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Do you miss the safety professional you once had time to be?

I think we can agree that things in the safety world are moving along at a pretty good clip, particularly when it comes down to ensuring ongoing compliance with the various and sundry nuances that are flowing forth from the regulatory firehose. Now I’m sure are those of you that would like nothing better than to pore over the various and sundry code handbooks to figure out best to apply the latest changes to your practices/organizations. But I can tell you this: That’s getting to be very close to a full-time job all on its own—and too many of the current generation of survey findings have as much to do with managing the behaviors of staff at point of care and point of service as they do in figuring out what interpretation is going to win the day going forward. So, as I hear of some findings that I would tend to characterize as “frequently cited,” I want to make sure that I share them with you. This week, here’s a couple of items relating to emergency power:

Under the standard dealing with the setup of your emergency power system, there is a “new” performance element that requires a remote manual stoop station (with identifying label) “to prevent inadvertent or unintentional operation.” The performance element also points toward having a remote annunciator (powered by a storage battery) outside the EPS location. Anecdotally, I understand this is coming up with a fair frequency out in California, so probably worth a look-see for your gen sets.

Under the standard dealing with the inspection, testing, and maintenance of emergency power systems, the weekly inspection (and associated documentation) finally shows up as a specific performance expectation, as does the annual fuel quality test (to ASTM standards, so please make sure that your documentation of those activities is up to date).

As a final note for this week; some updates to the behavioral healthcare Life Safety chapter considerations, mostly shifting the Life Safety Code® chapter references from Chapter 26 (Lodging or Rooming Houses) in the 2000 edition to Chapter 32/33 (new and Existing Residential Board and Care occupancies). The changes impact “small” facilities that provide sleeping arrangements for four to 16 individuals. I don’t see anything particularly substantive, or indeed troubling, in the new stuff, but if you feel otherwise after checking it out, then please sing out loud and clear.

Thank you falletin me: Some survey-related (and otherwise random) thoughts

The first order of business is a word of thanks to anyone and everyone within the sound of my “voice” – I truly appreciate you (sometimes invisible) folks out there in the audience. It continues to be a rare treat having the opportunity to converse with you on a regular basis (the rarer treat is when I get to actually meet folks in the flesh—definitely a delightful happenstance when it occurs) and I hope that I’ve managed to carry on this little slice ‘o safety without being boring, pedantic, etc. Oftentimes, compliance stuff is rather more torturous than not, but what’s the point of doing something if you can’t have a little fun amidst the abject seriousness of it all…

Next up, a couple of items that have appeared during recent surveys that signal (in some instances) a clarification of intent and/or a change in the focus of the physical environment surveys. Some of this you will find endlessly aggravating, particularly if you get cited for it; some of it has the overpowering stench of inevitability as the regulatory folks find new and inventive ways to keep the numbers of findings at record levels. In no particular order:


  • In the wake of the clarifying information relative to the management of ligature risks, make sure that (and this is primarily in the ED/regular inpatient settings) for the risk items you have identified as being medically or clinically necessary/essential to the appropriate care of behavioral health patients, make sure that your risk assessment specifically identifies the inherent risks of the remaining risks. For example, if you need to have a medical bed (with side rails, etc.) in the room, make sure that all the specific risk elements of that (or “the”) medical bed are clearly enumerated in the risk assessment. Saw a survey result recently for which the finding was not that the bed was in the room (the finding specifically noted that the bed was medically necessary), but that the risk assessment did not clearly identify the individual components of the bed: side rails, electrical cord, etc. The survey finding indicated that the risk management strategy employed by the organization was appropriate (in this instance, using 1:1 staffing for the at-risk patients), the only “issue” was not identifying the component risks in the risk assessment. I think/hope that this is something of an overreach and if I find out that there is some clarifying information forthcoming, I will surely share it with you.
  • Those of you with older facilities (and perhaps some “younger” facilities as well) are often faced with the proliferation of electrical panels (and sometimes medical gas zone shutoff valves) that are located in spots for which it is almost impossible to ensure that equipment, etc., is not parked directly in front of the panel, etc. Sometimes the panels, etc., are located in the corridors (it really does make one appreciate electrical closets!); some of you may even have the abject misfortune of having electrical panels in your utility rooms (my condolences); and others have panels out in the operational area of busy locations like food services/kitchen areas. I wish that I had good news to impart, but there do seem to be at least a couple of surveyors heck-bent on citing each and every instance of obstructed access to electrical panels. And don’t get me started on corridor med gas shutoffs with electrical receptacles installed directly underneath. Sometimes I wonder if we would run into these types of conditions if the folks doing the design work actually had to live in the space once it is constructed…
  • Staying on the electrical side of things, I’ve also seen an increase in recent findings relating to the use (primarily in patient care areas) of relocatable power taps/power strips/etc. I know the appropriate management of these devices has been “hittable” for a little while now and perhaps there was an unspoken “honeymoon” period for the industry to get things going in the right direction. If that is the case, it appears that the honeymoon is over, so you (particularly if “you” are in the bucket for survey in the next little while) probably should focus a bit on power arrangements in the areas where equipment use and power needs tend to be exponential. I still think the resources provided by ASHE are worth checking out if you have not already done so. It just might save you a painful survey experience.

Closing out, I leave you with this thought/opportunity; I won’t pretend to have an answer for it, but perhaps someone out there in the audience might. Fortunately, it doesn’t happen very often to me personally, but as I get to visit and meet new folks all the time, I am always fascinated by a certain type of individual: they will pledge that they will do anything to help the cause, with the unspoken understanding that that help hinges on their not having to do anything. Sort of a “ask me anything and if it involves no effort on my part, I’ll be all over it.” Again, fortunately, there doesn’t appear to be a proliferation of these folks in healthcare, and if the sounds completely foreign to you, that’s great. But if anyone has any tips for managing the eager-to-pledge non-participant, I’m all ears.

A most joyous and restful Thanksgiving to you and yours!

Breaking good, breaking bad, breaking news: Ligature Risks Get Their Day in Court

As I pen this quick missive (sorry for the tardiness of posting—it was an unusually busy week), the final vestiges of summer appear to be receding into the distance and November makes itself felt with a bone-chilling greeting. Hopefully, that’s all the bone-chilling for the moment.

Late last month brought The Joint Commission’s publication of their recommendations for managing the behavioral health physical environment. The recommendations focus on three general areas: inpatient psychiatric units, general acute care inpatient settings, and emergency departments. The recommendations (there are a total of 13) were developed by an expert panel assembled by TJC and including participants from provider organizations, experts in suicide prevention and design of behavioral healthcare facilities, Joint Commission surveyors and staff, and (and this may very well be the most important piece of all) representatives from CMS. The panel had a couple of meetings over the summer, and then a third meeting a few weeks ago, just prior to publication of the recommendations, with the promise of further meetings and (presumably) further refinement of the recommendations. I was going to “cheat” and do a little cut and pasting of the recommendations, but there’s a fair amount if explanatory content on the TJC website vis-à-vis the recommendations, so I would encourage you to check them out in full.

Some of the critical things (at least at first blush—I suspect that we, as well as they, will be discussing this for some little while to come) include an altering of conceptual compliance from “ligature free” to “ligature resistant,” which, while not really changing how we’re going to be managing risks in the environment, at least acknowledge the practical reality that it is not always possible to provide a completely risk-free physical environment. But we can indeed appropriately manage the remaining risks by appropriate assessment, staff monitoring, etc. Another useful recommendation is one that backs off on the notion of having to install “alarms” at the tops of corridor doors to alert that someone might be trying to use the door as a ligature point. It seems that the usefulness of such devices is not supported by reported experience, so that’s a good thing, indeed.

At any rate, I will be looking at peeling these back over the next few weeks (I’ll probably “chunk” them by setting as opposed to taking the recommendations one at a time), but if anyone out there has a story or experience to share, I would be more than happy to facilitate that sharing.

As a final note for this week, a shout out to the veterans in the audience and a very warm round of thanks for your service: without your commitment and duty, we would all be the lesser for it. Salute!


Workplace Violence: One Can Never Have Too Much Info…

I will freely admit that sometimes it takes me a while to get to everything that I want to share with you folks and this is one of those instances…

Back in May (yes, I know—mea culpa, mea culpa, mea maxima culpa—it was even longer ago that I was an altar boy), ECRI Institute published some information on violence in healthcare facilities that includes a white paper, some guidance on how to share the risk landscape of your facility as it relates to workplace violence and some other information that is accessible upon enrolling in a membership program (they have quite a few different programs, this week’s stuff comes from the Healthcare Risk Control program). I suspect that the provided information may be representative of a loss-leader to drive traffic to their website and service programs (much as this blog is a labor of love and obsession, its function is rather much the same—I don’t know that they would put up with my yammering otherwise), but the information available through the above links are certainly worth checking out (there are also free newsletters; as noted in this week’s headline, information coming directly to you saves having to hunt it down).

Another item on my mental to-do list (and it may very well be that it is on my to-done list, but a little reiteration never hurt anyone) was to encourage you to keep an close eye on The Joint Commission’s standards FAQ page (you have to do a lot of scrolling to get to the Hospitals section—they’ve changed the formatting of this section of their website and it just feels quite clunky to me). At any rate, there are way more FAQs than there used to be (maybe more than there needs to be, but if you make the presumption that the characterization of these questions as being frequently asked, then it is what it is) and you can’t really tell which ones have changed (they do highlight new FAQs; lots of pain management stuff on there right now). They used to include a date so you could more or less keep track of stuff. I’m going to guess that there’s going to be a lot of following up relative to the whole management of ligature risks—and make sure you talk to your organization’s survey coordinator to make sure you access the Suicide Risk Booster (there just seems to be something odd about that as a descriptor). As much as any issue there’s ever been in the physical environment, the management of ligature risks is one for which you cannot be too well prepared (think an infinite number of Boy Scouts and you’ll be moving in the right direction).


Survey Preparation—When do you start kicking the tires?

In the “old” days, the survey preparation cycle was a fairly well-defined undertaking—you knew (pretty much) when they were coming and about six months before their estimated arrival, prep activities began in earnest. Now, you might say, that it’s pretty freaking obvious that that particular strategy is not so great for ensuring results in the current climate (even though, at least at the moment, surveys are happening on that same 36-month recurrence—there have been a few wild card survey arrivals, but not like we’ve been led to expect), but I still find a lot of folks (particularly when it comes to bringing in an extra pair of eyes to look things over) are waiting until the “survey year” to really give the place a thorough review. Now, I am two minds on that topic—while I understand that the closer you can get to survey, the (purportedly) more accurate a picture you have of what things will look like during the actual survey, I also know (from experience) that if you find vulnerabilities (particularly when it comes to documentation), you really need to have something of a track record of compliance (12 months of pristine is a good place to be, though surveyors can certainly walk you back as far as they want—a greater risk for facilities that are smaller in terms of square footage) if you are going to “survive” with minimal findings—recognizing that it is really, really tough to pull off no physical environment findings.

In other news this week, emergency management stuff continues to take center stage as Jose takes aim at the Northeast (it’s beginning to appear that any place that could experience a hurricane is going to endure just that). On the Joint Commission website ( there’s an announcement that TJC is temporarily suspending survey activities in Florida, Puerto Rico, and the Virgin Islands, as well as the Houston area for organizations that have been severely affected by recent weather events. The posting does indicate that if there are questions, organizations should reach out to their Joint Commission Account Executives, which I suspect will involve ascertaining a working definition of “severely affected.” I’m sure that TJC-accredited organizations went through the appropriate notification sequence if they had to curtail or otherwise modify their services, in accordance with the requirement to notify TJC within 30 days of any substantive changes in operations (I think we’re still within the 30-day window from the onset of Harvey, but if your organization has altered services, etc., and not yet made the call to TJC, I would put that on the to-do list for this week). I guess it would be good not to have to go through a survey during the recovery phase, but I don’t know that it wouldn’t be worth seeing how well you could do in the midst of everything else.

Let’s see what else do we have? Ah yes—the Centers for Disease Control and Prevention have updated the hurricane preparedness page on their website; definitely a cornucopia of information for health care providers, response and recovery workers, as well as affected communities in general. Nothing jumps out at me as being super special, but I think all of the available information is worthy of review. I won’t say that I’ve pored over every bit of information, but with all that’s happened (and all that might yet be on the horizon), it’s nice to have some learned source material. Speaking of which, the Association for Linen Management has also published some disaster recovery guidelines; for those of you with operational responsibilities for linen, there’s some good stuff here (and not just the warm feeling I get whenever I think about my halcyon days managing the linen department) and definitely worth checking out.


Keep calm and stock up on emergency supplies

Hospitals are generally prepared for emergencies, but don’t be afraid to kick those tires one last time.

I don’t know that this last spate is officially the most congested high-intensity weather pattern we’ve ever encountered, but it has got to be right up there in the uppermost tier. As we continue to keep our thoughts on those who have been managing the effects of Harvey, Irma, and Jose, I suppose it’s only a matter of time before the critiques start arriving.

I do believe that hospitals in general are appropriately prepared to respond to emergencies (and I know for certain a number of hospitals that appropriately prepared). As I pen this, I am sitting at the airport in Charlotte, North Carolina, waiting to see if Irma is going to let me get to some client work this week or force me to be Boston-bound.

My philosophy about these things is that there is very little, if any, control that can be exercised as events unfold; the only true aspect of control is to be able to position yourself to make good decisions for the duration of whatever event you might be facing. From what I can gather, this was very much in effect as hospitals in the southeastern U.S. and into the Caribbean responded to recent weather events.

Not every physical plant fared as well as some, but one of the quirky things about catastrophes is they tend to be, well, catastrophic—if it had been business as usual, we probably wouldn’t be talking about it at the moment. At any rate, kudos to those folks who did what they had to do to keep things together, and our best to those for whom every preparation in the world could not have been enough.

In other news

I was going through some stuff I’ve had in the queue for a while that really didn’t fit thematically in the conversation of the week but that I think would be useful to bring to your collective attention. So, in brief (some of you will probably question my definition of brevity, but I can live with that), here they are:

  • For the foreseeable future, there will be a fair amount of scrutiny of the physical environment in your outpatient locations, and a key component of managing those environments is making sure that the folks who are keeping the place clean are on top of their game. It is not uncommon for organizations to have to use independent contract cleaning services for their outpatient locations, but clean is clean is clean—and we know some of the surveyors are not shy about getting out their white gloves and rooting around for GFM (gray fibrous material, a.k.a. dust). Patient environments need to be properly maintained–and you know who’ll suffer the consequences if that’s not happening.
  • Back in April, our friends in Chicago, The Joint Commission, published Quick Safety 32: Crash-cart preparedness; while not everything on their list is specific to the physical environment, there is a lot of fair info relative to process. There are certainly safety and security (not to mention life safety) implications if resuscitation supplies and equipment are not properly maintained—and this applies to your outpatient settings as well. Keep an eye on crash carts wherever they may be.
  • Finally, (and going way, way back to January 2017), The Joint Commission’s Quick Safety 30 covered the all-too-current topic of protecting patients during utility system outages. I think we can all agree that this summer has brought a few too many opportunities to test our mettle in this regard (and, again, great job everyone!), but, as we all know, utility systems can crap out at any time, with minimal warning. So, the watch words (or watch concepts, as it were) are “contingency” and “plans”—redundancies, staff ability to respond to disruptions, etc. are some of the keys to success. Quick Safety 30 also provides a couple of links to some contingency planning resources. The truism underneath all this stuff is that one can never be too prepared, so don’t be afraid to kick those tires one last time.


Any world that I’m welcome to…

Sometimes a confluence of happenings makes me really question the legitimacy of coincidence. For example, it can’t possibly be coincidence that our friends in Chicago use the backdrop of September to tell us how poorly we are faring relative to compliance in the management of the physical environment. Yet, like clockwork, September brings the “drop” of the most frequently cited standards (MFCS) during the first half of the year. (I did look back a few years to validate my pre-autumnal angst—they waited until October to publish the MFCSs in 2012.) And, for a really, really, really long time, the physical environment continues to maintain its hegemony in the hierarchy of findings.

In years past, we’ve analyzed and dissected the living heck out of the individual standards, looking at the EPs likely to be driving the numbers, etc. Anybody wishing to revisit any of those halcyon days, you can find the (not quite complete) collection here:

Anyhoooo… I really don’t see a lot of changes in what’s being found, though I will tell you that there has been a precipitous increase in the number of organizations that are “feeling the lash.” Last year’s most frequently cited standard, which deals with various and sundry conditions in the care environment (you might know it as EC.02.06.01, or perhaps not), was found in about 62% of organizations surveyed. This year, the percentage has increased to 68% of organizations surveyed, but that number was only good enough for 5th place—the most frequently cited standard (the one that deals with all that fire alarm and suppression system documentation*) was identified in a whopping 86% of the hospitals surveyed!

I think it’s important, at this point, to keep in mind that this is the first year of a “one and done” approach to surveying, with the decommissioning of “C” or rate-based performance elements. I don’t know that I have encountered too many places with absolutely perfect documentation across all the various inspection, testing, and maintenance activities relating to fire alarm and suppression system documentation. I also don’t know that I’ve been to too many places where the odd fire extinguisher in an offsite building didn’t get missed at some point over the course of a year, particularly if the landlord is responsible for the monthly inspections. Face it, unless you have the capacity to do all this stuff yourself (and I’m pretty sure I haven’t run into anyone who has unlimited resources), the folks charged with making this happen often don’t have an appreciation for what a missed fire extinguisher, missed smoke detector, etc., means to our sanity and our peace of mind.

As I’ve been saying right along, with the exceptions being management of the surgical environment and the management of behavioral health patients, what they are finding is not anything close to what I would consider big-ticket items. I refrain from calling the findings minutiae—while in many ways that is what they are, the impact on folks’ organizations is anything but minute. If the devil is indeed in the details, then someone wicked must have passed their CORI check for a survey job…

Relative to last week’s rant regarding policies; first a shout-out of thanks to Roger Hood, who tried to post on the website (and was unable to ) regarding the CMS surveyor Emergency Preparedness survey tool as a potential source for the TJC policy requirement. (It’s an Excel spreadsheet, which you can find here, in the downloads menu near the bottom of the page: Surveyor Tool – EP Tags.) While I “see” that a lot of the sections invoke “policies and procedures,” I still believe that you can set things up with the Emergency Plan (Operations / Response / Preparedness—maybe one day everyone will use the same middle for this) as your primary organizational “policy” and then manage everything else as procedures. I suppose to one degree or another, it’s something of an exercise in semantics, but I do know that managing policies can be a royal pain in the tuchus, so limiting the documents you have to manage as a “policies” seems to make more sense to me. But that may just be me being me…

*Update (9/7/17): Quick clarification (I could play the head cold card, but I should have picked up on this); the most frequently cited standard deals with fire suppression system stuff—gray fibrous material (GFM) on sprinkler heads, 18-inch storage, missing escutcheons, etc. While I suppose there is some documentation aspect to this, my characterization was a few bricks shy of a full load. Mea maxima culpa!

I said you’ll pay for this mischief…

In this world, or the next! Stand by for news…

In this most momentous of years / survey cycles, it appears that there may be at least one more shift in the firmament, that being a transition for a most notable AHJ. The grapevine has been singing this week. (You can reference either the Marvin Gaye or Gladys Knight version; at the moment, I’m leaning toward an invocation of Marvin as it pushes a follow of “What’s Going On”—Brother, Brother, indeed!) There seems to be a changing of the guard afoot in Mordor (or Oak Park, Illinois—take your pick) as it appears that the estimable Director of Engineering for The Joint Commission, George Mills, is transitioning out of the crucible that provides so much in the way of heartburn in the industry.

Word is that one of the engineers in the Standards Interpretation Group (SIG), John Maurer, will be taking the director’s position on an interim basis. Not by any means a comparison (my personal dealings with the departing incumbent have always been reasonable and assistive), but my past interactions with Mr. Maurer have always been thoughtful, helpful and equitable, including indication of how one might plot a course toward satisfactory compliance. In that regard, I don’t anticipate that this will engender a significant change in how business will be conducted, including the practical administration of the Life Safety portion of the accreditation survey process. While details have not yet been officially confirmed, I have no reason to think that the information in general is incorrect, so all I can say is best of luck to everyone as they (and we) embark on their new journeys and pray for a resurgence of benevolence across the board.

To round things out for this week, I would bring your attention to last week’s Joint Commission Quick Safety Issue (QSI #35 in an ongoing series—collect ‘em like baseball cards!) and the topic du jour: minimizing noise and distractions in OR and procedural units.

Now, you’ll get no argument from me that there are certain environments and situations for which noise minimization is desirable, and perhaps, essential. And, empirically, I can’t disagree with any of the characterizations indicated in QSI #35—there are quite a number of footnotes, none of which I have had the time to track down, but, again, I have no reason to think that the scholarship of the article is anything less than spot on. I guess the thought/question/concern I have relates to the practical application of this as an improvement activity (keeping in full mind that sometimes surgeons like to operate to music that ain’t exactly in the realm of quiet—think AC/DC’s “Back in Black” and you’ll be on the right track).

QSI #35 has a whole list of “safety actions to consider,” and the indication is that these are actions that “should” be considered. (But how often have you seen a “should” become very musty during survey…) I wonder if you’ll have the leeway to make the determination of whether you are appropriately managing noise in the procedural environment. I suppose it’s good that this hasn’t shown up in Perspectives

And then came the last days of May…

There’s been a ton of activity the past few weeks on both the Joint Commission and CMS sides of the equation (and if you are starting to feel like the ref in a heavyweight prize fight who keeps getting in the line of fire, yup, that’d be you!) with lots of information coming fast and furious. Some of it helpful (well, as helpful as things are likely to be), some perhaps less so than would be desirable (we can have all the expectations we want as to how we’d ask for things to be “shared,” but I’m not thinking that the “sharers” are contemplating the end users with much of this stuff). This week we’ll joust on TJC stuff (the June issue of Perspectives and an article published towards the end of May) and turn our attentions (just in time for the solstice—yippee!) to the CMS stuff (emergency preparedness and legionella, a match made in DC) next week.

Turning first to Perspectives, this month’s Clarifications & Expectations column deals with means of egress—still one of the more frequently cited standards, though it’s not hogging all the limelight like back in the early days of compliance. There are some anticipated changes to reflect the intricacies of the 2012 Life Safety Code® (LSC), including some renumbering of performance elements, but, for the most part, the basic tenets are still in place. People have to have a reliable means of exiting the (really, any) building in an emergency and part of that reliability revolves around managing the environment. So, we have the time-honored concept of cluttah (that’s the New English version), which has gained some flexibility over time to include crash carts, wheeled equipment, including chemotherapy carts and isolation carts that are being used for current patients, transport equipment, including wheelchairs and stretchers/gurneys (whichever is the term you know and love), and patient lift equipment. There is also an exception for fixed (securely attached to the wall or floor) furnishings in corridors as long as here is full smoke detector coverage or the furniture is in direct supervision of staff.

Also, we’ll be seeing some additional granularity when it comes to exiting in general: each floor of a building having two remote exits; every corridor providing access to at least two approved exits without passing through any intervening rooms or spaces other than corridors or lobbies, etc. Nothing particularly earth-shattering on that count. We’ll also be dealing with some additional guidance relative to suites, particularly separations of the suites from other areas and subdividing the areas within the suite—jolly good fun!

Finally, Clarifications & Expectations covers the pesky subject of illumination, particularly as a function of reliability and visibility, so head on over to the June Perspectives for some proper illuminative ruminations.

A couple of weeks back (May 24, to be exact), TJC unveiled some clarifications. I think they’re of moderate interest as a group, with one being particularly useful, one being somewhat curious and the other two falling somewhere in the middle:

ED occupancy classifications: This has been out in the world for a bit and, presumably, any angst relating to how one might classify one’s ED has dissipated, unless, of course, one had the temerity to classify the ED as a business occupancy—the residual pain from that will probably linger for a bit. Also (and I freely confess that I’m not at all sure about this one), is there a benefit of maintaining a suite designation when the ED is an ambulatory healthcare occupancy? As suites do not feature in the Ambulatory Occupancy chapters of the LSC, is it even possible to do so? Hmmmm…

Annual inspection of fire and smoke doors: No surprise here, with the possible exception of not requiring corridor doors and office doors (no combustibles) to be included. Not sure how that will fly with the CMSers…

Rated fire doors in lesser or non-rated barriers: I know this occurs with a fair degree of frequency, but the amount of attention this is receiving makes me wonder if there is a “gotcha” lurking somewhere in the language of the, particularly the general concept of “existing fire protection features obvious to the public.” I’m not really sure how far that can go and, given the general level of obliviousness (obliviosity?) of the general public, this one just makes me shake my head…

Fire drill times: I think this one has some value because the “spread” of fire drill times has resulted in a fair number of findings, though the clarification language doesn’t necessarily get you all the way there (I think I would have provided an example just to be on the safe side). What the clarification says is that a fire drill conducted no closer than one hour apart would be acceptable…there should not be a pattern of drills being conducted one hour apart. Where this crops up during survey is, for example, say all your third shift drills in 2016 were conducted in the range of 5 a.m. to 6 a.m. (Q1 – 0520; Q2 – 0559; Q3 – 0530; Q4 – 0540), that would be a finding, based on the need for the drills to be conducted under varying circumstances. Now, I think that anyone who’s worked in healthcare and been responsible for scheduling fire drills would tell you (at least I certainly would) that nobody remembers from quarter to quarter what time the last fire drill was conducted (and if they think about it at all, they’re quite sure that you “just” did a fire drill, like last week and don’t you understand how disruptive this is, etc.) If you can’t tell, third shift fire drills were never my favorite thing to do, though it beats being responsible for snow removal…

So that’s the Joint Commission side of the equation (if you can truly call it an equation). Next time: CMS!

Welcome to a new kind of tension…

In the “old” days, The Joint Commission’s FAQ page would indicate the date on which the individual FAQs had been updated, but now that feature seems to be missing from the site (it may be that deluge of changes to the FAQs (past, present, and, presumably, future) makes that a more challenging task than previously (I will freely admit that there wasn’t a ton of activity with the FAQs until recently). That said, there does appear to be some indication when there is new material. For example, when you click on the link (or clink on the lick), a little short of halfway down the page you will see that there’s something new relative to the storage of needles and syringes (they have it listed under the “Medical Equipment” function—more on that in a moment), so I think that’s OK.

But in last week’s (dated May 31, 2017) Joint Commission e-Alert, they indicate that there is a just posted FAQ item relating to ligature risks, but the FAQ does not appear to be highlighted in the same manner as the needle and syringe storage FAQ (at least as of June 1, when I am penning this item). Now I don’t disagree that the appropriate storage (recognizing that appropriate is in the eye of the beholder) of needles and syringes is an important topic of consideration, I’m thinking that anything that TJC issues relative to the appropriate management of ligature risks (and yes, it appears that I am far from done covering this particular topic) is of pretty close to utmost importance, particularly for those of you likely to experience a TJC survey in the next little while. I would encourage you to take a few moments to take a peek at the details here.

So, parsing these updates a bit: I don’t know that I’ve ever considered needles and syringes “medical equipment,” but I suppose they are really not medications, so I guess medical equipment is the appropriate descriptor—it will be interesting to see where issues related to the storage of needles and syringes are cited. As usual (at least on the TJC front) it all revolves around the (wait for it…) risk assessment. It’s kind of interesting in that this particular FAQ deals somewhat less specifically with the topic at hand (storage of needles and syringes) and more about the general concepts of the risk assessment process, including mention of the model risk assessment that can be found in the introductory section of the Leadership chapter (Leadership, to my mind, is a very good place to highlight the risk assessment process). So no particularly new or brilliant illumination here, but perhaps an indicator of future survey focus.

As to the ligature risks, I think it is reasonable to believe that there will be very few instances in which every single possible ligature risk will be removed from the care environment, which means that everyone is going to have to come up with some sort of mitigation strategy to manage those risks that have not been removed. With the FAQ, TJC has provided some guidance relative to what would minimally be expected of that mitigation strategy; while I dare not indicate verbatim (you will have to do your own clicking on this one—sorry!), you might imagine that there would need to be: communication of current risks; process for assessing patient risk; implementation of appropriate interventions; ongoing assessments of at-risk behavior; training of staff relative to levels of risk and appropriate interventions; inclusion of reduction strategies in the QAPI program; and inclusion of equipment-related risks in patient assessments, with subsequent implementation of interventions.

I don’t see any of this as particularly unusual/foreign/daunting, though (as usual) the staff education piece is probably the most complicated aspect of the equation as that is the most variable output. I am not convinced that we are doing poorly in this realm, but I guess this one really has to be a zero-harm philosophy. No arguments from me, but perhaps some important work to do.