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Pauline’s Preposterously Perilous Permutations

Or, for the less aged folks, we could use Penelope Pitstop’s Preposterously Perilous Permutations…

I’ve recently had the opportunity to review some fourth quarter (2016) Joint Commission survey reports and I have to tell you that I’m not seeing indication of the rosiest of futures when it comes to the physical environment. (I keep trying to convince myself that it is merely because of my perspective that things seem to be weighted so heavily in the direction of the physical environment—it is, after all, my “beat.”) That being said, there does seem to be a trend in “where” the findings are being found, so to speak. And that, my friends, is in the outpatient setting, particularly physician office practices.

The story kind of starts with the “reveal” of TJC’s prepublication of the 2017 EC and LS chapters. I suspect that we will continue to discuss the various and sundry permutations of peril that will befall us as we move through the process, but this week I wanted to focus on a corner of the Life Safety chapter that doesn’t necessarily get a lot of attention: the Ambulatory Health Care Occupancy standards and performance elements.

Contained within the Ambulatory Health Care Occupancy section are some notes, one of which appears to be very much like business as usual when it comes to determining what rules in and what rules out when it comes to ambulatory surgery services, and so we have something to the effect that the ambulatory-related standards apply to care locations where four or more patients (at the same time) are provided either anesthesia or outpatient services that render those patients incapable of being able to save themselves in an emergency (I’m paraphrasing a bit here—our friends in Chicago are very attentive to verbatim quotes of their content—you’d think that the Cubs win might put them in a better frame of mind, but that’s too much risk. Maybe they’re sore winners…).

So, we got that one, yes? Pretty straightforward, very much in keeping with how we’ve been managing our outpatient environments, etc.

But then we move on to the second note, and the slope gets a bunch more slippery (and again, I paraphrase): if you use TJC accreditation for deemed status purposes, the ambulatory LS standards apply to outpatient surgical departments in hospitals—regardless of how many patients are rendered incapable (so that’s one patient all the way up to however many patients you can render incapable of self-preservation…ouch!). Now, I guess we could have some fairly lengthy discussion about exactly what constitutes “outpatient surgical departments in hospitals.” Does that mean physically within the four walls of the hospital? Does it mean operated under the hospital’s license or CMS Certification Number (CCN)? At the moment, I’m tending to lean towards the latter, just because it would be so much more messy.) It will be interesting to see how this whole thing rolls out into survey reality; it is entirely possible that folks are already having these discussions with their TJC account reps as planning for the 2017 survey season begins in earnest, if anyone has some indication on how, for instance, office-based surgical procedures are being accounted for in the process. Can you imagine having an LS surveyor heading out to all those physician offices in which surgical procedures are occurring? It’s about half past Halloween, but that’s a pretty scary thought. Sooooo, you might want to start evaluating your offsite locations for compliance with the LS.03.01.XX standards and performance elements.

Some other potential vulnerabilities relate to the management of high-level disinfection activities in these same office environments. I’m seeing a lot of the same types of findings that were once associated with areas like ultrasound, cardiology, etc., basically locations in which instruments and equipment are being manually disinfected. Lately I’ve seen findings relating to eyewash stations (check those disinfectant products to make sure that if you have a corrosive product, you’ve got a properly ANSI-configured eyewash station and if you have one, make sure it’s being checked on a weekly basis), management of disinfectant temperature, ensuring there is sufficient ventilation, making sure secondary containers are properly labeled (including biohazard labels), using PPE in accordance with the disinfectant product’s Instructions for Use, etc. The real “danger” here is that this appears to be becoming a mix that results in significant survey impact relative to the physical environment, infection control, even surgical services. These are findings that can “squirt” (small pun intended) in many different directions, causing a big freaking mess, particularly when it comes down to clinical surveyors conducting the outpatient portion of the survey. You might want to make sure you’ve got a very robust means of communications from the outpatient sites to ensure that you can nip these types of findings in the bud. But you also probably want to do a little focus education with the folks out in the hinterlands to ensure that PPE is available and used, products are being used properly, etc. I know it becomes “one more thing” to do, but I think we have to come to grips with the reality that the surveyors are becoming very adept at generating lots and lots of findings in the physical environment; they understand that there are locations in almost any healthcare organization that are not “attended” quite as robustly and that if they pick at certain common vulnerabilities, they will be rewarded with findings. We need to take that away from them, toot sweet!

Keep documenting those risk assessments: the Conditions of Participation and other regulatory rapscallia still do not tell us how to appropriately maintain a safe environment, so we have to be diligent in plotting our own course(s). We get to decide how we do this, but we do have to actually make those decisions—and make them in a manner that provides evidence of the process. I know it probably seems like a lot of drudge work, but it’s pretty much what we have to do.

As a closing note, I’d like to thank all the veterans for their service, pride and dignity—we are all the better for it!

I wanna know: Have you ever seen the rain?

In our intermittently continuing series on the (final!) adoption of the 2012 Life Safety Code®, we turn to the one area about which I have still the most concerns—the magic land of NFPA 99. My primary concern is that while NFPA 99 contains lots and lots of references to risk assessments and the processes therein, I’m still not entirely convinced that the CMS oversight of the regulatory compliance process is going to embrace risk assessments to the extent that would allow us to plot our own compliance courses. I guess I will have to warily keep my fingers crossed and keep an eye on what actually occurs during CMS surveys of the physical environment. So, on to this week’s discussion…

When considering the various and sundry requirements relating to the installation and ongoing inspection, testing and maintenance of electrical system components, one of the key elements is the management of risk associated with electrical shock in wet procedure locations. NFPA 99 defines a wet procedure location as “(t)he area in a patient care room where a procedure is performed that is normally subject to wet conditions while patients are present, including standing fluids on the floor or drenching of the work area, either of which condition is intimate to the patient or staff.”

Typically, based on that description, the number of areas that would “rule in” for consideration as wet procedure locations is pretty limited (and depending on the nature, etc., of the procedures being performed maybe even less limited than that). But in the modern age, the starting point for this discussion (and this is specifically provided for under section 6.3.2.2.8.4 of the 2012 edition of NFPA 99) is that operating rooms are to be considered wet procedure locations—unless a risk assessment conducted by the healthcare governing body (yow!) determines otherwise (all my yammering over the years about risk assessments is finally paying off—woo hoo!). By the way, there is a specific definition of “governing body”: the person or persons who have overall legal responsibility for the operations of a healthcare facility. This means you’re going to have to get your boss (and your boss’ boss and maybe your boss’ boss’ boss) to play in the sandbox on this particular bit of assessmentry.

Fortunately, our good friends at ASHE have developed a lovely risk assessment tool (this is a beta version) to assist in this regard and they will share the tool with you in exchange for just a few morsels of information (and, I guess, a pledge to provide them with some useful feedback as you try out the tool—they do ask nicely, so I hope you would honor their request if you check this out—and I really think you should). Since I’m pretty certain that we can attribute a fair amount of expertise to any work product emanating from ASHE (even free stuff!), I think we can reasonably work with this tool in the knowledge that we would be able to present it to a surveyor and be able to discuss how we made the necessary determinations relative to wet procedure locations. And speaking of surveys and surveyors, I also don’t think it would be unreasonable to think that this might very well be an imminent topic of conversation once November 5 rolls around and we begin our new compliance journey in earnest. Remember, there is what I will call an institutional tendency to focus on what has changed in the regulations as opposed to what remains the same. And I think that NFPA 99 is going to provide a lot of fodder for the survey process over the next little while. I mean think about it, we’re still getting “dinged” for requirements that are almost two decades old—I think it will be a little while before we get our arms (and staff) around the ins and outs of the new stuff. Batten down the hatches: Looks like some rough weather heading our way!

At any rate, here’s the link to the wet procedure location assessment tool.

Hope everyone has a safe and festively spooky (or spookily festive) All Hallows Eve!

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…

And to the surprise of absolutely no one…

Last week, the good folks at The Joint Commission announced the list of the five most challenging standards for hospitals surveyed during the first six months of 2016 (for those of you remaining reluctant to subscribe to the email updates, you can find the details for all accreditation programs here. For the purpose of this discussion, the focus will be on the hospital accreditation program—but if you want to talk detail specific to your organization—and you are not a hospital, just drop a line).

While there has been some jockeying for position (the once insurmountable Integrity of Egress is starting to fade a wee bit—kind of like an aging heavyweight champion), I think we can place this little grouping squarely in the realm of the management of the physical environment:

 

  • 02.06.01—safe environment
  • 02.02.01—reducing the risk of infections associate with medical equipment, devices and supplies
  • 02.05.01—utility systems risks
  • 02.01.20—integrity of egress
  • 02.01.35—provision and maintenance of fire extinguishing systems

I suspect that these will be a topic of conversation at the various and sundry TJC Executive Briefings sessions to be held over the next couple of weeks or so, though it is interesting to note that about while project REFRESH (the survey process’s new makeover) has (more or less) star billing (we covered this a little bit back in May) , they are devoting the afternoon to the physical environment, both as a straight ahead session helmed by George Mills, but also as a function of the management of infection control risks, with a crossover that includes Mr. Mills. I shan’t be a fly on the wall for these sessions (sometimes it’s better to keep one’s head down in the witless protection program), but I know some folks who know some folks, so I’m sure I’ll get at least a little bit of the skinny…

I don’t think we need to discuss the details of the top five; we’ve been rassling with them for a couple of years now and PEP or no PEP (more on the Physical Environment Portal in a moment), I don’t believe that there’s much in the way or surprises lurking within these most challenging of quintuplets (if you have a pleasant or unpleasant surprise to share, please feel free to do so). And therein, I think, lies a bit of a conundrum/enigma/riddle. As near as I can tell, TJC and ASHE have devoted a fair amount of resources to populating the PEP with stuff. LS.02.01.35 has not had its day in the port-ular sunshine yet,  but it’s next on the list for publication…perhaps even this month; not sure about IC.02.02.01, though I believe that there is enough crossover into the physical environment world, that I think it might be even be the most valuable portal upon which they might chortle. And it does not appear to have had a substantial impact on how often these standards are being cited (I still long for the days of the list of the 20 most frequently cited standards—I suspect that that list is well-populated with EC/LS/IC/maybe EM findings). As I look at a lot of the content, I am not entirely certain that there’s a lot of information contained therein that was not very close to common knowledge—meaning, I don’t know that additional education is going to improve thing. Folks know what they’re not supposed to do. And with the elimination of “C” performance elements and the Plans for Improvement process, how difficult is it going to be to find a single

  • penetration
  • door that doesn’t latch
  • sprinkler head with dust or paint on it
  • fire extinguisher that is not quite mounted or inspected correctly
  • soiled utility room that is not demonstrably negative
  • day in which temperature or humidity was out of range
  • day of refrigerator temperature out of range with no documented action
  • missing crash cart check
  • infusion pump with an expired inspection sticker
  • lead apron in your offsite imaging center that dodged its annual fluoroscopy
  • missed eyewash station check
  • mis- or unlabeled spray bottle
  • open junction box

 

I think you understand what we’re looking at here.

At any rate, I look at this and I think about this (probably more than is of benefit, but what can one do…), even if you have the most robust ownership and accountability at point of care/point of service, I don’t see how it is possible to have a reasonably thorough survey (and I do recognize that there is still some fair variability in the survey “experience”) and not get tapped for a lot of this stuff. This may be the new survey reality. And while I don’t disagree that the management of the physical environment is deserving of focus during the survey process, I think it’s going to generate a lot of angst in the world of the folks charged with managing the many imperfections endemic to spaces occupied by people. I guess we can hope that at some point, the performance elements can be rewritten to push towards a systematic management of the physical environment as a performance improvement approach. The framework is certainly there, but doesn’t necessarily tie across as a function of the survey process (at least no demonstrably so). I guess the best thing for us to do is to focus very closely on the types of deficiencies/imperfections noted above and start to manage them as data, but only to the extent that the data can teach us something we don’t know. I’ve run into a lot of organizations that are rounding, rounding, rounding and collecting scads of information about stuff that is broken, needs correction, etc., but they never seem to get ahead. Often, this is a function of DRIP (Data Rich, Information Poor) at this point, I firmly believe that if we do not focus on making improvements that are aimed at preventing/mitigating these conditions (again, check out that list above—I don’t think there’s anything that should come as a surprise), the process is doomed to failure.

As I tell folks all the time, it is the easiest thing in the world to fix something (and we still need to keep the faith with that strategy), but it is the hardest thing in the world to keep it fixed. But that latter “thing” is exactly where the treasure is buried in this whole big mess. There is never going to be a time when we can round and not find anything—what we want to find is something new, something different. If we are rounding, rounding, rounding and finding the same thing time after time after time, then we are not improving anything. We’re just validating that we’re doing exactly the opposite. And that doesn’t seem like a very useful thing at all…

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…

Blame it on Cain…

We’ll see how long this particular screed goes on when we get to the end…

In my mind (okay, what’s left of it), the “marketing” of safety and the management of the physical environment is an important component of your program. I have also learned over time that it is very rare indeed when one can “force” compliance onto an organization. Rather, I think you have to coax them into seeing things your way. At this point, I think we can all agree that compliance comes in many shapes, colors, sizes, etc., with the ideal “state” of compliance representing what it is easiest (or most convenient) for staff to do. If we make compliance too difficult (both from a practical standpoint, as well as the conceptual), we tend to lose folks right out of the gate—and believe you me—we need everybody on board for the duration of the compliance ride.

For instance, I believe one of the cornerstone processes/undertakings on the compliance ride is the effectiveness of the reporting of imperfections in the physical environment (ideally, that report is generated in the same moment—or just after—the imperfection “occurs”). There are few things that frustrate me more than a wall that was absolutely pristine the day before, and is suddenly in possession of a 2- to 3-inch hole! There’s no evidence that something bored out of the wall (no debris on the floor under the hole), so the source of the hole must have been something external to the hole (imagine that!). So you go to check and see if some sort of notification had occurred and you find out, not so much. Somebody had to be there when it happened and who knows how many folks had walked by since its “creation,” but it’s almost like the hole is invisible to the naked eye or perhaps there’s some sort of temporal/spatial disruption going on—but I’m thinking probably not.

I’m reasonably certain that one can (and does) develop an eye/sense for some of the more esoteric elements of compliance (e.g., the surveyor who opens a cabinet drawer, reaches in, and pulls out the one expired item in the drawer), but do we need to educate folks to recognize holes in the wall as something that might need a wee bit of fixing? It would seem so…

At any rate, in trying to come up with some sort of catch phrase/mantra, etc., to promote safety, I came up with something that I wanted to share with the studio audience. I’d appreciate any feedback you’d be inclined to share:

WE MUST BE ABLE:

CAPABLE

RELIABLE

ACCOUNTABLE

SUSTAINABLE

I’m a great believer in the power of the silly/hokey concept when you’re trying to inspire folks; when you think of the most memorable TV ads, the ones that are funny tend to be the most memorable in terms of concept and product (the truly weird ads are definitely memorable, but more often than not I couldn’t tell you what product was being advertised). I think that as a four-part vision, the above might be pretty workable. What do you think?

Sometimes you have to ignore what your parents told you

Well, maybe ignore is a bit strong…

One of the recurring themes from my childhood was the not-infrequent exhortation from my mother: Don’t go looking for trouble (probably not an uncommon theme for everyone out there in the studio audience). But one of the more common themes that I’ve been running into are those instances in which trouble was lurking in the weeds, but folks weren’t necessarily successful in identifying/locating trouble spots. As near as I can tell, the worst thing that can happen during a survey (from a safety perspective) is when a surveyor identifies a condition or a practice about which you had no clue. It doesn’t happen a lot, but it does happen (usually followed by “Wow, I didn’t know that”).

There are a number of reasons for such a happenstance—sometimes folks really don’t know about something (though, dear reader, you are probably not in that number as we discuss a whole bunch of esoteric stuff). For instance, I still get a lot of folks who (and I have to believe that they are being completely candid) don’t know that hand sanitizer expires (or medicated lotion soap…or disinfectant wipes) or they are supremely confident that that is someone else’s concern (usually EVS when it comes to the many soaps, sanitizers, and disinfectants that populate the healthcare landscape). To my mind, it all goes back to the role of point of care/point of service folks (and I give the caregivers equal billing/accountability with the service-givers on this count) in being able to identify and report or otherwise manage risks in the physical environment.

But we as safety professionals have to be wicked diligent (as I pen this, it’s the day after the Boston Marathon, so that’s my gratuitous reference to Boston cultchah) in really working to ferret out all these little foibles, imperfections, etc. I think I’ve said this before in this forum (and no doubt will again), but whichever regulatory survey team shows up at your front/back/side door, they are going to find “stuff”—the human condition does not easily attain perfection, which leaves us vulnerable, vulnerable, vulnerable.

I recognize that everyone is stretched for time—too many meetings, too many spreadsheets, too many “too manys” to count—which only serves to “push” the maximization of the not-enough’s (not enough time, not enough resources, not enough support) in this adventure. Think of it as a challenge—there are folks out there doing stuff you would rather they not do—sometimes you only see the result (damaged walls and doors, unsealed penetrations, spills, thrills, chills) and we all have to be more effective in keeping on top of things.

Past lessons learned are a wonderful thing, but sometimes you have to go at things a little differently, so go out there and find some trouble spots. You’ll be glad you did!

 

This American Hospital: HAIs resulting from exposure to lead

As I think I’ve mentioned in the past, I listen to a fair amount of public radio when I’m in the car, and this past Saturday, I stumbled (I’ve found that my errands don’t always coincide with the start and end of programs—thank the gods of radio for podcasts and other forms of re-broadcast) into the middle of a story that I found quite compelling. The program itself is called This American Life and emanates from WBEZ in Chicago; the nominal purpose of the program is to provide a forum for the airing of stories about (natch!) This American Life, which allows it to cover a lot of ground. I always find the stories pretty interesting/compelling, etc., but this past weekend’s episode really got me thinking about the ongoing struggles faced by hospitals as they try to balance security, workplace violence management, the management of behavioral health patients, education of staff in being able to effectively manage crisis situations, etc. Basically, the whole gamut of issues relating to the continuing disenfranchisement of the behavioral health patient community. There are some places that do pretty well with this, but I think the opportunities to do better far outweigh the improvements made so far (that’s as close to editorializing as I’m going to do for the moment).

As I think about it, while Joint Commission compliance is probably THE hot button item when it comes to the management of risks and conditions in the physical environment, I truly believe that, at least for the folks who are typically responsible for managing the physical environment, this topic is by far the more complicated—very much in line with the prevention of healthcare-acquired infections—and, interestingly enough, there can be a crossover, but more on that in a moment.

The story deals with a “delusional” (my quotes) patient who, in the course of his stay in a hospital (you can find out a lot of the details by listening to the episode, which can be found here) encountered a situation in which he did indeed contract an HAI because of an exposure to lead, namely a bullet fired by a police officer in this patient’s hospital room. Now (trying not to sound too old), back in my days of operational responsibility, I have overseen dealings with behavioral health patients, on-duty police officers discharging their weapons in the ED, folks injured as a result of physical encounters with patients, etc. But I have to tell you (and at least some of this is the power of the storytelling in conjunction with the story being told), the sequence outlined in the episode is about as harrowing as you could imagine: not very good decisions are made and sustained; family members are perhaps not embraced as a source of useful information (I’m trying to avoid more editorializing—but tell me the story doesn’t ring some bells with you, particularly  if you’ve had operational responsibility for security), staff are perhaps not as well-prepared as they might otherwise be—a real cluster of ugliness.

I know things are never as cut and dried as they seem to be in the aftermath; you might find the “official” response from the hospital a little curious (I did as well, but I understood the forces in play—sounds like there might still be some lingering litigation), but this type of confluence of events is all too easy to imagine. I think it’s definitely in the best interests for the safety/security community to advocate for the management of these types of patients based on the underlying causes (mental illness, behavioral health issues) and not just a panicked response to the symptoms. Yes, we will always have that quotient of patients who are just [insert epithet of your choice here]. But safe care can’t be sacrificed in the rush—safe for the patients, safe for the staff.

Fear is not sustainable

A Welshman of some repute once noted that “fear is a man’s best friend” and while that may have been the case in a Darwinian sense, I don’t know that the safety community can rely as much on it as a means of sustainable improvement. I’ve worked in healthcare for a long time and I have definitely encountered organizational leaders that traded in the threat of reprisal, etc., if imperfections were encountered in the workplace (and trust me when I say that “back in the day” something as simple as a match behind a door—left by a prickly VP to see how long it stayed there—could result in all sorts of holy heck), it typically resulted in various recriminations, fingerpointing, etc., none of which ended up meaning much in the way of sustained improvement. What happened was (to quote another popular bard—one from this side of the pond), folks tended to “end up like a dog that’s been beat too much,” so when the wicked witch goes away, the fear goes too, and with it the driving force to stay one step ahead of the sheriff (mixing a ton of metaphors here—hopefully I haven’t tipped the obfuscation scales).

At any rate, this all ties back to the manner in which the accreditation surveys are being performed, which is based on a couple of “truisms”:

 

  1. There is no such thing as a perfect building/environment/process, etc.
  2. Buildings are never more perfect than the moment before you put people in them.
  3. You know that.
  4. The regulators know that.
  5. The regulators can no longer visit your facility and return a verdict of no findings, because there are always things to find.
  6. See #1.

Again, looking at the survey process, the clinical surveyors may look at, I don’t know, maybe a couple of dozen patients at the most, during a survey. But when it comes to the physical environment, there are hundreds of thousands of square feet (and if you want to talk cubic feet, the numbers get quite large, quite quickly) that are surveyed—and not just the Life Safety (LS) surveyor. Every member of the survey team is looking at the physical environment (with varying degrees of competency—that’s an editorial aside), so scrutiny of the physical environment has basically evolved (mutated?) since 2007 from a couple hours of poking around by an administrative surveyor to upwards of 30 hours (based on a three-day survey; the LS surveyor accounts for 16 hours, and then you will have the other team members doing tracers that accounts for at least another 16 hours or so) of looking around your building. So the question really becomes how long and how hard will they have to look to find something that doesn’t “smell” right to them. And I think we all know the answer to that…

It all comes back (at least in my mind’s eye) to how effectively we can manage the imperfections that we know are out there. People bump stuff, people break stuff, people do all kinds of things that result in “wear and tear” and while I do recognize that the infamous “non-intact surface” makes is more difficult to clean and/or maintain, is there a hospital anywhere that has absolutely pristine horizontal and vertical surfaces, etc.? I tend to think not, but the follow-up question is: to what extent do these imperfections contribute to a physical environment that does not safely support patient care? This is certainly a question for which we need to have some sense of where we stand—I’m guessing there’s nobody out there with a 0% rate for healthcare-acquired infections, so to what degree can we say that all these little dings and scrapes do not put patients at risk to the extent that we cannot manage that level of risk? My gut says that the environment (or at least the environmental conditions that I’m seeing cited during surveys) is not the culprit, but I don’t know. As you all know by now (if you’ve been keeping tabs on me for any length of time), I am a big proponent of the risk assessment process, but has it come to the point where we have to conduct a risk assessment for, say, a damaged head wall in a patient room? Yes, I know we want to try and fix these types of conditions, but there are certain things that you can’t do while a patient is in the room and I really don’t think that it enhances patient care to be moving patients hither and yon to get in and fix surfaces, etc. But if we don’t do that, we run the risk of getting socked during a survey.

The appropriate management of the physical environment is a critical component of the safe delivery of healthcare and the key dynamic in that effort is a robust process for reporting imperfections as soon as possible (the “if you see something, say something” mantra—maybe we could push on “if you do something, say something”) so resources can be allocated for corrective actions. And somehow, I don’t think fear is going to get us to that point. We have to establish a truly collaborative, non-knee-jerk punitive relationship with the folks at the point of care, point of service. We have to find out when and where there are imperfections to be perfected as soon as humanly possible, otherwise, the prevalence of EC/LS survey findings will continue in perpetuity (or something really close to that). And while there may be some employment security pour moi in that perpetual scrutiny, I would much rather have a survey process that focuses on how well we manage the environment and not so much on the slings and arrows of day-to-day wear and tear. What say you?

If you set things up correctly…they will still find stuff!

Those of you who are frequent readers of this little space are probably getting tired of me harping on this subject. And while I will admit that I find the whole thing a tad disconcerting, I guess this gives me something to write about (the toughest thing about doing the blog is coming up with stuff I think you folks would find of interest). And so, there is an extraordinary likelihood that you will have multiple EC/LS findings during your next triennial Joint Commission visit—and I’m not entirely convinced that there’s a whole lot you can do to prevent that from happening (you are not powerless in the process, but more in that in a moment).

Look at this way: Do you really think that you can have a regulatory surveyor run through your place for two or three days and at the end “admit” that they couldn’t find any deficiencies? I’ve worked in healthcare long enough to remember when a “no finding” survey was possible, but the odds are definitely stacked against the healthcare professionals when it comes to this “game.” And what amazes me even more than that is when folks are surprised when it happens! Think about, CMS has been taking free kicks on TJC’s noggin for almost 10 years at this point—because they weren’t finding enough issues during the triennial survey process. BTW, I’m not saying that there’s a quota system in place; although there are certainly instances in which surveyors over-interpret standards and performance elements, I can honestly say that I don’t find too many findings that were not (more or less) legitimate. But we’re really and truly not talking about big-ticket scary, immediate jeopardy kind of conditions. We are definitely talking mostly about the minutiae of the safety world—the imperfections, if you will—the slings and arrows of outrageous fortune that one must endure when one allows humans to enter one’s hallowed halls. People mess stuff up. They usually don’t mean to (though there are some mistakes, and I think you can probably think of some examples in your own halls), but as one is wont to say, feces occurs. And there’s a whole segment of each healthcare organization charged with cleaning up that feces—wherever and however it occurs.

So what it all comes down to is this: you have to know what’s going on in your building and you have to know where you stand as a function of compliance, with the subset of that being that you have to have a robust process for identifying conditions soon enough and far enough “upstream” to be able to manage them appropriately. We’ve discussed the finder/fixer dynamic in the past (here’s a refresher), so I won’t belabor that point, but we need to use that process to generate compliance data. Strictly speaking, you really, really, really need to acquaint yourselves with the “C” Elements of Performance; compliance is determined as a rate and if you can demonstrate that your historical compliance rate is 90% or better, then you are in compliance with that standard/EP. But if you’re not using the surveillance process, the finder/fixer process, the tracer process, the work order process, the above the ceiling permitting process, ad nauseum, to generate data that can be used to determine compliance, then you are potentially looking at a very long survey process. Again, it goes back to my opening salvo; they are going to find “stuff” and if you are paying good attention to what goes on in your organization, then they shouldn’t be able to find anything that you don’t already know about.

The management of the physical environment is, at its heart, a performance improvement undertaking. As a support process for hardwiring ongoing sustained improvement, a process for the proactive risk assessment of conditions in the physical environment is essential. As an example, the next assessment would use the slate of findings from your most recent surveillance rounds to extrapolate the identification of additional risks in the physical environment. For all intents and purposes, it is impossible to provide a physical environment that is completely risk free, so the key focus becomes one of identification of risks, prioritizing the resolution of those risks that can be resolved (immediate and long-term), and to develop strategies for managing those risks that are going to require resource planning and allocation over an extended period of time. The goal of the process is to ensure that the organization can articulate the appropriate management of these risks and to be able to provide data (occurrence reporting, etc.) to support the determination of that level of safety. By establishing a feedback loop for the management of risk, it allows the organization to fully integrate past actions into the improvement continuum. If you think of the improvement continuum as a football field (it is, after all, the season for such metaphors) or indeed any game “environment,” you need to know where you are in order to figure out where you need to go/be. The scrutiny of the physical environment has never been greater and there’s no reason to think that that is going to change any time soon. Your “power” is in preparing for the survey by being prepared to make full use of the post-survey clarification process—yup, they found a couple of doors that didn’t close and latch, a fire extinguisher that missed a monthly inspection or two, and on and on. Anticipate what they’ll find based on what you see every time you “look” (again, it’s nothing “new” to you—or shouldn’t be) and start figuring out where you are on the grid. That way, they can find what they want (which they will; no point in fighting it anymore) and you can say, thanks for pointing that out, but I know that my compliance rate for doors/fire extinguishers/etc. is 90%, 91%, 92%, etc. We want them to work very hard to find stuff, but find stuff they will (that’s a little Yoda-esque). We just have to know what do “aftah.”