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Madman Across the Water Management Program

This week brings us something of an unexpected development in the management of the physical environment as our friends in Chicago are seeking comments on a proposed standards revision that more clearly indicates the required elements for water management programs. I don’t know that I was expecting this change, though I suppose it falls under the “one outbreak is one too many” category, nor was I expecting the solicitation of commentary from the field (I look forward to seeing the results of the comment period). It would seem that the proposed performance element is based very closely on the CDC recommendations, which clearly take into consideration the guidance from ASHRAE 188 Legionellosis: Risk Management for Building Water Systems and ASHRAE 12 Managing the Risk of Legionellosis Associated with Building Water Systems, so it doesn’t appear that we’re breaking new ground here.

Additionally, we know from past discussions that CMS has been pretty focused on the risks associated with building water systems (most recently, here, but there are others), so this may be a case of ensuring that everyone is paying attention to the areas of (presumably) greatest risk. And, as near as I can tell, none of the existing COVID-related blanket waivers exempts folks from managing the risks associated with building water systems, so hopefully you’ve been staying with your identified frequencies for testing, etc. And if you haven’t, you probably should be identifying a game plan for ensuring that those risks are being appropriately managed.

Clearly, there’s a little time before these “changes” go into effect (the comment period ends November 16, 2020), but since this is pretty much what CMS has been looking for since 2017 or so, you want to have a solid foundation of compliance moving forward. I recognize with everything else going on at the moment, this might not be a priority, but this is one of those concerns in which proactivity will keep you out of compliance jail.

Until next time, hope you are all well and staying safe!

Is it really transparency if they have to catch you first?

A few months ago, I was working with a facility that, as it turns out, was experiencing challenges with managing temperature and humidity in some of their procedural areas. When I got to the space in question during the building tour, I took particular note of some portable dehumidifiers in a couple of the rooms (one of which hadn’t been emptied in enough time that water was pooling on the floor). In both rooms, the humidity level indicated on the monitoring devices in the rooms was in the 70+ range—a value most surveyors would consider a tad “moist” for a procedural area (my first thought was how high would the humidity be if they weren’t running additional dehumidifiers). At any rate, I asked to see the logs and found enough irregularities to ask to see the perioperative department director. I should mention that this was day four of a four-day consulting gig.

In meeting with the director, I was told that they were embracing full transparency in informing me that they had been experiencing environmental issues in this space for quite some time. My immediate response (which, I will admit, was a bit catty) was: “Is it really transparency if you only tell me after I’ve identified the issue?” I know that sometimes folks like to leave things to see if I can find them (or see if I remember something from the last time I was there) and I think I have a pretty good track record of identifying the various and sundry gaps that can make a good survey go bad in a hurry. But this one really caught me sideways (and continues to) relative to the transparency thing. As I’ve maintained is the case for managing garden variety deficiencies; if folks have to go look for things to fix that have already been identified, it doesn’t strike me as particularly efficient, but that may just be me…

In other news, our friends from Chicago recently published a piece penned by Herman McKenzie, the director of the engineering group at The Joint Commission (TJC); in the piece, Mr. McKenzie provides some insight into what FAQs have been updated, as well as some common concerns in the physical environment. I don’t know if we’ll be seeing Mr. McKenzie as a featured contributor to Perspectives, but hopefully this represents the re-commencement of regular information regarding TJC’s expectations in the physical environment. Generally, September/October is round about the time we hear about the most frequently cited standards during the first half of the year, but I guess that schedule (like pretty much everything else) has been knocked on its keister. At any rate, this link will take you to what’s current (I hesitate to say “new”, just because) in the management of the environment.

Until next time, please be well and stay safe!

I feel like we’ve crossed this bridge before…fire drills are all the RACE!

While the numbers are fairly small (though at almost 30% for a noncompliance rate during 2019 surveys, you could certainly make the case that almost any deficiencies in this area is too much), there remain a couple of common stumbling points when it comes to conducting fire drills. According to the August 2020 issue of Perspectives (get it at your newsstand now!), there continue to be issues with:

  • Not completing/documenting quarterly drills on every shift. I don’t know that there’s a whole lot of mystery here—sometimes you miss a drill. You don’t want to miss a drill; nobody wants to miss a drill! But sometimes the quarter expires so quickly that you don’t realize that a drill was missed until it’s too late. The links below will take you to The Joint Commission’s guidance on the topic, but my best advice is to set a reminder for March 10, June 10, September 10, and December 10 to check fire drill status. That way, you’ve got a couple of weeks if you need to get one in.

https://www.jointcommission.org/resources/news-and-multimedia/podcasts/take-5-the-environment-of-care-fire-drill-matrix-tool/

https://www.jointcommission.org/resources/patient-safety-topics/the-physical-environment/

  • The fire alarm signal was not transmitted on the third shift drills. I absolutely understand why this is still in the mix (as TJC has noted, the allowance for a coded signal for drills between 9P and 5A, does not preclude the transmission of the fire alarm signal). My best advice is to have a line item on your fire drill critique form that goes a little something like: Fire alarm signal transmitted – Yes   No. That way you are providing a surveyor documentation of the signal transmission where you know they’ll be looking.

https://www.jointcommission.org/standards/standard-faqs/hospital-and-hospital-clinics/environment-of-care-ec/000001235/

  • Not enough variation of times when fire drills are conducted; not too much more to say that hasn’t already been said—you have to mix it up—and make sure that the folks conducting the drills understand that once you’ve set up a fire drill schedule, it is to remain unchanged without approval. I know that sounds kind of draconian (and I suppose it is), but our surveyor friends have been rather inflexible on this count and you don’t want to get dinged for a measly 15 or 30 minutes of overlap in your drill times. In the words of the inimitable Moe Howard, when it comes to fire drills—SPREAD OUT! Or, if you’d rather use George Mills’ take on it, you can find that here (with some other Life Safety bon mots).

Now, at the moment, the survey process is not focusing on fire drills as a function of the 1135 Waivers in effect due to the COVID-19 maelstrom. So it would seem that we have a little bit of time to work on the finer points of fire drill compliance. I think the overarching focus is going to end up being (and I think this is likely to be the case with emergency management exercises) is how well you are doing relative to ensuring that “all staff” are participating. For the purposes of the education and training component, I would like to think that if we can demonstrate that everyone in the organization (including the folks in administration) participated, to some degree, over a two-year period, that will result in a finding of compliance during survey. Is it even possible for most places of size to get to everyone, every year? I’m thinking not, but feel free to disagree. I think it may end up going the route of hazard surveillance round frequency—you have to do as many as you have to do to cover the territory you need to cover. So, if in order to be effective, you have to do more than one fire drill per shift per quarter, then that becomes part of the algorithm used for your annual evaluation (or to use the annual evaluation as a place to ensure your clear assessment of the effectiveness of the program). There is always the potential for a surveyor to disagree with your fire drill schedule, as it relates to effective education of staff. Use the annual evaluation to document your assessment of the effectiveness—it may be the only way to keep the survey wolves away from the flock.

So, let’s get the flock out of here…

As always, hope you are well and staying safe. I’ve been traveling some over the past few weeks and, humans being humans, I think we’ve got a ways to go before we wrestle this thing to the ground, so keep those shields up!

Just when you thought it couldn’t possibly get any stranger…

But first (as promised), a word about fire drills (there will be more, maybe next week, depends on what comes flying over the transom…): About a month ago, I mentioned the possibility of a shift in fire drill frequencies for business occupancies from annual to quarterly. This was based on actual experiences during a state/CMS survey in the Southeast. At the time, it seemed a bit incongruous, but the lead Life Safety surveyor was very pointed in indicating that this was the “real deal.” Well, as it should turn out, it appears that somewhere between that pointed closing, and the receipt of the survey report and follow-up, there may have been a little excess stretching of the interpretive dance that we’ve all come to know (and not love). As of the moment, business occupancy fire drills will continue to be on the annual calendar and not the quarterly one. So, three cheers for that!

But the oddest headline of the past couple of weeks revolves around CMS and their “sense” that our friends in Chicago are being, for lack of a better term, overly transparent during the survey process, particularly during exit conferences at the end of each survey day. The thought given voice is The Joint Commission (TJC) is “(p)roviding too much detail or having extensive discussions before or during a facility inspection survey can potentially compromise the integrity of the survey process. Based on the level of detail shared, a facility could correct potential deficiencies mid-course, which would skew the findings and final outcome of the investigation,” (you can read the source article here). Exactly how this determination was made is not crystal clear to me, but it did occur during the process through which TJC’s deemed status was renewed—but only for two years.

For those of you who have participated in surveys over the year, I think we are in agreement that excessive clarity was not one of the hallmarks of the survey process, though it shivers my timbers to think of how they could become even less so. I have noticed a marked decrease in useful information, per issue, in Perspectives over the past few years, so maybe that’s one of the forums that will be less instructive as we enter the post-COVID era of accreditation surveys. We know that much of what goes down during a survey is the result of interpretation of regulations that are as broadly-scoped as they could possibly be (or are they?), so it would seem that we are looking at an even more opaque survey process—holy moley!

Until next time, be well and stay safe. We need each other—and perhaps never more than now!

Yes, I know I said fire drills, but…

Please feel free to accuse me of “dogging it,” but since I am on vacation this week and you all probably need something of a vacation from me, here’s just a quick blast relating to our latest conversation thread.

Hopefully, you noted the recent headlines indicating The Joint Commission’s (TJC) continued status as an accreditation organization with deemed status; you probably also noted that CMS continues to tighten the leash (if you will), approving their accreditation status for only two years. The CMS indicated, among other things that they “…are concerned about TJC’s review of medical records and surveying off-site locations, in particular for the Physical Environment Condition of Participation (CoP).” Talk about waving a red flag in front of a bovine nose or two!

I think we can intuit that the folks from CMS (not unlike, say, The Man from Glad, or UNCLE) were reasonably pointed in their discussions with TJC prior to making the announcement and, in the face of what might reasonably be interpreted as an existential threat, we can expect lots of attention paid to the outpatient setting(s) in general, and a keen focus on all things relating to the care environment. Certainly, the level of angst generated by this “omen” will hinge closely on how widespread your organization is and (potentially) how well your corporate structure compartmentalizes offsite locations. If you’re not sure, one thing you might consider doing is hopping over to TJC’s website for searching accredited organizations and see how your place “shakes out.” Nominally, each of the care locations they think you have should be represented, and it’s always fun to see if what’s there matches up with what you think you have. I can tell you with absolute certainty that there have been some surprises in the past and I have no reason to think the future holds anything different.

So, that’s our missive for this week  and we’ll cover fire drills next time—I wicked promise! Unless something else happens…

Take care and stay safe!

Emergency management in (you guessed it) ambulatory healthcare

I was really, really, really thinking that I’d be able to glom on to some other subject matter this week (which I suppose it partially true), but it would seem that I’m going to be mining this particular vein of compliance (recognizing that “vein” rhymes with “bane”—make of that what you will…) for at least a bit longer.

At any rate, our friends in Chicago recently indicated some changes relative to the requirements for emergency exercises, but it does seem to be that the changes are intended to reflect CMS reducing the number of required exercises, as referenced in the Emergency Preparedness final rule, to one exercise per year and you only have to conduct a “big” (for lack of a better descriptor) exercise every other year. By big, that would be either a community-based, full-scale exercise (if available) or a facility-based functional exercise.

You may, of course, conduct as many “big” exercises as you like, but in the opposite years, you can even run with a tabletop exercise (though there is a fairly specific setup for the tabletop, so make sure each of the elements is accounted for before you try to take credit). Also, if your organization experiences an actual emergency that requires activation of the emergency plan, you can count that as your activation for the year (and it’s beginning to look a lot like COVID-19 is going to populate a lot of folks’ 2020-2021 emergency management program events).

As a somewhat related aside, this reduces the number of performance elements relating to exercises from three to one, so I think we can count this as a victory for the downtrodden, etc.

I know a lot of folks sometimes struggle with how to involve the ambulatory healthcare locations in exercises, so I think this provides a simpler framework to consider when identifying potential compliance gaps/shortfalls.

I think next week we’re probably going to have a little chat regarding fire drills; the July 2020 issue of The Joint Commission Perspectives has some “clarifying” thoughts on the topic that are probably worth kicking around.

Until next time, hope all is well and you’re staying safe!

Stuck on the same refrain: Outpatient! Outpatient! Outpatient!

I’m hoping to break the spell in kind of a reverse Beetlejuice invocation…

As we try to obtain some level of clarity relative to the Joint Commission survey process moving forward, there is some indication (and a fair amount of it as far as I’m concerned) that they will be focusing even more closely (thoroughly, exhaustively, etc.) on documentation, which means the survey devil will be, as it always has been, in the details. And one of the truisms of spending more time with the documents is the element of interpretation that surveyors will be bringing to the table and what they will consider evidence of compliance. At the moment, it’s not clear who will be engaging in the document review for the outpatient settings if they are not defined as a healthcare or ambulatory healthcare occupancy, but there is most definitely a movement afoot to include LS/EOC documentation for all care locations. Now, the applicability of the document review is going to be based on what systems, protections, etc., are present at each of the care locations, but the clear expectation is that any system that is present will be maintained in accordance with the applicable code and/or regulation. For example, if you have an outpatient care location that has a fire department connection, then you need to make sure that you have the appropriate documentation of that inspection activity. Likewise, if you have sprinklers, then you better make sure that the sprinkler list is up to date and all pertinent information is available for inspection.

It seems that every week I’m thinking that I can set this aside and each week something else pops up that I feel is worth sharing (have you done an eyewash assessment yet for your outpatient care locations?) and I suspect that we’ve not reached the end of this conversation. That said, I think there is going to be increased focus on generating more findings and you could say that outpatient locations represent a whole mess of opportunities for doing just that. We know they’re coming, we just need to get ahead of the curve. Hope these are helping you strategize.

Be well and stay safe until next time…

Probably not the final word on outpatient clinic settings

Sometimes I have a difficult time finding a unifying “thread” for the weekly chronicle and other times the way forward is fairly clear. This week may be more towards the former, but I think I can tie things together with a little bit of judicious “bridging.”

First we’ll start with what can only be described as “old news,” though the topic (CMS continues to make frowny faces towards the various accrediting organizations, coupled with the odd glare or two) is as old as the hills. At any rate, if one were an accreditation organization (AO), one might look at the ongoing skirmishes ’twixt the Federales and their deemed status minions as an existential threat (the exact degree of the threat is tough to figure out: Can CMS “fire” all the AOs and still be able to ride herd on healthcare? I’m not so sure). It can’t be pleasant to be berated on a regular basis, reminded of one’s failings, etc., so the natural tendency would be to try to get out from underneath. And the one sure way of making that happen is to work towards generating lots and lots (and lots!) of findings, and if you can tie those findings to various levels of criticality, then you can demonstrate your value to the process. Certainly, the various AOs have generated a lot of findings within the hospital settings over the last few years and (at least for our friends at TJC) there’s been some branching out into the “field.”

One of the trends I’ve noticed as this “shift” has been occurring is a fair number of findings relating to eyewash stations  in all sorts of areas and I think a recently updated (June 26, 2020) TJC FAQ for hospital and hospital clinic settings may be instructive as a function of setting the stage (or the table—you pick) for increased focus on those instances in which surveyors feel you need an eyewash station and perhaps you do not have a risk assessment prepared that would indicate otherwise. As we have discussed in the past (you can find pretty much all of those mentions here), eyewash stations (or the lack thereof, of the care and feeding of) tend to generate findings, but (as long as you do the math) you only have to have them under certain very specific circumstances—circumstances with which surveyors are sometimes only passingly familiar.

That said, one other trendy thing I’ve noticed is that glutaraldehyde is starting to creep back into the healthcare safety landscape, which poses its own fair share of complexities when it comes to managing risks (some useful thoughts on that subject on Tim Richards’ blog). And sometimes, just sometimes, when one is discussing the far reaches of an organization, the creeping of something like glutaraldehyde can be much less noticeable than if it were under the white hot lights of the main campus (or the mothership, if you prefer). Sooooo, particularly for those of you with lots of offsite locations (or even only a few), keep an eye out for those funky things that “show up” at generally less than useful times. You might find out it’s the difference between survey success and having to write plans of correction for weeks on end…

Hope you are all staying safe and staying positive. It’s looking like the first wave of COVID-19 is not quite done with us (and I don’t think we can have a second wave until the first one is done), but I know you folks are keeping a lid on things: Keep up the good work!

They’re baaaack: TJC returns to the fray!

Last week, our friends in Chicago announced that they will be resuming the survey grind in June (in all candor, I too will be heading out on the highways and byways of the consulting world, though I can’t help but think how “neatly” June sets up, June 1 being a Monday and all—I know nature likes symmetry, etc., but this seems almost too convenient. But I digress).

While it is not yet completely clear how things will be different, it does sound like there will be a fair amount of analysis and communications with facilities being surveyed to ensure that the survey process goes as smoothly as possible from an operational perspective. To that end, if you happen to be at a facility “in the queue” for survey, the account executive coordinating the process will be reaching out to your organization to determine the impact the pandemic has had on your operations and what things look like in their “current state.”

It is also clear that social distancing will be in full force for the next little while (again, I’ll have a chance to weigh on some of those particulars as I recommence client visits), including limiting the number of individuals “present” in group sessions (audio and/or video conferencing will take on much wider application—I know some of your EOC/EM committees have a lot of moving parts); minimizing participants in tracer activities; appropriate use of PPE (as provided for each organization’s requirements—TJC expects you to provide whatever is appropriate); driving in separate cars for off-site location and/or home visits, etc.

The announcement also indicated that the focus of the process will be a thorough assessment, but not a retroactive review of compliance (I am curious as to how that will manifest itself, particularly in terms of inspection, testing and maintenance activities, and other elements of compliance in place prior to the onset of the pandemic). The announcement also indicates that implementation of your emergency operations plan will not be the focus of the survey so much as the development of an understanding of how your organization has adapted to the pandemic and look at current practices to evaluate the extent to which safe care, and a safe working environment are being provided.

 

When you get to the end, you get to start all over again…

I know you folks have (more or less) been under a constant bombardment of facts, figures, strategies, etc., relating to COVID-19 and, as every day brings us a little closer to a return to some sort of normalcy (It will be interesting to look back on how things changed as the result of the current emergency), I wanted to chat this week about one of those “other” things that is likely to be on the to-do list when we get to the recovery phase of this emergency. Not that long ago (OK, two weeks ago), we covered the potential for an intensification of scrutiny in the outpatient setting. And, as it should turn out, one of those areas of potential is the management of behavioral health patients in that setting. Last month (March 2020) our friends in Chicago posted an FAQ aimed at “hospital and hospital clinic settings” that talks about expectations relative to risk assessments in non-psychiatric units/areas in general hospitals. Of particular interest to me is the invocation of competency as a function of conducting the risk assessment “in areas where staff do not have the training to do this independently” and referencing “on-site psychiatric professional” as a potential resource. To me, that likely means that (and this may be the case of any risk assessment upon which you’ve modified practice, the environment, etc.) there will be questions about the risk assessment process, including “How do you know that the folks involved with the assessment were competent?” or something akin to that. I don’t know that everyone who has to (at least periodically) manage behavioral health patients is going to be able to access “on-site psychiatric professional” assistance, in which case it’s probably a good idea to clearly establish the credentials of the team or individual crafting the assessment. You can see what elements you’ll want to include here.

To aid in ensuring an appropriate environment for behavioral health patients, you might find the information assembled by the Center For Health Design to be useful. There is (almost literally) a ton of resources, from interviews, webinars, and podcasts to discussions of design elements, etc. As we have seen over the past few years, the management of the behavioral health environment is very much a moving target and the more information we have at our disposal, the more (dare I say) competence we can obtain. Every one of us is a caregiver to one degree or another and this is another useful resource that will help provide the most healing environment possible.

Please stay safe and (reasonably) sane ’til next time!