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Don’t Call It A Comeback: The Statement of Conditions breathes again!

Not a whole lot going on in the July 2019 issue of Perspectives, but it appears that a little more consideration will need to be paid to the Statement of Conditions (SOC) and Basic Building Information (BBI) sections of The Joint Commission’s web portal for hospitals and other healthcare organizations. The article in Perspectives indicates that we can expect some changes to the questions asked in the BBI section, though the only specific indication thus far is that the questions relating to square footage of your buildings will be aimed at obtaining greater specificity of information, ostensibly to aid in the planning of survey visits. The impression I always had when it came to the square footage ranges was that they tended to “look” at the upper end of the range information, sometimes “encouraging” additional survey days when they might not necessarily have been warranted. My consultative recommendation to folks was to use the comment section to indicate the precise (or would “exact” be the more appropriate descriptor?) square footage so there would be minimal potential for extra survey days. Should be interesting to see how this all shakes out over the next few months as more “reveals” make themselves known.

In other news, the next edition (2022—can you imagine!?!) of the FGI Guidelines for the Design of Healthcare Facilities is in the development pipeline and the good folks at FGI are looking for comments/suggestions to aid in that development, but the window for doing so is quickly closing. You can check out the skinny here, but please know that the comment, etc., period ends on June 30. So if you have some burning thoughts/suggestions for how we will be managing our future facilities (including renovation activities), now is the time for all good safety professionals to come to the aid of their craft (or something like that…).

To close out this week’s chatter, I would encourage you to (yet again!) check out Tim Richards’ blog regarding medical gas certifications and qualifications. As you’ve no doubt noticed, the ongoing codification of everything has really “leaned” into staff competencies and qualifications, sometimes to the point of really muddying the waters as to what really is required. When it comes to medical gas stuff, I don’t know that you’ll be surprised, but it might be useful information to share with your boss (or your boss’s boss). Check it out here.

Wishing each of you a most festive and safe Independence Day!

Time has come today (or perhaps time won’t let me…)

Last week, we started the discussion regarding findings relative to the inspection, testing, and maintenance of medical gas systems, which reminds me that I kind of skirted exactly how those findings were manifesting themselves.

The most common variant is for organizations that have established a less-frequent-than-annual schedule for the med gas system components, particularly the outlets (as they are usually the most numerous of the system components). Folks are doing half or a third or a quarter of their outlets on an annual basis, and they have not specifically identified the time frame in the Utility Systems Management Plan (USMP; feel free to give your USMP a quick check to see if you’ve defined the time frame(s) for the med gas system components and that your practice accurately reflects what is in the management plan, which is the other most common way this standard generates findings). Make sure you identify the time frame for the testing, etc., and make sure that what the management plan says accurately reflects the process (I know there’s a certain inescapable logic to this, but I’ve seen folks get tagged for this, so please just take a moment to make sure…).

How do we determine those time frames? Well, once again we can ping back through to EC.02.05.01, this time stopping at EP 4, which requires the identification (in writing—but of course) of inspection, testing, and maintenance intervals “based on criteria such as manufacturers’ recommendations, risk levels, or hospital experience.” I think that pretty much captures the gamut of possible criteria, but I’ll throw the question out to the studio audience: Anyone using anything other than those criteria? If so, please share. This would be required for all the utility systems on the inventory, so the next question becomes: What’s on your inventory and how did you populate that inventory?

Jumping back a wee bit further to EC.02.05.01, EP 2, it appears that we would choose between an inventory that contains all operating components of utility systems or we would establish the inventory based on “risks for infection, occupant needs, and systems critical to patient care (including all life-support systems).” Now, I’m not at all certain what you folks might doing individually (I suspect it will have at least something to do with the complexity of your systems and the component elements), but I’m going to guess we have a mix of both strategies of inventory creation. So the task then becomes one of fitting the medical gas system, in total or in pieces, into that decision, then considering the criteria noted under EP 4 to wrap things up in the form of a lovely little risk assessment. Then update the USMP to reflect whatever it is you’ve determined and you should be good to go.

A word of caution/advice: Once you’ve done the risk assessment, picked the maintenance strategy, determined the frequency, and updated the USMP, please remember that is always a wise move to periodically evaluate the decision you made relative to, well, basically anything in your USMP/inventory thing. And a fine spot to do that (if you prefer to call it an opportunity, you’ll get no grief from me) is the annual evaluation process. It comes down to a simple question: Have the maintenance strategies, frequencies, and activities provided reliable performance in support of patient care activities? And while the answer is also pretty simple (yes or no, maybe with a periodic instance of “don’t know” thrown in for good measure), it might be useful to develop a measurement that will tell you when the process is not working well. Could be something like “unscheduled disruptions resulting from preventable conditions” (which might indicate you need to increase your frequencies) or delays in care and/or treatment as the result of unscheduled disruptions (I am a very big fan of EC measurements that tie performance in the care environment back to the bedside—powerful stuff), things like that.

We always want to try and base our risk decisions on data, but sometimes you have to pick a course based on that rapidly vanishing commodity—common sense. When that occurs, I’d want to have some means of “telling” whether the decision was a good one, fold that into (or through) the annual evaluation process, and then move on to the next challenge (and there will surely be another challenge…any minute now). Hope you found this discussion helpful. I will again solicit any feedback that might be percolating out there—I love to know what you all are doing with this stuff, and so does the rest of the class.

I’m feeling a little (medical) gassy…

One Joint Commission survey finding I’ve noticed cropping up in a couple of instances has to do with the routine inspection, testing, and maintenance of critical components of medical gas and vacuum systems. I thought it might be useful to chat a bit about this, particularly as the standard/performance element language is among the more open-ended in terms of what may or may not be required.

EC.02.05.09, EP 1 indicates that the hospital must, in time frames defined by the hospital, inspect, test, and maintain critical components of piped medical gas systems, which include master signal panels, area alarms, automatic pressure switches, shutoff valves, flexible connectors, and outlets. These activities must be documented. So, we’ve got a couple of things going on—“time frames defined by the hospital” and “critical components of piped medical gas systems”—but not a whole lot of indication as to what the heck these are supposed to mean. Or is there something  that would lead us on a path towards conduction of a (you may have guessed this) risk assessment (did you guess, huh, did you? I bet you did…)?

Actually, as a starting point, EC.02.05.09 has a note that gives us a little something to grow on: See also EC.02.05.01, EP 3. Moving on (or back in the standards to EC.02.05.01, we see that EP 3 requires us to identify, in writing, inspection and maintenance activities for all operating components of utility systems on the inventory. Okay, so we have to have written procedures/protocols/ something that we can use to demonstrate compliance; BTW, there are a number of different approaches to maintenance that are allowable—predictive maintenance, reliability-centered maintenance, interval-based maintenance, or metered maintenance are all in the mix—and you can choose whichever of the strategies is appropriate to whatever you are maintaining. Pretty cool, yes?

So we establish what activities are going to be identified and what maintenance approach(es) we are going to be using, which gets us closer to the time frame, but perhaps not quite all the way there. And there is still the matter of how we might define “critical components of piped medical gas systems.” Stay tuned for our next installment…see you next week!

Mac’s Safety Space: Meanwhile, on the other side of town…interim gas measures?

One little item that seems to be popping up with increasing regularity is citing deficiencies in medical gas and vacuum testing reports that are not being managed in a demonstrative way. In some instances, folks have been tagged for the amount of time between identification and resolution, others for not having demonstrably managing the risks associated with a delay in resolving something, etc.

Now we’ve certainly had the “you can live and die during a survey based on what your vendors are documenting” discussion before, though that exchange has tended to focus on life safety device testing. This has the appearance of a fairly significant sea change relative to survey findings and I believe that it represents an overall move towards a risk management process that is not unlike the process outlined under the interim life safety measure (ILSM) standard and associated performance elements. Only time will tell as to how this effects the tenor of surveys and survey results, but I would ask you to think about this:

Any time a deficiency (any type of deficiency—doesn’t specifically have to be a life safety deficiency) or otherwise “unsafe” condition cannot be resolved immediately; there is an inherent risk to be managed. That’s just the nature of the beast. And that risk can be fairly variable in terms of its impact on our facilities and occupants, but how do we know if we don’t run it up the ol’ risk assessment flagpole and see if salutes are forthcoming.

Certainly, it is within our purview to prioritize our responses to stuff that needs to get done, but it would seem that if we do not have our t’s crossed and i’s dotted (until our eyes are crossed), we could be at risk for citation for taking too much time to complete our corrective action (yeah, I know, how much is too much?). But I think if we have a solid, documented process for assessing the risk, identifying any interim strategies for minimizing the risks until such time as the condition can be corrected, we can effectively manage the risk involved with a delay, both from an operational standpoint and a survey management standpoint.

At the end of the day (cliché alert), it is our responsibility to ensure that the safety is maintained at an appropriate level (also meaning that it is our responsibility to identify what appropriate looks like) at all times, even when things are not in perfect shape. When things are not in perfect shape, the mission then becomes one of figuring out how we make sure that any gaps are bridged, which effectively means some sort of interim measure (if you look closely, you’ll see the concept of interim measure doesn’t just show up under the ILSM standard – it’s in the emergency power standards, as well as in the emergency management chapter). It is up to us to manage our resources effectively, and sometimes that means that we can’t fix everything right away – and that’s okay.

As long as we make sure that the associated risks are managed just as effectively as we manage those resources. So, keep close tabs on those maintenance and testing documents getting shoved under your door, any one of them could be trouble during survey.

Which reminds me, if your testing vendors are not providing you with a complete summary of any and all deficient findings identified during the testing and maintenance activities, I plead with you to demand this of them. The surveyors now have more than enough time to find that little mission critical device failure buried on page 15 of the testing report and they’re going to ask you what you’re doing about it. If you didn’t get to page 15 in the report, you’re going to end up with some egg on your face and a probably an RFI (Requirement for Improvement), which won’t make anyone happy. A simple executive summary of deficiencies (or, if they didn’t find anything, a simple statement that says “yes, we didn’t find anything”) gives you one place to look and one access point to managing the risks associated with the finding. I know I don’t have time to read through all those reports and I suspect your time can be better spent, but perhaps that’s just me…