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Hortle didn’t hear a portal (with apologies to one T. Geisel)

As I get a little longer in the tooth, I find that I need to create reminders for myself of subjects to cover during our weekly visits. Typically, I will capture an idea as a draft email and return to it as time permits. At any rate, as you are very much aware, there’s been a lot of material in recent weeks that have precluded the need to dig into my archives, but in the interest of keeping my draft emails at a manageable level, as well as making sure that I cover all the discussion points that I wanted to share, over the next little bit (unless something breaks big or bad in the compliance world) I’m going to set the wayback machine for stun and run a few timeless classics (at least I think they’re timeless—please feel free to disagree). Let’s hark back to July to revisit a concept that occupies a lot of my waking time: stewardship and accountability for the management of the physical environment.

As I was lurking about Joint Commission’s Physical Environment Portal (PEP) to see if there were any updates to be found, I stumbled upon a missive in TJC’s leadership blog that I did not recall seeing. This dates back to October 2015 in those halcyon days of the early chortlings of the portal… (insert going back in time sound effects here).

In looking at this particular missive (penned by one G. Mills, Director, Department of Engineering—you can find the whole magillah here), there is some ground covered that is among my most favoritest of topics: the universality of the responsibilities when it comes to the management of the physical environment (and for those you who are keeping count, I have no idea how many times I’ve discussed this particular topic, but I’m going to guess it’s well into double digits. And that’s not even counting the number of times I’ve had variations of this conversation with clients). In the blog, Mr. Mills notes that “…the patient care environment is not owned by one group in the healthcare setting.” I couldn’t agree more and yet I still (still, still, still!) encounter organizations that have not fully embraced that concept—which results in very little surprise on my part that eight of the 10 most frequently cited standards are in the physical environment. Mr. Mills goes on to say, “(W)e cannot look to one group to keep the area clean, another to keep the area warm/cool, and then another group to treat patients independently.” But organizations continue to do just that, get bounced around during surveys, and still (still, still, still!) fail to grasp the team concept of managing the environment.

Now it’s certainly not every organization that has these issues, but until every organization gets “down” with this as a way of conducting the business of healthcare, the EC/LS findings will continue to pile up. The silos of clinical and non-clinical functions in healthcare organizations are no longer a tenable model—I’ve said it before and I will (no doubt) say it again—every individual working at every level in every healthcare organization is a caregiver. I’ll give you the direct/indirect split, but taking care of the patient in the bed is the role and responsibility of everyone. It is past time for a new paradigm. Let’s make it happen—even without updates to the PEP!

As a closing thought, I was rather remiss in my discussion of the final CMS emergency preparedness rule. I neglected to indicate that the new regulations are effective 60 days after publication in the Federal Register (which plunks us into November 2016—you can make a reference to turkeys if you like) and implementation must be completed by November 15, 2017 (again, I will stand by my stand that this is not going to be a very big deal for hospitals—I have yet to find anything that is well and truly new and/or different in what is actually required. As with all things, I suspect that the worm will turn on the interpretive dances of the surveyors).

At any rate, if you don’t have plans for next Tuesday at 1:30 pm EDT, you might want to check out the public call to discuss the new rule, hosted by CMS’ Medicare Learning Network. The call is scheduled to last 90 minutes and you can register here. I will be doing client work that day, but I suspect that there might one or two folks from the editorial world that may tune in, so I am looking forward to finding out what the “skinny” might be on all this stuff. Much ado about nothing or something wicked this way comes? I guess we’ll find out soon enough…

If accredited you wish to be, you must answer these questions three!

And other tales: If you thought the dervishes were whirling last week…you ain’t seen nothing!

Hortal hears a chortle from the portal: The much-anticipated (you tell me how hyperbolic that characterization might be…) return of updated content for the Joint Commission (oops, THE Joint Commission)’s Physical Environment Portal (PEP) has finally reached these shores. O frabjous day! Callooh! Callay! He chortled in his joy (from Jabberwocky by Lewis Carroll; see, chortling has been around for a while…).

The new content breaks down into three sections: one for facilities and safety folks, one for leadership, and one for clinical folks, lending further emphasis to the ongoing melding  of the management of the physical environment into a tripod-like structure (tripods having more stability and strength than a one- or two-legged structure—think about that one for a moment). At any rate, interestingly enough, the suggested solutions for both the clinical and leadership “legs” of the tripod are aimed at “supporting” the facilities “leg” through endorsement of the key process(es) as well as keeping smoke doors closed, not compromising closing devices (how may doors can a doorstop stop if a doorstop could stop doors?), and participation during construction activities. So, if you visit the noted URLs, you will find a whole bunch of stuff, some of it downloadable, to share with the other “legs” in your organization. It seems pretty evident to me, that at least part of the intent of the information shared, particularly the stuff earmarked for leadership and clinical folks, is to ratchet up the “investment” of those two groups in the management of the physical environment. On the face of it, nobody in healthcare has “time” to shoulder this burden on their own, hence the practical application of the tripod (sort of: that may be a bit of a reach on my part, but there’s some truth lurking around somewhere—and we will ferret it out).

Also breaking recently was the information (funneled from our fine friends at ASHE) that TJC is going to be including a set of three questions in the pre-building tour portion of the survey process (I think this is in addition to other questions that might be asked, including whether you have any identified Life Safety Code® (LSC) deficiencies). The intent, as described by Jim Kendig, TJC’s field director for surveyor management and development (I worked with Jim, like, a million years ago. Hi, Jim!), is to gather some pertinent/useful information before setting out to tour your facility.

Question 1: What type of firestopping is used in the facility?

Question 2: What is your organization’s policy regarding accessing interstitial spaces and ceiling panel removal?

Question 3: Which materials are used for high-level disinfection or sterilization?

On the face of it, I’m thinking the response to Question 1 might very well be the most challenging as I can’t recall too many facilities that have just one manufacturer’s product protecting their rated barriers. My consultative advice is you would be well-served to have some sort of document that identifies the various products in use, where they “live” in your organization, perhaps even color pictures of the products in situ so the surveyors will know what they are looking for (and please don’t try to pass off that yellow expanding foam stuff as an appropriate product—no point in getting into a urination competition with a surveyor over that). As to the other questions, as near as I can tell they’re pretty straightforward; the surveyor is going to have plan for extra time if a containment has to be erected/constructed for every ceiling tile removal or perhaps they will identify specific locations for inspections and just run through those one after the other. As to high-level disinfection and sterilization, lots of environmental and infection control opportunities for bungles there (BTW, it’s probably a very good idea to have a very good idea where those processes are occurring; it can be more widespread than you would prefer).

As a final thought for this week, I would encourage you to participate in ASHE’s survey of the potential impact of CMS’s requirement for all hospital outpatient surgery departments to be classified as Ambulatory Surgical occupancies under chapters 20 and 21 of the 2012 LSC. There is a fair amount of potential that this requirement is going to have an impact on facilities in which dental or oral surgery is being performed, plastic surgery, endoscopy, laser surgeries, etc. To help with the assessment of the impact of this change, ASHE is asking folks to complete a survey for each of the facilities you oversee that will be affected; you can find the survey here. https://app.smartsheet.com/b/form?EQBCT=c66f01e829184b648b4b0db3fd2cc552

I think it’s probably well worth your time to at least see what they’re asking about; I’m beginning to think that we are going to look back on 2016 as a really ugly year (compliance, popular culture, you name it!). Where’s that fast-forward button…or do we talk to Mr. Peabody and Sherman about that Wayback Machine…

Maybe these maps and legends have been misunderstood…

I don’t know about you folks, but The Joint Commission’s discontinuation of the PFI process has left me in a rather unsettled state. Heretofore, I think many of us (and I will include myself among that number) relied on TJC to provide some level of illumination into the inner workings of compliance as a function of what CMS is requiring. As I think I noted earlier, I was fully cognizant that CMS has been no particular fan of the PFI process as a means of ensuring compliance with the Life Safety Code®, but (presumably) there was always a tacit understanding—falling somewhat short of acceptance—that the PFI process wasn’t causing enough of a ripple in the fabric of compliance to warrant any direct intervention.

And now we find ourselves officially in August and still awaiting the arrival of the latest modular addition to The Joint Commission’s Physical Environment Portal (PEP), which was “scheduled” for a July release (at least that’s been the info posted on the portal site). At this point, I’m starting to think that the life safety modules may be on hold until the updated Life Safety chapter is unveiled later this year (presumably sometime ’twixt now and November). But the greater concern I have (and hopefully this is just a hyperbolic response to the deluge of changes) is whether the information contained in the PEP (and, to some degree, the physical environment FAQs) is as valuable (Useful? Reliable?) when it comes to keeping in line with CMS’ expectations. I think to one extent or another, we all relied on TJC as an arbiter/translator of how the physical environment Conditions of Participation could be interpreted/implemented from a practical/operational standpoint, but now I can’t help but wonder if that status has been torn asunder along with the PFI process. I’m probably over-thinking this, but I don’t have a feeling of comfort with the current state of things. I guess we shall see what we shall see—I, as always, remain optimistic, but, for whatever reason, it seems to be more of a struggle at the moment. But enough of that, for the moment…

As I was checking to see if there was an update to be found, I stumbled upon a missive in TJC’s leadership blog that I do not recall having seen before. So let me take you back about 10 months to those halcyon days of the early chortlings of the portal… (insert going back in time sound effects here).

In looking at this particular missive (penned by one G. Mills, Director, Department of Engineering—you can find the whole magillah here), there is some ground covered that is among my most favoritest of topics: the universality of the responsibilities when it comes to the management of the physical environment (and for those you who are keeping count, I have no idea how many times I’ve discussed this particular topic, but I’m going to guess it’s well into double digits. And that’s not even counting the number of times I’ve had variations of this conversation with clients…). In the blog, Mr. Mills notes that “…the patient care environment is not owned by one group in the healthcare setting.” I couldn’t agree more and yet I still (still, still, still!) encounter organizations that have not fully embraced that concept—which results in very little surprise on my part that eight of the 10 most frequently cited standards are in the physical environment. Mr. Mills goes on to say, “(W)e cannot look to one group to keep the area clean, another to keep the area warm/cool and then another group to treat patients independently.” But organizations continue to do just that, get bounced around during surveys, and still (still, still, still!) fail to grasp the team concept of managing the environment.

Now it’s certainly not every organization that has these issues, but until every organization gets “down” with this as a way of conducting the business of healthcare, the EC/LS findings will continue to pile up. The silos of clinical and non-clinical functions in healthcare organizations are no longer a tenable model—I’ve said it before and I will (no doubt) say it again—every individual working at every level in every healthcare organization is a caregiver. I’ll give you the direct/indirect split, but taking care of the patient in the bed is the role and responsibility of everyone. It is past time for a new paradigm—let’s make it happen—even without updates to the PEP!

Regardless of what happens in regards to the TJC/CMS dynamic, I think that healthcare as an industry needs to embrace this model for management of the physical environment. I know on an individual basis, everyone is wicked busy, but the success or failure of the management of the physical environment is a function of how ingrained the “see something, say something” philosophy is at point of care/point of service. You and I both know that I could say that I will speak of this no more, but you and I also know that the chances of my avoiding this topic are somewhere between slim and none…

AAMI: What you gonna do?

By necessity, this is going to be somewhat of a hodgepodge of stuff as there are no new postings to The Joint Commission’s PEP site. Looks like we’ll have to wait for July to see what they have to say about the intricacies of LS.02.01.30, though I suspect that we can anticipate some coverage of hazardous locations (Can’t they come up with a better descriptor? While I absolutely understand that the requirements are driven by the point at which the level of stored combustibles in a space is considered “hazardous,” I find that it can be rather challenging when communicating to the clinical folks as to why they shouldn’t randomly convert patient rooms to storage rooms. The refrain is typically “We don’t have anything hazardous in the room, we just have paper supplies, etc.” to which I respond, “Well, you’ve got an amount of paper supplies, etc., that is considered hazardous by the Authority Having Jurisdiction,” to which I tend to receive a blank look and an “oh.” Told you this was going to be a hodgepodge…

Getting back to our PEPpy discussion; I think we’ll find out a bit about smoke barriers, corridor walls, corridor doors, etc. But then again, with the adoption of the 2012 Life Safety Code®, the scheduled PEP modules may be deferred and perhaps they’ll post something relating to whatever changes will be occurring to the Life Safety chapter of the accreditation manual. I think that’s enough blathering about something that didn’t happen, so let’s talk about something that did happen.

At this point, you (or your organization—why I would think that you would have been involved in this is beyond me…) should be well-ensconced in the practical applications of the National Patient Safety Goal regarding the management of risk associated with clinical alarm systems as a function of the Joint Commission requirements thereof:

  • Leadership establishment of alarm system safety as an organizational priority
  • Identification of the most important alarm signals to manage
  • Establishment of policies and procedures for managing those most important alarm signals
  • Education of staff and licensed independent practitioners about the purpose and proper operation of alarms systems for which they are responsible

Hopefully you’ve got that all going in the right direction. But if you’re falling a little short or if, indeed, you’re not sure about progress, the good folks at the Association for the Advancement of Medical Instrumentation (AAMI) have a webpage devoted to information regarding clinical alarms. Those resources include a downloadable Clinical Alarm Management Compendium (maybe CLAMCOMP would be a good acronym) to assist you in these endeavors. If you haven’t yet checked out the AAMI materials, I would very much encourage you to do so (or encourage you to encourage whoever is managing this process in your organization) is because reference to this webpage is included in the rationale statement for this particular safety goal and the stuff that ends up in the accreditation manual has a tendency to take on an elevated criticality in the hands of some surveyors. We could certainly talk about what is and what isn’t “surveyable” as a function of its appearance in any of the manuals, but if you haven’t referenced the AAMI stuff, you are in a position to have defend why you haven’t used such an august reference in your pursuit of alarm safety. To add a bit of heft to this advice, you might also consider the May 18, 2016 edition of Joint Commission Online, in which there is a link to an article published by the AAMI Foundation entitled “Framework for Alarm Management Maturity.”

This may be much ado about nothing, or more likely, folks are already “down” with this. But on the off chance that somebody out there actually uses this space for information and hasn’t run across this, I think it’s worth a mention. You certainly want to make sure that your alarm management process is maturing in proper fashion.

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

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

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

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

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

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

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

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