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Every once in a while…

…I make good on the promise of brevity. Let’s see if this is one of those weeks.

As we continue to wind down from the various and sundry modifications that were made to the physical environment to provide appropriate care for patients (and appropriate levels of safety for staff) during the pandemic, it might be a good point to ascertain whether any of the persisting conditions/practices are representative of Life Safety Code® (LSC) or other compliance issues. I am very hopeful that folks are going to be able to “take some time off” this summer (working on the thought that last year, not so much), so my thought is to add (at least) one last go-round before the solstice is upon us—that way, if any regulatory f(r)iends show up over the next few months, you will have a defensible position for any lingering programmatic elements that could raise questions.

To aid in that endeavor, you might consider this article from Healthcare Facilities Management that provides some guidance on just that. There remains the whole notion that we have 60 days after the suspension of the Public Health Emergency (which was renewed in April) to “return to normal,” but it also can tie into whether your organization is still responding to the emergency. If your incident command structure has been discontinued, you may want to really start preparing for bridging any compliance gaps that may still be in place. As you know (by now), I tend to be a proponent for the risk assessment process and any time the future of compliance is uncertain, risk assessments are our best strategy for demonstrating compliance.

One other item for this week. I would encourage you to check out the capabilities of Smart911; while this may not be entirely work-related as a suggestion, from a peace of mind standpoint, ensuring that emergency responders have access to as much pertinent information (and you can decide what is, and what is not, pertinent—hmmm, could be another risk assessment). The more information responders have at their disposal (including your whereabouts if you’re notifying them on a mobile phone), there more quickly and effectively they can respond to the emergency. With all the issues of privacy, etc., there are certain entities that would be more effective in their response, and I think Smart911 makes a lot of sense to be included in trusted sources (hopefully that is not a fleeting thought). Check ’em out and see for yourself. If you’re not comfortable with the process, I get it, but reach out to your local emergency folks to see how they feel about it before you elect not to participate.

Just about a week left of spring 2021. I hope this finds you well and perhaps just a wee bit less anxious about your existence. Until next time…

Risk assessments: Don’t leave home without one!

An interesting phenomenon I’ve been encountering of late relates to the whole notion of having to do environmental risk assessments in locations that are not specifically designated for the management of behavioral health patients. At this point, I don’t know of any healthcare organizations that would be able to say that they would not be managing behavioral health patients, even if they don’t have inpatient bed capacity, though I suppose you might be able to set up a transfer policy with another local organization that does have inpatient capacity. But those beds are typically in fairly sort supply and might well end up with having to “hold” a behavioral health patient for a prolonged period of time. Maybe you can manage that continuum in your ED, but what if you had a surge of, hmmm, let’s say infectious patients. Is there a possibility that a behavioral health patient could end up on an inpatient unit? And could you say absolutely in either direction without having a risk assessment in your back pocket?

So you could make the case that moving the environmental concerns relating to behavioral health patients from the Environment of Care standards to the National Patient Safety Goals section of the accreditation program has clarified (to a degree) the expectations relative to the management of at-risk patients, but that clarity brings with it some mandates. The mandate comes in three pieces (so to speak): a thoughtful evaluation of the environment; a plan; and available resources to guide staff when you have to put at-risk patients in an environment that is not designated for managing that type of patient.

To my eyes and ears, a thoughtful evaluation of the environment sounds an awful lot like a risk assessment; the FAQ goes on to describe some examples of resources that could be provided to staff, including the use of an on-site psych professional to complete the environmental risk assessment if staff are not sufficiently competent to do so. Which means that, if you do use in-house staff, you might be pushed to identify how you know that the folks doing the evaluation of the space immediately before a patient is placed are competent to do so. Though I suppose that also means you might have to demonstrate how you evaluated the on-site psych person… ah, it never really ends, does it?

At any rate, if you have not done a quick (but thoughtful—gotta be thoughtful!) risk assessment of your non-BH patient spaces, it’s almost certainly worth your time to do so. To my mind, the best risk assessment of all is the one they don’t ask for because the effectiveness of the process is in evidence. But sometimes we don’t get credit for “doing the math in your head,” so the possession of the risk assessment is your best bet.

Thanks for tuning in. Please be well and continue to stay safe. Until next time…

Why does it happen? Because it happens…

As to that thought/question (or question/thought), for those of you working through your utility systems risk assessments to ensure compliance with NFPA 99 Chapter 4: How are you accounting for components/equipment that aren’t necessarily being managed through your work order system? I’m think of systems like pharmacy hoods, nurse call systems, IT equipment, etc. Strictly speaking, those would fall under the categories found in NFPA 99, so are you reaching out for the info or are those stakeholders doing their own risk assessments? To be honest, I’m not sure how much of a compliance vulnerability this might be. I know it’s important to identify and appropriately manage your high-risk utility systems components and that’s certainly a potential area of scrutiny during a survey (particularly if they start moving towards a more extensive, virtual document review process). It can be a chore trying to account for everything that would be considered a utility system component, especially if you don’t have it in “your” inventory.

I know there have been instances in the past relative to the management of medical equipment in which primary stakeholders like imaging or lab services manage their own equipment inspection, testing, and maintenance without ever really bringing performance data, etc., up through the EOC committee function. Anything that is considered medical equipment, as would be the case with utility systems equipment, is part of the hospitalwide program and needs to be represented as such. There is no specific frequency for these “branches” of your programmatic “tree” to be reported at EOC, but you need to be able to trace the associated processes as a function of your EOC program.

Have a great week and stay safe. Perhaps autumn will bring a change in fortunes!

The trouble with normal: Some things to consider as we ease back into recovery

I think we can all agree that there are a lot of stressors in motion as we navigate the unknowns of the pandemic; some of which one might not normally encounter and others are just an amped-up version of “business as usual.” As we near the end of May, it does seem like there is a little bit of movement towards a return to normalcy (recognizing that we’ve probably bid adieu to the “old” normal), which has prompted some consideration of the demands placed on our facilities’ systems and how best to position ourselves to safely engage the recovery phase of this historic emergency response.

Another point of agreement (hopefully) would be that elements relating to infection control are going to be scrutinized more than ever as the accrediting organizations get back to it. I suspect that at least part of that scrutiny will involve the overarching management of utility systems and their components. Fortunately, there is much to be learned from/shared by folks I consider to be excellent sources of information and insight.

As was the case before the onset of COVID-19, I think the management of building water systems is going to come into play and, particularly if you’ve had to reduce usage in some areas of your facility, bringing things back online represent some real challenges. Certainly, the focus on managing the risks associated with waterborne pathogens goes back more than just a few months, but the following should be enough for you to get ahead of the curve.

The first two articles, penned by Matt Freje from HCInfo, focus on some key planning/prevention considerations that, at the very least, should be a part of your planning risk assessment going forward. It’s all completely sensible and clear in direction, particularly as work towards appropriate management of environmental conditions for our most at-risk patient populations, and both articles are definitely work a look. They cover building water systems and Legionella concerns.

Finally, for this week, we have a webinar covering potential Legionella risks as we ramp our buildings up to normal speed, sponsored/presented by the good folks at the ScalingUp!H2O podcast. Lots of good information presented by Dr. Janet Stout of Special Pathogens Laboratory. There’s a slide presentation, hence its availability on YouTube, but (again) worth the 35 or so minutes of your time to check it out.

Please continue to stay safe and productive during the pandemic. Thank you for your hard work and dedication to keeping things on an even keel!

When you get to the end, you get to start all over again…

I know you folks have (more or less) been under a constant bombardment of facts, figures, strategies, etc., relating to COVID-19 and, as every day brings us a little closer to a return to some sort of normalcy (It will be interesting to look back on how things changed as the result of the current emergency), I wanted to chat this week about one of those “other” things that is likely to be on the to-do list when we get to the recovery phase of this emergency. Not that long ago (OK, two weeks ago), we covered the potential for an intensification of scrutiny in the outpatient setting. And, as it should turn out, one of those areas of potential is the management of behavioral health patients in that setting. Last month (March 2020) our friends in Chicago posted an FAQ aimed at “hospital and hospital clinic settings” that talks about expectations relative to risk assessments in non-psychiatric units/areas in general hospitals. Of particular interest to me is the invocation of competency as a function of conducting the risk assessment “in areas where staff do not have the training to do this independently” and referencing “on-site psychiatric professional” as a potential resource. To me, that likely means that (and this may be the case of any risk assessment upon which you’ve modified practice, the environment, etc.) there will be questions about the risk assessment process, including “How do you know that the folks involved with the assessment were competent?” or something akin to that. I don’t know that everyone who has to (at least periodically) manage behavioral health patients is going to be able to access “on-site psychiatric professional” assistance, in which case it’s probably a good idea to clearly establish the credentials of the team or individual crafting the assessment. You can see what elements you’ll want to include here.

To aid in ensuring an appropriate environment for behavioral health patients, you might find the information assembled by the Center For Health Design to be useful. There is (almost literally) a ton of resources, from interviews, webinars, and podcasts to discussions of design elements, etc. As we have seen over the past few years, the management of the behavioral health environment is very much a moving target and the more information we have at our disposal, the more (dare I say) competence we can obtain. Every one of us is a caregiver to one degree or another and this is another useful resource that will help provide the most healing environment possible.

Please stay safe and (reasonably) sane ’til next time!

Who remembers pop-o-matic Trouble?

In something of a variation on another bloggy evergreen, I ask the rhetorical question: To what, if any, extent have you included consideration of  board games in your physical environment risk assessments for behavioral health? As I think towards a generation (are they already here?) for which the glories of board games will be forever lost, our friends in Chicago offer the latest challenge in managing risks with our all-too-vulnerable patient populations (for those of you of a certain vintage, the description of a board game is very nearly worth the price of admission).

The article describes the quite inventive use of a plastic board game piece to defeat the reptilian tamper-resistant screws and suggest some alternative products that do not so easily surrender to such efforts. I don’t know that I’ve been privy to a lot of discussion relative to board games in the behavioral health setting, but I suppose this would come under the heading of “everything has an inherent, though perhaps not apparent, risk.” Based on some recent surveys, it seems that Joint Commission surveyors have been rather inventive in looking for physical environment elements that have not been specifically accounted for in the assessment process. The classic example is including medical beds in the risk assessment, but not specifically mentioning the risks associated with the ligature-resistance (or not) of the side rails, bed frame, etc. Sooooooo, if they have not yet been included in your risk assessment activities, it might be a good time to pull a little group together and ponder the use of board games (and perhaps other such items) as a function of the behavioral health physical environment risk assessment.

Should we think about Halloween candy as well?!?

Check and mate!

Last Call for 2018: National Patient Safety Goal on suicide prevention

While I will freely admit that this based on nothing but my memory (and the seeming constant stream of reasons to reiterate), I believe that the management of behavioral health patients as a function of ligature risks, suicide prevention, etc., was the most frequently occurring topic in this space. That said, I feel (reasonably, but not totally) certain that this is the last time we’ll have to bring this up in 2018. But we’ve got a whole 52 weeks of 2019 to look forward to, so I suspect we’ll continue to return to this from time to time (to time, to time, to time—cue eerie sound effects and echo).

If you’ve had a chance to check out the December 2018 edition of Perspectives, you may have noticed that The Joint Commission is updating some of the particulars of National Patient Safety Goal (NPSG) #15, which will be effective July 1, 2019, though something tells me that strategies for compliance are likely to be bandied about during surveys before that. From a strategic perspective, I suspect that most folks are already taking things in the required direction(s), so hopefully the recent times of intense scrutiny (and resulting survey pain for organizations) will begin to shift to other subjects.

At any rate, for the purposes of today’s discussion, there is (and always will be) a component relating to the management of physical environment, both in (and on) psychiatric/behavioral health hospitals and psychiatric/behavioral health units in general hospitals (my mother-in-law loves General Hospital, but I never hear her talking about risk assessments…). So, the official “environmental risk assessment” must occur in/on behavioral health facilities/units, with a following program for minimizing the risks to ensure the environment is appropriately ligature-resistant. No big changes to that as an overarching theme.

But where I had hoped for a little more clarity is for those pesky areas in the general patient population in which we do/might manage patients at risk to harm themselves. We still don’t have to make those areas ligature resistant, with the recommendation aimed at mitigating the risk for patients at high risk (the rest of the NPSG covers a lot of ground relative to the clinical management of patients, including identification of the self-harm risks). But there is a note that recommends (the use of “should” in the note is the key here, though I know of more than a handful of surveyors that can turn that “should” into a “must” in the blink of an eye) assessment of clinical areas to identify stuff that could be used for self-harm (and there’s a whole heck of a lot of stuff that could be used for self-harm) and should be routinely removed when possible from the area around a patient who has been identified as high risk. Further, there is an expectation that that information would be used to train staff who monitor these high-risk patients, for example (and this is their example, but it’s a good ‘un), developing a checklist to help staff remember which equipment, etc., should be removed when possible.

It would seem we have a little time to get this completed, but I would encourage folks to start their risk identification process soon if you have not already done so. I personally think the best way to start this is to make a list of everything in the area being assessed and identify the stuff that can be removed (if it is not clinically necessary to care for the patient), the stuff that can’t be removed (that forms the basis of the education of staff—they need to be mindful of the stuff that can’t be removed after we’ve removed all that there is to be removed) and work from there. As I have maintained right along, in general, we do a good (not perfect) job with managing these patients and I don’t think the actual numbers support the degree to which this tail has been wagging the regulatory dog (everything is a risk, don’t you know). Hopefully, this is a sign that the regulatory eyeball will be moving on to other things.

The coexistence of safety leadership and empathy

Two items this week; one survey-related musing and a suggestion for your holiday season reading list.

Monthly GFCI testing: How are you making that happen? While I believe this came up during a mock survey (albeit by an “official” accreditation organization that starts with the letter “C,” ends with a “Q” and greets you if you look in the mirror…), these things sometimes feed on themselves, so to speak. And, since this is one for which I suspect folks might have some challenges, I figured I’d open this Pandora’s Box just in time for the holiday season.

In this particular mock survey, the facilities folks were asked to produce documentation of the monthly testing of the ground fault circuit interrupter (GFCI) receptacles, which is required as a function of the manufacturer’s instructions for use. In this particular instance, the response was generally minimal, with some questioning back as to the validity of the question. Of course, a quick web search for the GFCI receptacles in question (manufactured by Hubbell) revealed that, why yes indeedy, the monthly testing is right there in the details (I think this may be a good take on who lives in the details, but I digress). In this particular instance, the hospital wasn’t doing it, hadn’t done a risk assessment—either as a singularity or as a function of including the receptacles in an Alternative Equipment Management (AEM) program. So, I put the question to the studio audience: How many of you folks out there are doing the monthly testing of the GFCI (or are you not)? Have you gone the AEM route for this one? Seems like it would be a good candidate with which to get your feet “wet” relative to the risk assessment process. Somehow, I think this might be the dawn of the latest “gotcha” finding, so maybe a little fair warning is in order.

Moving on to the bookshelf (I still read books—I don’t mind using a tablet for some stuff, but for real “reading,” I still like the tactile sensation of a book), I’m in the middle (well, a little past middle, say ¾) of a book entitled “Forged in Crisis—The Power of Courageous Leadership in Turbulent Times” by Nancy Koehn. The book contains five stories of historical figures (Ernest Shackleton, Abraham Lincoln, Frederick Douglass, one less well-known to me—Dietrich Bonhoeffer—and Rachel Carson). So far, and probably because his story was the least familiar to me, the Dietrich Bonhoeffer portion of the book was most interesting. He was a minister in Germany during the period leading up to, and through, World War II. I won’t spoil any of the details but one key element of Herr Bonhoeffer’s leadership that’s identified (among others) is empathy, with the point being “the more volatile the larger environment, the more crucial it is for…others with significant authority to appreciate the experiences of those with less power and fewer options.” For a number of reasons (some personal, some professional) that struck me as a very useful quality to possess when one is trying to manage a large and complex environment, particularly consideration of that less power/fewer options dynamic. At any rate, I’m all in favor of lionizing positive role models, so if you have some reading time over the holidays, you might find this a most compelling read.

I got those travelin’ code compliance blues…

One occupational hazard (or probably more correctly an occupational preoccupation) I find is a constant awareness of code violations wherever I go. It seems that there are an awful lot of airports, concert venues, and the like that are engaged in upgrading facilities, and often, there are plenty of opportunities to look up into the areas above the ceiling envelope. Now I absolutely understand why healthcare gets a lot of scrutiny relative to concerns of life (and general) safety—far too many folks incapable of self-preservation to put them at risk. But as I wander around looking at stuff, I’m thinking we’re dealing with a whole mess of folks (euphemistically called passengers) in almost a collective daze, mesmerized by their cell phones, etc., who would be difficult to manage in the event of an emergency (I also have no doubt that the folks in charge in these various venues have already considered this and have plans in place).

At any rate, just this morning, I was privy to a number of open junction boxes, cabling attached to sprinkler piping, the odd penetration (don’t have the life safety drawings to hand, so I can’t say), in areas just outside of the main construction zone(s)—and no, I didn’t see a posted infection control risk assessment, but it does make one wonder whether it might not be such a bad thing. Presumably things are well-isolated from an HVAC standpoint, though certainly less so from a noise standpoint, but the whole thing does periodically give one (or at least gives me) pause. It is generally acknowledged that healthcare is a heavily regulated industry, and while I think we could certainly engage in extensive debate about the prioritization of risk when it comes to some of the minor imperfections that have become so much a part of the typical survey report, I don’t know that I would alter the accreditation process (which is kind of self-serving as helping folks manage the process is how I make a living).

In the end, this probably a little ado about nothing, but sometimes one is charged with channeling one’s inner curmudgeon…

One item as we close out this week, Health Facilities Management is soliciting input on the operational challenges relating to various monthly inspection and testing items (exit signs, elevator recall) as a function of (more or less) “if you already have a reduced resource pool with which to work, how are you going to manage these.” Check out an article discussing this in general, which includes links to the surveys for each area of consideration. ASHE has been a very effective advocate over time when it comes to compliance activities, so I think it would be good to make your voice heard.

There’s no such thing as someone else’s code: Infection control and the environment (again…)

Periodically, I field questions from folks that require a little bit (well, perhaps sometimes more than a little) of conjecture. Recently, I received a question regarding the requirements in ASHRAE 170-2008 regarding appropriate pressure relationships in emergency department and radiology waiting rooms (ASHRAE 170-2008 says those areas would be under negative pressure, with the caveat that the requirement applies only to “waiting rooms programmed to hold patients awaiting chest x-rays for diagnosis of respiratory disease”).

Right now, that particular question is kind of the elephant in the room from a regulatory perspective; there is every indication that The Joint Commission/CMS are working their way through ASHRAE 170-2008 and have yet to make landfall on this particular requirement—as far as I know—feel free to disabuse me of that notion. The intent of the requirement (as I interpret it) is to have some fundamental protections in place to ensure that an isolated respiratory contagion does not have the capacity of becoming a legitimate outbreak because of inadequate ventilation. Now, you could certainly use the annual infection control program risk assessment to identify whether your waiting rooms are “programmed to hold patients awaiting chest x-rays for diagnosis of respiratory disease” based on the respiratory disease data from the local community (and you might be able to obtain data from a larger geographic area, which one might consider a “buffer zone”).

Best case scenario results in you being able to take this completely off the table from a risk standpoint, next best would be that you introduce protocols for respiratory patients that remove them from the general waiting rooms (depending on the potential numbers, you may not have the space for it), worst case being that you have to modify the current environment to provide appropriate levels of protection. The notation for this requirement does provide some relief for folks with a recirculating air system in these areas, which allows for HEPA filters to be used instead of exhausting the air from these spaces to the outdoors, providing the return air passes through the HEPA filters before it introduced into any other spaces.

Knowing what I do about some of the ventilation challenges folks have, I suspect that it may make more sense to pursue the HEPA filtration setup than it would be to try to bring each of the spaces under negative pressure, but (going out on a limb here) that might be a question best answered by a group of knowledgeable folks (including an individual of the mechanical engineering persuasion) as a function of the (wait for it…) risk assessment process.

Ultimately, it comes down to what the Authority Having Jurisdiction chooses to enforce; that said, it might be worth having someone work through your state channels or by putting the question to the Standards Interpretation Group at Joint Commission (I suspect that their response would not be not particularly instructive beyond the usual “do a risk assessment” strategy, but there is a new person running the Engineering group at TJC, so perhaps something a little more helpful might be forthcoming). At any rate, as noted above, I’ve not heard of this being cited, but I also know that if there’s an outbreak tied to inadequate ventilation somewhere, this could become a hot topic pretty quickly (probably not as hot as ligature risks at the moment, but you never know…).