RSSAll Entries Tagged With: "The Joint Commission"

I’ve been there, I know the way: More Executive Briefings goodness

You’ve probably seen a smattering of stuff related to the (still ongoing as I write this) rollout of this year’s edition of Joint Commission Executive Briefings. As near as I can tell, during the survey period of June 1, 2017 to May 31, 2018, there were about 27 hospitals that did not “experience” a finding in the Environment of Care (EC) chapter (98% of hospitals surveyed got an EC finding) and a slightly larger number (97% with a Life Safety chapter finding) that had no LS findings. So, bravo to those folks who managed to escape unscathed—that is no small feat given the amount of survey time (and survey eyes) looking at the physical environment. Not sure what he secret is for those folks, but if there’s anyone out there in the studio audience that would like to share their recipe for success (even anonymously: I can be reached directly at stevemacsafetyspace@gmail.com), please do, my friends, please do.

Another interesting bit of information deals with the EC/LS findings that are “pushing” into the upper right-hand sectors of the SAFER matrix (findings with moderate or high likelihood of harm with a pattern or widespread level of occurrence). Now, I will freely admit that I am not convinced that the matrix setup works as well for findings in the physical environment, particularly since the numbers are so small (and yes, I understand that it’s a very small sample size). For example, if you have three dusty sprinkler heads in three locations, that gets you a spot in the “widespread” category. I don’t know, it just makes me grind my teeth a little more fiercely. And the EP cited most frequently in the high likelihood of harm category? EC.02.02.01 EP5—handling of hazardous materials! I am reasonably confident that a lot of those findings have to do with the placement/maintenance of eyewash stations (and I’ve seen a fair number of what I would characterize as draconian “reads” on all manner of considerations relating to eyewash stations, which reminds me: if you don’t have maintenance-free batteries for your emergency generators and you don’t have ready access to emergency eyewash equipment when those batteries are being inspected/serviced, then you may be vulnerable during your next survey).

At the end of the day, I suppose there is no end to what can be (and, clearly, is) found in the physical environment, and I absolutely “get” the recent focus on pressure relationships and ligature risks (and, soon enough, probably Legionella–it was a featured topic of coverage in the EC presentation), but a lot of the rest of this “stuff” seems a little like padding to me…

If it’s September, it’s time for Executive Briefings!

I suspect that, over the next few weeks, as I learn of stuff coming out of the various and sundry Joint Commission Executive Briefings sessions, I’ll be sharing some thoughts, etc., in those regards here in the ol’ blog.

The first thing to “pop” at me was some information regarding Chapter 15 (Features of Fire Protection) in NFPA 99 Health Facilities Code (2012 edition) relating to the management of surgical fire risks. If you’ve not had a chance to check out section 13 of said chapter, I think it will be worth your while as there are a couple of things that in the past one might have described as a best practice. But, with the official adoption of NFPA 99 by CMS, this has become (more or less, but definitely more than before) the law of the land. From a practical standpoint, I can absolutely get behind the concepts contained in this section (I’m pretty comfortable with the position that any surgical fire is at least one more than we should have), but from a strict compliance standpoint, I know that it can be very challenging to get the folks up in surgery to “play ball” with the physical environment rules and regulations.

As one might expect, the whole thing breaks down into a few components: hazard assessment; establishment of fire prevention procedures; management of germicides and antiseptics; establishment of emergency procedures; orientation and training. I think the piece of this that might benefit from some focused attention relates to the management of germicides and antiseptics, particularly as a function of the required “timeout” for the germicide/antiseptic application process. And yes my friends, I did say “required”; Section 15.13.3.6 indicates (quite specifically) that a preoperative “timeout” period shall be conducted prior to the initiation of any surgical procedure using flammable liquid germicides or antiseptics to verify that:

  • Application site of flammable germicide or antiseptic is dry prior to draping and use of electrosurgery, cautery, or a laser
  • Pooling of solution has not occurred or has been corrected
  • Any solution-soaked materials have been removed from the operating room (OR) prior to draping and use of electrosurgery, cautery, or a laser

Now, I will freely and openly admit that I’ve not done a deep dive into the later chapters of NFPA 99 (though that’s on my to-do list), so I hadn’t bumped into this, but I can definitely see this being a potential vulnerability, particularly in light of the recent FDA scrutiny (and it goes to Linda B’s question in follow-up to a recent blog posting—I probably should have turtled to this at that point—mea maxima culpa). At any rate, nothing in this section of NFPA 99 is arguable unless you don’t have it in place and a surveyor “goes there,” so perhaps you should be sure that your OR folks are already “there” sooner rather than later.

Two closing items:

  • The good folks at the Facilities Guidelines Institute have provided a state-by-state resource identifying which states have adopted the FGI guidelines (completely, partially, not really). You can find that information here.
  • Also,  Triumvirate Environmental is presenting a couple of webinars over the next little while that might be of interest. The one this week (sorry for the short notice) deals with the recently established by EPA’s Hazardous Waste e-Manifest Program and then the week after next, there’s a program on Best Practices to Optimize Your Waste Documentation Program. While I can’t call these crazy risky survey vulnerabilities, EC.02.02.01 is still percolating around the top of the most frequently cited list, so it never hurts to obtain greater familiarity with this stuff.

Enjoy your week safely!

Changing (not so much) perspectives on survey trends: Infection Control and Medication Safety

By now I suspect that you’re probably seen/heard that the survey results for the first half of 2018 are only surprising to the extent that there are no surprises (well, maybe a small one, but more on that in a moment). There’s a little bit of jockeying for position, but I think that we can safely say that the focus on the physical environment (inclusive of environmental concerns relating to infection control and prevention) is continuing on apace. There’s a little bit of shifting, and the frequencies with which the various standards are being cited is a wee bit elevated, but the lion’s share of the survey results that I’ve seen are indicative of them continuing to find the stuff they will always be able to find in this era of the single deficiency gets you a survey “ding.” The continuing hegemony of LS.02.01.35 just tells me that dusty sprinklers, missing escutcheons, stacked-too-high storage, etc., can be found just about anywhere if the survey team wants to look for it.

One interesting “new” arrival to the top 10 is IC.02.01.01, which covers implementation of the organization’s infection control plan. I have seen this cited, and, interestingly enough, the findings have involved the maintenance of ice machines (at least so far) and other similar utility systems infection control equipment such as sterilizers (for which there is a specific EP under the utilities management standards). I suspect that what we have here is the beginning of a focus on how infection control and prevention oversight dovetails with the management of the physical environment. I know that this is typically a most collaborative undertaking in hospitals, but we have seen how the focus on the “low hanging fruit” can generate consternation about the overall management of programs. As I’ve noted countless times, there are no perfect environments, but if don’t/can’t get survey credit for appropriately managing those imperfections, it can be rather disheartening.

Couple other items of note in the September issue of Perspectives, mostly involving the safe preparation of medications. As you know, there are equipment, utility systems, environmental concerns, etc., that can influence the medication preparation processes. The Consistent Interpretations column focuses on that very subject and while the survey finding numbers seem to be rather modest, it does make me think that this could be an area of significant focus moving forward. I would encourage you to check out the information in Perspectives and keep a close eye on the medication preparation environment(s)—it may save you a little heartache later on.

CMS Ligature Risk Update: Not quite finished…

Cast aside the doubt that nothing good came come this way again!

On July 20, 2018, CMS issued further information regarding its expectations for ensuring that behavioral health patients are being provided a safe and appropriate environment. There had been some indication that CMS might be undertaking their own analysis of the current state of things, but it appears that CMS is going to incorporate the outcomes of The Joint Commission’s (TJC) suicide panel (in which CMS representatives participated) into a comprehensive ligature risk interpretive guidance. The memorandum does not indicate when we can expect the finalized interpretive guidance, but things do seem to be moving at a pretty good clip, so I’m thinking (maybe, just maybe), we’ll see that information before the end of the year. As a point of information (and you know I’m all about the points), the Joint Commission guidance cited in the CMS memorandum can be found here: and some clarifying FAQs issued by TJC last month (but not specifically referenced in the CMS memorandum) can be found here: (the information specific to ligature risks is about half way down the page). I know we’ve covered this over the past few months, but I can never be sure at which point in the conversation folks tune in, so I figured it doesn’t hurt to have links for what is current (at the moment…).

For those of you who have not yet tackled all of the particulars relating to the guidance issued from Joint Commission (mostly because you do not use TJC for deemed status accreditation purposes), I do think that the compliance path appears to be fairly reasonable and straightforward from an implementation standpoint. That said, until the interpretive guidance is finalized by CMS, there will likely continue to be some surveyor interpretation in the mix, particularly on the part of those accreditation and regulatory organizations other than Joint Commission (DNV, CIHQ, HFAP, state agencies, etc.). Which means it will be incumbent upon pretty much all hospitals to know where they stand relative to TJC recommendations, particularly as a function of how the strategies and facilities modifications they’ve made meet the intent of the recommendations. Some recent non-TJC survey activities indicate that the “other” accreditation organizations are starting to focus on this topic and, right now, are very much where TJC was in early 2017 when surveyors were inclined to identify anything and everything as a potential, unmanageable risk. And lots of re-surveys following in the wake of those determinations

Beyond a familiarity/assessment relative to the TJC recommendations, the “other” piece of which you need to be mindful is that whatever fixes they identify need to be completed before survey or there will likely be some back and forth relative to Immediate Threat, the need for re-survey, etc.  As we’ve discussed in the past (and this surely goes beyond ligature-resistant hardware), a lot of folks with a significant number of fixes are very much at the mercy of the supplies of needed hardware, etc. At a minimum, hospitals that haven’t completed their “laundry list” of fixes must have a risk assessment in place that outlines not only what is to be done from a facilities standpoint, but what strategies are in place to ensure that the risk to patients is being properly managed in the interim (this is very similar to the survey methodology dealing with Interim Life Safety Measures). As I’ve told folks time and again, you don’t get credit for doing the math in your head—at the end of the day, when you have a survey team “in the house,” the only “good” risk assessment is a risk assessment that is fully documented, approved by the appropriate organizational authorities, etc. If you don’t have an assessment ready to go for survey, it’s likely to be a very tough slog.

At any rate, it does appear that this one is going to be winding down in terms of survey activity, which will bring no small measure of relief to the survey preparation process, but it does beg the question of whether this is the last big environmental dope-slap or if there’s something else waiting in the wings to make us crazy. Any thoughts?

Odds and Sods: Clearing out the Safety Brain

Once again, I come face-to-face with my depository for blog postings and the like, so we have something of a mixed bag this week, with very little in the way of a common theme…

I’m sure folks saw the news story regarding the dead woman found in a stairwell of a hospital power plant and it got me to thinking about the increasing importance of ensuring that all your unmonitored perimeter points are as secure as they can be. It appears that the woman was able to gain access to the stairwell and was either too confused or otherwise compromised to make her way back out. The hospital has since hardened the perimeter of the power plant, but I think this points out that you really need to encourage folks to be on the lookout (security rounds can really only go so far) for unusual circumstances/ folks in their environments. It may be that there was nothing that could be done to prevent this tragedy, but I think it serves as a reminder that you really can’t be too secure.

As something of a parallel pursuit, HCPro recently re-aired a webinar presented my good friend and colleague Ken Rohde on the topic of occurrence reporting and its impact on operations, including the safety realm. Ken is an awesome presenter with a completely useful take on how safety operations impact, and are impacted, by how we manage occurrence reporting, particularly as a source of data for making improvements. If you have some monies in your budget for education, I really encourage you to check out the On-Demand presentation and let Ken help you improve your safety program.

In other parts of my noggin, I was looking at the crosswalk that TJC provides in the online version of their accreditation manual and was contemplating what is referenced as the applicable CMS requirement that “drives” the documentation requirements under EC.02.03.05 EP #28. In all candor, what prompted me to look was this nagging feeling that there are a lot of other required process documentation elements in other parts of the Environment of Care standards and whether there is a likelihood of those documentation requirements being carried over to things like generator testing, medical gas and vacuum system testing, etc. (for you pop culture enthusiasts, I consulted the magic 8 ball and it says “signs point to yes”; for those of you not yet familiar with the amazing technology that is the Magic 8 Ball, find more here). And when I looked at the TJC/CMS crosswalk, I noted that not only is the Life Safety Code® invoked as a referenced requirement, but also the Emergency Preparedness Condition as a function of the provision of alternate sources of energy for maintaining fire detection, extinguishing, and alarm systems. It may not be an imminent shift, but I think you would do well to consider adopting the documentation format outlined under EC.02.03.05 EP #28—it will help organize compliance and maybe, just maybe, keep you a half-step ahead of the sheriff…

On a closing note, I have (yet another) summer reading recommendation for folks: I think we can all agree that the use of effective communications is one of the most powerful tools that we can bring to our safety practices. As you all know every well (I’ve been inflicting this on you all for many, many…), I do tend towards more florid descriptors (that’s one there; I mean who uses “florid” anymore?), which can make comprehension difficult across a multi-faceted audience if you do not take into consideration the entirety of the audience. At any rate, I recently finished Alan Alda’s latest If I Understood You, Would I Have This Look on My Face?, which deals with the science of communications and provides a lot of thought-provoking suggestions on how we might improve the effectiveness of interpersonal communications at every level of life. For me, the most compelling insight was the notion that is the responsibility of the person doing the communicating to make sure that the audience is comprehending what is being communicated. That prompted me to reflect on any number of conversations I’ve had over the years, more or less revolving around the frustration with an audience that “just doesn’t get it” and the thought that perhaps the audience (in all its parameters) merits more consideration when things don’t work out in the way it was planned. At any rate, I found a lot of interesting perspectives on communications and (it’s a pretty quick read) I think you might find a nugget or two for your own use.

Wagging the dog: Can Accreditation Organizations influence each other?

In last week’s issue of HCPro’s Accreditation Insider, there was an item regarding the decision of the folks at the Healthcare Facilities Accreditation Program (HFAP) to update their Infection Control standards for acute care hospitals, with the intent of alignment with CMS expectations (you can find the article here) We’ve certainly covered the concerns relative to Legionella and the management of risks associated with aerosolizing water systems and this may only be a move to catch up on ground already covered by other accreditation organizations (our friends in Chicago already require the minimization of pathogenic biological agents in cooling towers, domestic hot- and cold-water systems, and other aerosolizing water systems), but I’m thinking it might also be something of a “tell” as to where survey focus might be drifting as we embark upon the second half of 2018. Certainly, waterborne pathogens are of critical importance to manage as a function of patient vulnerability (ideally, we want folks to get better during their hospital stays), so it makes perfect sense for this to be on the radar to some degree. At this point, the memorandum from CMS outlining their concerns has been with us for about a year, with an immediate effective date, so hopefully you are well-entrenched in managing those water systems. If this one is still on your to-do list, I think it’s probably advisable to making it a priority to get it to your “to-done” list. But you should definitely check out the latest “clarification” from CMS. While the memo indicates that this does not impose any new expectations or requirements, it does make it a little clearer as to what surveyors are supposed to be checking.

As I think Mr. Gershwin once opined about summer and the easiness of living, it would be nice to be able to set a spell and take one’s shoes off, but vigilance is always the order of the day.

On a somewhat lighter note, I just finished reading Our Towns – A 100,000 Mile Journey Into The Heart of America, which outlines the efforts of a number of (mostly smallish) municipalities across the United States in positioning themselves for a positive future (positive positioning—I kind of like that). The focus is mostly on the socioeconomics of different parts of the country, with a focus on how diversity can be employed in bettering a community (that’s probably a little ham-handed as a descriptor, but you can find an excerpt here if you like). As my work allows me to travel to a lot of places, while I haven’t been to a lot of the same destinations as the Fallows, I do recognize a lot of the stories and a lot of the challenges facing folks lately (and I think you might, too). I would describe the tone of the book as hopeful, so if you’re looking for something to read at beach/pond/summer cottage, etc., you might consider giving Our Towns a shot.

 

A quiet week in Lake Forgoneconclusion: Safety Shorts and Sandals!

But hopefully no open-toed sandals—maybe steel toed sandals…

Just a couple of quick items as we head out of the Independence Day holiday and into the heat of the summah (and so far, scorching has been the primary directive up here in the Northeast—hope it’s cooler where you are, but I also hope it didn’t snow where you are either…but I guess if you were in Labrador last week, all bets are off).

When last week’s musings on the ligature risk stuff in the July Perspectives went to press (or when I finished my scribbling), the new materials had not yet made their way to TJC’s Frequently Asked Questions page, though I thought that they might—and that’s exactly what has happened. To the tune of 17 new FAQs for hospitals, so if you haven’t yet laid eyes on the July Perspectives, head on over to the FAQ page and immerse yourself in the bounty (that’s a somewhat weird turn of phrase, but I’m going to stick with it).

While you’re there, you should definitely poke around at some of the other stuff on the FAQ page. There are lots and lots of recommendations for risk assessment types of activities, so if you’re looking for some risk minimization opportunities, you might find some useful thoughts. Of particular note in this regard is the practical application of safety practices in those organizational spaces for which your oversight is somewhat more intermittent; I’m thinking offsite physician practices or medical office buildings and similar care locations. Depending on where you are and where they are, it might not be quite so easy to keep a really close eye on what they’re doing. And while I tend to favor scheduling surveillance rounds with folks in general, I also know that if you don’t stop by from time to time, you might not catch any lurking opportunities (and they do tend to be lurksome when they know you’re coming for a visit). In a lot of the survey results I’ve seen over the last 18 months or so, there’s still a pretty good chunk of survey findings generated during the ambulatory care part of the survey process. Safety “lives” at the point of care/service, wherever that may be—definitely more ground to cover now that in the past. At any rate, I think you could use the FAQ stuff as a jumping off point to increase the safety awareness of folks throughout—and you can do that independently of anyone’s vacation schedule (including your own).

Hope you and yours had a most festive 4th!

Will it go ’round in circles? More managing the physical environment relative to suicide risk!

Hopefully you have already gotten a chance to look through the July 2018 issue of Perspectives for the latest reveals on how (at least one accrediting body) is working through the issues relating to ensuring each organization has a safe environment for the management of behavioral health patients. There is a fair amount of content (this comes to us in the form of FAQs—presumably these will find their way to the official FAQ page, if they have not yet done so) and splits up into three general categories: inpatient psych units, emergency departments (ED), and miscellaneous. (I’m going to guess that the FAQs relative to managing at risk patients in acute care settings is going to merit their own FAQ edition, so I guess we’ll have to stay tuned.)

I don’t know that I would term anything to be particularly surprising (lots of emphasis on the various and sundry risk assessment processes that comprise an integrated approach to such things), though they do make some efforts to describe/define, going so far as to indicate that only patients with “serious” suicidal ideation (those with a plan and intent) need to be placed under “demonstrably reliable monitoring” (aka 1:1 monitoring), with the further caveat that the monitoring be linked to immediate intervention, which means something in terms of competency, education, experience, etc. Clearly (and I completely agree with this) there is an expectation relative to who does the monitoring that probably doesn’t include a rookie security officer or other newbie. I personally have advocated for a very long time the use of folks who are specifically prepared for these types of activities, so maybe that idea is going to approach something of a standard. We shall wait and see.

Another interesting item is the indication that if you (and, yes, I mean you!) designate a room in your ED as a “safe room,” then the expectation (at least for TJC) is that room (or rooms if there are more than one) would be ligature resistant. Makes sense, but I think it does represent something of a caution for those of you looking at designating safe rooms in your EDs (and perhaps extending to the inpatient side of things—probably in the next installment). I guess the other interesting thing (and this probably doesn’t apply to all) relates to freestanding EDs: the recommendations (you can check out the November 2017 issue of Perspectives for the particulars if you’ve not yet done so) for EDs would apply. I understand that this is rather a big deal in general and is very close to endlessly complex in the practical application of the management of risks. I think this is one “ball” we’re going to be keeping an eye on for the next little while.

To end this week in the truth is stranger than almost anything category, I was looking through an email (devoted to all things culinary) and I noted a headline: “We’re All Using Clorox Wipes Wrong, Apparently” and I said to myself, “Dwell times have entered the vernacular of the American household” (I’m not saying it’s anything more than a toehold, but still) and darned if I wasn’t pretty much spot on. The other “revelation” is the absence of bleach in some of the kitchen wipe products identified in the article (I think I knew that, but I can’t really say when I might have acquired said knowledge). There’s also some information on what surfaces should be cleaned with certain kitchen wipes, etc. At any rate, I thought it worth sharing, at least as an example of how our work can span all demographics.

Happy Independence Day to all!

With a purposeful grimace and a terrible sound: Even more emergency management!

As much as I keep promising myself that I’ll poke at something more varied, the news of the day keeps turning back in the direction of emergency preparedness, in this case, just a little bit more on the subject of continuity of operations planning (COOP).

Late last week, our friends in Chicago proffered the latest (#41) in their series of Quick Safety (QS) tips, which focuses on elements of preparedness relating to COOPs (nobody here but us chickens). Within the QS tip (small pun intended), our Chicagoan overlords indicate that “continuity of operations planning has emerged as one of the issues that…need to address better in order to be more resilient during and after the occurrence of disasters and emergencies.” The QS also indicates a couple of best practice focus areas for COOPs:

  • Continuity of facilities and communications to support organizational functions.
  • A succession plan that lists who replaces the key leader(s) during an emergency if the leader is not available to carry out his or her duties.
  • A delegation of authority plan that describes the decisions and policies that can be implemented by authorized successors.

Now, I will freely admit that I always thought that this could be accomplished by adopting a scalable incident command structure, with appropriate monitoring of critical functions, inclusive of contact information for folks, etc. And, to be honest, I’m not really sure that having to re-jigger what you already have into something that’s easy for surveyors to discern at the 30,000-foot survey level is going to make each organization better prepared. I do know that folks have been cited for not having COOPs, particularly as a function of succession planning and delegation of authority (again, a properly structured HICS should get you most of the way there). So, I guess my advice for today is to figure out what pieces of your current EOP represent the COOP requirements and highlight them within the document (I really, really, really don’t want you to have to extract that stuff and create a standalone COOP, but if that helps you present the materials, then I guess that’s what you’d have to do…but I really don’t like that we’ve gotten to this point). At any rate, the QS has lots of info, some of it potentially useful, so please check it out here.

As a closing thought: I know folks are working really diligently towards getting an active shooter drill on the books, with varying degrees of progress. As I was perusing various media offerings, I saw an article outlining the potential downsides of active shooter-type drills. While the piece is aimed at the school environment, I think it’s kind of an interesting perspective as it relates to the practical impact of planning and conducting these types of exercises. It’s a pretty quick read and may generate some good discussion in your “house.”

And you may find yourself in another part of the survey process (more HazMat fun)

And you may ask yourself, well, how did I get here?

As is sometimes the case, I like to respond to questions from the “studio” audience and last week I received a question from the field that I think is worth a few inches of verbiage here. The question, as luck would have it, relates to the ascendancy of EC.02.02.01 (with 63% of the hospitals being surveyed taking hits), the management of hazardous materials and wastes.

While it may seem a little incongruous, with a side order of daunting, I think that the primary reason for the ascendance of EC.02.02.01 is that there are any number of things that can generate findings, particularly from the clinical surveyors (not that the LS surveyor couldn’t find stuff, but from what I’ve seen in recent survey reports, a lot of the HazMat findings are being generated during “regular” tracers). So, in no particular order:

  • emergency eyewash equipment (availability/accessibility/documentation of testing & maintenance)
  • availability and use of personal protective equipment (PPE) in accordance with product Safety Data Sheets (SDS)
  • management of hazardous energy sources, particularly as it relates to managing lead PPE;
  • labeling of secondary containers
  • management of hazardous gases and vapors (particularly as a function of ventilation, but also monitoring if you happen to have folks still using glutaraldehyde and/or cadmium-based products)
  • ensuring appropriate staff education is in place, particularly Department of Transportation education for staff signing manifests
  • with the odd issue relating to staff being able to competently access SDS

We’ve certainly spent our fair share of time talking about eyewash equipment (surveyors are as prone to over-interpretation as anyone, so you better have a clearly articulated risk assessment in your back pocket), and, interestingly enough, on May 31 (my birthday!), the folks at HCPro are hosting a webinar on the evergreen topic of eyewash stations, so you may want to give that look-see (listen-hear?).

I think the stuff surveyors are kicking folks on is pretty straightforward. I mean, just think about unlabeled or inappropriately labeled secondary containers—what’s the likelihood that you’ve got one out there somewhere in your organization? An unlabeled spray bottle; a biohazard container for which the label was washed off—lots of opportunities for the process to come up short.

At any rate, the list above is representative of what I’ve seen (in consulting practice and in actual survey reports). Anybody have any other potential findings that they’ve seen?