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E to the E to the E to the E: Next step(s) towards a reporting culture

Thinking that this may have gotten lost in the year-end shuffle, I wanted to take a moment to cover a little ground relative to Sentinel Event Alert (SEA) #60: Developing a reporting culture: Learning from close calls and hazardous conditions. I believe (I was going to say “know,” but that’s probably a little more hyperbolic than I can reasonably venture, but I’m basing it on your “presence” here—you folks are all about getting better and on the off chance that I provide something useful to that end, I’m pleased to have you along for the ride) that you folks are committed to ongoing evaluation of performance, occurrences, funky happenstance, etc. and so little of this will come as anything resembling revelation. That said, I think we do need to prepare ourselves for the wild and wacky world of surveyor overreach and draconian interpretation. Part of my “concern” (OK, perhaps most of it) revolves around the innate simplicity of the thrust of SEA #60. It’s straightforward, cogent, and all the things you would want through which to develop a compliance framework:

  • Establish trust
  • Encourage reporting
  • Eliminate fear of punishment
  • Examine errors, close calls and hazardous conditions

But, how do you know when you’ve actually complied with this stuff? Is this more of an activity-driven requirement: We’re going to do A, B, and C to “establish” trust, then we’ll do D, E, F, G, and H to encourage reporting? (Aren’t we already encouraging reporting?) And the whole “eliminate fear” thing (I’ve had one or two bosses that would have a hard time not administering some sort of retributory action if you messed up)…how do you pull that off? Likely, the examination of errors and close calls is a normal part of doing business, but the examination of hazardous conditions seems less of a fit in this hierarchy. My own tendency when I find a hazardous condition is to try and resolve it (I do love a good session of problem-solving), but maybe it’s more of an examination once someone reports the condition as hazardous. Not quite sure about that.

At any rate, there’s lots of information available on the subject, including an infographic on the 4E methodology, as well as the usual caches of information, etc. which you can find here and here and here.

I am a big fan of encouraging the reporting of stuff by the folks at the point of care/point of service, so to the extent that this moves healthcare in that direction, I’m all for it. So, my question to you is: Does  this represent a shift for the way in which you practice safety in your organization or perhaps gives you a little bit more leverage to get folks to “say something if they see something”? Does this help or is it just so much “blah, blah, blah”?

What the world needs now: Effective management of workplace violence

By now I’m sure you’ve all noted the unveiling of the latest Sentinel Event Alert (#59 for those of you keeping count) from our friends in Chicago; this particular SEA represents the third swing at concerns and considerations relative to workplace safety, inclusive of workplace violence. But, as I look at the information and guidance provided in the May 2018 issue of Perspectives, it makes me wonder what pieces of this remain elusive to folks, beyond the “normal” operational challenges of providing effective safety education to staff on a regular basis.

So, my questions for the group are these:

  • Have you clearly defined workplace violence?
  • Have you put systems into place across your organization that enable staff to report workplace violence events, inclusive of verbal abuse?
  • Have you identified all the potential sources of data relative to workplace violence occurrences?
  • Are you capturing, tracking, and trending all reports of workplace violence, inclusive of verbal abuse and attempted assaults, when no harm occurred?
  • Are you providing appropriate follow-up and support to victims, witnesses, and others impacted by workplace violence, including psychological counseling and trauma-informed care?
  • Are you reviewing each case of workplace violence to determine the contributing factors?
  • Are you analyzing data related to workplace violence, and worksite conditions, to determine priority situations for intervention?
  • Have you developed any quality improvement initiatives to reduce incidents of workplace violence?
  • Have you provided education to all staff in de-escalation, self-defense, and response to emergency codes?
  • Are you evaluating on an ongoing basis the effectiveness of your workplace violence reduction initiatives?

If your response to any of these questions is “no” or “not sure,” it’s probably worth (at the very least) some discussion time at your EOC and/or organizational QAPI committee, but I have a strong suspicion that most of you have already identified the component pieces identified above in your own efforts. That’s not to say that there aren’t improvement opportunities relative to workplace violence (as there likely always will be), but I do think we’ve made some pretty decent strides in this regard over the past few years. There was a time when the incidence rate was sufficiently concentrated to certain healthcare environments (cities, urban areas, etc.), but, and this is probably the toughest risk element to truly manage, it appears that workplace violence can happen at any time, anywhere. In some ways, it reminds me of the early days of the Bloodborne Pathogens standard and Universal Precautions; it was frequently a struggle for safety and infection control folks to sufficiently encourage good behaviors (and lord knows hand washing can still be a struggle), but much of what was initially viewed as foreign, inconvenient, etc. has finally been (something close to) hardwired into behaviors.

Again, I’m not convinced that this revisitation of covered territory helps anything more than increasing the risks of getting hammered during a survey if you can’t specifically identify how your program reflects their expert advice, but maybe it will help to gently remind organizational leaders that this one’s not going to go away.

Roll over Beethoven!

As we mark the passing of yet another (couple of) pop culture icon(s), I’m feeling somewhat reflective as I place fingers to keyboard (but only somewhat). As I reflect on the potential import of Sentinel Event Alert #57 and the essential role of leadership, one of the common themes that I can conjure up in this regard has a lot to do with the willingness/freedom of the “generic” Environment of Care/Safety program to air the organization’s safety-related (for lack of a better term—if you have a better one that’s not really PC, send it on) dirty laundry (kick ’em when they’re up, kick ’em when they’re down). I’ve seen a spate of folks getting into difficulties with CMS because they were not able to demonstrate/document the management of safety shortfalls as a function of reporting those shortfalls up to the top of their organization in a truly meaningful way. As safety professionals, you really can’t shy away from those difficult conversations with leadership—leaky roofs that are literally putting patients and staff at risk (unless you are doing incredibly vigorous inspections above the ceiling—or even under those pesky sinks); HVAC systems that are being tasked with providing environmental conditions for which the equipment was never designed; charging folks with conducting risk assessments in their areas…perhaps the impact of reduced humidity on surgical equipment. There’s a lot of possibilities—and a lot of possibility for you to feel the jackboots of an unhappy surveyor. One of the responsibilities of leaders, particularly mid-level leaders—and ain’t that all of us—is to work things through to the extent possible and then to fearlessly (not recklessly) escalate whatever the issue might be, to the top of the organization.

I was recently having a conversation with my sister about an unrelated topic when we started discussing the subtle (OK, maybe not so subtle) differences between two of my favorite “C” words: commitment and convenience. My rule of thumb is that convenience can never enter the safety equation at the expense of commitment (I suppose compliance works as well for this) and all too often I see (and I suspect you do, too) instances in which somebody did something they shouldn’t have because to do the right thing was less convenient than doing the wrong (or incorrect) thing. Just last week, I was in an MRI suite in which there were three (count ’em: 1, 2, 3) unsecured oxygen cylinders standing (and I do mean standing) in the MRI control right across the (open) door from the MRI. There was nobody around at the moment and I thought if there was a tremor of any magnitude (and I will say that I was in a place that is no stranger to the gyrations of the earth’s crust) and those puppies hit the deck, well, let’s just say that there would have a pretty expensive equipment replacement process in the not-too-distant future. The question I keep coming back to is this: who thinks that that is a good idea? I know that recent times have been a struggle relative to segregation of full and not full cylinders, but I thought we had really turned a corner on properly securing cylinders. These are the times that try a person’s soul: tell Tchaikovsky the news! Compliance ≠ Convenience…most of the time.

Do you know the way to TIA?

Last week we touched upon the official adoption of a handful of the Tentative Interim Agreements (TIA) issued through NFPA as a function of the ongoing evolution of the 2012 edition of the Life Safety Code® (LSC). At this point, it is really difficult to figure out what is going to be important relative to compliance survey activities and what is not, so I think a brief description of each makes (almost too much) sense. So, in no particular order (other than numerical…):

  • TIA #1 basically updates the table that provides the specifications for the Minimum Fire Protection Ratings for Opening Protectives in Fire Resistance-Rated Assemblies and Fire-Rated Glazing Markings (you can find the TIA here). I think it’s worth studying up on the specific elements—and perhaps worth sharing with the folks “managing” your life safety drawings if you’ve contracted with somebody external to the organization. I can tell you from personal experience that architects are sometimes not as familiar with the intricacies of the LSC—particularly the stuff that can cause heartburn during surveys. I think we can reasonably anticipate a little more attention being paid to the opening protectives and the like (what, you thought it couldn’t get any worse?), and I suspect that this is going to be valuable information to have in your pocket.
  • TIA #2 mostly covers cooking facilities that are open to the corridor; there are a lot of interesting elements and I think a lot of you will have every reason to be thankful that this doesn’t apply to staff break rooms and lounges, though it could potentially be a source of angst around the holidays, depending on where folks are preparing food. If you get a literalist surveyor, those pesky slow cookers, portable grills, and other buffet equipment could become a point of contention unless they are in a space off the corridor. You can find the whole chapter and verse here.
  • Finally, TIA #4 (there are other TIAs for the 2012 LSC, but these are the three specific to healthcare) appears to provide a little bit of flexibility relative to special locking arrangements based on protective safety measures for patients as a function of protection throughout the building by an approved, supervised automatic sprinkler system in accordance with 19.3.5.7. Originally, this section of the LSC referenced 19.3.5.1 which doesn’t provide much in the way of consideration for those instances (in Type I and Type II construction) where an AHJ has prohibited sprinklers. In that case, approved alternative protection measures shall be permitted to be substituted for sprinkler protection in specified areas without causing a building to be classified as non-sprinklered. You can find the details of the TIA here.

 

I suppose before I move on, I should note that you’re probably going to want to dig out your copy of the 2012 LSC when looking these over.

As a quick wrap-up, last week The Joint Commission issued Sentinel Event Alert #57 regarding the essential role of leadership in developing a safety culture (some initial info can be found here). While I would be the last person to accuse anyone of belaboring the obvious (being a virtual Rhodes Scholar in that type of endeavor myself), I cannot help but think that this might not be quite as earth-shattering an issuance as might be supposed by the folks in Chicago. At the very least, I guess this represents at least one more opportunity to drag organizational leadership into the safety fray. So, my question for you today (and I suspect I will have more to say on this subject over the next little while—especially as we start to see this issue monitored/validated during survey) is what steps has your organization taken to reduce intimidation and punitive aspects of the culture. I’m reasonably certain that everyone is working on this to one degree or another, but I am curious as to what type of stuff is being experienced in the field. Again, more to come, I’m sure…

Teddy Roosevelt would likely not cotton to these monkeyshines…

Our former president, one Theodore Roosevelt (when are Simon and Alvin going to run for office? I think their time is nigh…) is famous for a number of things, including the introduction of “bully” as a positive adjective (if you want to check out the manuscript that started it all, you can find it here). Unfortunately, the verb bully is very much a presence in today’s society (reaching near pandemic proportions in the various social media forums), including the healthcare industry. Now, I have certainly kvetched once or twice about the lack/loss of civility in general and our good friends in Chicago have taken up the gauntlet, and I think we can all agree: “bullying has no place in healthcare.”

As I reflect on the past 50 or so years (maybe a little more towards the so, but that’s just between us), I can look back on any number of encounters with bullies (only one black eye and that was rather a long time ago), including the 35+ years in healthcare. Bullies come in all shapes, sizes, social position, jobs, etc., and you can’t always tell right away who might rule in (or out) for this least desirable (well, maybe not least, but purty darn close) of personality flaws. Sometimes it’s folks who are in positions of authority/power, sometimes not, sometimes it even comes with a smile (though I’ve noted that those smiles rarely, if ever, reach the eyes), but I think I can safely say that bullying behavior engenders some of the most unpleasant “environments” that we are likely to experience. In the latest Quick Safety publication, Joint Commission offers some insight into the cultural elements that exist/foment when bullying is present in the healthcare environment. And while the Quick Safety publications are not necessarily enforceable as standards, this does tie back to Sentinel Event Alert #40 (Behaviors that undermine a culture of safety), which is aimed at the appropriate management of various forms of disruptive behavior, including bullying. At any rate, the Quick Safety article specifically references some action items that were included in the Sentinel Event Alert:

 

  • Educate all team members on appropriate professional behaviors that are consistent with the organization’s code of conduct
  • Hold all team members accountable for modeling desirable behaviors
  • Develop and implement policies and procedures/processes that address:
    • Bullying
    • Reducing fear of retaliation
    • Responding to patients and families who witness bullying
    • Beginning disciplinary actions (how and when)

 

So, my question to you is: How are things going in this area of concern? I don’t know that I’ve run into anyone who’s been able to completely eliminate bullying (or, as I think about it, anyone who’s been able to demonstrate a reduction in such behaviors—it just seems to be much more of a constant escalation, but that may just be me). I’m hoping that perhaps someone will have some stories to share with the group, even tales of efforts that fell short of the mark. We know it’s out there and I’m thinking that the release of this Quick Safety article may be a harbinger of future survey focus—how would you respond if the question came up during survey? I think it’s a reasonably safe pontification to say that bullying really doesn’t help to get things accomplished (again, recognizing that there are certain mindsets that might disagree, but I suspect those that disagree might be of the bullying persuasion), but I am interested in hearing about your experiences.

Clinical alarms: Getting the word out

All things being equal, I suspect that folks are wrestling with the very expansive elements of the Sentinel Event Alert regarding the management of medical device alarms (Sentinel Event Alert #50). I think the important thing to do is to first document a risk assessment that takes into account the various clinical alarm systems, identifying those that might legitimately be considered critical and use that as the starting point. I think it would behoove you to involve the folks in clinical engineering as they probably have performance data that would be very useful (equipment that they find during preventive maintenance activities that perhaps are not appropriately configured for audibility, etc.), it would also be important to include any potential occurrence reporting data that might indicate that there have been issues involving audibility of clinical alarms, etc. To be honest, I am not so sure that any one organization’s approach will be sufficiently universal to be used across the board beyond a simple “these are the specific risks involved with the clinical alarms you’ll be using” (in recognition that this may vary based on clinical location/service) and “these are the specific strategies we are using to appropriately eliminate/mitigate those risks.” I know that may sound like an overly simple approach, but if you do a good job on the risk assessment groundwork, you will have everything you need to manage the education process. As a further enticement, the Sentinel Event Alert web page noted above also includes links to a couple of podcasts that discuss the Alert in pretty fair detail. I don’t know that I’d recommend listening to it on the treadmill, but it’s probably a good way to combine work and exercise…

Hospital fire reveals several truths about emergency preparedness

There’s an update on a fire at Lawrence & Memorial Hospital in New London, CT, in this week’s issue of our free sister e-newsletter, Emergency Management Alert.

As a consultant, I frequently ask folks what kind of scenarios they are using to comply with EM.03.01.03, EP 3, which mandates an emergency response exercise, including an escalating scenario in which the hospital is unable to be supported by the local community.

One of the truisms I’ve observed over time is that [more]

Curiously, the EC standards aren’t mentioned in the new Sentinel Event Alert

I saw that The Joint Commission published a new Sentinel Event Alert about preventing technology-related errors.
In reviewing the Alert, The Joint Commission takes some pains to identify standards and performance elements that already exist in this regard, but they don’t mention EC.02.04.01, EP 1, which states the “hospital solicits input from individuals who operate and service equipment when it selects and acquires medical equipment.”
Now, in the Alert, one of the issues that could result in a threat to care and patient safety is when clinicians and other staff are not included in the planning process. To be honest, my first thought was that they were mostly going after medical equipment, though it does appear that this Alert is more aimed at information management and technology improvements.
That said, there is certainly a practical application to this Alert relative to the coordination of medical equipment and peripheral technologies, especially as devices and technology become more and more inextricably linked.
Not that you would ever encounter a surveyor that expanded upon the printed scope of a Sentinel Event Alert into unexpected waters, but if we consider the advice contained in the Alert as best practices, there may be a tacit obligation from the EC end to at least consider some of the identified risks.
After all, it’s not about doing what someone tells us to do, it is about using any available resource to ensure that we are maintaining our care environments in a risk-free, or at least risk-neutral, manner. Can anyone say risk assessment? Sure you can! I suspect I’ll be talking about risk assessments during my session at our 3rd Annual Hospital Safety Center Symposium in May.