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Pay a great deal of attention to the man behind the curtain: More ligature survey stuff!

This week’s installment is rather brief and (at least for the moment) is germane only to those folks with inpatient behavioral health units. During a recent TJC survey of a behavioral health hospital, I was able to catch a glimpse into the intentions of the information revealed last November (holy moly, it’s almost been a year!). I have to admit that the “cadence” of this particular guidance was a little confusing to me at the time, but now I “get” it.

In discussing the recommendations regarding nursing stations (nursing stations with an unobstructed view so that a patient attempt at self-harm at the nursing station would be easily seen and interrupted), the article in Perspectives goes on to indicate that areas behind self-closing/self-locking doors do not need to be ligature-resistant. The consideration that I want to share with you is that a self-closing/self-locking door is not the same as a door that is always locked (maybe you figured that out as a proactive stance, but I always considered control over locked spaces to be sufficiently reliable, but it would seem not to be the case). At any rate, if you take the guidance at its word, if you have a space on your behavioral health unit that has ligature risks contained therein, then you best have doors that self-close and lock. You may have a lot of doors that secure ligature-present spaces that do not self-close and lock; if that’s the case, you may want to reach out to the Standards Interpretation Group for official feedback on this. All I can tell you is that it’s been cited in at least one recent survey and it does reflect the content shared last November (I think it would have been my inclination to separate the nursing station concept from the “other” areas for the sake of clarity, but I can see where things “fall” now that it’s come up during a survey), so it’s definitely worth some consideration in your “house.”

Sometimes you have to ignore what your parents told you

Well, maybe ignore is a bit strong…

One of the recurring themes from my childhood was the not-infrequent exhortation from my mother: Don’t go looking for trouble (probably not an uncommon theme for everyone out there in the studio audience). But one of the more common themes that I’ve been running into are those instances in which trouble was lurking in the weeds, but folks weren’t necessarily successful in identifying/locating trouble spots. As near as I can tell, the worst thing that can happen during a survey (from a safety perspective) is when a surveyor identifies a condition or a practice about which you had no clue. It doesn’t happen a lot, but it does happen (usually followed by “Wow, I didn’t know that”).

There are a number of reasons for such a happenstance—sometimes folks really don’t know about something (though, dear reader, you are probably not in that number as we discuss a whole bunch of esoteric stuff). For instance, I still get a lot of folks who (and I have to believe that they are being completely candid) don’t know that hand sanitizer expires (or medicated lotion soap…or disinfectant wipes) or they are supremely confident that that is someone else’s concern (usually EVS when it comes to the many soaps, sanitizers, and disinfectants that populate the healthcare landscape). To my mind, it all goes back to the role of point of care/point of service folks (and I give the caregivers equal billing/accountability with the service-givers on this count) in being able to identify and report or otherwise manage risks in the physical environment.

But we as safety professionals have to be wicked diligent (as I pen this, it’s the day after the Boston Marathon, so that’s my gratuitous reference to Boston cultchah) in really working to ferret out all these little foibles, imperfections, etc. I think I’ve said this before in this forum (and no doubt will again), but whichever regulatory survey team shows up at your front/back/side door, they are going to find “stuff”—the human condition does not easily attain perfection, which leaves us vulnerable, vulnerable, vulnerable.

I recognize that everyone is stretched for time—too many meetings, too many spreadsheets, too many “too manys” to count—which only serves to “push” the maximization of the not-enough’s (not enough time, not enough resources, not enough support) in this adventure. Think of it as a challenge—there are folks out there doing stuff you would rather they not do—sometimes you only see the result (damaged walls and doors, unsealed penetrations, spills, thrills, chills) and we all have to be more effective in keeping on top of things.

Past lessons learned are a wonderful thing, but sometimes you have to go at things a little differently, so go out there and find some trouble spots. You’ll be glad you did!

 

How many feet in a mile? How many square feet in a smoke compartment?

I recently came across a survey finding that I thought would be worth sharing with the class. In this particular survey, an organization was cited because it had not identified the square footage of their smoke compartments on its life safety drawings (this was a Direct Impact finding relative to maintaining a current e-SOC). In looking over the information published in the October 2012 issue of Perspectives (See the highlight box on p. 12 entitled “What to Include in Life Safety Code Drawings.” Please check it out if you have not yet done so; anything that shows up in Perspectives is enforceable as a standard!), I clearly see that there is a requirement to include the square footage of any areas designated as suites.

The only mention of smoke compartments indicates that they are required to be identified by location, but there is no mention of the square footage. Now this would seem to be a case of a surveyor interpreting (perhaps even over-interpreting) a requirement based on information that has not appeared in either the standards manual or in Perspectives (square footage for smoke compartments isn’t mentioned in the February 2012 issue of Environment of Care News either). I think this would be a good survey finding with which to practice using the clarification process and I suspect that the organization in question is going to make good use of that process.

Hey, how about that new app(liance focus during TJC surveys)?

I don’t know that it represents a significant focus change or if it’s just one of those blips that one might encounter when you hear about survey results, but there is a little groundswell relative to the management of appliances (basically everything that is not clinical equipment, which it appears could extend to utility systems equipment, but there’s no clear sense of that just yet).

I think we can agree than the healthcare environment is chock-a-block full of all manner of devices and appliances from toasters and microwave ovens to refrigerators; from desk lamps to radios and who knows what else. So in that great expanse of possibilities, there have been at least two recent surveys in which the process for managing these types of appliances/devices have come under come scrutiny, resulting in some RFIs for folks.

Now, there are no specific standards or EPs that speak to the management of these appliances/devices, but it appears that where opportunities in this realm are being funneled is our old friend EC.02.01.01, generally a “there was no policy or risk assessment in place to indicate how the risks associated with…” (quotes are mine as I am paraphrasing the general concept). Not that long ago we talked about how far one might need to go when it comes to the ever-present specter of the risk assessment process, and I guess the short answer is: Here’s another instance to flex the ol’ risk assessment muscles.

And so I ask of you: How are you guys managing these pesky appliances? Incoming functional safety inspection (you turn it on and presto, it works) with periodic visual inspections during surveillance rounds? Regularly scheduled preventive maintenance (PM) activities? Re-inspection when something gets busted and is repaired? Inquiring minds (as they are wont to do) await your input!

Thela Hun Ginjeet (and a great big dose of humidity)

Not to belabor or otherwise abuse the deceased equine, I wanted to share with you a potential solution for those of you who might be struggling with high humidity levels in your surgical procedure areas. Let me first say that I’m not an engineer, so I can’t necessarily speak to the science/mechanics of this strategy, but my friends in a nationwide hospital system have employed this with some success. As they say on TV (and radio, and just about anywhere there’s a legal disclaimer), actual results may vary. Consult your (insert professional here) if conditions persist…

And so we have this: Set the discharge temperature of the air handler(s) feeding your ORs (or any other spots where you are having challenges with humidity) to a lower setpoint, to where the reheat coils come on and dry the air. The colder supply air temps from the air handler should trigger the reheat coils to come on, and potentially dry some of that moist air.

Just to give you some geographical context, the folks who appear to be having some luck with this strategy for managing humidity are in those quintessentially arid locations such as Florida, the Carolinas, and Mississippi (when these folks get a new sweater for Christmas, it’s not necessarily something they’d wear). So in the interest of sharing (which generally equates with caring), I figured I’d throw this out there for consideration.

Any folks out there in radioland who’ve tried this and had successes (or not), let me know in the comments. I don’t think this one’s going away any time soon as a survey hot topic, so anything we can do to help each other makes a lot of sense to me, but that might just be me…

We are the champions

Now there may be some folks out there who are thinking that there are certain topics to which I have administered beatings akin to the deceased equine, but sometimes there are other folks who appear to share at least some of my “wacky” perspectives on how to manage safety in the healthcare environment.

So, I encourage you to contact the individual in your organization responsible for coordinating Joint Commission accreditation and ask them to share with you the February 2013 issue of Joint Commission Perspectives. And, if you turn to p. 9, you will find the latest column penned by George Mills entitled “Safety Champions—Making Health Care Safety Everyone’s Business.” And to this, I say hallelujah! Those of you who’ve been with me since we started this little space (it’s been years and years, I tell you, years and years) will recognize this as a common theme (I think I’ve twisted it every which way, over time, but you should recognize the basic form) and still one that I believe holds a key to compliance success ( I refrain from referring to it as “the” key, because the education “key” is pretty gosh-darn important as well).

And, interestingly enough, Mr. Mills’ column in the March 2013 issue of Perspectives focused on, wait for it…

RISK ASSESSMENTS!

Can I get an A(ssess)MEN(ts)! Stay tuned: You know I’ll have something to add to that conversation…

Finders and fixers: Can we get them to say something if they see something?

One of things that continuously comes up on my pondering list is how to enlist the eyes, ears, noses, and fingers of frontline staff in the pursuit of the early identification of risks in the physical environment. Unless one of the facilities maintenance folks happens to be in the right place at the right time, in all likelihood, an aberrant condition is going to manifest itself to somebody working out at the point of care/point of service. And my firm belief is that the organizations that manage environmental risks most effectively (including the “risks” associated with unannounced regulatory survey visits) are the organizations that have most effectively harnessed these hundreds, if not thousands, of agents in the field 24/7.

So, my latest take on this is that we can subdivide the totality of every (and, really, any) organization into two main constituencies—finders and fixers. The key is to get the finders mobilized, so the fixers (who, truth be told, in most organizers are currently finder-fixers) can focus on actually repairing/replacing stuff. I’m at a loss to explain why this can be such a difficult undertaking, so I’ll ask you, dear reader: What do you think? Or if you’ve found a way to really mobilize the “finders” in your organization, how did you make it happen? Did you have to guilt them into it, did you establish a “bounty” system for reporting conditions, etc.? I am firmly convinced that if we can enlist these folks in the identification of hazards, we can really move towards a process for ensuring constant readiness.

One thing leads to another

An interesting development on the survey front this year; it may be merely a blip on the compliance radar screen (I know of two instances in which this happened for sure—but if you folks know of more, please share), but if this signals a sea change in how The Joint Commission is administering surveys, you’d best have your ducks in a row.

So, I’ve heard tell of two instances in which the survey team arrived at an organization with the results of the previous triennial survey clutched in their paws, with the intent being to validate that the actions submitted as part of the Evidence of Standards Compliance (ESC) process did indeed remedy the cited deficiency. Now I think we can agree that the degree to which we can fix something and keep it fixed over the course of 36 or so months can be a bit of a, how shall we say, crap shoot. As we’ve noted in one fashion or another, lo these many years, fixing is easy—keeping it fixed is way difficult.

And so dear friends, those of you in the survey bucket for 2013 should dig out those survey results from last time, review the ESC submittal and make sure that what was accepted by TJC as a means of demonstrating compliance with the standards is indeed the condition/practice that is in place now. And the reason this is so very, very important, just to complete the thought, is that there is a pesky little standard in the APR chapter of your beloved Accreditation Manual  (APR stands for Accreditation Participation Requirements, and the standard in question is APR.01.02.01) that requires “(t)he hospital provides accurate information throughout the accreditation process.” So if a surveyor gets to thinking that there may have been some less than forthcoming aspect of your action plans, etc., you could be looking at a Preliminary Denial of Accreditation, a most unpleasant state of affairs, I assure you. So let’s give those “old” findings at least one more ride around the track and make sure that we’ve dotted all the “i’s” and crossed all the “t’s.”