…when you don’t know the reason…
Some Joint Commission goodness for your regulatory pleasure!
For those of you in the audience that make use of the online version of the Accreditation Manual, I would implore you to make sure that when you are reviewing standards and performance elements that you are using the most current versions of the requirements. I think we can anticipate that things are going to be coming fast and furious over the next few months as the engineering folks at TJC start to turn the great ship around so it is in accordance with the requirements of the 2012 edition of just about everything, as well as reflecting the CMS Conditions of Participation. To highlight that change, one example is the requirement for the testing of the fire alarm equipment for notifying off-site fire responders (decorum prevents me from identifying the specific standard and performance element, but I can think of at least 02.03.05.5 things that might serve as placeholders, but I digress); the January 1, 2017 version of the standards indicates that this is to occur at a quarterly frequency (which is what we’ve been living with for quite some time), but the January 9, 2017 version indicates that this is to occur on an annual basis, based on the 2010 edition of NFPA 72. In looking at the 2010 edition of NFPA 72, it would appear that annual testing is the target, but I think this speaks to the amount of shifting that’s going to be occurring and the potential (I don’t know that I would go so far as to call it a likelihood, but it’s getting there) for some miscommunications along the way. At any rate, if you use the online tool (I do—it is very useful), make sure that you use the most current version. Of course, it might be helpful to move the older versions to some sort of archived format, but that’s probably not going to happen any time soon.
Speaking of updates, last week also revealed additional standards changes that will be taking effect July 1, 2017 (get the detailed skinny here). Among the anticipated changes are the official invocation of NFPA 99 as guidance for the management of risk; some tweaking of the language regarding Alternative Equipment Management (AEM) program elements, including the abolition (?!?) of the 90% target for PM completion and replacing it with the very much stricter 100% completion rate (make sure you clearly define those completion parameters!); expansion of the ILSM policy requirements to include the management of Life Safety Code® deficiencies that are not immediately corrected during survey (you really have to look at the survey process as a FIFI—Find It, Fix It!—exercise); the (more or less) official adoption of Tentative Interim Agreements (TIA) 1, 2, and 4 (more on those over the next couple of weeks) as a function of managing fire barriers, smoke barriers, and egress for healthcare occupancies; and, the next (and perhaps final) nail in the coffin of being able to sedate patients in business occupancies (also to be covered as we move into the spring accreditation season). I trust that some of this will be illuminated in the upcoming issues of Perspectives, but I think we can safely say that the winds of change will not be subsiding any time soon.
Also on the TJC front, as we move into the 2017 survey year, those of you that will likely be facing survey, I encourage you to tune in to a webinar being presented on the SAFER (Survey Analysis For Evaluating Risk) matrix, which (aside from being transformative—a rather tall order and somewhat scary to consider) will be the cornerstone of your survey reports. We’ve covered some of the salient points here in the past (this is quickly becoming almost very nearly as popular a topic for me as eyewashes and general ranting), but I really cannot encourage you enough to give this topic a great deal of attention over the coming months. As with all new things TJC, there will be a shakedown cruise, with much variability of result (or this is my suspicion based on past experiences)—it is unlikely that this much change at one time is going to enhance consistency or it’s hard to imagine how it would/could (should is another matter entirely). At any rate, the next webinar is scheduled for Tuesday, March 7, 2017; details here.
Please remember to keep those cards and letters coming. It’s always nice to hear from folks. (It almost makes me think that there’s somebody out there at the other end of all those electrons…) Have a safe and productive week as we await the arrival of Spring!
As we find 2017 reapplying time’s onslaught against pop culture icons, once again there’s a small “c” cornucopia of stuff to cover, some perhaps useful, some most assuredly not (that would be item #1, except for the advice part). Allons-y!
As goes the passage of time, so comes to us the latest and latest edition of the Joint Commission’s Survey Activity Guide (2017 version). There does not appear to be a great deal of shifting in the survey sands beyond updating the Life Safety Code® (LSC) reference, reordering the first three performance elements for the Interim Life Safety Measure (ILSM) standard, and updating the time frame for sprinkler system impairments before you have to consider fire watches, etc. They also recommend having an IT representative for the “Emergency Management and Environment of Care and Emergency Management” (which makes EM the function so nice they named it twice…), which means that, yes indeedy, the emergency management/environment of care “interviews” remain on the docket (and review of the management plans and annual evaluations—oh, I wish those plans would go the way of the dodo…) for the building tour as well. Interestingly enough, there is no mention of the ILSM assessment discussion for any identified LSC deficiencies (perhaps that determination was made to late in the process)—or if there is, I can’t find it. So for those of you entertaining a survey this year, there’s not a ton of assistance contained therein. My best advice is to keep an eye on Perspectives—you know the surveyors will!
And speaking of which, the big news in the February 2017 issue of Perspectives is the impending introduction of the CMS K-tags to the Joint Commission standards family. For those of you that have not had the thrill of a CMS life safety survey, K-tags are used to identify specific elements of the LSC that are specifically required by CMS. Sometimes the K-tags line up with the Joint Commission standards and performance elements and sometimes they provide slightly different detail (but not to the point of being alternative facts). As TJC moves ever so closely to the poisoned donut that is the Conditions of Participation, you will see more and more readily discernible cross-referencing between the EC/LS (and presumably EM) worlds. At any rate, if I can make one consultative recommendation from this whole pile of stuff, I would encourage you to start pulling apart Chapter 43 of the 2012 LSC – Building Rehabilitation, particularly those of you that have been engaged in the dark arts of renovation/upgrading of finishes, etc. You want to be very clear and very certain of where any current or just-completed projects fall on the continuum—new construction is nice as a concept (most new stuff is), but new construction also brings with it requirements to bring things up to date. This may all be much ado about little, but I’d just as soon not have to look back on 2017 as some catastrophic survey year, if you don’t mind…
Until next time, have a Fabulous February!
Hope everyone is having a good week and that the rather stormy weather impacting so many parts of the country has not created too much of a challenge for you and your organizations.
This week is another (sort of) catch-all of topics, starting first with a little bit of CYA advice.
Lately there have been several instances (of which I am aware—can’t say for sure if this is an iceberg, but it “feels” like it might) of some very adverse accreditation/deemed status decisions based on insufficient documentation that organizational leadership had been effectively informed of conditions in the physical environment that required additional resources, etc. It’s not that organizational leadership was unaware of the conditions, but more that there was no trail of documented discussion (committee minutes, surveillance rounds, etc.) by which the organization could demonstrate to the surveyors that they had everything under control. In fact, the impression given because of the lack of a documented trail was exactly the opposite.
While nobody is really keen on telling their boss about problems of significance, especially problems for which the means of resolving them are elusive or beyond one’s resources (don’t want to look like you can’t do your job effectively), it is of critical importance to be able to escalate these types of issues to (or near) the top of the organization. Typically, this is about having to fund something (at least in my experience); maybe it’s a roof replacement; maybe it’s replacing some HVAC equipment—I’m sure most folks have a list of things for which it is a struggle to get traction. Let’s face it, unless it’s a new building, facilities infrastructure improvements, safety stuff, etc., is not particularly sexy, so when the capital improvement budgets come and go, it’s a tough sell. But sell it you must and you must keep pushing it—eventually those improvements (or lack thereof) are going to impact patient care and that’s when things can go south in a hurry. We always want to be respectful and not panicky, etc., but, please believe me, when the three- and four-letter regulatory folks knock on the door, you want to be in a position to describe how issues are brought to the attention of leadership. It may not be too pleasant in the moment (okay, in all likelihood, it won’t be pleasant at all), but it can save a whole lot of grief later on.
Next up (and this is something in the way of a commercial), The Joint Commission is hosting a webinar on Tuesday, February 7 to provide information on the new SAFER matrix, which is going to be an important feature of your survey report. We first covered it back in May, but now that they’ve been using it for the past few months (in behavioral health hospitals), it’s possible (I’m hoping likely, but I don’t want to get too amped up) that they will be sharing some useful information from the field. At any rate, particularly for those of you anticipating surveys in the next six to 12 months, I would try to make time for this one. I truly believe that every good intention is put into these survey changes, but I think we can all agree that those good intentions figure very prominently on a certain road…
Finally, this week, I would encourage you to look really, really, really closely at your interim life safety measures (ILSM) policy. TJC conducted a consultant conference last week and it is my understanding that the one significant shift in the survey of the physical environment is that there is going to be a lot of focus on the practical application of ILSMs as a function of Life Safety Code® deficiencies that cannot be immediately corrected. You have to make sure that your policy reflects an ongoing, robust process for that part of the equation. I think the conclusion has been drawn that folks generally have it together when I comes to ILSMs and construction, but are rather less skilled when it comes to those pesky LS deficiencies. We know they tend to focus on areas where they feel there are vulnerabilities (how else might one explain the proliferation of EC/LS/EM findings in recent years). This is a big one folks, so don’t hesitate to dial in with questions.
As we play yet another round of mishegas, it occurs to me that it’s been a while since I’ve really been able to tee off on something. Oh well, I guess it’s the little stuff that makes things interesting…maybe the February issue of Perspectives will provide fodder for my rant-mill… stay tuned.
First up, we have the (probably timely) demise of that titan of healthcare apparel, the powdered medical glove. It seems that the Food & Drug Administration (FDA) has determined that the risks to the health of users and those upon whom those gloves are used (including bystanders) are so egregious that it instituted an immediate ban on their use, effective January 18, 2017. The potential dangers include severe airway inflammation from inhalation of the powder; wound inflammation and post-op adhesions from contact with the powder, and allergic reactions from breathing powder that carries proteins from natural rubber latex gloves. You can get the whole picture here. While I do believe that powdered wigs are still de rigeur in certain circles (constitutional re-enactors, for one) despite the opening line in the VIN News article, I hope that these actions are not a prelude to restrictions on powdered doughnuts (or donuts, depending on your preference—for the record, my favorite is raspberry jelly!)
Breaking it down with TJC
Our friends at the American Society for Healthcare Engineering (ASHE) announced this week that they will be offering a series of webinars aimed at uncovering the mysteries of deep space, no wait, to introduce us to the inner workings of the 75 new performance elements in the Joint Commission standards, effective, well, pretty much right now. The featured presenter for the kickoff presentation is none other than Joint Commission’s Director of Engineering George Mills and it promises to be a rollicking good affair. That said, I do hope you are an ASHE member: if you are, the webinar is free; otherwise it’s $125, which seems a little steep for a single program (the advertising says this is a series of webinars, but this appears to be the only program scheduled at the moment, so your guess is as good as mine at this point). If I may indulge in a short rant, I’m still not convinced that having to pay to obtain access to TJC information that is not otherwise available as part of one doing business with the accrediting agency is a good thing. Not everyone has money in their budgets to do this (either membership in professional organizations or accessing educational programs) or the personal means to do this stuff on their own. While I am absolutely in favor of participation in professional organizations, I’m not sure that access to the insight of regulators is, while nice, the way things should be. Shutting up now…
Cue heavy breathing…
And let us end on a note of “Holy smokes, that was a near miss” (and I definitely did not see this one at the time—nor did I hear a ton of squawking). Last May, CMS decided to disallow hospitals from having security units that provide care for justice-involved individuals such as inmates and those in the custody of law enforcement or the state Department of Corrections. I’ve not worked with a ton of hospitals that have forensic units, but they are an important means of enabling hospitals to provide a safe environment for all while ensuring your forensic patient populations have appropriate access to needed inpatient healthcare services. Again, I didn’t hear a lot about this one, so it may be that the hue and cry was aimed in other directions; the American Hospital Association took up the cause and were able to convince CMS to rescind the “ban” (you can see the revised Survey & Certification memorandum here). This would have been a big time pain in the posterior for at least some number of folks, and may still be – I would encourage you to take a peek at the memorandum, including the scenarios presented at the end of the document—probably worth sharing with your organization’s leaders. I’m not exactly sure why CMS would have elected to go the route of disallowing security units for “justice-involved individuals” (that makes ’em JIIs—probably not an acronym that will catch on), though I would guess that ensuring patient rights are not violated in the process is a likely contributing factor. That said, any time a memorandum goes out on a specific topic, it seems to result in that topic becoming a wee bit hotter in the aftermath. No guarantees, but this might be a focus area in the coming months…
Crash carts on flame with rock and roll!
I figured I’d start out the newly minted 2017 with a few brief items of interest: a device warning from FDA, some thoughts regarding post-Joint Commission survey activities, and a free webinar that some of you might find of interest.
On December 27, the Food & Drug Administration (FDA) communicated a warning letter to healthcare providers regarding potential safety issues with the use of battery-powered mobile medical carts. The warning is based on FDA’s awareness of reports of “explosion, fires, smoking, or overheating of equipment that required hospital evacuations associated with the batteries in these carts.” Apparently, the culprits are those carts powered by high-capacity lithium and/or lead acid batteries and it also appears that there is a distinct possibility that you might just a few of these rolling around in your facility. Fortunately, the warning (you can see the details here) also contains some recommendations for how to manage these risks as a function of the preventive maintenance (PM) process for the battery-powered mobile medical carts; as well as recommendations for what to do in the event a fire occurs (might be a good time to think about testing your organization’s fire response plan as a function of response to a Class C electrical fire). The warning letter also contains some general recommendations for managing the mobile medical carts. So, if you were wondering whether you were going to have anything interesting to put on the next EOC Committee agenda, this one might just fit the bill. As a final thought on this, I think it very likely that our comrades in the regulatory surveying world might be interested in how we are managing the risks associated with these carts—and if you’re thinking risk assessment, I couldn’t agree more!
Moving on to the post-survey activity front, TJC division, for those about to be surveyed (I salute you!), I have some thoughts/advice for preparing yourselves for a slight, but nevertheless potentially dramatic, shift in what you will need to provide in your Evidence of Standards Compliance—a plan for ongoing compliance. Now I will admit that in some instances, being able to plot a course for future compliance makes a lot of sense; for example, managing pressure relationships in procedural areas. If you get tagged for that during a survey, I think it’s more than appropriate for them to want to know how you’re going to keep an eye on things in the future. But what about the million and one little things that could come up during a survey (and with the elimination of the C elements of performance, I think we all know that it’s going to seem like a million and one findings): doors that don’t latch, barrier penetrations, dusty sprinkler heads, etc. There already exist processes to facilitate compliance; are we going to be allowed to continue to use surveillance rounds as the primary compliance tool or is the survey process going to “push” something even more invasive? It is my sincere hope that this is not going to devolve into a situation in which past sins are held in escrow against future survey results—with compounding (and likely confounding) interest. Sometimes things happen, despite the existence/design/etc. of a reasonably effective process. As I’ve said before (probably too many times), there are no perfect buildings, just as there are no perfect plans. Hopefully perfection will not become the expectation of the process…
As a final note for this week, one of the bubbling under topics that I think might gain some traction the new year is the management of water systems and the potential influence of ASHRAE 188: Legionellosis: Risk Management for Building Water Systems. I know we’ve touched on this occasionally in the past and I think I’ve shared with you the information made available by our good friend at the Centers For Disease Control and Prevention (check it out, if you haven’t yet done so), but in the interest of providing you with some access to a little more expertise than I’m likely to muster on the topic, there is a free webinar on January 19 that might be worth your time. In the live online event, “Following ASHRAE 188 with Limited Time, Money, and Personnel: Pressure for Building Operators and Health Officials,” respected expert Matt Freije will briefly discuss the pressure facing building operators as well as health officials regarding compliance with ASHRAE 188 to minimize Legionella risk, suggest possible ways to reduce the pressure, and then open the conversation to the audience. The 60-minute webcast begins at 1 p.m. EST. It’s free but space is limited; you can register here.
So that’s the scoop for this week. I hope the new year is treating you well. See you next week!
A mixed bag of stuff this week (dig, if you will, a picture: sleigh full of regulatory madness), including the Perspectives coverage of the Emergency Management standards. But first, a little musing to usher in the change of the seasons.
The nature of my work/vocation requires me to travel a fair amount—and I am not whining about that—it’s my choice to continue to do so, and I understand that if the travel gods are displeased, there is no point in kvetching, but I digress. One of my favorite travel pastimes is watching fellow travelers as they navigate the various and sundry obstacles that one might encounter as they complete the check-in/TSA gauntlet, etc., after which, they generally “crash” in the gate areas or airline clubs. One of the most fascinating/disturbing trends (and I suspect you’ve probably witnessed this yourselves—perhaps even in your own homes) is groups of people (even families!) staring at their devices…and saying not a word to each other. I can’t help but think that if we can’t (or I guess more appropriately, don’t) converse in our private lives, it’s going to have a not-so-good impact on discourse in the workplace. We are better when we are talking—and even technological isolation is still isolation-y.
Hopping down from the ol’ soapbox, just a quick couple of words on the Emergency Management stuff in Perspectives. Interestingly enough (almost to the point of being strangely enough), it appears that folks responding to emergencies have found that the EM standards facilitate effective response—go figure! While I am certainly glad to hear that, I’m not necessarily surprised, mind you. After all, the basic tenets of small “e” emergency management are what inform the big “E” Joint Commission chapter, so if there’s stuff that doesn’t lend itself to response, recovery, etc., I would hope that it would have been expunged by now. Another area of emphasis in the article is the importance of collaboration with the community and other health providers when you are dealing with a significant emergency (as an aside, the CMS final rule also highlights the importance of that collaboration), which (once again) makes a great deal of sense from a practical standpoint. The article closes out with some links to useful information; I’d encourage you to check them out once the stockings are hung by the chimney with care:
- Joint Commission Emergency Management Resources: I’d bookmark this page as it does appear that content is being updated on a fairly regular basis
- Joint Commission Journal on Quality and Patient Safety: Some of the concepts will, no doubt, be very familiar: safety huddles, serious safety event classification to identify and track undesirable events—good (best) practices to observe.
Finally, to close out this epistle, I would encourage you to climb into the wayback machine and revisit those halcyon days of Sentinel Event Alert #37 and the management of emergency power systems, etc. My gut tells me that e-power is going to continue (if not increase) to be a focal point for pretty much any and all regulatory systems and the advice provided in SEA #37 relative to evaluating your e-power capabilities, assessing the reliability of normal power, etc., can only become more timely as our reliance on technology grows at an almost exponential rate. We certainly don’t want to get caught unawares on the e-power front and I’d be willing to bet that there have been some changes in the technology infrastructure in your place that might be significant enough for some analysis. At any rate, some more links to peruse once you’ve laid out the cookie and milk for that right jolly old elf:
Beyond that, I hope that we all get a chance to turn off the technology for a bit over the next couple of weeks (and I mean that in the best possible way—I am no Luddite!) and allow some real-time reflection with our family, friends and, indeed, the world at large.
Here’s hoping that 2017 rings in the return of civil discourse!
And so we turn again to our perusal of the bounty that is the December issue of Perspectives and that most splendid of pursuits, the Clarifications and Expectations column. With the pending changes to the Life Safety (LS) chapter, it appears that we are in for a sequential review of said chapter, starting at the beginning (the process/program for managing LS compliance within your organization) and (at least for now) moving to a deep dive into the ILSM process in January—so stay tuned!
So let’s talk a little bit about the requirements relative to how the physical environment is designed and managed in such a manner as to comply with the Life Safety Code® (LSC). Previously, there were but four performance elements here: assigning someone to manage the process (assessing compliance, completing the eSOC, managing the resolution of deficiencies); maintaining a current eSOC; meeting the completion time frames for PFIs (did you ever think we would get to a point where we could miss those three letters?); and, for deemed status hospitals, maintaining documentation of AHJ inspections. For good or ill (time, as always, will be the final judge), the number of performance elements has grown to six with a slight modification to some of the elements due to the shift away from the eSOC as one of the key LS compliance documents and the evolution (mutation?) of our friend the Plan for Improvement into the Survey-Related PFI. With greater numbers of performance elements, I guess there will be a subsequent increase in confusion, etc. regarding interpretations (yours, mine, theirs) as to what it all means, which leaves us with requirements to:
- Designate resources for assessing life safety compliance (evidence could be letters of assignment, position descriptions, documentation in meeting minutes); the survey process will include an evaluation of the effectiveness of the chosen method(s) for assessing LS compliance
- Performance of a formal LS compliance assessment of your facility—based on time frames determined by your organization (big freaking hint: “best practice” would be at least annually); you can modify/adjust time frames based on the stability of your physical environment (if there’s not a lot going on, you might be able to reduce frequencies, though I haven’t been to too many places that didn’t have some activities that would impact LS compliance (Can you say “network cabling”? Sure you can!). Also, there is mention of the use of certain performance elements sprinkled throughout the LS chapter that will be used for any findings that are not specifically covered by the established performance elements. Clearly, there is a desire to leave no stone unturned and no deficiency unrecorded. Yippee!
- Maintaining current and accurate life safety drawings; we’ve covered this in the past (going back to 2012), but there are still some folks getting tagged for having incomplete, inaccurate or otherwise less-than, life safety drawings. Strictly speaking, the LS drawings are the cornerstone of your entire LS compliance efforts; if they need updating and you have a survey any time in the next 12-18 months, you better start the leveraging process for getting them reviewed/revised. They don’t tell you how to do it, but if they’re not on auto-cad at this point, you better have a wizard for whatever program you are using. All they need to do is find one inconsistency and they can cite it…ugh! Check out the list in Perspectives and make sure that you can account for all of it.
- Process for resolving deficiencies identified during the survey; we know we have 60 days to fix stuff found during the survey (and hopefully they don’t find anything that will take longer than that to resolve—I have this feeling that that process is going to be exceptionally unwieldy—and probably unyielding to boot). The performance element covers the process for requesting a time-limited waiver—that’s got to happen within 30 days of the end of the survey. Also, the process for requesting equivalencies lives here (if folks need a refresher on equivalencies, let me know and I will put that on the list for 2017 topics). Finally, this is also where the official invocation of the ILSM process as a function of the post-survey process is articulated (I think we covered that pretty thoroughly last week, but if you have questions—go for it!).
- Maintaining documentation of any inspections and approvals (read: equivalencies) made by state or local AHJs; you’ve got to have this stuff organized and in a place you can lay your hands on it. Make sure you know how often your AHJs visit and make sure that you have some evidence of their “presence.” I think it also makes sense to keep any inspections from your property insurers handy—they are almost as powerful an AHJ as any in the process and you don’t want to run afoul of them—they can have a significant financial impact if something goes sideways with your building.
- The last one is a little curious to me; I understand why they’re saying it from a global perspective, but it really makes me wonder what prompted specific mention. You can read the details of the language in Perspectives, but my interpretation of this is “don’t try any funny stuff when you’re renovating interior spaces and leave 4-foot corridor widths, etc., when you have clearly done more to the space than ‘updated finishes.’” I think this is the call-to-arms relative to having a good working knowledge of Chapter 43 of the 2012 You need to know what constitutes: repair; renovation; modification; reconstruction; change of use or occupancy classification; addition (as opposed to subtraction). Each of these activities can reach a degree/scope that “tips” the scales relative to the requirements of new versus existing and if you haven’t made that determination (sounds very much like another risk assessment, don’t it?) then you can leave it in the hands of a surveyor to apply the most draconian logic imaginable (I think draconian logic might be oxymoronic—and you can put the accent on either syllable), which will not bode well for survey success.
That’s the word from unity for this week; next week, we’ll check up on some Emergency Management doings in the wake of recent flooding, including some updates to the Joint Commission’s Emergency Management Portal (EMP?). Hope your solstice salutations are merry and bright until next time!
As the ol’ Physical Environment Portal remains barren of new goodies (maybe we will awake the morning of December 25 and find crisply wrapped interpretations under the tree—oh, what joy for every girl and boy!), we will turn yet again to the annals of Perspectives to mayhap glean some clarity from that august source of information. I suspect that as the December issue is chock-a-block full of life safety and emergency management goodness, we’ll be chatting about the contents for a couple of sessions. First, the big news (or what I think/suspect is the news that is likely to have the most far-reaching implications for survey year 2017): a survey process change relative to the evaluation of Interim Life Safety Measures. Actually, I should note that, as the changes were effective November 17, 2016, those of you experiencing surveys ‘twixt then and the end of the year will also be subject to this slight alteration.
So, effective 11/17/16 (the 46th anniversary of the recording of Elton John’s landmark live album 11/17/70—coincidence? Probably…), the evaluation of your ILSM process (inclusive of the policy, any risk assessments, etc.) will be expanded to include discussion of how, and to what extent, ILSMs will be implemented when there are LS deficiencies identified during your survey that (presumably) cannot be immediately corrected, based on your ILSM policy. Sounds pretty straightforward, but it does make me wonder how the LS surveyor is going to have enough time to review your documentation, thoroughly survey your facility, and then sit down to review any LS findings and discuss how your ILSM policy/process comes into play. I have to tell you, when I first read this, my thought immediately went to “one more day of LS surveying to endure for any reasonably-sized hospital” and, taking into consideration all the other changes going on, while I hope I am incorrect, it does make me wonder, wonder, wonder. Also, the ILSM(s) to be implemented until the deficiency is resolved will be noted in the final survey report, so it probably behooves you to have a process in place to be able to FIFI (find it, fix it) every LS deficiency as it is encountered—and since everything counts with the abolition of the “C” performance elements, you know what you probably need to do.
At any rate, with the announcement that we can expect full coverage of the ILSM standard, there was also a note that an additional performance element has been added to provide for any additional ILSMs you might want to use that are not specifically addressed in the other performance elements for this standard. I’m not exactly sure how this would play out from a practical standpoint; maybe you could specifically include in your policy a provision for checking exit routes in construction only when the space is occupied, etc. As near as I can remember, the only instance I can think of somebody being cited for having an ILSM in their policy that did not precisely reflect the performance elements in the standard was back when the EP regarding the prohibition of smoking was discontinued from the standard; there were a few persnickety surveyors who cited folks for not having removed that from their policy (persnickety is as persnickety does), but that’s all I can think of.
Next week, we’ll chat a bit about some of the pending changes to the Life Safety chapter wrought by the adoption of the 2012 Life Safety Code®. In a word, riveting!
Another hodgepodge of stuff this week. I suppose with the holidays, I could be lazy and break these up into smaller chunks of bloggy goodness—maybe next week, but first some ponderings.
I was penning some thoughts relative to the current state of accreditation and a common theme kept reasserting itself: the recent changes are going to absolutely nothing to help decrease the number of findings in the physical environment and, in fact, are much more likely to increase the number (and probably types) of findings experienced during regulatory inspections. Now, I suppose this is rather an extension of the alignment with CMS (I mean, whoever received a visit from those folks and escaped completely unscathed? Perhaps some, but not a whole bunch, I’d venture to guess) and how that philosophy (scorched earth seems like a particularly apropos descriptor—at least at the moment) aligns with the idea/sense/concept that perfection is a noble goal, but not particularly obtainable on this particular space-spinning blue sphere. I’ve said it before, I’ll (no doubt) say it again: they are going to find “stuff” when they visit you—they have to! But that brings me back to the age-old question of what value does this level of attention to minutia bring to the process. I don’t think there’s anyone among us that believes that we have achieved a level of perfection of heretofore untold proportions—has a lot to do with why we have to show up at work every day, n’est-ce pas? There has got to be a better way to facilitate improvement in the management of the healthcare environment without brandishing the regulatory equivalent of a sharp stick (if not a cattle prod). So, as we wind down the 2016 season, those one-off OFIs have now been converted into a cluster of regulatory middle fingers—ouch! Okay, hopping down from the soapbox.
In the December 2016 issue of Perspectives, there is a fair discussion on how the Interim Life Safety Measures (ILSM) process is going to be utilized (perhaps even evaluated) during the survey process. In the October Perspectives, there was coverage of how a completed project (that involved ILSM implementation) would be reviewed to evaluate the effectiveness of the ILSM process. There was also discussion indicating that construction-related deficiencies would not be cited as specific RFIs but rather as a function of the ILSM performance elements. But the December publication offers yet another nuance to the process—when you have a Life Safety Code® deficiency identified during survey, there will be a resultant “discussion” of the deficiency and an inquiry as to which ILSM will be implemented to protect building occupants until such time as the deficiency (or deficiencies) is corrected. I think the important thing to keep in mind here is that the requirement is to implement your ILSM policy, which would then provide criteria for determining what, if any, of the ILSMs would be implemented. I also think that now would be a really good time to dust off your ILSM policy and run it through a couple of test deficiencies to ensure that your policy supports a reasonable approach to ILSM implementation. Finally (on this subject), in the days when clarification of findings was a worthwhile endeavor, it never “paid” to fix stuff during the survey (fixing a condition was tantamount to admitting that you had messed up), but now that everything gets cited, the simplest ILSM to implement is “none at all because we fixed the condition.” Can somebody give me a “that’s a pain in the posterior”? Amen!
As a final thought (or perhaps thoughts) for the week, I think we have to treat any construction or renovation activities as an invasive procedure, so we need to come up a process akin to the Universal Protocol adopted by the folks in surgery to make sure that everyone is on the same page before the activity starts (and that especially includes contractor staff—I am absolutely convinced that we could do a better job with that process). As an offshoot of this, I think it might be time to adopt a process for periodically evaluating the construction/renovation management process, much as we evaluate the 6+1 EC/EM functions. I can’t think of a single “normal” process that has more potential for disruption, angst, chaos—you name it—than the construction and renovation process. Some folks are fortunate enough to have in-house resources for the management of these activities, but even then there can be opportunities for improvement–the communications process springs to mind as being frequently flawed.
Until next time, I bid you as much holiday cheer as you can tolerate!
First off, please accept my bestest wishes to you and yours for a most joyous and restful (or as restful as you want it to be) Thanksgiving holiday.
To paraphrase a certain musical ensemble, what a long, strange compliance year it’s been. Hopefully, 2016 will head off into the realm of history with a whimper (I think we’ve experienced enough “bangs” to take us well into 2017 and beyond). And so, a little casserole of safety stuff to tide you over ’til next week. First up, some risk assessment deliciousness, courtesy of NFPA 99.
I had intended to discuss this back a few weeks, but there has been a lot to discuss these past few weeks. At any rate, I was able to get a look at the CMS update portion of the Executive Briefings presentation and it appears that there was some discussion relating to the practical application of how a space is used to determine the risk category for the equipment and/or systems used to support that space. My sense of this is that it’s not so much the space itself as it is, but rather what processes, etc., exist within the space you are evaluating, using the definitions from NFPA 99. So, the methodology focuses on an analysis of facility systems and equipment based on the risks associated with failures of those systems:
Category 1—Facility systems in which failure of such equipment or system is likely to cause major injury or death of patients or caregivers
Category 2—Facility systems in which failure of such equipment or system is likely to cause minor injury to patients or caregivers
Category 3—Facility systems in which failure of such equipment is not likely to cause injury to patients or caregivers
Category 4—Facility systems in which failure of such equipment would have no impact on patient care.
So, moving to the definitions in NFPA 99, you sort the above concepts based on how the space is used:
- Facility systems and equipment for critical care rooms would be Category 1
- Facility systems and equipment for general care rooms would be Category 2
- Facility systems and equipment for basic care rooms would be Category 3
- Facility systems and equipment for support rooms would be Category 4
Each of the chapters in NFPA 99 (gas and vacuum systems, gas equipment, electrical systems, HVAC, etc.) have provisions for the different categories, as applicable, so it appears that the expectation (at least as it was presented at Exec Briefings) is that the organization of the facilities systems and equipment would reflect this methodology. To be honest, I think this may be more of an issue with re-packaging how things are equipped and maintained; maybe including the category designation on work orders, etc. I don’t know that this is going to extend to TJC’s activities, though with the bad marks it received on its CMS report card, it seems unlikely that TJC will become more reasonable…time, as they say, will tell.
Another potential complication for survey year 2017 (I’m pretty confident of this, but not yet certain about the timeline for implementation) is a broadening of the Evidence of Standards Compliance (ESC) process to include at least two more considerations. At the moment, the ESC process requires a response to the following categories: Who (is responsible for the correction); What (was done to correct the deficiency); When (the corrective action was completed); How (the corrective action was implemented and will be sustained), and Measure of Success (for those pesky “C” performance elements—to which we will bid a hearty “adieu” on January 1, 2017). I think we’re all pretty familiar with that part of the process (I can’t imagine that anyone’s had a survey with no findings in the physical environment, though I suppose the infamous “bell” curve might dictate otherwise), but there is indication that with the removal of the Measure of Success category, we will have two additional elements to document within the framework/context of the corrective action: Leadership Involvement and Preventive Analysis. At the moment, it appears that the sequence will look something like this:
I think being able to account for leadership involvement is a pretty straightforward response (I think probably the best way to frame this would be to identify the boss of whoever the “who” would be; and perhaps that boss’ boss, depending on the circumstance), but I suspect that the Preventive Analysis portion of the response could get quite complicated. As near as I can tell, it would be an amalgam of the root cause that resulted in the finding and the strategy for preventing future deficiencies, although minimizing the risk of recurrence might be a more useful viewpoint—as I like to tell folks, it’s the easiest thing in the world to fix something and the among the most difficult things to keep that something fixed. Hopefully, this will end up being no more than a little more water under the bridge, but I guess as long as findings in the physical environment remain a focus, the sustainment of corrective actions will be part of the conversation.
And on that note, I bid you a Thanksgiving to eclipse all yet experienced: gobble, gobble!