tension…

In the “old” days, The Joint Commission’s FAQ page would indicate the date on which the individual FAQs had been updated, but now that feature seems to be missing from the site (it may be that deluge of changes to the FAQs (past, present, and, presumably, future) makes that a more challenging task than previously (I will freely admit that there wasn’t a ton of activity with the FAQs until recently). That said, there does appear to be some indication when there is new material. For example, when you click on the link (or clink on the lick), a little short of halfway down the page you will see that there’s something new relative to the storage of needles and syringes (they have it listed under the “Medical Equipment” function—more on that in a moment), so I think that’s OK.

But in last week’s (dated May 31, 2017) Joint Commission e-Alert, they indicate that there is a just posted FAQ item relating to ligature risks, but the FAQ does not appear to be highlighted in the same manner as the needle and syringe storage FAQ (at least as of June 1, when I am penning this item). Now I don’t disagree that the appropriate storage (recognizing that appropriate is in the eye of the beholder) of needles and syringes is an important topic of consideration, I’m thinking that anything that TJC issues relative to the appropriate management of ligature risks (and yes, it appears that I am far from done covering this particular topic) is of pretty close to utmost importance, particularly for those of you likely to experience a TJC survey in the next little while. I would encourage you to take a few moments to take a peek at the details here.

So, parsing these updates a bit: I don’t know that I’ve ever considered needles and syringes “medical equipment,” but I suppose they are really not medications, so I guess medical equipment is the appropriate descriptor—it will be interesting to see where issues related to the storage of needles and syringes are cited. As usual (at least on the TJC front) it all revolves around the (wait for it…) risk assessment. It’s kind of interesting in that this particular FAQ deals somewhat less specifically with the topic at hand (storage of needles and syringes) and more about the general concepts of the risk assessment process, including mention of the model risk assessment that can be found in the introductory section of the Leadership chapter (Leadership, to my mind, is a very good place to highlight the risk assessment process). So no particularly new or brilliant illumination here, but perhaps an indicator of future survey focus.

As to the ligature risks, I think it is reasonable to believe that there will be very few instances in which every single possible ligature risk will be removed from the care environment, which means that everyone is going to have to come up with some sort of mitigation strategy to manage those risks that have not been removed. With the FAQ, TJC has provided some guidance relative to what would minimally be expected of that mitigation strategy; while I dare not indicate verbatim (you will have to do your own clicking on this one—sorry!), you might imagine that there would need to be: communication of current risks; process for assessing patient risk; implementation of appropriate interventions; ongoing assessments of at-risk behavior; training of staff relative to levels of risk and appropriate interventions; inclusion of reduction strategies in the QAPI program; and inclusion of equipment-related risks in patient assessments, with subsequent implementation of interventions.

I don’t see any of this as particularly unusual/foreign/daunting, though (as usual) the staff education piece is probably the most complicated aspect of the equation as that is the most variable output. I am not convinced that we are doing poorly in this realm, but I guess this one really has to be a zero-harm philosophy. No arguments from me, but perhaps some important work to do.