Something old and something new(ish): old rant, new requirement.
As we move ever onwards toward the close of our first year “under” the 2012 Life Safety Code® (talk about a brave new world), there was one item of deadline that I wanted to touch upon before it got too, too much further into the year. And that, my friends, is the requirement for an annual inspection of fire and smoke door assemblies—for those of you keeping track, this activity falls under the EOC chapter under the standard with all those other pesky life safety-related inspection, testing, and maintenance activities (don’t forget to make sure that your WRITTEN documentation of the door assembly inspection includes the appropriate NFPA standards reference—in this case, you have quite a few to track: NFPA 101-2012 for the general requirements; NFPA 80-2010 for the fire door assemblies; and, NFPA 105-2010 for the smoke door assemblies). Also, please, please, please make sure that the individual(s) conducting these activities can “demonstrate knowledge and understanding of the operating components of the door being tested” (if this sounds like it might be a competency that might need to be included in a position description and performance evaluation, I think you just might be barking up the correct tree). The testing is supposed to begin with a pre-test visual inspection, with the testing to include both sides of the opening. Also, if you are thinking that this is yet another task that will be well-served by having an inventory, by location, of the door assemblies, you would indeed be correct (to the best of my knowledge). As a caveat for this one, please also keep in mind that this would include shaft access doors, linen and trash chute—while not exactly endless, the list can be pretty extensive. At the moment, from all I can gather, fire-rated access panels are optional for inclusion, though I don’t know that I wouldn’t be inclined to have a risk assessment in one’s back pocket outlining the decision to include or not to include (that is the question!?!) the access panels in the program.
I’m thinking you will probably want to capture this as a recurring activity in your work order system, as well as developing a documentation form. Make sure the following items are covered in the inspection/testing activity:
- No open holes or breaks in the surfaces of either the door or the frame
- Door clearances are in compliance (no more than ¾ inch for fire doors; no more than 1 inch for corridor doors; no more than ¾ inch for smoke barrier doors in new buildings)
- No unapproved protective plates greater than 16 inches from the bottom of the door
- Making sure the latching hardware works properly
- If the door has a coordinator, making sure that the inactive door leaf closes before the active leaf
- Making sure meeting edge protection, gasketing, and edge seals (if they are required—depends on the door) are inspected to make sure they are in place and intact
I think the other piece of the equation here is that you need to keep in mind that “annual” is a minimum frequency for this activity; ultimately, the purpose of this whole exercise is to develop performance data that will allow you to determine the inspection frequency that makes the most sense for compliance and overall life safety. Some doors (and I suspect that you could rattle off a pretty good list of them without even thinking about it too much) are going to need a little more attention because they “catch” more than their fair share of abuse (crash, bang boom!). Now that this isn’t an optional activity (ah, those days of the BMP…), you might as well make the most of it.
Putting on my rant-cap, I’d like to steal just a few moments to lament the continuing decline of decency (it used to be common; now, not so much) when it comes to interactions with strangers (and who knows, maybe it’s extending into familial and friendial interactions as well—I sure hope not!) I firmly believe that any and every kindness should be acknowledged, even if it’s something that they were supposed to do! My favorite example is stopping for pedestrians (and if you’ve been behind me, yes that was me stopping to let someone complete the walk); yes, I know that in many, if not most, places, the law requires you to stop for pedestrians in a crosswalk, but I think the law should also require acknowledgement from the pedestrians. Positive reinforcement can’t possibly hurt in these types of encounters. Allowing merging traffic to move forward (signaling is a desirable approach to this, but you should also signal the person who let you in). I’m not sure if we’re just out of practice or what, but I’d ask you to just try a little more to say “hi” or “thanks” or give somebody a wave when they aren’t jerks (and just so we’re straight, a wave includes more than just the middle digit). Maybe I’m going a little Pollyanna here, but the world is just not nice enough lately. Hopefully we can make an incremental improvement…
Just a quick drop of the microphone to let you know that our friends in Chicago are presenting a webinar on the SAFER methodology that The Joint Commission will use during hospital surveys starting in January. As we’ve discussed previously, with the removal of standard types (As and Cs and whatever else you can conjure up) and the introduction of the “Survey Analysis for Evaluating Risk (SAFER) matrix to prioritize resources and focus corrective action plans in areas that are in most need of compliance activities and interventions,” it appears that once again we are heading into some white water rapids (certainly Class 4, with intermittent burst of Class 5/6—better wear your life vest). That said, I appears that the webinar (scheduled for November 15) is for a limited audience number, but I do think that it might be useful to listen in to hear what pearls may (or may not) be uttered. You can register here and it also appears that the session will be recorded and made available on the TJC website (as near as I can tell, the webinar is free, so check your local listings).
Ciao for now. Back next week with more fun than you can shake a stick at…
Yet another mixed bag this week, mostly from the mailbag, but perhaps some other bags will enter into the conversation. We shall see, we shall see.
First up, we have the announcement of a new Joint Commission portal that deals with resources for preventing workplace violence. The portal includes some real-world examples, some of the information coming from hospitals with whom I have done work in the past (both coasts are covered). There is also invocation of the Occupational Safety & Health Administration (lots of links this week). I know that everyone out there in the listening audience is working very diligently towards minimizing workplace violence risks and perhaps there’s some information of value to be had. If you should happen to uncover something particularly compelling as you wander over to the Workplace Violence Portal, please share it with the group. Bullying behavior is a real culture disruptor and the more we can share ideas that help to manage all the various disruptors, we’ll definitely be in a better place.
And speaking of a better place, I did want to bring to your attention some findings that have been cropping up during Joint Commission surveys of late. The findings relate to being able to demonstrate that you have documented a risk assessment of the areas in which you manage behavioral health patients; particularly those areas of your ED that are perhaps not as absolutely safe as they might otherwise be, in order to have sufficient flexibility to use those rooms for “other” patients. Unless you have a pretty significant volume of behavioral health patients, it’s probably going to be tough to designate and “safe” rooms to be used for behavioral health patients only, so in all likelihood you’re going to have to deal with some level of risk. I suppose it would be appropriate at this juncture to point out that it is nigh on impossible to provide an absolutely risk-free environment; the reality of the situation is that for the management of individuals intent on hurting themselves, the “safety” of the environment on its own is not enough. Just as with any risk, we work to reduce the risk to the extent possible and work to manage what risks remain. That said, if you have not documented an assessment of the physical environment in the areas in which you manage behavioral health patients, it is probably a worthwhile activity to have in your back pocket. I think an excellent starting point would be to check out the most recent edition of the Design Guide for the Built Environment of Behavioral Health Facilities, which is available from the Facilities Guidelines Institute. There’s a ton of information about products, strategies, etc. for managing this at-risk patient population. And please keep in mind that, as you go through the process, you may very well uncover some risks for which you feel that some level of intervention is indicated (this is not a static patient population—they change, you may need to change your environment to keep pace), in which case it is very important to let the clinical folks know that you’ve identified an opportunity and then brainstorm with them to determine how to manage the identified risk(s) until such time as corrective measures can be taken. Staff being able to speak to the proactive management of identified risks is a very powerful strategy for keeping everybody safe. So please keep that in mind, particularly if you haven’t formally looked at this in a bit.
As a closing thought for the week, I know there are a number of folks (could be lots) who purchased those customizable EOC manuals back in the day and ever since have been managing like a billion policies, which, quite frankly, tends to be an enormous pain in the posterior. I’m not entirely certain where all these policies came from, but I can tell you that the list of policies that you are required to have is actually fairly limited:
- Hazard Communications Plan (OSHA)
- Bloodborne Pathogens Exposure Control Plan (OSHA)
- Respiratory Protection Program (OSHA)
- Emergency Operations Plan (CMS & Accreditation Organizations)
- Interim Life Safety Measures Policy (CMS & Accreditation Organizations)
- Radiation Protection Program (State)
- Safety Management Plan (Accreditation Organizations)
- Security Management Plan (Accreditation Organizations)
- Hazardous Materials & Waste Management Plan (Accreditation Organizations)
- Fire Safety Management Plan (Accreditation Organizations)
- Medical Equipment Management Plan (Accreditation Organizations)
- Utility Systems Management Plan (Accreditation Organizations)
- Security Incident Procedure (Accreditation Organizations)
- Smoking Policy (Accreditation Organizations)
- Utility Disruption Response Procedure (Accreditation Organizations)
Now I will freely admit that I kind of stretched things a little bit (you could, for example, make the case that CMS does not specifically require an ILSM policy; you could also make the case that it is past time for the management plans to go the way of <insert defunct thing here> at the very least leaving it up to the individual organizations to determine how useful the management plans might be in real life…). At any rate, there is no requirement to have any policies, etc., beyond the list here (unless, of course, I have left one out). So, no policy for changing a light bulb (regardless of whether it wants to change) or policy for writing policies. You’ll want to have guidelines and procedures, but please don’t fall into the policy “trap”: Keep it simple, smarty!
Earlier this week, I received a question regarding the need to do a risk assessment that would allow (or prohibit) the use of toasters in break rooms, etc., due to the open heating element. I should probably mention that this “finding” was not at the hands of The Joint Commission, but rather one of the other acronymic accreditation agencies, but these things do tend to travel across agency boundaries, so it may be a topic of conversation for your “house.” At any rate, the request was aimed more at identifying a format for documenting the risk assessment (an example of which follows), as the surveyor who cited the toasters indicated that a risk assessment supporting continued use of the toasters would be sufficient. Special survey hint: If a surveyor indicates that a risk assessment would be an acceptable strategy for whatever practice or condition might be in question, you should consider that a pretty good indication that there is no specific regulatory guidance in any direction for the subject at hand. Though I will also note that if a surveyor does not “bite” on a risk assessment, it doesn’t mean that there is a specific regulation/statute/etc. that specifies compliance, so even if there appears to be no relief from a risk assessment, a thorough review of what is actually required is always a good idea. Which probably represents a good point to discuss the risk assessment components:
- Issue Statement. Basically a recap of what the condition or practice that has been identified as being problematic/a vulnerability, etc.. Using this week’s topic—the use of open element appliances in break rooms, etc. (no reason to confine the discussion to toasters; might as well include toaster oven, grills, and other such appliances)
- Regulatory Analysis. Reviewing what is specifically indicated in the regulations: CMS Conditions of Participation; Accreditation Agency standards and performance elements; state and local laws and regulations should definitely be discussed, as well as any other Authorities Having Jurisdiction (AHJ) that might weigh in on the topic. For the open element appliance discussion, I always encourage folks to check with their property insurer (they are a very important, and frequently overlooked, AHJ); they might not tell you that you can or can’t do something (again, based on whether there is an actual regulatory requirement), but they might tell you that if you do X and have a fire, etc., they might elect not to cover damages.
- Literature Review. Review any manufacturer recommendations or information from specialty society or trade associations. Staying with our friends the toasters, most of the devices in use in your organization are probably manufactured “For Household Use Only”; you might be hard-pressed in the risk assessment to be able to indicate definitively that the devices are being used in accordance with that level of use (I mean I love toast as much as the next person, but I don’t toast a whole loaf every day…). As a consultative aside, my philosophy has always been to encourage (okay, mandate, but only when I was in a position to make the call) the use of commercial-grade toasters. Yes, they are more expensive, but they are also less likely to self-immolate, which (in my book) is rather a good thing. We definitely don’t need things bursting into flames in our break rooms, etc.
- Review of Safety, Quality and Risk Management Data. Check your records. You know you’ve had accidental activations of the fire alarm system (though I do believe that toaster events have faded to a distant second behind microwave popcorn). Is there evidence that your organization is not doing an appropriate job of managing these devices/appliances. I suppose you could take into consideration anecdotal data, but I would be very careful as that can be tricky.
- Operational Considerations and Analysis. Discuss how things are being managed now; how often are the appliances being cleaned, serviced, etc. Is that often enough? Is there sufficient smoke detection, suppression, etc.? Do you need to have “official” guidelines for safe toaster use (no sticky, gooey toaster strudels, etc.)? If you’re going to allow something (recognizing that a prohibition is the easiest thing to police from a surveillance perspective), you may find that folks will require a bit of sensible direction to manage the risks effectively.
- Organizational Position and Policy Statement/Approval and Adoption. Once you’ve figured out what you want to do, just outline the position you are adopting, make sure that what you’re doing is not in opposition to any existing policy or plan, and then run it through the appropriate committees for final approval and adoption by the organization. In most instances, there is absolutely no reason to establish a specific policy for these things; set it up as a guideline or a protocol or a standard operating procedure (SOP). There are really very few policies that are required by law or regulation. Please don’t feel the need to populate your EOC manuals with a million and one incidental policies (I think this might be a good topic of future conversation).
There are many ways to “skin” a risk assessment and the methodology indicated above may not be suitable for all audiences, but it is a very good way to document the thoughtful analysis of an issue (be it identified during a survey or during your own surveillance activities), particularly when logic does not immediately prevail. (And believe me, logic doesn’t prevail as often as it used to. It makes me sad to think about all the gyrations that have been “committed” because we’ve been forced to deal with something that is “possible” as opposed to “probable” or “actual.” And if you’re thinking that the management of cardboard is somewhere in that equation, you would indeed be correct…) It all goes back to the subtle dynamics between what you “have” to do versus what you “could” do—to a very large extent, at least in terms of the regulations, we get to make our own way in the world. But that world is full of surveyors who are perfectly willing to disagree with any decision we’ve ever made; and they tend not to allow us to do the risk assessment math in our heads (pity, that). This is a pretty straightforward way to get your work on paper. I hope you find it useful.
As we await new content on the PEP (aka the newly-popular Joint Commission offering, the Physical Environment Portal), I want to draw your attention to an interesting development on another part of the Joint Commission’s website: the ever-popular (such popularity and minimal polarity…) Frequently Asked Questions page (now re-imagined as Standards Interpretations—really, check it out). And let me tell you, there is a ton of newly configured information to be found. If I were really attentive to such things (I usually am, but in this case I wasn’t expecting such a sweeping re-imagination of this part of the TJC website), I would be able to tell you how much more information there is to be had, but I think I can safely say that, at least in terms of the numbers of entries, the amount has easily doubled in relation to the “old” FAQ page. Some of the material appears to be derived from information that had been previously shared through George Mills’ Clarifications and Expectations column in Joint Commission Perspectives; other bits and pieces seem to be derived from information shared on the PEP. There also seems to be some stuff that hinges on the practical application of the now-expiring CMS categorical waivers (which I guess means there will be some updating of content in the not-too-distant future) and some other stuff that appears to have been developed specifically for this new page. (Dare we call it the Standards Interpretation Portal? We’ll be able to engage in regular SIP-ing!)
At any rate, I’m going to be poring over these entries with great interest and I would recommend that you keep a close eye on the SIP as well. Remember, the interpretations published on the SIP (I really do like that!) are “enforceable” as standards, and there’s no reason to think that TJC surveyors aren’t going to be checking out these materials as well. One interesting note: I don’t recall seeing any official announcement regarding the re-birthing of the FAQs (I won’t claim that I track every utterance from the folks in Chicago), so I may be pre-empting the grand unveiling (if you have a standards question, don’t forget to SIP!).
One item that really caught my fancy (and this was in response to a client question) was the entry regarding oxygen storage, which I know has plagued a number of organizations, particularly as a function of the segregation requirements. My thoughts on this have been that the simplest means of separation is to focus on full and not-full as the segregation metric; most folks do not have sufficient space to be able to reasonably pull off the full/in use/empty trifecta and NFPA 99 really only requires that the full cylinders be separated from everything else. So, if you use the full/not full designations, it’s not only a simpler decision-making process in the moment, it appears to be in keeping with the information shared on the SIP.
I’ll let you be the judge of what’s going to work in your organization, but I do believe that the fewer complications in the mix, the greater the likelihood of compliance.
I recommend you starting SIP-ing right away and maintain your compliance hydration throughout the hot summer months!
There are a couple of developments on the Joint Commission front. They’re deleting some 131 performance elements from across the accreditation manual; a few are EC-related, but none in the EM or LS chapters, I want to take a few moments to look at the tea leaves before I weigh—maybe I’ll include in our upcoming edition of portal chortlings—we’re about due for a fireside chat, but anyways…
This just in: The Clarifications and Expectations column penned by Mr. Mills is “on hiatus,” but scheduled to return in June 2016. Curiouser and curiouser…
Last week I was working with a client on answering a citation that had come up during a TJC survey (not their survey, but someone else’s—sometimes folks will share post-survey intel). The finding was related to the storage of toilet paper and paper towel in a housekeeping closet, based on (presumably) the notion of the housekeeping closet as a “soiled” area and the toilet paper and paper towel being “clean” supplies (remembering that when we use toilet paper, the rolls are right next to the toilet OMG…OMG…OMG!). Now I am reasonably certain that (much like some other conditions and/or practices I will note in a moment) there are no specific regulatory standards that speak to how and where one is to store paper supplies, etc., so, once again, we come up against the assumed role of the surveyor cadre in prescribing practices instead of assessing how well a risk is being managed. Are there housekeeping closets that are somewhat less reputable looking than others? Absolutely! Are there risks associated with storing paper products in housekeeping closets? Absolutely! Are there risks associated with storing paper products in clean utility rooms, including the potential for pests? Absolutely! Is this a discussion that could go on forever? Absolutely!
To paraphrase the late, great Lewis Allen (you probably know him just as “Lou”) Reed, I am sick of it. I am sick of seeing findings like “linen cart cover was not down,” “solid bottom shelf was not in place,” “materials stored under a sink,” “toilet paper and paper towel stored in a housekeeping closets,” “cardboard boxes in clean utility rooms.” The whole concept of the management of the physical environment is supposed to be based on managing the risks is that very same physical environment. Show me how whatever condition being cited is actually resulted in a risk that is being appropriate managed—not merely the possibility of a potentially increased risk if the planets are in the correct alignment, etc., etc., ad nauseum. Every time I think about the “war on cardboard,” I grind my whole being (not just my teeth); yes, there are places where cardboard ought not be broken down (sterile supply areas, etc.) but those locations are very limited. Show me that we’re not managing the cardboard appropriately. Show me real evidence (not online pictures) that we are legitimately dealing with cardboard critter condos. I absolutely, beyond any shadow of doubt, understand and recognize the risk potential of cardboard, but if there’s no evidence that the cardboard boxes are doing anything more than appropriately holding the contents of said boxes, how does that become a citable offence? When I think of the hundreds of thousands of dollars that have been wasted purchasing plastic bins that (channeling T. Swift here) never, ever, ever, ever (is that too many “evers”?) get cleaned…check ’em out if you don’t believe me. And never mind the kabillion of labor hours devoted to removing all the whatevers from those cardboard boxes and putting them in the plastic bins as opposed to delivering the box full of stuff and then throwing that every same box away when it is empty. In fact, I would submit to you that by getting rid of the cardboard, we have made it exponentially more difficult to manage expiring product. Old days: case with expiration date on it; when case is empty, throw case away—boom! New days: plastic bin almost empty so we dump more product in on top of the old stuff (Oh sure, we’re taking the old stuff out and then placing it in a bag on top of the new stuff to ensure the old stuff gets used first. Yup, that’s what’s happening, yes indeedy…) I’m sure each of you can think of some “practice” that’s being enforced in your organization that is based on not much in the way of logic (logic doesn’t seem to prevail as much as it used to—I can’t think that that’s a good thing). I think we need to take a stand. (“I’m rather unhappy about the current state and I’m not inclined to support it any longer” or the more pointed “I’m mad as hell and I’m not going to take it anymore.” We safety professionals are more inclined towards the genteel first versions when in polite conversation, but deep inside, you know what I’m talkin’ about!)
Okay, that’s probably enough on that topic for the moment (I’m going to guess that there may be one or two heads nodding in the affirmative at this point in my screed, though perhaps there are others that might disagree). If there’s such a strong feeling about this stuff, then the regulators should be very clear about those “clarifications and expectations.” There’s a process for reviewing the survey results before the final results are provided to each organization. Use it to remove these findings that are truly no more than surveyor bias (yeah, it’s like how tough it is to reverse an official decision in sports). Unless, of course, the purpose of the current survey process is to generate as many findings as humanly possible…nah—who’d believe that!
So join us next week as we add another section to our construction of the immortal portal cortile chortle…
Eventually, I will run out of these, but hopefully not before the EC portal is perfectly populated and otherwise polished off…
Late last week brought the announcement of new material being posted to The Joint Commission’s Environment of Care portal, this month’s offering focusing on those pesky compliance issues relating to ensuring that building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat. The performance elements chosen for additional coverage relate to unprotected openings in fire-rated walls and floors (Can you say “penetrations”? I thought you could!); fire doors have functioning hardware—positive latching, self- or auto-closing—and compliant gaps and undercuts; and making sure that openings in 2-hour fire-rated walls are rated for 1.5 hours.
I guess when it comes down to the perennial survey findings, after egress-related issues, the construction and maintenance of fire-rated barriers is something akin to an old friend. Depending on how many of these puppies (rated barriers—walls and floors; and fire doors), the likelihood of there being some sort of imperfection is fairly good, and since the Life Safety portion of the survey process devotes so much more time (than in the old days) to the inspection of these locations, I can’t say that it’s an overwhelming shock that those imperfections are being identified during the survey process. Interestingly enough, at least at the moment, there is no component of the new posting aimed at the organizational leadership element (yes, Virginia, there is no fireside chat this month on this topic) and the information on the portal page (say that 10 times fast) is a wee bit to the sparse end of the spectrum (there are a couple of links to the Joint Commission Resources webpage for some free downloads), though there is an “example of improved compliance” that provides a flowchart representation of the importance of barrier management as a function of protecting patients (and allowing for evacuation to exist as a last resort). I don’t know, it just seems like there’s something missing from this month’s update. (Mention of the BMP springs to mind. The spirit is represented in the free downloads—a pair of articles from EC News back in 2012, but no specific mention). I suppose one could make the case that there’s not a whole heck of a lot to be said about the practical aspects about maintaining rated assemblies, inclusive of walls, floors, doors, etc. Again, perfection for these life safety features is most elusive and often fleeting. So the question becomes: how do you “capture” these deficiencies as close to their genesis as you can?
One favorite concept of mine (and it gets a mention in the free downloads) is the bounty system as a function of your permitting process—I think (in case you really hadn’t noticed) that anything we can do to enlist the active participation of point of care/point of service staff in these activities—and what better way than to make a game of it? I guess it all comes down to a mix of reinforcing positive behaviors (for frontline staff who identify the miscreants without permits in return for cash and prizes—okay, maybe not so much) and discouraging negative behaviors (by giving the unpermitted miscreants the boot to give them time to ponder their wicked ways). I’ve never had the opportunity to actually operationalize an above the ceiling bounty system. Anyone out there have any success stories they could share? Or, indeed, if you have stories about bounty programs that didn’t quite make the mark, those are always worth sharing.
Not a really banger of a portal update this month (I wonder if the number of findings have been reduced yet—it will be interesting to see what type of impact the portal has on the number and nature of findings…), but I guess you can’t hit a home run at every at bat. Play ball!
Flexible Spending Account, Federal Student Aid, Food Services of America, Focused Standards Assessment.
So, I am forced to pick one. While I’m sure the lot of them is most estimable in many ways, I suppose the choice is clear: the freaking Focused Standards Assessment (kind of makes it an FFSA, or a double-F S A…what the…).
Just to refresh things a bit, the FSA is a requirement of the accreditation process in which a healthcare organization (I’m thinking that if you weren’t in healthcare, you probably would be choosing one of the other FSAs) reviews its compliance with a selected batch of Joint Commission accreditation requirements. The selections include elements from the National Patient Safety Goals, some direct and indirect impact standards and performance elements, high-risk areas, as well as the RFIs from your last survey—and I know you’ve continued to “work” those Measures of Success from your last survey. Ostensibly, this is very much an “open book” test, if you will—a test you get to grade for yourself and one for which there is no requirement to share the results with the teacher (in this case, The Joint Commission—I really don’t understand why folks submit their results to TJC, but some do—I guess some things are just beyond my ken…).
The overarching intent is to establish a process that enhances an organization’s continuous survey readiness activities (of course, as I see various and sundry survey results, I can’t help but think that the effectiveness of this process would be tough to quantify). I guess it’s somewhat less invasive than the DNV annual consultative visits, though you could certainly bring in consultants to fulfill the role of surveyor for this process if some fresh eyes are what your organization needs to keep things moving on the accreditation front.
I will freely admit to getting hung up a bit on the efficacy of this as a process; much like the required management plans (an exercise in compliance), this process doesn’t necessarily bring a lot of value to the table. Unless you actually conduct a thorough evaluation of the organization’s compliance with the 45 Environment of Care performance elements, 13 Emergency Management performance elements, 23 Life Safety performance elements (15 for healthcare occupancies, eight for ambulatory healthcare occupancies)—and who really has the time for all that—then does the process have any value beyond MBW (more busy work)? I throw the question out to you folks—the process is required by TJC, so I don’t want anyone to get in trouble for sharing—but if anyone has made good use of this process, I would be very interested in hearing all about it.
This is my last piece on the FSA process for the moment, unless folks are clamoring for something in particular. I had intended to list the EPs individually, but I think my best advice is for you to check them out for yourself. That said, I have a quick and dirty checklist of the required elements (minus the EP numbers, but those are kind of etched into my brain at this point). If you want a copy, just email me at email@example.com.
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”:
- There is no such thing as a perfect building/environment/process, etc.
- Buildings are never more perfect than the moment before you put people in them.
- You know that.
- The regulators know that.
- The regulators can no longer visit your facility and return a verdict of no findings, because there are always things to find.
- 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?
I know that this is typically characterized as a season of giving, but I have somewhat of a huge favor to ask of you folks out there in the depths of the blogosphere, so I hope you will bear with me.
With an almost astonishing regularity, the first of each month continues to bring with it a new module being posted in the Environment of Care portal. For the month of December 2015, the featured topic is the Built Environment, inclusive of elements covered under EC.02.06.01, which (as you may recall) was the #1 most frequently cited standard during the first six months (Freudian typo: When I first typed this passage, I came up with “first sux months”—make of that what you will…).
Since I know a lot of folks have been tapped on this one (both as a function of the published data and my own experiences), I was keen to look over the new material—including the latest fireside chat from our partners in compliance George Mills, director of engineering at TJC and Dale Woodin, executive director at ASHE, which covers EP 1 and EP 13 (in separate episodes). One of the interesting things I noticed was, in describing the many and varied findings that are generated under EP 1, a direct comparison was made to OSHA’s General Duty Clause as a function of how this particular EP is being used. Now, the GDC concept as a part of TJC’s survey efforts is certainly not unknown to us (in the “old” days, EC.02.01.01 used to be the catch-all for general safety findings) and basically it comes down to pretty much anything that isn’t quite as it should be (what I have taken to euphemistically describing as imperfections). Could be stained ceiling tiles, could be non-intact flooring, wall, or horizontal surfaces. Could be nurse call cords that are not properly configured (too long, too short, too wrapped around restroom grab bars), could be improperly segregated compressed gas cylinders. The list of possibilities is pretty much infinite.
The second video episode talks about maintaining temperature, humidity, and air-pressure relationships in the “other” locations (pretty much everywhere that isn’t an invasive procedure area or an area that supports invasive procedure areas). I know that there’s been some consternation from findings relating to issues such as pressure relationships in clean utility and soiled utility rooms (clean rooms have to blow and soiled rooms have to suck, so to speak), pressure relationships in pharmacies (positive), laboratories (negative) and so on. There’s some discussion about how these types of conditions might manifest themselves in the environment and the importance of staying on top of these things, particularly during surveys (personal note: my consultative advice is to have an action plan for checking all these various areas that have pressure relationship requirements the moment you learn that “Elvis,” my code name for TJC, is in the building). It is very, very clear that the Life Safety surveyor is going to be checking pressure relationships early on in the survey process—you want to have a very, very good idea of where you stand in the applicable areas.
At any rate, the favor I have to ask (and I’m sure I’ve gone on long enough that the favor is blissfully in the past) is for those of you who’ve viewed the contents of the portal (according to TJC figures, there were 48,000 views of the first two modules; I know I account for a couple of those, but clearly others have checked things out, though it might be interesting to see how many of that number are TJC surveyors…), particularly those of you who have been surveyed in the last few months: Has the material actually been helpful? Part of me feels that the materials are presented in such a general fashion that it makes them less useful from a practical standpoint (perhaps the better part of me), but since I don’t have to worry so much about day-to-day stuff anymore, I will freely admit that I’m too far away from it to be able to say. That said, I am really keen to hear if you think they’ve done a good job, not-so-good job, or somewhere in between. Pretty much any sense of whether the material has been helpful (of course, I could ask the same question about this space, as well, so feel free to weigh in—I always like feedback).
As a final note for this week’s epistle, you may be curious to read about what TJC’s leadership thinks about the portal. You may recall a bit of hand-wringing at the beginning of the year, by Mark Pelletier, the COO of accreditation and certification operations at TJC, regarding the recent “spike” in EC/LS findings (you can find my comments, including a link to Mr. Pelletier’s comments from January, here). As we all know very well, the torture in the EC/LS world has continued (presumably until morale is restored), but the EC Portal is being looked upon as “a light at the end” (at the end of what, I’m not sure, as it isn’t specifically indicated). The thing I keep coming back to in my mind’s eye, is that the typical list of findings is what (again, my “imperfections”) are the types of conditions and practices that, while not perfect (yes, we are imperfect) are not conditions that significantly increase the risks to patients, staff, visitors, etc. If these imperfections are not managed correctly, they could indeed become something unmanageable, but I’m just not convinced that the environment is the big boogie man when it comes to healthcare-acquired infections, which is pretty much the raison d’etre for this whole focus. I keep telling myself that it’s job security, but it frustrates the bejeezus out of me…
Mr. Pelletier’s latest can be found here.
And on that note, I wish you a most joyous holiday season and a safe and inspiring New Year! I may find the urge to put fingers to keys twixt now and the end of the year, but if I do not, please know that it’s taking every ounce of my self-control not to pontificate about something. Consider the silence my gift to you!
Be well and stay in touch as you can!