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Time has come today (or perhaps time won’t let me…)

Last week, we started the discussion regarding findings relative to the inspection, testing, and maintenance of medical gas systems, which reminds me that I kind of skirted exactly how those findings were manifesting themselves.

The most common variant is for organizations that have established a less-frequent-than-annual schedule for the med gas system components, particularly the outlets (as they are usually the most numerous of the system components). Folks are doing half or a third or a quarter of their outlets on an annual basis, and they have not specifically identified the time frame in the Utility Systems Management Plan (USMP; feel free to give your USMP a quick check to see if you’ve defined the time frame(s) for the med gas system components and that your practice accurately reflects what is in the management plan, which is the other most common way this standard generates findings). Make sure you identify the time frame for the testing, etc., and make sure that what the management plan says accurately reflects the process (I know there’s a certain inescapable logic to this, but I’ve seen folks get tagged for this, so please just take a moment to make sure…).

How do we determine those time frames? Well, once again we can ping back through to EC.02.05.01, this time stopping at EP 4, which requires the identification (in writing—but of course) of inspection, testing, and maintenance intervals “based on criteria such as manufacturers’ recommendations, risk levels, or hospital experience.” I think that pretty much captures the gamut of possible criteria, but I’ll throw the question out to the studio audience: Anyone using anything other than those criteria? If so, please share. This would be required for all the utility systems on the inventory, so the next question becomes: What’s on your inventory and how did you populate that inventory?

Jumping back a wee bit further to EC.02.05.01, EP 2, it appears that we would choose between an inventory that contains all operating components of utility systems or we would establish the inventory based on “risks for infection, occupant needs, and systems critical to patient care (including all life-support systems).” Now, I’m not at all certain what you folks might doing individually (I suspect it will have at least something to do with the complexity of your systems and the component elements), but I’m going to guess we have a mix of both strategies of inventory creation. So the task then becomes one of fitting the medical gas system, in total or in pieces, into that decision, then considering the criteria noted under EP 4 to wrap things up in the form of a lovely little risk assessment. Then update the USMP to reflect whatever it is you’ve determined and you should be good to go.

A word of caution/advice: Once you’ve done the risk assessment, picked the maintenance strategy, determined the frequency, and updated the USMP, please remember that is always a wise move to periodically evaluate the decision you made relative to, well, basically anything in your USMP/inventory thing. And a fine spot to do that (if you prefer to call it an opportunity, you’ll get no grief from me) is the annual evaluation process. It comes down to a simple question: Have the maintenance strategies, frequencies, and activities provided reliable performance in support of patient care activities? And while the answer is also pretty simple (yes or no, maybe with a periodic instance of “don’t know” thrown in for good measure), it might be useful to develop a measurement that will tell you when the process is not working well. Could be something like “unscheduled disruptions resulting from preventable conditions” (which might indicate you need to increase your frequencies) or delays in care and/or treatment as the result of unscheduled disruptions (I am a very big fan of EC measurements that tie performance in the care environment back to the bedside—powerful stuff), things like that.

We always want to try and base our risk decisions on data, but sometimes you have to pick a course based on that rapidly vanishing commodity—common sense. When that occurs, I’d want to have some means of “telling” whether the decision was a good one, fold that into (or through) the annual evaluation process, and then move on to the next challenge (and there will surely be another challenge…any minute now). Hope you found this discussion helpful. I will again solicit any feedback that might be percolating out there—I love to know what you all are doing with this stuff, and so does the rest of the class.

I’m feeling a little (medical) gassy…

One Joint Commission survey finding I’ve noticed cropping up in a couple of instances has to do with the routine inspection, testing, and maintenance of critical components of medical gas and vacuum systems. I thought it might be useful to chat a bit about this, particularly as the standard/performance element language is among the more open-ended in terms of what may or may not be required.

EC.02.05.09, EP 1 indicates that the hospital must, in time frames defined by the hospital, inspect, test, and maintain critical components of piped medical gas systems, which include master signal panels, area alarms, automatic pressure switches, shutoff valves, flexible connectors, and outlets. These activities must be documented. So, we’ve got a couple of things going on—“time frames defined by the hospital” and “critical components of piped medical gas systems”—but not a whole lot of indication as to what the heck these are supposed to mean. Or is there something  that would lead us on a path towards conduction of a (you may have guessed this) risk assessment (did you guess, huh, did you? I bet you did…)?

Actually, as a starting point, EC.02.05.09 has a note that gives us a little something to grow on: See also EC.02.05.01, EP 3. Moving on (or back in the standards to EC.02.05.01, we see that EP 3 requires us to identify, in writing, inspection and maintenance activities for all operating components of utility systems on the inventory. Okay, so we have to have written procedures/protocols/ something that we can use to demonstrate compliance; BTW, there are a number of different approaches to maintenance that are allowable—predictive maintenance, reliability-centered maintenance, interval-based maintenance, or metered maintenance are all in the mix—and you can choose whichever of the strategies is appropriate to whatever you are maintaining. Pretty cool, yes?

So we establish what activities are going to be identified and what maintenance approach(es) we are going to be using, which gets us closer to the time frame, but perhaps not quite all the way there. And there is still the matter of how we might define “critical components of piped medical gas systems.” Stay tuned for our next installment…see you next week!

Do you have to be so negative/positive?

Time for a little update from the field during survey year 2013. If there’s one topic (or topical set, if you will) that’s causing much angst in the survey world, it’s the focus being paid to areas that have specific environmental performance requirements (e.g., air pressures, temperature, humidity). Last year there seemed to be a little bit of a “run” on issues relating to low humidity, but with the issuance of the CMS categorical waiver, I think the low humidity problems are going to fade into the sunset. But that still leaves us with high humidity conditions and those pesky pressure relationships—I can pretty much guarantee that, for the foreseeable future, Joint Commission surveyors are going to be scrutinizing your logs, field testing your pressure relationships and all manner of mischief when it comes to this stuff. So, I would advise you to start doing the same. Check those logs going back to last year’s rather toasty environs. Did you experience out-of-range values in your procedure rooms? If so, were there any documented actions in response to those out-of-range values? Clearly, if there was no documented response, you are potentially looking at a finding during survey, but if you can demonstrate that you have a well-controlled process now, then maybe you can convince the survey team that past performance doesn’t indicate current or future results and you can negotiate a more favorable settlement. Remember, this is an area that can drive a condition-level finding for CMS in no time flat. You need to have an effective process in place or you will definitely suffer the slings and arrows of outrageous survey fortune—and I don’t think any of us wants that. I know I wouldn’t like it…

I’m fixing a hole

For our next topic of conversation regarding George Mills’ address to the folks in ASHE last year, we take up the ever-vexing task of managing penetrations. Now, there’s certainly been a lot of ire pointed towards the folks who run cabling in healthcare—IT, cabling contractors, etc. But this represents something of a sea change in the public face of this problem—while there certainly any number of “perps” when it comes to making holes in rated barriers, there is a very clear sense that appropriate management of the process results in the buck stopping at a single destination: the desk of the facilities management professional.

So, a quick show of hands: How many folks are using an above the ceiling work permitting process? That many? That’s a pretty good number. But how are you administering that process? Have you told the entire organization about the process? Maybe established a bounty for finding folks working in the ceiling without a permit? You have tens of thousands, if not hundreds of thousands, of square feet in which mischief can occur above the ceiling. If you establish the condition that anyone (and that means  folks employed by the hospital—everyone is equal in the eyes of a penetrated rated barrier) working above ceiling must display a permit on the ladder or lift—and get folks to call in when someone is working without a permit, then you can start to manage the process. By the way, I’m a great believer in rewarding folks who drop a dime for this and don’t be cheap; at least buy ’em lunch somewhere nice. And if you find you’re spending too much money feeding your dime-droppers, then that means that your permit process is not working very effectively!

When you find someone working above the ceiling without a permit, throw the bum out! Nothing draws attention to a process like a good swift kick in the pocketbook. If someone does not want to work by our rules, then they can work elsewhere, pure and simple. Then they can explain to their boss why they couldn’t finish a job, as opposed to you having to explain to your boss why you’re getting an RFI for rated barrier penetrations. I know which scenario I’d prefer…

One last thought: As for “existing” penetrations, Mr. Mills clearly indicated the expectation that facilities will undertake an above-the-ceiling inspection at least once per year to catch any deficiencies that were not captured by the normal process. Then you either fix them properly or manage them as a PFI (with applicable ILSM assessment—please don’t forget that piece of the puzzle). It’s really just that simple.

Suites for the sweet

Continuing our coverage of George Mills’ address to the ASHE folks last fall, we turn to what was described as an area with a “lot of problems”:  The management of suites.

So, before we get started on this one, I’d like you to make a mental list of all the areas in your organization that have been designated as suites (if you’re not sure what a “suite” is, please e-mail me on the side at the address listed below and I will try to help you to get acquainted with this most useful of life safety concepts). Now that you have that mental list appropriately populated, take out your life safety drawings and check to see how many of those suites are specifically identified (this means the perimeter boundaries of the suite, as well as the square footage of the suite). If you have suites that you have mentally designated, but haven’t gone through the process of having them identified on your life safety drawings, in all likelihood you are looking at RFIs for anything from corridor storage to non-latching corridor doors (suites can have stuff and patient rooms doors that don’t latch – benefit!).

In some ways, this very much comes under the category of things that you have to “know”; it is not nearly enough to “think” that something is compliant. If you expect to successfully navigate the survey process, you have to translate the “think” to the “know.” As a facilities management professional, it is incumbent upon you to have absolute knowledge of where your facility “lies” on the compliance chart. By all means, use your vendors and service folks to gain that knowledge, but be assured of one thing: They won’t be the ones in the “hot seat” come survey time—and you’d better know how to cool off that seat.