OSHA Says Face Coverings Not Considered PPE Under Its Standard

By: November 30th, 2020 Email This Post Print This Post

By Guy Burdick , EHS Daily Advisor

The Occupational Safety and Health Administration (OSHA) does not consider cloth face coverings personal protective equipment (PPE), the agency said on November 18 in an update to its frequently asked questions (FAQs) about coronavirus disease 2019 (COVID-19).

OSHA revised its advice for employers following an updated scientific brief from the Centers for Disease Control and Prevention (CDC) about community use of cloth face masks to control the spread of SARS-CoV-2, the virus that causes COVID-19. The CDC now recommends the use of masks, especially nonvalved multilayer cloth masks, to prevent transmission of SARS-CoV-2.

Cloth masks can both block the mask wearer’s exhaled respiratory droplets and particles and offer the wearer some personal protection through droplet and particle filtration, according to the CDC.  However, the filtration effectiveness of different masks has varied widely across the studies so far performed due to differences in study design and the particle sizes analyzed, the CDC said.

One study found that during a COVID-19 outbreak aboard the aircraft carrier U.S.S. Theodore Roosevelt, servicemembers who practiced precautions, including avoiding common areas, practicing physical distancing, and wearing face masks, had a lower infection rate than servicemembers who did not report taking precautions. The use of face coverings on board was associated with a 70% reduced risk, according to the CDC.

A study of a high-exposure event, when two symptomatically ill hair stylists interacted for an average of 15 minutes with 139 clients during an 8-day period, found that none of the 67 clients who subsequently agreed to an interview and testing developed an infection. The stylists and clients all complied with a local ordinance and company policy to wear face masks while in the salon.

Despite encouraging reports from the CDC, OSHA does not believe there is enough information currently available to determine whether any particular cloth face covering provides enough protection from SARS-CoV-2 to be considered PPE under the agency’s standard. The CDC indicated that more research is needed to determine the blocking and filtration effectiveness of various materials.

The design, construction, and fabric selection of a mask all can have a substantial impact on the overall effectiveness of a face covering as personal protection. OSHA acknowledged current efforts to develop a consensus standard on the design and performance of face coverings at ASTM International (formerly the American Society for Testing and Materials).

OSHA continues to encourage workers to wear face coverings, if appropriate in work environments, when in close contact with others to reduce the risk of spreading the SARS-CoV-2 virus. Three states so far—VirginiaMichigan, and Oregon—have established emergency temporary standards (ETSs) for workplace COVID-19 exposures, and each has different requirements for face coverings. Oregon’s rule requires cloth face coverings in indoor spaces, regardless of physical distancing. Michigan requires employers to provide face masks at no cost to employees.

proposed ETS in California also would require employers to provide no-cost face coverings, as well as no-cost COVID-19 testing. There is no federal ETS for workplace COVID-19 exposures. OSHA has cited employers for violations of the General Duty Clause of the Occupational Safety and Health Act, along with violations of recordkeeping, reporting, and respiratory protection standards. The agency so far has proposed penalties totaling $2,851,533.

KPA COVID-19 Operations Checklist

By: November 30th, 2020 Email This Post Print This Post

Companies are facing many risks associated with COVID-19. Since it’s not going away in the short-term, you need to put strategies in place to protect employees and customers.

Establishing a plan and training employees can demonstrate that you put forth a “good faith effort” to regulatory agencies like OSHA.

This checklist reviews the steps to create a thoughtful COVID-19 operating strategy including:

  • Appointing a COVID-19 coordinator and response team
  • Develop an infectious disease plan
  • How to operate if absenteeism rises; and more

Download the COVID-19 Operations Checklist now for free here

Amid COVID-19, OSHA issues respirator guidance for long-term care facilities

By: November 12th, 2020 Email This Post Print This Post

By Guy Burdick, EHS Daily Advisor

The Occupational Safety and Health Administration (OSHA) issued respiratory protection guidance for assisted living, nursing home, and other long-term care facilities. The guidance focuses on the use of respirators while emphasizing a primary reliance upon engineering and administrative controls for controlling exposures, consistent with good industrial hygiene practice and the agency’s traditional adherence to the “hierarchy of controls.”

The industrial hygiene “hierarchy of controls” is a series of workplace safety and health interventions that begins with elimination of hazards, followed by substitution, then engineering controls, administrative controls (including work practices), and personal protective equipment (PPE).

OSHA has instructed its compliance safety and health officers in its area offices to exercise discretion in the enforcement of the respiratory protection standard during the coronavirus disease 2019 (COVID-19) pandemic. COVID-19 is a respiratory disease caused by the SARS-CoV-2 virus.

The agency insists that workers wear respirators when necessary, such as when in close contact with a resident of a long-term care facility with suspected or confirmed coronavirus infection. Employees then must wear an N95 filtering facepiece respirator (FFR) or equivalent or a higher-level respirator approved by the National Institute for Occupational Safety and Health (NIOSH).

The guidance describes other source control measures, including the use of cloth face coverings, face masks, and U.S. Food and Drug Administration (FDA)-cleared or -authorized surgical masks. Healthcare workers should wear such source control products or devices at all times while inside a long-term care facility, according to the agency, including in break rooms or other spaces where they might encounter other people.

OSHA told employers that they should reassess their engineering and administrative controls, such as ventilation and practices for physical distancing, hand hygiene, and cleaning and disinfecting surfaces, to identify changes that could avoid over-reliance on respirators and other PPE. OSHA reminded employers that the agency has temporarily allowed for some enforcement flexibility regarding respirators, including requirements for annual fit testing that consumes disposable respirator supplies.

However, the agency also reminded employers that when respirators must be used, employers must implement a written, worksite-specific respiratory protection program that includes medical evaluation, fit testing, training, and other elements of the agency’s respiratory protection standard (29 CFR 1910.134).

OSHA offered employers the following advice for administering a respiratory protection program during the ongoing pandemic:

  • Consider alternatives to N95 FFRs, including other FFRs (for example, P100s and N99s); reusable elastomeric respirators; and powered air-purifying respirators (PAPRs), given shortages of N95 FFRs during the pandemic.
  • Choose eye and face protection to be worn with the type of respirator used, but exercise care to ensure the eye or face protection does not interfere with the seal of the respirator.
  • Consult NIOSH’s list of approved N95 FFRs and warnings about counterfeit respirators or misrepresentation of NIOSH approval.
  • Assign a suitably trained program administrator to oversee all elements of the program, such as an infection prevention and control practitioner or a nurse administrator, or consider hiring a local industrial hygiene consulting service if no suitably trained administrator is available on staff.
  • Conduct a risk assessment to identify which workers are at risk of exposure to any airborne hazards such as SARS-CoV-2, tuberculosis (TB), Legionella, or certain hazardous chemicals, and classify exposure risk to SARS-CoV-2, according to OSHA’s four risk exposure levels.
  • Implement procedures for performing medical evaluations of workers required to use respirators to determine their ability to safely wear a respirator before needing to wear one in the workplace; identify a physician or other licensed healthcare professional who can conduct medical evaluations and maintain confidentiality.
  • Ensure that any worker using a tight-fitting respirator is fit tested following OSHA-approved fit-test protocols before initial use and whenever a different respirator size, style, model, or make is used.
  • Establish procedures and schedules for the maintenance and storage of any respirators used beyond a single use, including procedures for cleaning, disinfecting, storing, repairing, and discarding respirators.
  • Train workers who wear respirators on how to properly put them on (donning) and take them off (doffing), as well as how to conduct proper user seal checks and recognize respiratory hazards in their workplace and the capabilities and limitations of respirators.

Checking in on Your Organizational Safety Culture

By: November 11th, 2020 Email This Post Print This Post

By Guy Burdick, EHS Daily Advisor

A few weeks ago during the EHS Daily Advisor’s Safety Culture Week, we provided a wide array of content to help you build a safety culture that is effective all year round. But to maintain a healthy culture, it’s important to constantly check in on it. So, how is your safety culture? You might begin by asking yourself, “What does ‘safe’ look like?” Is it a low recordable incident rate? Is it a lower number of workers’ compensation claims?

Safety conversation

Rido / Shutterstock.com

Measuring outcomes is important, but you may need to dig deeper to understand how those outcomes affect your business and the underlying hazards, risks, and risky behaviors that lead to accidents and incidents.

The most obvious sign of a troubled safety culture is workers who fail to comply with safety rules, policies, and procedures. Worse than mere disregard for rules is risky worker behavior. You need your employees to fall in line, especially now.

Worker compliance is even more critical during the ongoing coronavirus disease 2019 (COVID-19) pandemic, starting with the risk of a sick employee showing up for duty. There are engineering and administrative controls you can put in place to help prevent infections, like installing plexiglass shields where distancing of 6 feet or more is impractical, staggering shifts and installing additional time clocks to prevent close contact at shift changes, and removing chairs and tables in break rooms. However, preventing infections relies heavily on individual behaviors, from social distancing and the proper use of cloth face coverings to hand-washing, cough and sneeze etiquette, and staying home when sick.

Where duties can be performed remotely, an effective telework policy can help ensure workers do not show up sick at your workplace, but you may want to add start-of-shift screening that includes temperature checks and symptom assessments.

Resuming operations following state-imposed shutdowns and continuing operations during the uncontrolled spread of COVID-19 may require new approaches specific to a pandemic response. You should begin by assessing how the pandemic has affected your organizational culture.

You may need to communicate new operational objectives to your employees and update how you deliver safety training to your employees in addition to incorporating infection prevention into your training programs. You also may need to add resources to reinforce safety training for employees who have been away from the workplace. Some states have new regulations with COVID-19 training requirements.

You also need to communicate your new policies and practices with your employees to counter any reentry anxiety.

Healthcare PPE

spwidoff / Shutterstock.com

Patient and Worker Safety in Health Care

The impact of safety culture can extend beyond employees themselves, as researchers at Imperial College London recently found. A positive safety culture in a healthcare facility can result in improved patient safety and better patient health outcomes. Training and support for redeploying healthcare workers during the onset of the COVID-19 pandemic resulted in better safety attitudes and a reduced number of reported safety incidents.

The Occupational Safety and Health Administration (OSHA) years ago acknowledged the benefits of linking patient and worker safety after the release of an Institute of Medicine (IOM) report, “To Err is Human: Building a Safer Health System.” IOM concluded that a safer environment for patients would also be a safer environment for workers and vice versa. Several studies have shown a correlation between a strong safety culture and the safe handling of sharps and bloodborne pathogens.

According to the IOM report, a strong safety culture in a healthcare facility is created through:

  • The actions management takes to improve both patient and worker safety,
  • Employee participation in safety planning,
  • The availability of appropriate protective equipment,
  • The influence of group norms regarding acceptable safety practices, and
  • The organization’s socialization process for new personnel.

An effective safety and health management program can help employers find and fix workplace hazards before workers are hurt, according to OSHA. Many healthcare facilities may already have a safety and health management program in place to conform to Joint Commission standards. Joint Commission certification usually is a prerequisite for insurance, Medicaid, and Medicare reimbursement.

OSHA has identified management leadership, worker participation, hazard identification and assessment, hazard prevention and control, education and training, and system evaluation and improvement as key elements to an effective safety and health management program.

The National Institute for Occupational Safety and Health (NIOSH) even has a National Occupational Research Agenda (NORA) for the healthcare and social assistance sector. As part of the healthcare and social assistance research agenda, NIOSH developed a “Stop Sticks” Campaign focused on the knowledge, behaviors, and attitudes of healthcare workers surrounding the use of devices with sharps injury protection (SIP).

Safety Rules Compliance

Even in the best of times, employees “bending” or breaking workplace safety rules and procedures can have serious consequences—even the loss of a limb.

For example, evidence emerged in a lockout/tagout case at a Wal-Mart distribution center that company and contract employees regularly circumvented company procedures for entering an Electrified Monorail System (EMS) consisting of trolleys to move pallets of merchandise within the warehouse. Employees for Wal-Mart and its contractor, Swisslog Logistics, crossed over fixed conveyors to enter the EMS. Employees also had placed pieces of cardboard over the light curtains between loops of the EMS—an employee tripping a light curtain normally would stop the trolleys in that section—resulting in the light curtains being in a muted state. Employees could walk from one loop to another without tripping a light curtain, even where trolleys operated in full-speed mode. An employee servicing trolleys was struck by one, and a piece of machinery penetrated his leg.

Rank-and-file employees aren’t the only challenges to your safety culture, and the threat can be hard to spot if it is one of your managers and supervisors. A research study last year found that abusive behavior among managers and supervisors degraded safety behavior and led to poor safety outcomes among workers.

Bullying bosses can make workers become more self-centered, causing them to forget to comply with safety rules or ignore opportunities to promote others’ safer work behaviors. It even can create circumstances in which other people are likely to become injured.

You should intervene with abusive managers and supervisors, researchers suggest, by utilizing training programs to improve managers’ and supervisors’ skills in interacting with the employees they supervise so they have the skills to provide discipline and feedback in ways that are not offensive or threatening. Researchers also recommend that you promote a civil and engaged working environment, strengthening social bonds among employees to create a buffer that limits the negative consequences of their boss’s bad behaviors. You may even want to institute a transparent performance evaluation process so employees have no question about their social status in the workplace.

You also need to ensure that “safety first” is more than a motto and that all your managers and supervisors are steeped in safety culture.

You can get real-world results from a strong safety culture when supported by emerging safety technologies. Researchers found that trucking companies that have strong safety cultures and take advantage of advanced safety technology have seen better safety outcomes than motor carriers that don’t.

Best practices in a strong trucking safety culture require a consistency that includes:

  • Having zero-tolerance policies for hours-of-service violations;
  • Implementing improvements in hiring policies and training protocols and modifying driver scheduling to reduce fatigue;
  • Informing drivers about the carrier’s safety culture during orientation and including all employees—not just drivers—in safety training and education; and
  • Sharing carrierwide safety indicators with managers and drivers.

Training can be critical. Researchers have found strong evidence that training affects worker safety and health behavior, especially behavior surrounding ergonomic hazards.

Training needs to be geared toward the intended audience, taking employees’ cultural and educational backgrounds into consideration, including literacy levels. In some instances, training may need to be delivered in a language other than English.

The American Society of Safety Professionals (ASSP) has suggested looking at safety training at a higher level and integrating it into an overall safety and health management system. Safety and health management programs also include safety observations, safety audits, job hazard analyses, and incident investigations.

These elements can help reinforce a strong safety culture in your facility or at your jobsites.

Safety training

OhLanlaa / Shutterstock.com

‘Hidden’ Safety Culture

You also need to be aware that there may be a “hidden” safety culture, like the one among the employees at the Walmart distribution center. This hidden safety culture may be starkly different from your stated policies and procedures. It cannot be found in the safety manual sitting on the safety manager’s desk.

First, you will need to embrace a certain amount of discomfort. Issues with your safety culture may not be obvious, and you will need to persist until you get to the underlying issues.

Next, look below the surface for hidden “mixed” messages, picking up on the internal forces that can lead to unsafe actions. Develop consistent messaging that reinforces how workers should perform their duties safely.

Develop your pattern-recognition skills. Look for common threads in incident investigation reports. Look, too, for employees’ jury-rigged solutions for challenges to safety and comfort, like padding adhered to sharp workstation edges. There may be issues with your current equipment, and replacing some of it may offer you low-cost solutions.

Continue asking the right questions, but realize you may not be able to “see the forest for the trees” and may need to bring in outside help.

While fostering a strong safety culture among a diverse, multigenerational workforce has its challenges, older workers still in the workforce can offer a model of safe workplace behaviors that younger workers can emulate. Older workers tend to become injured less often, although their injuries may be more severe when they do become injured. They may have knowledge about hazards in the workplace picked up over years of experience.

Your safety culture also may need to adjust to cultural differences in an increasingly diverse workforce. You need to become aware of your own biases, as some workers may not have grown up receiving the same cultural messages as you and other employees. Do not let your assumptions hinder your safety efforts.

While you and some of your employees may perfectly understand American sports metaphors like “team” and “teamwork,” workers raised in other cultures may be more accustomed family metaphors when referring to work colleagues.

Check your assumptions so your safety policies and procedures do not become “lost in translation.” Encourage a free exchange of ideas. Different is not necessarily better or worse.

You need a safety culture that works for you today during a pandemic and every day after the outbreak.

11 Rules for Safe Handling of Hazardous Materials

By: November 11th, 2020 Email This Post Print This Post

By Chris Kilbourne
, EHS Daily Advisor

These 11 rules are presented in no particular order. They are all top priorities for chemical handlers. However, feel free to rearrange them in whatever order you think is best for your workplace, your workers, and your material hazards.

You’ll undoubtedly have other safety rules to add to the list. Better yet, present the list in a safety meeting and get employees involved in helping you add to the list. This will create a sense of ownership over your safe chemical handling rules. To employees, they’ll be “our” rules rather than “their” rules. That way, people will be more likely to follow them.

Rule #1. Follow all established procedures and perform job duties as you’ve been trained.

Rule #2. Be cautious and plan ahead. Think about what could go wrong and pay close attention to what you’re doing while you work.

Rule #3. Always use required PPE—and inspect it carefully before each use to make sure it’s safe to use. Replace worn out or damage PPE; it won’t provide adequate protection.

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Rule #4. Make sure all containers are properly labeled and that the material is contained in an appropriate container. Don’t use any material not contained or labeled properly. Report any damaged containers or illegible labels to your supervisor right away.

Rule #5. Read labels and the material safety data sheet (MSDS) before using any material to make sure you understand hazards and precautions.

Rule #6. Use all materials solely for their intended purpose. Don’t, for example, use solvents to clean your hands, or gasoline to wipe down equipment.

Rule #7. Never eat or drink while handling any materials, and if your hands are contaminated, don’t use cosmetics or handle contact lenses.

Rule #8. Read the labels and refer to MSDSs to identify properties and hazards of chemical products and materials.

Rule #9. Store all materials properly, separate incompatibles, and store in ventilated, dry, cool areas.

Rule #10. Keep you and your work area clean. After handling any material, wash thoroughly with soap and water. Clean work surfaces at least once a shift so that contamination risks are minimized.

Rule #11. Learn about emergency procedures and equipment. Understanding emergency procedures means knowing evacuation procedures, emergency reporting procedures, and procedures for dealing with fires and spills. It also means knowing what to do in a medical emergency if a co-worker is injured or overcome by chemicals.

OSHA Raises Its Civil Penalties for 2020 by Nearly 2%

By: February 10th, 2020 Email This Post Print This Post

On January 15, the Occupational Safety and Health Administration (OSHA) raised its civil penalties (85 Fed. Reg. 2,292) by approximately 1.8%. The final rule implements annual inflation adjustments of civil monetary penalties assessed or enforced by OSHA and other agencies within the Department of Labor (DOL) in 2020, as required by the Inflation Adjustment Act (Pub. L. 114-74).

OSHA’s penalty increases for workplace safety and health violations include:

  • For a willful violation, in which an employer knowingly failed to comply with an OSHA standard or demonstrated a plain indifference for employee safety, the minimum penalty increases from $9,472 to $9,639 and the maximum penalty increases from $132,598 to $134,937;
  • For each repeated violation for an identical or substantially similar violation previously cited by the agency, the penalty ceiling rises from $132,598 to $134,937;
  • For each serious violation for workplace hazards that could cause an accident or illness that would most likely result in death or serious physical harm, the maximum penalty increases from $13,260 to $13,494;
  • For each other-than-serious violation, the maximum penalty increases from $13,260 to $13,494;
  • For each failure to correct violation, the maximum penalty increases from $13,260 to $13,494; and
  • For each posting requirement violation, the maximum penalty increases from $13,260 to $13,494.

The new penalty amounts take effect immediately, applying to any penalties assessed after January 15.

On November 2, 2015, Congress enacted the Federal Civil Penalties Inflation Adjustment Act Improvements Act of 2015, the Inflation Adjustment Act, to improve the effectiveness of civil monetary penalties and maintain their deterrent effect.

On July 1, 2016, the DOL published an interim final rule establishing an initial “catch-up” adjustment for civil penalties the Department administers. The Labor Department has issued annual inflation adjustments of civil penalties in 2017, 2018, and 2019.

The department is required to calculate the annual adjustment based on the Consumer Price Index for all Urban Consumers (CPI-U). Annual inflation adjustments are based on the percent change between the October CPI-U preceding the date of the adjustment, and the prior year’s October CPI-U.

The current adjustment is based on the percent change between the October 2019 CPI-U and the October 2018 CPI-U. The cost-of-living adjustment multiplier for 2020, based on the Consumer Price Index (CPI-U) for the month of October 2019, not seasonally adjusted, is 1.01764.

Existing penalty amounts are multiplied the multiplier, 1.01764, and then rounded to the nearest dollar.

If an OSHA Compliance Safety and Health Officer (CSHO) finds a hazard or standard violation during an onsite inspection, the inspector may issue citations and penalties. Inspections begin with a presentation of agency credentials and an opening conference and include a worksite walkaround and closing conference.

If the agency issues any citations or penalties, an employer may request an informal conference with the OSHA Area Director to discuss citations, penalties, abatement dates, or any other information pertinent to the inspection. The agency and the employer may work out a settlement agreement to address hazards found during an inspection.

OSHA has stated that its primary goal is correcting workplace safety and health hazards and ensuring compliance rather than imposing citations and collecting penalties.

Originally published on EHS Daily Advisor

Start Small to Create a Safety Culture

By: January 22nd, 2020 Email This Post Print This Post

By Jenny Slayton, Institute for Healthcare Improvement

We often hear about health care organizations that focus on creating a culture of safety. At Vanderbilt University Medical Center, it reminds us of how often in our journey we’ve paused and asked ourselves, “Will we ever get there?” The correct answer is that the job will never really be done because it’s an ongoing process. But we have a plan and we are on our way.

We started small. Just a few tests of change led us to establish a systemwide strategic plan for safety and quality. But it didn’t happen overnight.

Personnel in any size health care organization face massive amounts of work. This can paralyze us from trying anything new. We think we don’t have time, but just about everyone has time to start their pursuit of a safety culture.

How Vanderbilt Started Small

Start by doing something focused enough to represent a proof of concept. Run some PDSA cycles to fail fast and learn before presenting a plan to leadership. We chose something that allowed us to work out some of the kinks in our system.

We had been working on quality and safety initiatives for years, but our turning point occurred when we decided to improve our handwashing. “Choosing handwashing may seem trivial,” says Gerald Hickson, MD, Vanderbilt University Medical Center Senior Vice President for Quality, Safety and Risk Prevention. “But in years of working on this challenge, we still had difficulty performing this basic task in a highly reliable way.” Consequently, what sounded like a simple project became a stepping stone towards creating Vanderbilt’s organization-wide plan to address change.

At Vanderbilt, we didn’t ask, “Who in the world could be opposed to washing their hands?” Instead, we asked, “Are we willing to mutually support each other in our pursuit of high reliability?” This was important because the second approach is about values and our willingness to work together on our journey. It’s not about singling out individuals for blame.

In a safety culture, if one medical professional observes another who is not using the foam dispenser, they should avoid being judgmental. Instead, they should be willing to speak up about our collective commitment to our patients and each other. That is the type of culture we are pursuing.

4 Keys to Building a Safety Culture

At Vanderbilt, we’ve applied what we learned from our handwashing work to a range of other safety improvement opportunities. Says Hickson, “We first learned to wash our hands. We then decided that reliably implementing a certain practice bundle would reduce surgical site infections. Vanderbilt team members understood that [we were going to use] the same approach to roll out our new safety plan.” Here are some important lessons we’ve learned:

  • Commit to safety — We must be dedicated to preventing injury to our patients and each other. “You ensure that each new quality and safety initiative is aligned with your strategic goals,” says Hickson.
  • Demonstrate Respect — Modeling respect begins with senior leaders. You don’t have a culture of safety if people, especially leaders, don’t treat each other with respect and don’t respect safe medical practices like washing our hands, scrubbing the hub [to prevent central line infections], or using antibiotics thoughtfully. “Medical professionals have to trust that, if they speak up, what they say is going to be heard,” says Hickson.
  • Focus on quality — At Vanderbilt, this means measuring ourselves against the best health care systems in the world. We wouldn’t be satisfied with being average.
  • Focus on value — Remember that the goal should be to pursue high-quality outcomes from the patient and community perspectives. Our hand hygiene and surgical site infections prevention work, for example, have brought value to Vanderbilt, our patients, and our entire community.  

Personalizing Safety

At Vanderbilt, we have also tried to shift our culture from just thinking about rates and incidences to seeing our patients as individuals. “We harmed Sue. She was a 29-year-old mother of two.” Using our patients’ names puts our numbers into context and motivates us to design better systems to improve care. This approach reminds us why we got into health care in the first place.

Creating a safety culture also means promoting professional accountability while respecting fellow health care team members. For example, imagine someone who has repeatedly declined to follow the handwashing protocol. We sit down and have a conversation with them instead of pointing fingers. We acknowledge that team members work hard, and we all struggle from time to time. We work together to identify what’s gone well, sort out what the data tells us, and find best practices to move forward.

You also need to equip key team members to create a culture of safety and respect. For Vanderbilt, IHI’s Certified Professionals in Patient Safety (CPPS) credential has become instrumental to our organization’s mission. We have 26 individuals who are certified so far. Certification connects our team members to others outside Vanderbilt who regularly think about the pursuit of safety. Our team members also see certification as a professional development credential because they enter our leadership pipeline upon completion.  

We can’t always predict the challenge of the day, but we can prepare team members with the right training and support them throughout our safety journey. You don’t go out one day and run a marathon. You start by running for 30 minutes, and then building strength and stamina from there. The journey can begin by doing just one new thing.

Jenny Slayton, RN, MSN, is Executive Director of Quality Improvement for Vanderbilt University Medical Center.

Suicide prevention NPSG now applies to Critical Access Hospitals

By: January 21st, 2020 Email This Post Print This Post

By Brian Ward

Critical access hospitals (CAHs) accredited by The Joint Commission (TJC) will be expected to implement National Patient Safety Goal (NPSG) Standard NPSG.15.01.01 starting July 1, 2020. This standard is aimed at preventing suicides among patient populations and has been posted on the prepublications standards pages.
In the December edition of The Joint Commission’s Perspectives announcing the requirement, the accreditor noted concerns about the very high rate of suicides in rural communities that critical access hospitals serve. Suicide rates in rural counties are 25% higher than in urban areas.  

NPSG.15.01.01 has applied to hospitals and behavioral healthcare programs since 2007 and there were several significant standard changes that took effect in 2019. The Joint Commission released a clarification about those changes in May 2019.

Those who want to learn more about the suicide prevention NPSG are asked to contact Stacey Paul, RN, MSN, APN, PMHNP-BC, project director, clinical, Department of Standards and Survey Methods.

Medical Malpractice Rate Dropped Over 10-Year Period

By: January 20th, 2020 Email This Post Print This Post

By Jay Kumar

The last decade has seen a decline in the number of medical malpractice claims in the United States, which can be attributed to tort reform and improved quality of care, according to experts on a panel at the American Society for Health Care Risk Management’s (ASHRM) annual conference in Baltimore.

Looking at the findings of a 2018 benchmarking report from CRICO Strategies, there were 124,000 malpractice claims made from 2007 to 2016, said Gretchen Ruoff, MPH, CPHRM, CPPS, senior program director for patient safety at CRICO Strategies. A division of The Risk Management Foundation of the Harvard Medical Institutions Incorporated, CRICO Strategies published its report Medical Malpractice in America earlier this year and made it available for free download.

“We really feel this is a true representation of medical malpractice in America,” said Ruoff, noting that the medical professional liability case rate decreased 27% over the 10-year span. “There’s been an overall drop in risks across the country.”

Tort reform helped drive down the number of cases, said Paul Greve, JD, RPLU, DFASHRM, senior director, healthcare risk solutions, Markel Assurance.

When looking at the number of defendants per 100 physicians, the steepest decline was in OB-GYN claims with a 44% drop over 10 years, Ruoff said. The drop is possibly attributable to focused safety efforts in labor & delivery over the last 15 years, but more research is needed, she added.

A second report released by The Doctors Company examined rates of physician claims from 2006 to 2018. Ruoff said expenses and indemnity payments rose as expected. Case management expenses increased over time, outpacing inflation, Ruoff said.

From a claims perspective, the time to resolution has decreased, but experts have become increasingly expensive and costs have gone up for physician support and trial preparation, she said.

The proportion of cases naming multiple defendants is growing, with the study finding the following:

  • Cases with two-plus defendants increased, adding expense costs to every case (31% in 2007 to 37% in 2018)
  • 260 additional defendants per year since 2007
  • Average expenses per defendant is $25,000
  • $6.5 million in additional expenses per year since 2007

Average expenses are rising the fastest for zero-indemnity cases, going up by 4.7% per year. Contributing factors may include provider protection-focused philosophies of resourcing vigorous defense for cases without merit, and an unwillingness to pay on cases without malpractice.

Average indemnity payments increased 3% annually. In line with expectations, increase outpaced CPI by 1.3% per year (but slower than medical inflation)

Ruoff said cases closed with indemnity payments under $1 million are going down, while payments over $1 million are up 6%.

Growth is fastest in the $3 million to $11 million layer, growing from 17% to 22% over the last decade. Growth is driven by the volume of these cases, not increase in the average severity per layer, she added.


The CRICO report findings identified several general trends that impacted medical professional liability over the 2007-2016 period, including hospitals purchasing physician practices/employment model, Greve said. Hospital merger and acquisition activity increased notably, and the rapid rise of  hospital/healthcare costs has led to a disdain of healthcare organizations, he noted.

“Our hospitals and hospital systems are being viewed, especially by juries, as sitting on a big pot of money,” said Greve. “This corporatization has caused a deterioration of goodwill toward hospitals,” which explains why we’re seeing some of these mega-verdicts.

On the physician side, “we are seeing groups grow larger and larger,” said Darrell Ranum, JD, CPHRM, vice president, patient safety and risk management for The Doctors Company. There’s a concern about the influence of investor money on these groups, he added.

This is where high reliability helps, Ruoff said. Organizations are being encouraged to “change internal culture to have an impact on these big external things.”

The report also found that deeply coded cases provide actionable insights, said Ruoff. High-severity injuries are 41% more likely to lead to an indemnity payment. In addition, medical expenses for patients under 40 with grave injuries drive costs up.

The vast majority of cases stem from three categories: Surgical, medical, and diagnosis. Surgical cases are most prevalent, diagnosis is most costly, and medical treatment is becoming more common.

Forty-four percent of surgical cases involve ambulatory care patients, Ruoff said. Orthopedic procedures are most prevalent, with perforations/lacerations as the top injury category.

Ranum said The Doctors Company report had very similar findings to the CRICO report.

Ambulatory or day surgery cases comprised 54% of the cases, with hospital operating room cases at 46%.

“When we repeat studies a few years down the line, we’re seeing fewer cases, but repeat issues,” said Ranum.

Looking at diagnosis-related cases, the majority (30%) were led by missed/delayed cancer diagnoses, including breast, lung, colorectal, uterine and ovarian, and skin cancers, noted Ruoff.

Of a total of 55,377 closed claims in the CRICO claims database, 21% were diagnostic-error claims, said Greve. The median patient age was 49 and 51.7% of patients were female.

“It’s a pervasive and persistent problem,” he added.

The “big three” disease categories of claims were cancers (37.,8%), vascular events (22.8%), and infections (13.5%). They accounted for 61.7% of all diagnostic error claims. A majority of errors (71%) occurred in the ambulatory care setting.

Ruoff said cases with clinical judgment factors are most prevalent and they increase the odds of high-severity injury and high payment. Clinical judgment is the key component of missteps during assessment, testing, and follow up, she noted.

“The diagnosis of complications that occurred in surgery that were not recognized during surgery is a huge component,” said Ranum.

Using the data

Organizations must use this data to effect change, Ruoff said. “There’s safety in numbers,” she added. “Use numbers like this to collaborate and form patient safety strategies.”

Patient feedback is valuable, Ruoff said. Complaints can be indicators of faulty systems, provider-related behavior, and issues of provider well-being.

Greve recommended creating a list of resources: Insurance company materials, CRICO Strategies website (for algorithms, case studies, practice assessment and education resources), and specialty society websites.

Review information available to you, he said. While you don’t need to do quantitative analysis, you can  look for evidence that should prompt further investigation. Then seek comparative perspective (via your patient safety organization and national medical professional liability claims data) for context and collaboration, Greve noted.

“Your data doesn’t have to be perfect,” he said.

CMS offers training on new electronic form for restraint-related deaths

By: January 17th, 2020 Email This Post Print This Post

By A.J. Plunkett (aplunkett@decisionhealth.com)

As of January 1, CMS eliminated the paper version of the form to report patient deaths associated with restraint or seclusion. Form CMS-10455 must be filed through an electronic version.

CMS announced the new electronic form and provided instructions on how to use it, including a video, in an Quality, Safety & Oversight Group memo, on December 2, 2019. Memo #QSO-20-04-Hospital-CAH DPU, “Electronic Form CMS-10455, Report of a Hospital Death Associated with Restraint or Seclusion,” can be found online here: https://www.cms.gov/electronic-form-cms-10455-report-hospital-death-associated-restraint-or-seclusion-0

In a newsletter to clients, Patton Healthcare Consulting noted that the requirements on which deaths to report remain the same. Only the method of reporting has changed.

“The QSO memo also details the specific fields of information which must be submitted, but this becomes somewhat easy in that you are filling in the blanks on the form,” says Patton Healthcare. “CMS also describes what the regional office will do with the information submitted including evaluating it for a potential survey and sharing of information with the accrediting bodies. Since this new process is effective immediately you will want to review the QSO memo and slide deck and make sure that the individual responsible at your hospital for reporting such deaths has the information.”

The memo also includes a link to the video for surveyors on how the deaths are to be reported. That can be viewed at: https://surveyortraining.cms.hhs.gov/pubs/ClassInformation.aspx?cid=0CMSRHDRS_ONL

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