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The Matrix Unloaded…Overloaded: Somehow stuff keeps happening…

Interesting read in the October 2021 Perspectives relative to some Life Safety chapter considerations that have earned a place in the Consistent Interpretation column. The thing that really caught my eye was the potential for these conditions to show up in the upper right hand corner of Ye Olde (SAFER) Matrix—a fate that befalls only a few choice conditions. I’m not so sure these are the conditions I would have thought could “bump” up into that corner, but I guess it’s all subject to interpretation. Fortunately, they don’t appear to be cited very frequently (from a high of just over 12% to a low of just over 0.5%) so perhaps it’s more a question of the frequency in which these conditions might be identified during a survey. While you’re definitely going to want to look at the details, the types of things identified in the article are things like: missing fireproofing; “missing” sprinkler heads; issues with two-hour walls, particularly occupancy separations; proper fire protection rated components in opening protectives (so, no 20-minute fire doors in 2-hour rated walls); painted-over door labels (How many of these would you need to have to push a high-risk/high-frequency finding? Beats me…).

Again, nothing that gets cited with any great frequency is in the mix (the performance element under which the door label issue would be cited “sits” at about a 10% finding rate), and, as I think about it, none of these are things I see with any frequency, though I suppose you could make the case that some of this extends into the territory of “if you look long enough and hard enough, there’s always one.” For example, in all likelihood, if you have fireproofed steel in your facility, there will be a section of fireproofing that was knocked off/removed/damaged, etc.; same thing with the painted-over door labels—there’s probably one somewhere (which causes me to reflect on the nature of environmental surveys as scavenger hunts). Definitely something to keep an eye on (and encourage your line staff to be on the lookout for them too).

To conclude with a little more LS goodness, I’ve been sitting on this one for a little bit (OK, maybe a little more than a little…since February), but as the intense chaos of the pandemic ebbs and flows (but never really subsides to any great degree), Health Facilities Management published a short article on the importance of the risk assessment process to ensure appropriate management of the risks associated with rapid-cycle facility modifications to accommodate all sorts of shifts in volume, acuity, patient types, etc. While some of the risk assessment would probably have to be retrospective (unless your policy specifically prohibits retrospective review), it might be worth going back to look at modifications to egress and, perhaps, fire protection features when you were creating COVID units from thin air. There are almost always lessons to be learned and the more we can hard-wire into the process moving forward, the safer we’ll all be in the long run.

That’s all for now. See you next week!

You better? You bet!

It would seem that while the rest of the world has been busy responding to a pandemic, the folks behind the scenes have been working on identifying the lessons learned and memorializing them in an update to Appendix Z. At first glance, it seemed that this was more a codification of past updates, but as a I looked through the thing in its entirety, it does seem like the changes are more significant/substantive than I thought. That said, I do think that much of the updated material is aimed at helping surveyors to understand what is (and what is not) actually required and that, as with everything in our world, customization of approaches, etc., is not only desirable, but is really the only way to “roll” when it comes to appropriately preparing to respond to an(y) emergency. I suppose one could make the case that, after all of this hoo-hah of the past year-plus, if we’ve not managed to improve our preparedness, then what exactly have we been doing?

Part of the dynamic I keep coming back to with all this is if it were “business as usual,” then it wouldn’t be an emergency. And one of the defining aspects of an emergency is that it tends to push the normal limits of an organization. I remember the hue and cry that went out immediately following Superstorm Sandy’s trek up the East Coast regarding the level of hospital preparedness—because people struggled at the outset. But when the final report from CMS was issued, it turned out that hospitals generally did what they had to do to keep patients and staff safe.

As we look back at the past 18 months or so, I suspect that each organization within the sound of my voice is better prepared than previously for managing the impact of a long-term pandemic event. I also suspect that there have been any number of improvement opportunities identified and I am hopeful that, among other things, your organizational leadership has gained a greater appreciation for emergency preparedness as a proactive undertaking (recognizing that response is typically characterized by reactivity). The truth of the matter is this: while emergency preparedness does not, in and of itself, generate revenue. Effective emergency preparedness allows an organization to continue generating revenue while the feces is striking the rapidly rotating blades—and that makes all the difference in the world.

I suspect that this is going to take a couple of sessions to work through some of the subtleties of the updates, so I would encourage you to start chipping away at this as wander through the very merry month of May. There is a lot of material to digest and while I don’t see anything that’s making me crazy from a survey prep standpoint, I’ll let you be the judge of how that shakes out—at least for the moment.

Before I close out this week’s chat, I did want to tip you to one resource that I think will be really helpful. One of the more painful aspects of the Emergency Preparedness Final Rule has been that the official document that is Appendix Z is designed to include the requirements for all provider types, which makes an already complex set of rules that much more confusing. But someone (bless them, whoever they are) worked to peel out the requirements for each provider type, so if you’re not a “regular” hospital or you have operational responsibilities for more than one provider type, you can find the specifics for each here. There are other resources as well, but just having the requirements by provider type is (at least to me) crazy wonderful—and I hope you think so too.

Next week, we’ll chat about some of the ways in which organizational leaders are going to be looped into this on an ongoing basis—if that doesn’t sound like fun…

Will meeting in person ever come back?

And perhaps more importantly: Does it make a difference?

As I’ve been working with folks over the past few months, it’s been kind of interesting to see how much impact social distancing and its component elements have had on the management of the care environment, at least from an oversight standpoint. Folks have been able to keep their eye on the prize for the most part, but it’s tough to figure out how effective meetings are when participation and other more traditional metrics are almost impossible to determine, never mind measure. For you folks out there reading this: Has this been something discussed during meetings, included in annual evaluations, or have you kept your head down and plowed through the past year (I suspect there’s a fair amount of plowing)? COVID has been such an attention-seeker in so many ways and remains the center of attention for so many folks—it seems impossible to think that we won’t be unraveling things for quite some time to come.

Turning to the May edition of Perspectives, it’s interesting to note that our friends from Chicago say they managed to conduct over 1,100 surveys in hospitals during 2021 (Does that means 1,100 hospitals were surveyed? Somehow, I’m thinking not). What is also interesting is that the presentation of the survey findings data has taken something of a turn in that the focus is not only on specific performance elements, but also on those findings that generate the findings of greatest survey criticality (read: adverse survey decisions). From looking at the hospital data, it appears that only a couple of findings of immediate threat to health/life were in the mix (mostly relating to the management of patients with suicidal ideation, though there was on related to infection control), but it would seem that there are a whole bunch of findings in the “red” (the highest risk category in the matrix). By my reckoning, now that the physical environment is not occupying all the top spots, the hot spots for high risk in the care environment are ventilation, safe, clean areas for patients, and the management of chemical risks (hmmm, could that be a euphemism for eyewash stations?), with a side order of whatever relates to infection control concerns like high-level disinfection and the management of patient care equipment.

I don’t know that there’s anything that is particularly shocking about the slate of focus areas; that said, it will be interesting to see how findings shift (or not) now that the onsite surveys are back on line with the intent of poking around more in the outpatient settings. As an indicator, can we intuit anything from the Ambulatory Care Top 10? Indeed, I think there is—and that “anything” is anything in the environment that has an impact on infection control—disinfection, ventilation, cleanliness, ITM of sterilizing equipment. The common themes do emerge without too much scrutiny.

I think we know what we have and I think we know where they are going with all of this, though it makes me sad that loaded sprinkler heads won’t be at the top of the list. Although I suspect that it will remain among the most frequently cited single conditions; how could it not?

So, that’s this week’s missive. I hope you all continue to be well and are working to stay safe. If you’re finally thinking about embracing travel, please take measures to protect yourself. I’m seeing a lot of variation when it comes to masking, but I can’t tell who has been vaccinated and who hasn’t (unless everyone starts wearing a t-shirt…).

Be well and I’ll be back at you next week, which, if my calendar is correct, will be May. Who’d a thunk it?

Folks back home surely have called off the search…

We knew it was going to happen eventually, but our friends in Chicago have made it official (just in time for the implementation of Daylight Savings Time—for those of you participating), the return of the (more or less) completely unannounced surveys by The Joint Commission (see the first article in the March 10 edition of Joint Commission Online). To be honest (and I try never to be anything but), I really can’t say how far behind they are on the survey front. I can’t imagine that there’s not going to be some serious catching up to do, and, since the public health emergency is still in play, I’m not sure how much time they’ll be given by the feds to reach some sort of survey plateau.

Presumably, they will continue to rely on the CMS COVID data (we talked about that a little while back; if you’ve somehow managed to misplace that link, you can find it here) to determine where the trouble spots might be (if you look at the latest data, the results are promising; hopefully we won’t be remembering the beginning of March as the—yet another—calm before the storm), so if you’re in a “red” county, that may be enough to avoid being in the first wave. I suppose the other dynamic is how survey teams will they be able to field—it sounds like this is going to be a busy week for folks, so if they show up on your front door step, please know that this community is standing by with best wishes for success.

As an adjunct to the return of the survey, TJC unveiled the 2021 Survey Activity Guide, which, among other things, formally speaks to the elimination of the Environment of Care interview session, indicating that topics previously covered in the session will find their way into the EC/LS tracer activities. Thus, effectively giving the LS surveyors another hour or so to wander the halls, with the implication being that they may go to/get to places in your house where they’ve not previously been. I’m not entirely certain, though I suppose if you have a fair amount of square footage there may be one or two spots that might not have been ransacked before, but I’m guessing you have a pretty decent idea of where they’ve not been, so it might be worth kicking those tires, so to speak. We know for a pretty fair certainty that they will be visiting the kitchen (after all, there’s a checklist and far be it for a checklist to go unchecked…).

They’ve also updated/revised the list of documents, including the return (don’t call it a comeback!) of the Statement of Conditions and Basic Building Information, something of a focus on water management programs (make sure you have your ASHRAE and CDC ducks in a row) and the management of line isolation monitors (if you have them). And, of course, the perennial attentions to the Management Plans (I’m not going to say anything more about those for a bit…) and annual evaluation process. Oddly enough, it appears that the document list also includes things that are not required to be documented, but rather are in place to remind you and the surveyors of some specific expectations like, oh, how ’bout, managing safety risks. I almost forgot about that…

So, hopefully the survey process will be less lion and more lamb as we get things rolling again. I think most organizations are experiencing some variation of PTSD and I don’t think that kicking folks in the head is going to be very helpful. The fact that healthcare has managed to keep things going over the past 12 months is a testament to the effectiveness of our processes, etc. I’m not expecting pats on the back (as deserved as they may be), but I do expect some reason in the administration of the survey process—or at least, that’s my hope—especially for everyone that’s in the barrel for this coming few weeks.

Please be well and stay safe—and keep doing what you’re doing. You folks are amazing, and don’t forget it!

Remote control: Don’t forget to close the loop

It would seem that the likelihood of ongoing remote surveys is growing in relation to the number of organizations awaiting survey. To be honest, I’ve not seen an official accounting of where the various accreditation organizations (AO) are falling relative to survey delays. That said, I can’t imagine that there must be a fairly significant backlog of surveys to be conducted, so I suppose we’d best be prepared for at least some of that process to occur remotely—particularly document review. To that end, if you missed this news item, I think it will help provide an understanding of how the process is evolving (mutating?!?); the focus of the piece is how DNV is administering the process, but there are certainly some clues as to how the process in general is likely to “exist” over the next little while.

One thing I hadn’t encountered before (or if I had, it was lost in the slipstream of last year) is the COVID data being provided by CMS. It appears that the information is updated on a regular basis (at this writing, the most recent information was for the period ending December 23, 2020) and while it is labeled as Nursing Home Data, CMS feels that the data is applicable to survey planning for hospitals. It appears that unless you are in a “green” county (you’ll see what I mean when you download the spreadsheet), then you probably won’t be seeing a “live” survey team (will we have to face zombie survey teams?). In traveling the past few months and living in a state that requires a negative test before returning or self-quarantining, I can tell you that those green windows sometimes don’t stay open for very long. Fortunately, I have not yet been in a position where I have tested positive away from home—probably my second worst fear; the worst fear being to bring this stuff back home to share with my family.

That said, my own practice has been very much “out in the field,” with a mix of some remote document review. I really do miss the interaction of document review with the folks who are actually responsible for the critical processes. It’s very difficult to have an appreciation for the process when you can’t discuss the operational challenges, the process for making corrections, etc. One of the “common” themes I’ve noted is that the documentation provided remotely tends not to include evidence of corrective actions; certainly this is something I’m accustomed to asking for when I’m doing onsite document review, but I don’t know of too many surveyors that wouldn’t be looking to “close the loop” on any identified deficiencies as soon as they find them in the documentation and it’s tough to really hold someone’s feet to the fire relative to producing corrective action documentation when you are not “in the building” with a specific ending point for the survey. There are certainly any number of surveyors who will cite an organization for failing to provide evidence of corrective actions and I think remote document review only increases the potential for missing pieces of the puzzle.

So my consultative recommendation is this: Make sure that you attach evidence of corrective actions to any documentation you might provide remotely to a survey team. You know you’re going to be asked for it anyways, so you might as well get ahead of the “ask.”

That’s it for this week. I hope you continue to be well and stay safe—we will get through this!

As I look out the window, it’s snowing, which reminds me that we’ve got to keep turning with the world, so I will let you get back to it. Until next time, hope you are well and staying safe. For those of you who are in the process of receiving the vaccine, thank you for your service!

Just in time for the holidays: Shoes are dropping all over the place, including business occupancies!

Just when you thought that maybe, just maybe, 2020 had run out of surprises, our friends in Chicago have taken one last (hopefully) opportunity to create a little chaos in the future by introducing us to their latest brainchild—the Life Safety chapter standards and performance elements prescribing the management of business occupancies.

I don’t know that there’s anything particularly surprising in the mix, and, ultimately, may help healthcare organizations endure the scrutiny of surveyors that insist on applying healthcare occupancy requirements to business occupancies. In some ways, it also helps to clarify certain general concepts (for example, the protection of hazardous areas—I suspect you’ll be installing some door closers before too long) that were always applicable, but not always meted out during surveys. There are approximately 30 new performance elements (I count 29, but I can never tell when my math skills will legitimately start to deteriorate…) to chew on, but the “good” news is that these are not coming online until July 1, 2021, so perhaps you will have had enough time to really kick the tires in your clinics, etc.

These changes will be in play for behavioral health and critical access hospitals as well, you can find the links for each of those here.

There are also some EC and LS changes coming to behavioral health, but I think we’ll dig into those next time.

In the face of all of this, I hope that each of you has a safe and joyous holiday season and that we all get a really spiffy New Year. I think we’re earned it!

Feeling pretty psyched: Some good news to share!

In full recognition that the longer the COVID-19 condition persists, the crazier it gets to folks on the front lines, so my intent is to (try—we’ll see how this works out—you know me) limit editorializing and provide you with brief episodes of useful content.

This week, it gladdens my heart to let you know that the good folks at the American Society for Health Care Engineering (ASHE) published a template (and guidance information) to facilitate facilities and safety professionals’ requests for an 1135 Waiver relating to the potential for compliance gaps relative to inspection, testing, and maintenance of fire safety and other equipment. You can find the template and table at the ASHE website. It’s a fairly straightforward process and the template (and corresponding table) really simplifies the thought process; I would encourage each and every one of you to check out these materials and get your waiver requests in the queue. To my way of thinking, this will make things a whole lot easier as we deal with survey activities in the aftermath of COVID-19 and, in the short term, allow you to focus on the important things: Supporting patient care at your organization.

Stay safe and stay in touch as you can—you guys rock!

Identifying issues and finding solutions…

…versus identifying issues and pointing fingers.

I think we can all agree that (at least for the moment) our friends in the regulatory survey services world have misplaced the location of their customers and, as a result, have become significantly more punitive in administering the survey process. Of course, the accreditation survey team always tells organizations that, despite the umpty-ump number of findings, they are a quality organization and really, this was a good survey. I have yet to hear of any instances in which the survey team “supported” anything other than a positive vibe, but it seems that, in growing numbers, that vibe is not really translating past the point of the exit conference.

Now, I know that it is not the role of the accreditation organizations to do anything more than identify deficiencies (I have hopes that a more consultative approach will re-emerge before too long, but I am not holding my breath), but what I keep bumping into are instances in which the folks (internal and external to an organization) charged with preparing organizations for survey are almost as punitive in their administration of the survey prep process. The purpose of environmental rounding/touring, etc., is to help folks become as prepared as possible and to identify strategies for sustaining compliance. It is not about the “gotcha,” with follow-up paperwork. My personal philosophy (as a safety professional in general, but certainly as a consultant) is that my obligation to the process is to help get things going in the right direction, even to the point of cleaning up a spill or picking something up off the floor while touring. Certainly, I can (and do) identify lots of things that need attention, because there are always lots of things to find that need attention (this goes back to my “no perfect buildings” philosophy; probably too much philosophy for so early in the year, but so be it). But I go into this having suffered at the hands of consultants (and others) who are not as interested in helping work through an issue to achieve some sort of sustainable solution.

As an example, I recently heard about an instance in which the environment of care rounding team had identified a resolution to a pesky issue (in this case, ensuring that specimen containers were appropriately labeled) but did not share that resolution with the entire organization. So last time, a “sticky” label was affixed to the container, but the label didn’t stick so well; this “failure mode” was communicated to the folks in infection control, but there was no immediate follow-up. So, next rounding activity, a specimen container to which a “sticky” label had been affixed was, in the local parlance (not really), nekkid in terms of labeling. Well, after the labeling issue had been cited, it was “revealed” that, after some consideration (may have been careful consideration, but less careful in the communication), it was determined that the containers would be stenciled in more permanent fashion. Interesting thing, the “finding” still required response, etc. even though the “finding” was the result in a communications misfire.

At any rate, as I think I’ve noted here before, there’s no regulatory statute that requires us to shoot ourselves in the foot, or, indeed, to engage in friendly fire. To my way of thinking, internally punitive surveying is not helpful and since we know the “real thing” isn’t particularly helpful (to healthcare organizations, at any rate), doesn’t it make more sense to work together towards sustainable compliance?

Quick closing question: While I was having some lab work done today, I noticed that the emergency eyewash station in the sink area was covered with a clear plastic bag. Has anyone out there in blogland encountered this or are practicing it? I’m thinking that this adds a step to activation of the eyewash station, but perhaps there’s a risk assessment that supports it. Just asking for a friend…

What we all want: If everything is priority one, then everything is priority none

As our friends from Chicago appear to be embarking in earnest on their charge to be as unpredictable as possible (I know of one instance in which a triennial survey “landed” about 10 months early—if that doesn’t merit a “yow,” I’m not sure what does…), the general concept of constant readiness would seem to be in flux (I think we all “knew” that the true survey window was considerably more limited than what it could be).

To that point, lately I’ve been working with folks who are well and truly within a survey window (lots of folks poking around in healthcare organizations these days…) and I’ve been noticing a tendency for folks requesting things to use “tomorrow” (or something similarly unrealistic) when identifying a requested completion date. And then raising a fuss when things are not repaired/replaced/refurbished almost instantly, which puts the folks who actually have to get the work done in a rather precarious position, depending on how quickly/dramatically the fussiness gets escalated. I think we can agree that expectations like instantaneous gratification do not lend themselves to thoughtful assessment of risk, or even (truth be told) basic triaging of tasks. I know that in crisis mode things can become a little unhinged, but the way the survey process is starting to turn, if we don’t find a way to really hardwire that classic finder/fixer dynamic as a way of like, the potential for chaos as a way of life is fairly strong.

So, the question I have for you out there in the studio audience is this: Does anybody have any unique methodologies they’d be inclined to share? I will freely admit to being at something of a disadvantage in that it has been a very, very long time (other than some interim gigs) since I’ve had day-to-day operational responsibilities in a hospital so there are probably technology solutions, etc., that could be leveraged in pursuit of focused order. But I also know that there is still a fair amount of what I like to call the “corridor work order request,” which, in my younger years, was probably not that big a deal, but now, as I approach my dotage, I find that I am not able to instantly recall quite as much “stuff” (I’m still pretty good, but the seams are much more apparent now).

I’m sure you are all following (with perhaps varying degrees of trepidation) the events unfolding in China relative to the Wuhan coronavirus; if you’re not making a regular stop at the CDC website for updates, etc., I would highly suggest it be a touch point at least every day or so. It’s starting to manifest itself a  bit stateside and I suppose, given the omnipresence of travel these days, it’s only a matter of time before it starts showing up in less-populated regions of the country. You can find as much information as is available here. Hopefully, this one subsides quickly, but preparedness, it seems, is everything these days.

In a world of magnets and miracles: Shifting the sands of compliance

At the risk of engaging in non-sequiturial (which autocorrect keeps insisting should be non-equatorial) content, I want to touch on a couple of short items that came across my desk over the last couple of days. I don’t know that they specifically relate to each other, but I can imagine a sufficiently powerful pattern recognition program that could link the two (think really, really big picture).

First up, we have some conversation relative to CMS’ efforts to increase the validity of the process by which CMS oversees (or validates) the work of the various accreditation organizations (AO) as they engage in the deemed status survey process. Until recently, the CMS validation process involved a survey visit close on the heels of the AOs (typically within 60 days or so) to see how closely the completed survey met the expectations of CMS vis-à-vis the Conditions of Participation. Historically, there have always been gaps between what was found by the AOs and what was found by CMS, with a lot of pushback on the part of the AOs relative to the timing of things—healthcare organizations are, if nothing else, fluidity personified. So, in response to the timing pushback, CMS has started co-surveying with TJC in real time; so, instead of dealing with your usual complement of TJC surveyors, you also get to host—at the same time—a group of CMSers. Ostensibly, the purpose of the CMS team is to observe the survey efficacy of the Joint Commission team,  but I think you can see where what has never been a “pleasant” experience could really go sideways. I personally have not heard any tales of folks having experienced this type of event, but I feel certain that someone I know will be able to share some stories of daring do and horror-filled antics. Any takers? It would seem (based on a blog post from TJC) that some organizations have expressed gratitude for not having to go through two separate survey events, and there’s a general sense that the CMS/AO survey findings are of a piece, so I guess that’s a good thing. But somehow…

At any rate, at the moment, if your organization is going to have this extra special survey experience, there will be prior notification, but there appear to be plans afoot to end up at a point in which these extra special surveys will be completely unannounced. It also appears that moving in that direction will require some modification to the language in the Conditions of Participation that authorize the validation surveys. According to the blog, the current process is in place through federal FY 2020 (October 1, 2019 through September 30, 2020), so I guess we’ll have to wait and see how things go.

To take this in a completely different direction (well, maybe not completely…) I came across an article providing some advice on conducting one-on-one meetings with staff. As a consultant, it’s been rather a while since I’ve had to administer one-on-one staff meetings, so this may be old hat to you folks with current operational oversight of line staff, but it did prompt me to think about past practices and I can see where this might be helpful in a lot of different ways. I am a firm believer in trying to make every encounter more useful and I think this might be a strategy worthy of your consideration. So, if you need something to read as we start the wind-down of summer (it’s the last week of August—how did that happen?!?), I think this would be worth your time (and please let me know if you think otherwise—any and all feedback is most appreciated!).

Have a safe and festive Labor Day!