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Documentary evidence: Sounds like you’re going to have to push a little more paper next survey!

A few weeks ago, our friends in Chicago upped the ante in releasing the updated documentation list for the Life Safety portion of the survey (you can find it—and I really, really, really suggest that you do so sooner rather than later—by logging into your Joint Commission portal and the clicking through the following internal links: > Survey Process, > Survey Activity Guide, > Additional Resources). And this is definitely a case of the list having shifted towards documentation of activities and conditions for which folks have been struggling to get in line. Now, from anecdotal discussions with folks, there’s not always a ton of time available for document review. So, in a lot of instances, the focus is on inspection, testing and maintenance of fire alarm and suppression systems equipment, emergency and standby power supply systems, medical gas and vacuum systems, with some “drift” into fire drills and other more or less standard areas of concern/coverage, including the management plans (sometimes—and those don’t appear to have earned a mention on the updated list).

However, according to that same updated document list, looks like a lot of focus on inventory lists (operating components of utility systems; high-risk operating components on your inventory, infection control components); “embracing” (you can think of that as reviewing and adopting) manufacturer recommendations for inspection, testing and maintenance of utility systems or outlining the Alternative Equipment Maintenance program being used. And the same types of things for medical equipment—inventory, high risk equipment, consideration of manufacturer recommendations, etc. It also appears that there will be focus on sterilizer inspection, testing, and maintenance; compliance of your hyperbaric facilities (if you have them) with Chapter 14 of NFPA 99-2012; testing manual transfer switches in your emergency power supply system. Let’s see, what else…oh yes, for those of you with recently (I’m guessing that pesky July 6, 2016 date is the key point in time) constructed or renovated procedural areas, you need to make sure that you have (and are testing) task lighting in deep sedation and general anesthesia areas (the annual testing requirement is for a 30-minute test).

I’m sure there’s other stuff that will pop to the surface as we move through this next phase of the survey process; I’m curious about how much in-depth looking they’re going to be able to do and still be able to get to the lion’s share of your building (unless they start using unmanned drones…). I’m also curious that they don’t specifically indicate the risk assessment identified in Chapter 4 of NFPA 99-2012 (it has been asked for during CMS surveys), but that may be for the next iteration. Part of me can’t help but think back to those glory days when we wished for adoption of the 2012 Life Safety Code®; I guess we can take full advantage of the operational flexibilities inherent in suite configuration and a couple more things, but it never really seems to get any easier, does it?

At any rate, please hop on your organization’s TJC portal and give the updated list a look. If you see something that gives you hives, sing out: we’re all here to help!

Not enough rounding in the world: Compliance and readiness in the face of everyday chaos…

As I was engaged in my walk this morning (the sun just starting to cast its light on the Rockies!), I was pondering the complexities of the healthcare environment as a function of compliance. One of the truisms of my practice is that I am good at finding those points where things don’t quite gel. Sometimes (most times, to be honest), it’s relatively minor stuff (which we know is where most of the survey findings “live”) and every once in a while (mostly because my eyes are “fresh” and can pick out the stuff that’s happened over time; as I like to say, squalor happens incrementally), you find some bigger vulnerabilities (maybe it’s a gap in tracking code changes or a process that’s really not doing what you need it to do). So, after tooling around for a couple of days, folks will inevitably ask me “what do you look for?” and I will stumble through something like “I try to find things that are out of place” or something like that.

This morning, I had something of an epiphany in how that question actually informs what I do: it’s not so much what I look for, it’s what I look “at.” And that “at,” my friends, is everything in a space. One of the process element that gets drilled into housekeeping folks (I’m pretty sure this is still the case, it definitely was back in 1978 when I started this journey), is to check your work before you go on to the next thing, and that means going back over everything you were supposed to do. I’ve had conversations with folks about what tools I’ve seen that have been effective (and I do believe in the usefulness of tools for keeping track of certain problematic or high-risk conditions), but only in very rare circumstances have I “relied” on a tool because I have an abject fear of missing something critical because I had a set of queries, if you will. I would submit to you that, from a compliance standpoint, there are few more complex environments in which to provide oversight than healthcare. It is anything but static (almost everything except for the walls can move—and does!) and in that constant motion is the kernel of complication that makes the job of facilities safety professional infinitely frustrating and infinitely rewarding.

So, I guess what I’m advising is not to limit your vision to “for,” but strive for “at everything—and if you can impart that limitless vision to the folks who occupy your organization’s environment, you will have something quite powerful.

 

Who can turn the world on with her smile?

As we find 2017 reapplying time’s onslaught against pop culture icons, once again there’s a small “c” cornucopia of stuff to cover, some perhaps useful, some most assuredly not (that would be item #1, except for the advice part). Allons-y!

As goes the passage of time, so comes to us the latest and latest edition of the Joint Commission’s Survey Activity Guide (2017 version). There does not appear to be a great deal of shifting in the survey sands beyond updating the Life Safety Code® (LSC) reference, reordering the first three performance elements for the Interim Life Safety Measure (ILSM) standard, and updating the time frame for sprinkler system impairments before you have to consider fire watches, etc. They also recommend having an IT representative for the “Emergency Management and Environment of Care and Emergency Management” (which makes EM the function so nice they named it twice…), which means that, yes indeedy, the emergency management/environment of care “interviews” remain on the docket (and review of the management plans and annual evaluations—oh, I wish those plans would go the way of the dodo…) for the building tour as well. Interestingly enough, there is no mention of the ILSM assessment discussion for any identified LSC deficiencies (perhaps that determination was made to late in the process)—or if there is, I can’t find it. So for those of you entertaining a survey this year, there’s not a ton of assistance contained therein. My best advice is to keep an eye on Perspectives—you know the surveyors will!

And speaking of which, the big news in the February 2017 issue of Perspectives is the impending introduction of the CMS K-tags to the Joint Commission standards family. For those of you that have not had the thrill of a CMS life safety survey, K-tags are used to identify specific elements of the LSC that are specifically required by CMS. Sometimes the K-tags line up with the Joint Commission standards and performance elements and sometimes they provide slightly different detail (but not to the point of being alternative facts). As TJC moves ever so closely to the poisoned donut that is the Conditions of Participation, you will see more and more readily discernible cross-referencing between the EC/LS (and presumably EM) worlds. At any rate, if I can make one consultative recommendation from this whole pile of stuff, I would encourage you to start pulling apart Chapter 43 of the 2012 LSC – Building Rehabilitation, particularly those of you that have been engaged in the dark arts of renovation/upgrading of finishes, etc. You want to be very clear and very certain of where any current or just-completed projects fall on the continuum—new construction is nice as a concept (most new stuff is), but new construction also brings with it requirements to bring things up to date. This may all be much ado about little, but I’d just as soon not have to look back on 2017 as some catastrophic survey year, if you don’t mind…

Until next time, have a Fabulous February!

Don’t ask, don’t tell, don’t tell, don’t get in trouble…

Hope everyone is having a good week and that the rather stormy weather impacting so many parts of the country has not created too much of a challenge for you and your organizations.

This week is another (sort of) catch-all of topics, starting first with a little bit of CYA advice.

Lately there have been several instances (of which I am aware—can’t say for sure if this is an iceberg, but it “feels” like it might) of some very adverse accreditation/deemed status decisions based on insufficient documentation that organizational leadership had been effectively informed of conditions in the physical environment that required additional resources, etc. It’s not that organizational leadership was unaware of the conditions, but more that there was no trail of documented discussion (committee minutes, surveillance rounds, etc.) by which the organization could demonstrate to the surveyors that they had everything under control. In fact, the impression given because of the lack of a documented trail was exactly the opposite.

While nobody is really keen on telling their boss about problems of significance, especially problems for which the means of resolving them are elusive or beyond one’s resources (don’t want to look like you can’t do your job effectively), it is of critical importance to be able to escalate these types of issues to (or near) the top of the organization. Typically, this is about having to fund something (at least in my experience); maybe it’s a roof replacement; maybe it’s replacing some HVAC equipment—I’m sure most folks have a list of things for which it is a struggle to get traction. Let’s face it, unless it’s a new building, facilities infrastructure improvements, safety stuff, etc., is not particularly sexy, so when the capital improvement budgets come and go, it’s a tough sell. But sell it you must and you must keep pushing it—eventually those improvements (or lack thereof) are going to impact patient care and that’s when things can go south in a hurry. We always want to be respectful and not panicky, etc., but, please believe me, when the three- and four-letter regulatory folks knock on the door, you want to be in a position to describe how issues are brought to the attention of leadership. It may not be too pleasant in the moment (okay, in all likelihood, it won’t be pleasant at all), but it can save a whole lot of grief later on.

Next up (and this is something in the way of a commercial), The Joint Commission is hosting a webinar on Tuesday, February 7 to provide information on the new SAFER matrix, which is going to be an important feature of your survey report. We first covered it back in May, but now that they’ve been using it for the past few months (in behavioral health hospitals), it’s possible (I’m hoping likely, but I don’t want to get too amped up) that they will be sharing some useful information from the field. At any rate, particularly for those of you anticipating surveys in the next six to 12 months, I would try to make time for this one. I truly believe that every good intention is put into these survey changes, but I think we can all agree that those good intentions figure very prominently on a certain road…

Finally, this week, I would encourage you to look really, really, really closely at your interim life safety measures (ILSM) policy. TJC conducted a consultant conference last week and it is my understanding that the one significant shift in the survey of the physical environment is that there is going to be a lot of focus on the practical application of ILSMs as a function of Life Safety Code® deficiencies that cannot be immediately corrected. You have to make sure that your policy reflects an ongoing, robust process for that part of the equation. I think the conclusion has been drawn that folks generally have it together when I comes to ILSMs and construction, but are rather less skilled when it comes to those pesky LS deficiencies. We know they tend to focus on areas where they feel there are vulnerabilities (how else might one explain the proliferation of EC/LS/EM findings in recent years). This is a big one folks, so don’t hesitate to dial in with questions.

 

The song changes and yet remains the same…

There was a time when The Joint Commission actually seemed to be encouraging folks to fully engage with the clarification process in all its bountiful goodness. And I certainly hope that folks have been using that process to ensure that they don’t (or didn’t) have to “fix” processes, etc., that might not have been absolutely perfect in execution, but were not, by any stretch of the imagination, broken. But now, it appears that the bounty is going to be somewhat less bountiful as TJC has announced changes to the process, effective January 1, 2017. Please forgive my conspiracy theorist take on this, but it does seem that the new order in the accreditation world appears to lend itself to survey reports that will be increasing in the number of findings, rather than a reduction—and I am shocked! Okay, perhaps “shocked” is a tad hyperbolic. BTW, in a new Advocacy Alert to members, it appears that ASHE has come to the same conclusion, so it’s not just me…hoorah!

And so, the changes:

 

  • Any required documents that are not available at the time of survey will no longer be eligible for the clarification process (basically, the vendor ate my homework). It is important for everyone to have a very clear understanding of what TJC means by “required documents”—there is a list on your organization’s Joint Commission extranet site. My advice, if you have not already done so, is to immediately coordinate the download of that list with your organization’s survey coordinator (or whoever holds the keys to accessing that information—it may even be you!) and start formulating a process for making sure that those documents are maintained in as current a fashion as possible. And make sure your vendors are very, very clear on how much time they have to provide you with the documentation, as well as letting you know ASAP whether you have any deficiencies/discrepancies to manage—that 60-day correction window can close awfully quickly!
  • While I never really liked to employ this strategy, there were times when you could use clerical errors in the survey document to have things removed from the survey report. Areas that were misidentified on the report (non-existent to your facility; not apropos to the cited finding, for example, identification of a rated door or wall where there is none, etc.) or perhaps the location of the finding was so vague as to be impossible to identify—these have all been used successfully, but (apparently) no more. Now whether this means that there will be more in-depth discussions with the survey team as they prepare the report is unknown at this time, but even if one slips by (and I can tell you, the survey reports in general are much more exact—and exacting—in their description of the deficiencies and their locations), it won’t be enough to remove it from the report (though it could make your ESC submittal a bit more challenging if you can’t tell what it is or where it is).
  • The other piece of this is, with the removal of “C” Elements of Performance, you can no longer go the audit route to demonstrate that you were in substantial compliance at the time of survey. So now, effectively, everything is being measured against “perfection” (son of a…); miss one month’s check on a single fire extinguisher and—boom—finding! One rated door that doesn’t latch? Boom—finding! One sprinkler head with dust or a missing escutcheon? Boom—finding! And, as we touched on last week, it’s not just your primary location (aka, “the hospital”) that’s in play—you have got to be able to account for all those pesky little care sites, even the ones for which you are not specifically providing services. Say, for example, the landlord at one of your off-sites is responsible for doing the fire extinguisher checks; if something is missed (and hey, what’s then likelihood of that happening…), then you are vulnerable for a finding. So, unless you are prepared to be absolutely, positively perfect, you’d best be making sure that your organization’s leadership understands that the new survey reality is not likely to be very pretty.

I would like nothing better than to tell you that with the leadership change in Washington there will be a loosening of the regulatory death grip that is today’s reality, but somehow I don’t think that’s gonna happen…

A funny thing happened on the way somewhere…

One of the benefits of doing a lot of traveling and having a fairly well-developed case of OCD is having plenty of time to ponder ponderables and imponderables (I think it may be more fun than it sounds, but there are days when I’m not at all sure). At any rate, one of the things I’ve been tossing around in my head is the whole deal with the testing of defibrillators, particularly in areas that are not open 24/7. I suspect that, in most, if not all, instances, defibrillators are considered to be in the high-risk/life support category (I don’t think I’ve run into anyone that is managing them otherwise), so the question becomes this: in light of the Joint Commission performance elements indicating that high-risk/life support equipment is to be maintained in accordance with the Original Equipment Manufacturer (OEM) recommendations, if you have defibrillators in your inventory that require daily user testing (or some similarly constructed variation) and have those defibrillators in areas that are not open 24/7, how are you ensuring compliance relative to the OEM recommendations? I know of at least one hospital (which shall remain nameless) that does the user test on a once-monthly basis and I am curious as to how that might play out during a survey. Minimally, I think it would be a good idea to review the defibrillators you have in the inventory and see if there are any funky requirements/recommendations beyond the traditional preventive maintenance cycles. And please include the blogosphere when you figure out what you have; my fear is that this could become a means of generating more unpleasant findings during surveys if we don’t get out ahead of this thing. High risk and life support combine to make a very scary survey scenario in my mind’s eye (can you say immediate jeopardy?) and in the hands of a by-the-book, pain in the keister surveyor (not that there are any of those)…

A change will do you good…but what about no change? Exact change?

I’m sure you’ve all had a chance to look over the April 2014 issue of Perspectives, in which EC and LS findings combined to take seven of the top 10 most frequently cited standards during 2013, with issues relating to the integrity of egress taking the top spot.

At this point, I don’t think there are any surprises lurking within those most frequently occurring survey vulnerabilities (if someone out there in the audience has encountered a survey finding that was surprising, I would be most interested in hearing about it). The individual positions in the Top 10 may shift around a bit, but I think that it’s pretty clear that, at the very least, the focus of the TJC survey process has remained fairly constant these past couple of years.

Generally speaking, my sense about the TJC survey cycle is that specific focus items tend to occur in groups of threes (based on the triennial survey cycle, with the assumption being that during each three year period, every hospital would be surveyed—and yes, I do know what happens when you assume…) and I think that 2013 may well represent the end of the first go-round of the intensive life safety survey process (I really believe that 2009-2010 were sort of beta-testing years). So the question I have for you good citizens of the safety world: Has anyone been surveyed yet this year? With follow-up questions of:

  • Did you feel you were better prepared to manage the survey process this time?
  • Was the survey process different this time?
  • More of the same?
  • More difficult?
  • Less difficult?

I’m hoping to get a good sense of whether the tidal wave of EC/LS findings has indeed crested, so anyone interested in sharing would have my gratitude. Please feel free to respond to the group at large by leaving a comment here or if you prefer a little more stealthy approach, please e-mail me at smacarthur@greeley.com or stevemacsafetyspace@gmail.com.

Well, hello there, Mr. Vendor Man: Can we see your papers?

Reaching into the old e-mailbag, a question was raised regarding who “owns” the process for credentialing and what survey vulnerabilities might be lurking in the process. Now I can start by saying that there are no specific requirements as to a credentialing process for vendors; the overarching expectation is that vendors are like any other risk—something to be managed appropriately. Certainly, if you have equipment vendors scrubbing out and assisting in the OR, then that has a more far-reaching implication than a vendor who is responsible for managing copy machines. I suppose if you had to stretch things a bit, whoever is responsible in the organization for managing contracts would certainly be in a leadership position for stuff like this, but that responsibility can be more or less genericized as a function of “services will be provided in accordance with all applicable standards and regulations, including CMS, Joint Commission, state, etc. This would include consideration of such things as competence of the vendors (as an example, I will invoke Clinical Engineering relative to oversight of the contract services provided by external vendors—how do you make sure that contract equipment services personnel are adequately competent, etc.?). I don’t know that you could ever really trace it back to one or two folks in terms of ownership of the process—an organization of any complexity, etc. is going to have many, many contracts for various and sundry services, so there would almost have to be some division of responsibility (I say almost because I suppose you could maybe find the person with worst case of OCD in the organization and hand the responsibility to them—you’ll sleep at night—but he or she probably never will again) that ultimately ties back to senior leadership.

All that said, survey preparation comes down to knowing that the organization is effectively managing contract service vendors (and I’m using that term at its most expansive definition—everybody that provides services that is not directly employed by the hospital would have to be considered in the mix). You could certainly distill this group down to those which would be considered most critical (if that sounds like a risk assessment, you would be correct) and then identify a strategy for monitoring and periodic evaluation of performance. It’s all about having an effective process; generally speaking, TJC generally “leans” on this only when they’ve identified a clear and present failure mode; so if the vendors are adequately competent and behave themselves while under your roof, you should be okay—but you have to have some sense of whether than is indeed the case.

BTW: I had no intention of sexism in the headline; I was going to do the split Mr./Ms. Vendor Person,  but, I don’t know, Mr. Vendor Man seems a little more rock and roll…

Steak tips, turkey tips, and compliance tips—such a deal!

I’m not entirely certain what to make of this, but I always try to share anything I come across that might prove useful to you folks in the field. Back in July (yes, I know we are now edging towards the wintry portion of our year—we’ve had a lot of stuff to discuss), in one of the regular editions of Joint Commission Online, there was a list of compliance tips for the most frequently cited Life Safety standards.

Nothing wrong with that, as a going concern, but where I kind of got bogged down when I looked at the tips is that they weren’t necessarily in reference to stuff I’ve seen most in the field. All code compliance tidbits, to be sure, but again, not necessarily the type of stuff with which I’ve seen folks struggle.

As an example, the first tip deals with the required clear width of doors to sleeping rooms, egress doors, and doors to diagnostic treatment areas (existing construction must have at least 32 inches of clear width; new construction must have at least 41½ inches of clear width). Now I can think of a few instances in which I’ve encountered doors that were a might on the narrow side, but I’m also thinking door width is driving this particular standard (LS.02.01.20—egress requirements) to be among the most cited in all of survey land? I don’t know, which is why I’m not sure what to make of this. At any rate, make of it what you will—just make sure you grill those tips to your liking.