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Prioritize this…

During a recent survey, an interesting question was posed to the folks in Facilities, a question more than interesting enough to bring to your attention. The folks were asked to produce a policy that describes how they prioritize corrective maintenance work orders and they, in turn, asked me if I had such a thing. In my infinitely pithy response protocol, I indicated that I was not in the habit of collecting materials that are not required by regulatory standard. Now, I’m still not sure what the context of the question might have been (I will be visiting with these folks in the not too distant future and I plan on asking about the contextual applications of such a request), but it did give me cause to ponder the broader implications of the question.

I feel quite confident that developing a simple ranking scheme would be something that you could implement without having to go the whole policy route (I am personally no big fan of policies—they tend to be more complicated than they need to be and it’s frequently tougher to follow a policy 100% of the time, which is pretty much where the expectation bar is set during survey). I think something along the lines of:

Priority 1 – Immediate Threat to Health/Safety

Priority 2 – Direct Impact on Patient Care

Priority 3 – Indirect Impact on Patient Care

Priority 4 – No patient care impact

Priority 5 – Routine repairs

would work pretty well under most, if perhaps not all, circumstances. The circumstance I can “see” that might not quite lend itself to a specific hierarchy is when you have to run things on a “first come, first served” basis. Now I recognize that since our workforces are incredibly nimble (unlike regulatory agencies and the like), we can re-prioritize things based on their impact on important processes, so the question I keep coming back to is how can a policy ever truly reflect the complexities of such a process without somehow ending up with an “out of compliance with your policy” situation? This process works (or I guess in some instances, doesn’t) because of the competence of the staff involved with the process. I don’t see where a policy gets you that, but what do I know?

You may want to smoke during surveys

I could have sworn that I had covered this last year, but I can find no indication that I ever got past the title of this little piece of detritus, so I guess better late than never.

One of the more interestingly painful survey findings that I’ve come across hinge on the use of a household item that previously had caused little angst in survey circles—I speak of the mighty tissue paper! There has been any number of survey dings resulting from tissue paper either being blown or sucked in the wrong direction, based on whether a space is supposed to be positive or negative. And this lovely little finding has generated a fair amount of survey distress as it usually (I can’t say all, but I don’t know of this coming up in a survey in which the following did not occur) drives a follow-up visit from CMS as a Condition-level finding under Physical Environment/Infection Control.

The primary “requirements” in this regard reside under A-Tag 0726 and can be found below. Now I’m thinking that tissue paper might not be the most efficacious measure of pressure relationships, which (sort of—give me a little leeway here) begs the question of whether you should be prepared to “smoke” the doorway/window/etc. for which the tissue paper might not be as sensitive to the subtleties of pressures. I think it’s a reasonable thing to plan for—as much because there can be a whole lot at stake.  So, I’ll ask you to review the materials below and be prepared to discuss…

A-0726

(Rev. 37, Issued: 10-17-08; Effective/Implementation Date: 10-17-08)

§482.41(c)(4) – There must be proper ventilation, light, and temperature controls in pharmaceutical, food preparation, and other appropriate areas.

Interpretive Guidelines §482.41(c)(4)

There must be proper ventilation in at least the following areas:

• Areas using ethylene oxide, nitrous oxide, glutaraldehydes, xylene, pentamidine, or other potentially hazardous substances;

• Locations where oxygen is transferred from one container to another;

• Isolation rooms and reverse isolation rooms (both must be in compliance with Federal and State laws, regulations, and guidelines such as OSHA, CDC, NIH, etc.);

• Pharmaceutical preparation areas (hoods, cabinets, etc.); and

• Laboratory locations.

 

There must be adequate lighting in all the patient care areas, and food and medication preparation areas.

Temperature, humidity and airflow in the operating rooms must be maintained within acceptable standards to inhibit bacterial growth and prevent infection, and promote patient comfort. Excessive humidity in the operating room is conducive to bacterial growth and compromises the integrity of wrapped sterile instruments and supplies. Each operating room should have separate temperature control. Acceptable standards such as from the Association of Operating Room Nurses (AORN) or the American Institute of Architects (AIA) should be incorporated into hospital policy.

The hospital must ensure that an appropriate number of refrigerators and/or heating devices are provided and ensure that food and pharmaceuticals are stored properly and in accordance with nationally accepted guidelines (food) and manufacturer’s recommendations (pharmaceuticals).

Survey Procedures §482.41(c)(4)

• Verify that all food and medication preparation areas are well lighted.

• Verify that the hospital is in compliance with ventilation requirements for patients with contagious airborne diseases, such as tuberculosis, patients receiving treatments with hazardous chemical, surgical areas, and other areas where hazardous materials are stored.

• Verify that food products are stored under appropriate conditions (e.g., time, temperature, packaging, location) based on a nationally-accepted source such as the United States Department of Agriculture, the Food and Drug Administration, or other nationally-recognized standard.

• Verify that pharmaceuticals are stored at temperatures recommended by the product manufacturer.

• Verify that each operating room has temperature and humidity control mechanisms.

• Review temperature and humidity tracking log(s) to ensure that appropriate temperature and humidity levels are maintained.

 

Kind of vague, yes indeedy do! Purposefully vague—all in the eye of the beholder. Lots of verification and ensuring work, if you ask me, but this should give you a sense of some of the things about which you might consider focusing a little extra attention.

He ain’t HVA, he’s my opportunity

An interesting topic came across my desk relative to a January 2013 survey, and it pertains to the use of your HVA process as a means of driving staff education initiatives.

During the Emergency Management interview session during this particular survey, the surveyor wanted to know about the organization’s hazard vulnerability analysis (HVA) process and how it worked. So, that’s pretty normal—there are lots of ways to administer the HVA process—I prefer the consensus route, but that’s me.

But then the follow-up question was “How do you use the HVA to educate staff and their actions to take?” Now, when I first looked at that, I was thinking that the HVA process is designed more as a means of prioritizing response activities, resource allocations, and communications to local, regional, and other emergency response agencies, etc., but staff education? Not really sure about that…

But the more I considered the more I thought to myself, if you’re going to look at vulnerability as a true function of preparedness, then you would have to include the education of staff to their roles and responsibilities during an emergency as a critical metric in evaluating that level of preparedness. The HVA not only should tell you where you are now, but also give you a sense of where you need to take things to make improvements and from those improvements, presumably there will be some element of staff education. A question I like to ask of folks is: “What is the emergency that you are most likely to experience for which you are least prepared?” Improvement does not usually reside in things you already do well/frequently. It’s generally the stuff that you don’t get to practice as often that can be problematic during real-life events. One example is the management of volunteer practitioners—this can be a fairly involved process. But if you haven’t practiced it during an exercise, there may be complexities that will get in the way of being able to appropriately respond during the emergency. Which is why I recommend if you haven’t practiced running a couple of folks through the volunteer process, what better time than during an exercise?

Don’t know why there’s no sun up in the sky…stormy weather!

In case you’ve not heard (I don’t see as much info on the various list servs I monitor when it comes to the timing of the unannounced survey process), there have been some instances this year when unannounced Joint Commission surveys have been occurring months earlier than anticipated (nobody has gone outside of their official “window,” which opens 18 months prior to the anniversary date of your last triennial survey).

Certainly during 2012, there were some folks who went six weeks or so early, but we’re talking four or five months early. There was some indication that the incredibly reliable nasty weather in the Midwest and Northeast over the last little while has resulted in some schedule juggling by the folks in Chicago (and doing as much traveling as I do, I can well understand the impact of stinky weather). As has become an increasingly familiar mantra, you can’t predict future survey activities/results based on past experiences, but I figured it might be worth sharing the possibility. You all are supremely prepared for your survey I’m sure, but I figured I’d share that bit of info.

One other survey process wrinkle of some note is the tale of an organization that was anticipating a five-day onsite survey and ended up having a four-day survey—with additional surveyors on the team to compress the five days of activities into four days. So, for those of you with five-day surveys who have blocked off Mondays in hopes of maybe blocking out the entire week, there may be a little surprise in store. This has only happened once that I know of, but if anyone out there has a story to share on that front, I’m sure we would all be very interested to hear.

At any rate, as I type this, I am looking out at a very gray day at the airport in Chicago with a forecast of snow. I guess we’re not quite a week into spring, so this must just be a period of transition. Hopefully we transition pretty darn quickly. I do wonder “where those birdies is” (with apologies to Mr. Nash)…

Documentary evidence: More you need to know…

Another perpetually sticky wicket in the survey process (and we’ve discussed this, oh, once or twice before) is the timeliness of documentation from maintenance and testing vendors and the expectations of how that process has to be managed. During an ASHE-sponsored webinar last fall, George Mills posited the scenario in which there is a delay (delay times can vary, but you probably have a pretty good idea of how long you have to wait for reports to come back from your vendors) in receiving a report for fire alarm testing in which a handful of devices failed during routine testing. If you don’t receive the failure information immediately upon its identification by the vendor, what you are saying, in effect, is that it’s okay for me not to “know” (there’s that word again) how reliable my fire alarm system is for a month while I’m waiting for the report. If any of you think that it is indeed “okay” not to know might want to think about another line of work. From an empirical standpoint, a failed fire alarm device puts the building occupants (patients, staff—you know, those folks) at a greater risk, which is never, never, never a good idea. And what if you don’t get the report for six weeks, the failed devices haven’t been replaced, and now you’re looking at the possibility for having to manage the deficiency with a PFI, ILSM assessment—the whole magillah. Truthfully, you have better things to do with your time.

Mr. Mills’ suggestion (and I think it’s a good one, having made the suggestion at least once or twice in the past) is to ensure (either contractually or otherwise) that any deficiencies identified are in your possession before they “complete” their work. You can set it up so they let you know at the end of each testing day (that would be my preference) or at the end of the engagement. But you have got to have that information in your possession as soon as it can be made available to you. The occupants of your building depend on each and every element of your systems—fire alarm, fire extinguishment, medical gas and vacuum, emergency power—you know that list by heart and it’s your responsibility that they are managed appropriately.