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Is you is or is you ain’t a required policy?

Yet another mixed bag this week, mostly from the mailbag, but perhaps some other bags will enter into the conversation. We shall see, we shall see.

First up, we have the announcement of a new Joint Commission portal that deals with resources for preventing workplace violence. The portal includes some real-world examples, some of the information coming from hospitals with whom I have done work in the past (both coasts are covered). There is also invocation of the Occupational Safety & Health Administration (lots of links this week). I know that everyone out there in the listening audience is working very diligently towards minimizing workplace violence risks and perhaps there’s some information of value to be had. If you should happen to uncover something particularly compelling as you wander over to the Workplace Violence Portal, please share it with the group. Bullying behavior is a real culture disruptor and the more we can share ideas that help to manage all the various disruptors, we’ll definitely be in a better place.

And speaking of a better place, I did want to bring to your attention some findings that have been cropping up during Joint Commission surveys of late. The findings relate to being able to demonstrate that you have documented a risk assessment of the areas in which you manage behavioral health patients; particularly those areas of your ED that are perhaps not as absolutely safe as they might otherwise be, in order to have sufficient flexibility to use those rooms for “other” patients. Unless you have a pretty significant volume of behavioral health patients, it’s probably going to be tough to designate and “safe” rooms to be used for behavioral health patients only, so in all likelihood you’re going to have to deal with some level of risk. I suppose it would be appropriate at this juncture to point out that it is nigh on impossible to provide an absolutely risk-free environment; the reality of the situation is that for the management of individuals intent on hurting themselves, the “safety” of the environment on its own is not enough. Just as with any risk, we work to reduce the risk to the extent possible and work to manage what risks remain. That said, if you have not documented an assessment of the physical environment in the areas in which you manage behavioral health patients, it is probably a worthwhile activity to have in your back pocket. I think an excellent starting point would be to check out the most recent edition of the Design Guide for the Built Environment of Behavioral Health Facilities, which is available from the Facilities Guidelines Institute. There’s a ton of information about products, strategies, etc. for managing this at-risk patient population. And please keep in mind that, as you go through the process, you may very well uncover some risks for which you feel that some level of intervention is indicated (this is not a static patient population—they change, you may need to change your environment to keep pace), in which case it is very important to let the clinical folks know that you’ve identified an opportunity and then brainstorm with them to determine how to manage the identified risk(s) until such time as corrective measures can be taken. Staff being able to speak to the proactive management of identified risks is a very powerful strategy for keeping everybody safe. So please keep that in mind, particularly if you haven’t formally looked at this in a bit.

As a closing thought for the week, I know there are a number of folks (could be lots) who purchased those customizable EOC manuals back in the day and ever since have been managing like a billion policies, which, quite frankly, tends to be an enormous pain in the posterior. I’m not entirely certain where all these policies came from, but I can tell you that the list of policies that you are required to have is actually fairly limited:

  • Hazard Communications Plan (OSHA)
  • Bloodborne Pathogens Exposure Control Plan (OSHA)
  • Respiratory Protection Program (OSHA)
  • Emergency Operations Plan (CMS & Accreditation Organizations)
  • Interim Life Safety Measures Policy (CMS & Accreditation Organizations)
  • Radiation Protection Program (State)
  • Safety Management Plan (Accreditation Organizations)
  • Security Management Plan (Accreditation Organizations)
  • Hazardous Materials & Waste Management Plan (Accreditation Organizations)
  • Fire Safety Management Plan (Accreditation Organizations)
  • Medical Equipment Management Plan (Accreditation Organizations)
  • Utility Systems Management Plan (Accreditation Organizations)
  • Security Incident Procedure (Accreditation Organizations)
  • Smoking Policy (Accreditation Organizations)
  • Utility Disruption Response Procedure (Accreditation Organizations)

Now I will freely admit that I kind of stretched things a little bit (you could, for example, make the case that CMS does not specifically require an ILSM policy; you could also make the case that it is past time for the management plans to go the way of <insert defunct thing here> at the very least leaving it up to the individual organizations to determine how useful the management plans might be in real life…). At any rate, there is no requirement to have any policies, etc., beyond the list here (unless, of course, I have left one out). So, no policy for changing a light bulb (regardless of whether it wants to change) or policy for writing policies. You’ll want to have guidelines and procedures, but please don’t fall into the policy “trap”: Keep it simple, smarty!

Tiers of a clown

With all the folderol relating to the changes in the management of life safety conditions in our facilities (Thanks CMS! Thanks TJC!), one of our other favorite regulatory acronyms got into the act when, effective August 1, our good friends at OSHA (the Occupational Safety and Health Administration) increased the tiers of its penalty structure about 78% for citations issued by OSHA on or after August 1, if the related violations occurred after November 2, 2015. So the penalty structure looks a little something like this:

 

Type of Violation Current Maximum Penalty New Maximum Penalty
Serious
Other-Than-Serious
Posting Requirements
$7,000 per violation $12,471 per violation
Failure to Abate $7,000 per day beyond the abatement date $12,471 per day beyond the abatement date
Willful or Repeated $70,000 per violation $124,709 per violation

 

Apparently, this is all based on Congress enacting legislation requiring the various and sundry federal agencies to adjust their civil penalties to adjust for inflation, so I’m guessing there will be other entities jacking up the prices noncompliance. So, I guess the $5471 / $54,709 increases are based on inflation since the last time they did their adjustments (makes me think it’s probably been a while), though they are curious numbers, but I guess it’s not that often that anyone has to pay the top dollar penalty.

The question has been bandied about as to whether or not the increase in the civil penalty is going to increase compliance, but the more I think about it, the more I suspect that compliance will stay right around where it’s always been. I suppose you might have a boss or two who will take greater interest in occupational safety (especially those that read, say, the Wall Street Journal,  and it appears that the penalty structure changes about as often as a new edition of the Life Safety Code® is adopted by CMS), but I’m guessing that interest will be closer to fleeting than not.

I suppose I should clarify my thoughts about compliance: we are not perfect as an industry (and there are those that will take great pains to remind us of our imperfections, including all those acronymic wonders), but when you think about all the moving pieces that we have to deal with on a constant basis, I believe that healthcare generally does a pretty good job on the occupational safety and health front. Again, imperfections abound, and we typically recognize them and work towards reducing incident rates to the extent possible. But I don’t think we do that because we are afraid of being fined by OSHA; I think it’s because, as committed safety professionals (and some days, you really are eligible for commitment with this job), it is the right way of going about managing safety in our organizations.

So the “ding” is bigger if the Big O has an issue with how you’re managing things, but I think the charge to safety professionals is clear and constant. You can read the official “word” from OSHA, including the final rule and some spiffy FAQs. But drink plenty of coffee…

 

What is the most dangerous place in your organization?

If you asked a dog the question in the title above, would it say, “Woof”? (Though some might say kitchen…I sometimes do.)

I’ve been encountering a fair number of roof-related opportunities and I wanted to give the topic an airing. I’m not entirely certain what prompted my thinking about rooftops (it’s way beyond Christmas), but I can say that I’ve encountered a bit of a run on unsecured roof hatches/access doors in hospitals (and hotels, too—I suppose I spend as much time in hotels as I do in hospitals—a certain inescapable logic coming into play on that count).

I will admit that I’m no fan of hatches from a practical standpoint (being rather stout and not particularly tall in the physique department), but I’m kind of surprised at the number I’ve encountered that are not secured (and I’m not talking about something that’s sort of secured, though I’ve seen some not-particularly-well-secured hatches as well). I know it’s important for Facilities/Plant Ops staff to have access to roofs, as well as emergency responders, but leaving these types of locations without any security seems way beyond a reasonable strategy. We’re certainly no stranger to the stories of patients wandering off (and I suppose you can’t always predict who might be prone to wandering) and I don’t know that I would want to hang my hat on the “remote” likelihood of someone “stumbling” on to an unsecured roof hatch, so I would ask you to please be attentive to the hatches and “batten them down” if they should have any level of uncontrolled access.

But just so we’re clear, it goes beyond hatches. It is of critical importance that you have a very hardened perimeter for all your roof areas. I don’t know how many times I’ve found propped, unattended doors because someone didn’t feel comfortable “trusting” a vendor (e.g., window washers) with the key to the access door. And I think it is a very well-established truism that doors for which folks do not have keys tend to get propped (I bet we could distill that into some sort of mathematical equation) and the likelihood of the propping is in proportion (I’m guessing inverse, but maybe not) to the risks of leaving that door unsecured. It may even be worth considering having roof access doors and hatches on your “Elvis” list (i.e., that list of critical things to check when you know you’ve got surveyors in the building—oxygen cylinders, corridor clutter, etc.). It’s all part of making absolutely sure that no one is inadvertently put at risk (I don’t believe that folks would purposefully leave a roof door unsecured and unattended—and I hope there’s no one out there to challenge that belief with a real life example).

Finally, don’t forget about fall protection for the folks you allow on the roof, particularly if you have minimal or no parapets. Interestingly enough, our good friends at the Occupational Safety & Health Administration have a few choice thoughts regarding fall protection; you can start that journey here. Even if it’s somebody working for a contractor, if you have a fall, your organization is likely to be mentioned as prominently as the contractor—and if you ask me, that’s no way to get on the front page of the local newspaper. So, the secret word for the week is “protection”: protection of patients, protection of staff, protection of contractors—it’s all part of the mix.

Next up (unless my calendar is lying to me), we should have another fabulous edition of Portal Chortling, with perhaps a side of Fireside Chat. Stay tuned!

I’m happy, hope you’re happy too…

A couple of weeks ago, HCPro’s Accreditation Insider featured an article that addressed a study published by the American Journal of Infection Control on compliance by nurses with the many and varied requirements of the Bloodborne Pathogens standard.

I guess I’m of two minds about the study; it is a somewhat smallish sample size (116 nurses were studied), though presumably statistically valid (not being wicked up on the whole statistical analysis thang, I wouldn’t even presume to presume, but I’m thinking that it would hardly have been worth publishing if it were not of some note). I think in my heart of hearts that (at this point) I would have hoped for better compliance numbers but again I’m not certain that I was particularly surprised that gloves aren’t worn all the time, hands are not washed as often as is necessary (e.g., after taking care of patients, after taking off gloves), and face shields are not worn as often as would be advisable given the risks (no big surprise on the face shields—it is a struggle, struggle, struggle—not just for the potential of an exposure to blood or other potentially infectious materials (OPIM to those among you that are acronymically inclined), but also for potential chemical exposures. (Everybody wants a freaking eyewash station “in case”, but nobody wants to use appropriate PPE to ensure that “case” doesn’t occur—jeepers!)

I haven’t had a chance to actually read the study (yes, I know—shame!), but the article in Accreditation Insider doesn’t really get into what the compliance barriers might have been (I honestly don’t know if the study gets into some of the causative factors), which I think would have been instructive. Apparently, the study concludes with a recommendation for stricter enforcement of compliance policies and to address problem areas with better monitoring and staff education. Now, those are fine things indeed, but kind of begs the question as to what constitutes better monitoring and staff education. I will go on the record here (I don’t think I have previously, but if I have, mea maxima culpa) as no particular fan of computer-based learning. I “get” that it is more convenient for folks to do and thus, generally results in better “compliance” when it comes down to numbers of folks completing the required “modules,” etc. And I also “get” that it is compliant from a regulatory standpoint (BTW, just because I “get” something doesn’t necessarily mean that I am convinced that such claims are valid). What I don’t find as I travel the highways and byways of healthcare facilities is evidence that this process results in an enhancement of staff competence and knowledge. I don’t necessarily think of myself as a Luddite (in fact, I’m pretty okay with a lot of technology), but I don’t know that convenience is the yardstick by which we should be measuring the effectiveness of education. Rant over…

Before I hop along, I do have one favor to ask (and it sort of relates to the above). I understand that, from a sterile processing perspective, it is important to do some sort of enzymatic pre-treatment of soiled instruments so the OPIM doesn’t get all caked and hardened on the surface of said instruments. The favor (or question) is this: Has anyone identified a product that will appropriately pre-treat instruments but not require emergency eyewash equipment? If you have a risk assessment of that determination, that would be very cool. I’m running into another uptick in the proliferation of eyewash stations—I’m a great believer in having them when they are appropriate, but I’m no fan of eyewash stations “in case” (that sounds somewhat familiar…where have I seen that before?). Any feedback would be most appreciated.

Happy Mardi Gras for those of you disposed towards that kind of celebratory activity…

Oh no, Mr. Bill!

I always view with great interest the weekly missives coming from The Joint Commission’s various house organs, particularly when there’s stuff regarding the management of the physical environment. And one of the more potentially curious/scary “relationships” is that between the good folks in Chicago and the (I shan’t editorialize) folks at the Occupational Safety & Health Administration. They’ve had a nodding acquaintance over the years, but there is evidence in some quarters (I’ve seen a decided uptick in survey findings relating to hazardous materials and waste inventories—as we’ve noted before, a list of your Safety Data Sheets is not going to be enough on its own to satisfy a finding of compliance with the Hazard Communications standard), that concerns relative to occupational health and safety are becoming a target area during Joint Commission surveys.

At any rate, last week, buried in last Wednesday’s action-packed edition of Joint Commission Online, there was an item highlighting the OSHA updates of key hazards for investigators to focus on during healthcare inspections.

Now I can’t imagine that the list of key hazards would come as a surprise to anyone in the field (in case you were wondering, they are: musculoskeletal disorders (MSD) related to patient or resident handling; bloodborne pathogens; workplace violence; tuberculosis; and slips, trips and falls—surprise!), as these are pretty typically the most frequently experienced occupational risks in our industry. What remains to be seen, and what I suspect we need to be keeping in mind as the wars for accreditation supremacy continue, is whether this OSHA guidance translates across to TJC survey methods and practices (I don’t think TJC is as “beholden” to OSHA as they are to CMS, but who knows what the future may hold). That said, I don’t think it would be unwise or in any way inappropriate to shine as much “light” as possible on your organization’s efforts to manage these occupational risks. I’m guessing your most frequently experienced occupational illness and injury tallies are going to include at least two or three of the big five (I suspect that TB may be the least frequent for hospitals, though if you count unprotected/unanticipated exposures, the numbers might be a little higher). Perhaps (if you have not already done so) some performance indicators relating to the management of these risks (successful or unsuccessful) might be a worthwhile consideration as we continue through the EC/safety evaluation cycle (I know some of you are doing your evaluations based on the fiscal year cycle, of which many are wrapping as we speak). And remember, there’s no rule that says you can’t develop and implement new indicators mid-cycle. Take a good look at the numbers you have and figure out whether your organization is where it needs to be from a performance standpoint. If the numbers are good—it might behoove you to ask the question or whether that level of performance is the result of good design or good fortune (there’s nothing wrong with good fortune, though it does tend to be less reliable than good design). As with so many of our critical processes, the more we can hardwire compliance/good practice, the easier our jobs can be. Perhaps that’s an overly optimistic thought, but as I gaze out over Boston Harbor this morning, optimism doesn’t seem to be misplaced—optimism is good to have when flying!

A cautionary tale

During a recent CMS survey, one hospital in the Northeast was cited during the inspection of the physical environment for a vent on the roof of the laboratory that was labeled “caution.” The problem—not enough information. As these folks were preparing their response, they asked me what the correct wording would be. And the answer (and I realize I haven’t used this one in a while)? It depends.

Strictly speaking, as a function of the Hazard Communication Standard, the nature of the risk of which one is being cautioned should be identified. In the case of the lab vent, it could be signage indicating that the exhaust is a biohazard or a poison, etc. When you think about it (or even if you don’t), a sign that just says “caution” doesn’t really tell enough of the story—at least in terms of how persons on the roof should be managing the risks. Many, if perhaps not most, OSHA surveyors would accept the biohazard symbol on the vent; or, alternatively, you could also include identification of rooftop hazards in your roof access protocol (I’m sure you have one of those). It sounds like there will probably have to be some follow-up discussion with the inspector to either ask him for some guidance (I’m guessing there may get some generic instruction, but not much in the way of specifics) or at least run by him what the plan of correction will entail. It would be most stinky to have your corrective action plan kicked back because they don’t like how you’ve worded the signage, etc. Fixing identified issues is one thing, but when it gets into the gray area of how you would effectively manage risk is a little bit more tenuous—way better to err on the side of caution.

New webcast provides training on OSHA HazCom revisions, GHS updates

OSHA requires hospitals to have completed training by December 1, 2013 on its revised Hazard Communication Standard for all staff who come into contact with hazardous chemicals. On Wednesday, January 8, 2014, HCPro is presenting a webcast to help you understand the changes and train staff on the GHS updates. In this 90-minute program, expert speakers Marge McFarlane and Paul Penn will explain what staff need to know to be safe and to implement the GHS changes. In addition, McFarlane and Penn will participate in a live question-and-answer session.

You can find more information and register for the webcast here.

 

Train staff on revised HazComm standard with new DVD

OSHA’s revised Hazard Communication standard requires hospitals and other healthcare facilities to have trained staff on the new Globally Harmonized System (GHS) by December 2013. The intent is to make the identification of hazardous chemicals much quicker and easier, and to make it faster to find recommended first aid procedures in the event of worker exposure.

HCPro will offer several staff training solutions to help facilities, including Hazard Communication Training: Implementing the GHS, a new DVD that will be available in December. This video will help you:

  • Meet OSHA requirements for training employees on the Hazard Communication standard
  • Train staff to understand the revised Hazard Communication standard
  • Improve hazardous chemical safety in your facility
  • Learn the new pictograms issued by OSHA

Chemical manufacturers aren’t required to comply with the new regulations until June 1, 2015. That means there will be close to a two-year gap during which employees will need to understand the traditional material safety data sheets (MSDS) as well as the new safety data sheets (SDS).

Visit the HCPro Marketplace for more information and to order.

Pictograms of matchstick men

In our ongoing series (okay, perhaps that’s a rather ambitious descriptor, but there’s been more than one) relative to the upcoming implementation of the changes to OSHA’s Hazard Communication standard, you might find the information regarding the required pictograms helpful in getting your organization’s folks up to speed on what things are going to look like in the future.

The use of the pictograms is not mandated until June 2015, but I think this will improve the communicability of the hazards of products used by staff in the field. Check out the new graphics here.

Uniformly clean

Reaching in once again to the viewer mailbag, we find a question regarding the laundering of staff uniforms. In this particular instance, this organization is moving from a business casual dress code for medical staff to providing scrubs (three sets each) to promote uniformity of attire (sorry, I couldn’t resist the pun). Now that the decision has been announced, there’s been a little pushback from the soon-to-be scrub-wearing folks as to whether the organization has to launder the scrubs if they become contaminated with blood or OPIM (the plan is for folks to take care of their own laundering).

So, in digging around a bit I found an OSHA interpretation letter that covers the question regarding the laundering of uniforms is raised and includes the following response:

Question 6: Is it permissible for employees to launder personal protective equipment like scrubs or other clothing worn next to the skin at home?

Reply 6: In your inquiry, you correctly note that it is unacceptable for contaminated PPE to be laundered at home by employees. However employees’ uniforms or scrubs which are usually worn in a manner similar to street clothes are generally not intended to be PPE and are, therefore, not expected to be contaminated with blood or OPIM. These would not need to be handled in the same manner as contaminated laundry or contaminated PPE unless the uniforms or scrubs have not been properly protected and become contaminated.

To my way of thinking, if the scrubs were to become contaminated, which would appear to be the result of the scrubs not having been properly protected (I’m reading that as “not wearing appropriate PPE), then the tacit expectation is that they would be handled in the same manner as contaminated laundry or contaminated PPE and since it is inappropriate for PPE to be laundered at home, then provisions would need to be made for the laundering of contaminated scrubs/uniforms. Now, you could certainly put in place safeguards, including the potential for corrective actions, if you have a “run” on folks getting their uniforms contaminated. It’s certainly possible that, from time to time, a uniform might become contaminated, but the proper use of PPE should keep that to a minimum.

How are folks out there in radio land managing scrubs that are used as uniforms (as opposed to being used as PPE)? Are you letting folks take care of their own garments or doing something that’s a little more involved? Always happy to hear what’s going on out there in the field.

And if I can take a moment of your time, I’d like to take this opportunity to remember my late colleague David LaHoda. This is the type of question he loved to answer and I loved helping him help folks out there in the great big world of safety. David, you are missed, my friend!