These are a few of my favorite things: Safety Risk Assessments!

A somewhat mixed bag of news items for you this week: a cornucopia of compelling content, if you will…

The Center for Health Design has published a pretty cool safety risk assessment tool that is available free on its website, although you do have to register (also free). The web page offers an introductory video describing the risk assessment, so you can check it out before you register.

In other news, Maine became the first state to ban flame retardants in upholstered furniture. As I travel the highways and byways of these United States, I see a fair amount of holiday decorations that have been treated with flame retardant sprays of various manufacture as folks try to provide a cheery environment for patients and not run afoul of the safety Grinches (and I use that term with all due respect and affection, having been a Grinch myself once or twice in the past). I don’t know if we’ll be able to say “as Maine goes, so goes the nation,” but this might have some interesting impact on the field-treating of combustible decorations.

As our final note this week, data from the U.S. Nurses’ Health Study II suggests that there is an increased risk of Chronic Obstructive Pulmonary Disease (COPD) among nurses with frequent exposure (at least once a week) to disinfectants in certain tasks (cleaning of surfaces, etc.): https://www.ersnet.org/the-society/news/nurses-regular-use-of-disinfectants-is-associated-with-developing-copd . The study indicates some of the “culprits” as glutaraldehyde, bleach, hydrogen peroxide, alcohol, and quaternary ammonium compounds. The article on the link also indicates that a recent European study of folks working as cleaners also showed an increased risk for COPD (somehow, not a surprising revelation to me). I think the bottom line on this (and perhaps our charge moving forward) is (and the article doesn’t really mention this) ensuring that folks are using appropriate PPE when they are using those types (or any type) of disinfectant products. PPE is always a tough thing to “sell” to folks, and while I think folks do understand that there are risks involved (just as there are risks associated with all sorts of behaviors—smoking springs to mind), there does seem to be a reluctance to take proper precautions every time one engages in these types of activities. I know this stuff isn’t particularly “sexy” when it comes to the topics of the day, but reinforcing basic protective measures can’t be a completely lost cause, can it?

Lazy days of autumn: CMS does emergency management (cue applause)!

I suppose you could accuse me of being a little lazy in this week’s offering, but I really want you to focus closely on what the CMS surveyors are instructed to ask for in the Emergency Management Interpretive Guidelines (more on those here; seems like forever ago), so I’ve done a bit of a regulatory reduction by pulling out the non-hospital elements (I still think they could have done a better job with sorting this out for the individual programs) and then pulling out the Survey Procedures piece—that’s really where the rubber meets the road in terms of how this is going to be surveyed, at least at the front end of the survey process.

I suspect (and we only have all of recorded history to fall back on for this) that as surveyors become more comfortable with the process, they may go a little off-topic from time to time (surprise, surprise, surprise!), but I think this is useful from a starting point. As I have maintained right along, I really believe that you folks have your arms around this, even to the point of shifting interpretations. This is the stuff that they’ve been instructed to ask for, so I think this is the stuff that you should verify is in place (and, really, I think you’ll find you’re in very good shape). There’s a fair amount of ground to cover, so I will leave you to it—until next week!

BTW, I purposely didn’t identify which of the specific pieces of the Final Rule apply to each set of Survey Procedures. If there is a hue and cry, I will be happy to do so (or you can make your own—it might be worth it to tie these across to the requirements), but I think these are the pieces to worry about, without the language of bureaucracy making a mess of things. Just sayin’…

Survey Procedures

• Interview the facility leadership and ask him/her/them to describe the facility’s emergency preparedness program.
• Ask to see the facility’s written policy and documentation on the emergency preparedness program.
• For hospitals and critical access hospitals (CAH) only: Verify the hospital’s or CAH’s program was developed based on an all-hazards approach by asking their leadership to describe how the facility used an all-hazards approach when developing its program.

Survey Procedures

• Verify the facility has an emergency preparedness plan by asking to see a copy of the plan.
• Ask facility leadership to identify the hazards (e.g., natural, man-made, facility, geographic, etc.) that were identified in the facility’s risk assessment and how the risk assessment was conducted.
• Review the plan to verify it contains all of the required elements.
• Verify that the plan is reviewed and updated annually by looking for documentation of the date of the review and updates that were made to the plan based on the review.

Survey Procedures

• Ask to see the written documentation of the facility’s risk assessments and associated strategies.
• Interview the facility leadership and ask which hazards (e.g., natural, man-made, facility, geographic) were included in the facility’s risk assessment, why they were included and how the risk assessment was conducted.
• Verify the risk assessment is based on an all-hazards approach specific to the geographic location of the facility and encompasses potential hazards.

Survey Procedures

Interview leadership and ask them to describe the following:

• The facility’s patient populations that would be at risk during an emergency event
• Strategies the facility (except for an ASC, hospice, PACE organization, HHA, CORF, CMHC, RHC, FQHC and end stage renal disease (ESRD) facility) has put in place to address the needs of at-risk or vulnerable patient populations
• Services the facility would be able to provide during an emergency
• How the facility plans to continue operations during an emergency
• Delegations of authority and succession plans

Verify that all of the above are included in the written emergency plan.

Survey Procedures

Interview facility leadership and ask them to describe their process for ensuring cooperation and collaboration with local, tribal, regional, state, and federal emergency preparedness officials’ efforts to ensure an integrated response during a disaster or emergency situation.

• Ask for documentation of the facility’s efforts to contact such officials and, when applicable, its participation in collaborative and cooperative planning efforts.
• For ESRD facilities, ask to see documentation that the ESRD facility contacted the local public health and emergency management agency public official at least annually to confirm that the agency is aware of the ESRD facility’s needs in the event of an emergency and know how to contact the agencies in the event of an emergency.

Survey Procedures

Review the written policies and procedures which address the facility’s emergency plan and verify the following:

• Policies and procedures were developed based on the facility- and community-based risk assessment and communication plan, utilizing an all-hazards approach.
• Ask to see documentation that verifies the policies and procedures have been reviewed and updated on an annual basis.

Survey Procedures

• Verify the emergency plan includes policies and procedures for the provision of subsistence needs including, but not limited to, food, water and pharmaceutical supplies for patients and staff by reviewing the plan.
• Verify the emergency plan includes policies and procedures to ensure adequate alternate energy sources necessary to maintain:

o Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions;

o Emergency lighting; and,

o Fire detection, extinguishing, and alarm systems.

• Verify the emergency plan includes policies and procedures to provide for sewage and waste disposal.

Survey Procedures

• Ask staff to describe and/or demonstrate the tracking system used to document locations of patients and staff.
• Verify that the tracking system is documented as part of the facilities’ emergency plan policies and procedures.

Survey Procedures

• Review the emergency plan to verify it includes policies and procedures for safe evacuation from the facility and that it includes all of the required elements.
• When surveying an RHC or FQHC, verify that exit signs are placed in the appropriate locations to facilitate a safe evacuation.

Survey Procedures

• Verify the emergency plan includes policies and procedures for how it will provide a means to shelter in place for patients, staff and volunteers who remain in a facility.
• Review the policies and procedures for sheltering in place and evaluate if they aligned with the facility’s emergency plan and risk assessment.

Survey Procedures

• Ask to see a copy of the policies and procedures that documents the medical record documentation system the facility has developed to preserves patient (or potential and actual donor for OPOs) information, protects confidentiality of patient (or potential and actual donor for OPOs) information, and secures and maintains availability of records.

Survey Procedures

• Verify the facility has included policies and procedures for the use of volunteers and other staffing strategies in its emergency plan.

Survey Procedures

• Ask to see copies of the arrangements and/or any agreements the facility has with other facilities to receive patients in the event the facility is not able to care for them during an emergency.
• Ask facility leadership to explain the arrangements in place for transportation in the event of an evacuation.

Survey Procedures

• Verify the facility has included policies and procedures in its emergency plan describing the facility’s role in providing care and treatment (except for RNHCI, for care only) at alternate care sites under an 1135 waiver.

Survey Procedures

• Verify that the facility has a written communication plan by asking to see the plan.
• Ask to see evidence that the plan has been reviewed (and updated as necessary) on an annual basis.

Survey Procedures

• Verify that all required contacts are included in the communication plan by asking to see a list of the contacts with their contact information.
• Verify that all contact information has been reviewed and updated at least annually by asking to see evidence of the annual review.

Survey Procedures

• Verify that all required contacts are included in the communication plan by asking to see a list of the contacts with their contact information.
• Verify that all contact information has been reviewed and updated at least annually by asking to see evidence of the annual review.

Survey Procedures

• Verify the communication plan includes primary and alternate means for communicating with facility staff, federal, state, tribal, regional and local emergency management agencies by reviewing the communication plan.
• Ask to see the communications equipment or communication systems listed in the plan.

Survey Procedures

• Verify the communication plan includes a method for sharing information and medical (or for RNHCIs only, care) documentation for patients under the facility’s care, as necessary, with other health (or care for RNHCIs) providers to maintain the continuity of care by reviewing the communication plan.

o For RNCHIs, verify that the method for sharing patient information is based on a requirement for the written election statement made by the patient or his or her legal representative.

• Verify the facility has developed policies and procedures that address the means the facility will use to release patient information to include the general condition and location of patients, by reviewing the communication plan

Survey Procedures

• Verify the communication plan includes a means of providing information about the facility’s needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee by reviewing the communication plan.
• For hospitals, CAHs, RNHCIs, inpatient hospices, PRTFs, LTC facilities, and ICF/IIDs, also verify if the communication plan includes a means of providing information about their occupancy.

Survey Procedures

• Verify that the facility has a written training and testing (and for ESRD facilities, a patient orientation) program that meets the requirements of the regulation.
• Verify the program has been reviewed and updated on, at least, an annual basis by asking for documentation of the annual review as well as any updates made.
• Verify that ICF/IID emergency plans also meet the requirements for evacuation drills and training at §483.470(i).

Survey Procedures

• Ask for copies of the facility’s initial emergency preparedness training and annual emergency preparedness training offerings.
• Interview various staff and ask questions regarding the facility’s initial and annual training course, to verify staff knowledge of emergency procedures.
• Review a sample of staff training files to verify staff have received initial and annual emergency preparedness training.

Survey Procedures

• Ask to see documentation of the annual tabletop and full scale exercises (which may include, but is not limited to, the exercise plan, the AAR, and any additional documentation used by the facility to support the exercise.
• Ask to see the documentation of the facility’s efforts to identify a full-scale community based exercise if they did not participate in one (i.e., date and personnel and agencies contacted and the reasons for the inability to participate in a community based exercise).
• Request documentation of the facility’s analysis and response and how the facility updated its emergency program based on this analysis.

Survey Procedures

• Verify that the hospital, CAH, and LTC facility has the required emergency and standby power systems to meet the requirements of the facility’s emergency plan and corresponding policies and procedures
• Review the emergency plan for “shelter in place” and evacuation plans. Based on those plans, does the facility have emergency power systems or plans in place to maintain safe operations while sheltering in place?
• For hospitals, CAHs, and LTC facilities which are under construction or have existing buildings being renovated, verify the facility has a written plan to relocate the EPSS by the time construction is completed

For hospitals, CAHs, and LTC facilities with generators:

• For new construction that takes place between November 15, 2016 and is completed by November 15, 2017, verify the generator is located and installed in accordance with NFPA 110 and NFPA 99 when a new structure is built or when an existing structure or building is renovated.  The applicability of both NFPA 110 and NFPA 99 addresses only new, altered, renovated or modified generator locations.
• Verify that the hospitals, CAHs and LTC facilities with an onsite fuel source maintains it in accordance with NFPA 110 for their generator, and have a plan for how to keep the generator operational during an emergency, unless they plan to evacuate.

Survey Procedures

• Verify whether or not the facility has opted to be part of its healthcare system’s unified and integrated emergency preparedness program. Verify that they are by asking to see documentation of its inclusion in the program.
• Ask to see documentation that verifies the facility within the system was actively involved in the development of the unified emergency preparedness program.
• Ask to see documentation that verifies the facility was actively involved in the annual reviews of the program requirements and any program updates.
• Ask to see a copy of the entire integrated and unified emergency preparedness program and all required components (emergency plan, policies and procedures, communication plan, training and testing program).
• Ask facility leadership to describe how the unified and integrated emergency preparedness program is updated based on changes within the healthcare system such as when facilities enter or leave the system.

To close out this week’s bloggy goodness, Diagnostic Imaging just published a piece on emergency preparedness for radiology departments that I think is worth checking out: http://www.diagnosticimaging.com/practice-management/emergency-preparedness-radiology . Imaging services are such a critical element of care giving (not to mention one of the largest financial investment areas of any healthcare organization) that a little extra attention on keeping things running when the world is falling (literally or figuratively) down around your ears. I think we can make the case that integration of all hospital services is likely to be a key element of preparedness evaluation in the future—this is definitely worthy of your consideration.

Fall On Me: Keeping Emergency Management Changes in Perspective

As I was ruminating on a topic for this week’s conversation, the October issue of Perspectives came zipping over the electronic transom, and I think there is just enough stuff here to cobble together a relatively cogent offering to you all out there in the blogosphere (that’s right—after 10+ years, I’m working on cogency—who’d a thunk…)

First up is the announcement of proposed changes to the Emergency Management chapter (I say proposed, because the indication is that these changes still require approval by CMS) with an intended survey implementation date of November 15, 2017 (when the Emergency Management final rule takes full effect). From my experiences with folks, I still don’t think they’re barking up a tree for which we cannot (collectively) provide a reasonable response, but if you’re interested in what they think they need to change in the standards, the list of additions includes consideration of:

• Continuity of operations and succession plans
• Documentation of collaboration with local, tribal, regional, state, and federal EM officials
• Contact information on volunteers and tribal groups
• Documented annual training of all new/existing staff, contractors, and volunteers
• Integrated health care systems
• Transplant hospitals

Again, I don’t see anything that strikes me as being particularly daunting, though there’s still a fair amount of angst relative to these changes (as is the case with anything that changes). I know there’s been some consternation relative to managing Memorandums of Understanding (or Memoranda, if that be your preference) and Alternate Care Sites, but I think the important thing to keep in mind is that the journey to the Final Rule started back when the 2008 TJC standards were in full bloom. And I suspect that those of you who have been doing this for a while recall those heady days of focus on MOU’s, ASC’S, COOP’s and the like, concepts that have really kind of faded into the operational ether as the efficacy of those approaches has yielded wildly inconsistent levels of preparation. For some folks, MOU’s, ASC’s and COOP’s are essential, but I’ve also seen evidence that when the feces is striking the rapidly rotating blades, it is often the group that shows up first with the closest thing to cash that has access to resources. When you think about it, things like MOU’s are only an agreement to do the best one can under the circumstances—that’s why the interface with local and regional EM authorities is so very important. At any rate, next we’ll chat a bit about what the CMS survey instructions involve and why I think you folks are going to be in pretty good shape. I am curious as to whether or not there is an intent to modify the emergency response exercise requirements to more closely mirror the Final Rule—I guess all in the fullness of time.

Moving on to other Perspectives topics, it would seem that last month’s Clarifications and Expectations column was indeed the last official communication under George Mills’ direction. The column is on hiatus for the moment—I guess we’ll have to wait and see whether November brings it back (though oy could certainly make the case that EC-EM-LS topics are taking up a fair amount of space in the monthly Perspectives, Clarifications and Expectations columns notwithstanding).

There is a new Sentinel Event Alert (#58!) regarding issues relating to inadequate hand-off communications; the reason I mention it here is that, while the focus in Perspectives is very much on the clinical side of things, I think there is more than a little crossover into the safety / physical environment realm. I’m just planting the seed here, but I suspect that I will have more thoughts on this in the coming little while.

Finally (for this week), there is a piece on Workplace Violence as a function of screening for early detection of risk to harm self or others. I suspect that this may be a harbinger of next steps as it relates to how organizations are managing at-risk patients, particularly as a function of the current focus on ligature risks. In recognition that all the risks that are not medically/clinically necessary have removed, if you don’t have a pretty robust screening process in place, it makes it very challenging to manage the risks that remain. At any rate, I’d keep an eye on this one—much as they’ve been peeling the Infection Control “onion” over the past couple of years, I think this is how they’re going to expand focus in the behavioral health realm.

But, as a subset of that, I did want to muse a bit on those instances when entities that were thought of as “friendly” turn out (under certain circumstances) to be not so much. I suspect that most of you saw the news item back in July regarding the nurse working in the ED of a hospital in Salt Lake City, UT, who was forcibly arrested by local police for not acquiescing to a request that was not allowed by organization policy (if you missed it, you can see some of the story here or here.) I mention this only to point out that the management of this stuff is not always simple (OK, it pretty much never is simple), but this does offer up yet another facet to how facilities safety and security professionals have to proactively advocate for staff (and patient) safety. Some of the images of the arrest are most harrowing and definitely beg the question of how this came to pass in this day and age (or maybe it’s not as questionable an outcome as perhaps it might once have been). At any rate, it’s always important to periodically review what I refer to as the “rules of engagement,” particularly when it comes to interacting with law enforcement folks. If our folks can’t be protected from our “friends,” then what shot do we have against an unknown/unknowable “foe.”

Healthcare Leadership Culture Moving Forward: What I (probably) didn’t do during my summer vacation

As a frequent traveler, I tend to read a fair amount in transit (my preferred operating system for reading is the traditional “hard copy”, aka “books” most often from the coffers of the public library), and in doing so, I try to mix in fiction and non-fiction titles. Also, as a function of traveling, I hear about a lot of stuff on the radio (usually the local NPR station—there’s almost one of those everywhere I go), which is not quite as mesmerizing as chasing videos on YouTube, but I’ve found that there’s a whole world of stuff out there, some of which I only learn about because I’m in the right place at the right time. To that end, I have a few suggestions to share with you that (hopefully) will remove some of the happenstance of discovering something you might not otherwise have encountered. So here I present to you, if you will, a fall reading list.

To ease into things, first up is an article from the September 2017 issue of Occupational Health & Safety entitled “The Right Amount of Leadership Done Easy” by Robert Pater. The opening premise asks the question of how many folks have adopted a strategy because it was easy, even though it was ineffective. I liken this to the “all purpose” response to deficiencies in the environment that focuses on more education of staff, when the response should really by aimed towards why the current education process is not as effective as it needs to be, based on results. My philosophy on this is that (unless you have a woefully inadequate education process) staff have received as much education as they need to. You may need to tweak subject matter over time as risks and conditions change. At any rate, I found the article to raise some interesting / thought-provoking concerns and I think definitely worth checking out.

I just finished reading “Shooting Ghosts: A U.S. Marine, a Combat Photographer, and Their Journey Back from War” by Thomas J Brennan USMC (Ret) and Finbarr O’Reilly. I’ve heard both of the authors interviewed recently (yes, on NPR) and found their account of recent events in various war/strife zones compelling enough to take on the book. Now, you may well ask, what does this have to do with healthcare? And I can tell you there is a lot to do with healthcare—from Mr. Brennan’s travails with the management of behavioral health patients (Mr. Brennan suffered a traumatic brain injury during a deployment in Afghanistan and has been dealing with the consequences of that event) in the VA and civilian systems to some insight to how healthcare can more effectively manage care and treatment of folks by learning more about the “patient experience” (definitely a buzzword in healthcare). At any rate, Mr. Brennan and Mr. O’Reilly’s stories are harrowing, both from an experiential standpoint, but also on (and this is my “take”) the uncertainty of the treatment process—even when practitioners act with certainty.

Next up, we have the Managing Millenials for Dummies Cheat Sheet; a little while back, we covered some the more operational aspects of the impact of millennials in our workplaces (and believe me, they’re not going away), from their view of the world to the more tribal aspects of their attire and personal presentation. I think those of us older (I’m more than half way to my next colonoscopy, so I can no longer consider myself among the young ‘uns) folks can say with some degree of accuracy that things have changed a bit over the last 10-15 minutes (OK, maybe even years, but sometimes it’s overwhelming to look that far back into the past) and I think you’ll find the Cheat Sheet both amusing and perhaps somewhat illuminating. It would be nice if all these generational “buckets” were more easy to profile, but it might beg some questions with/for folks you have working for you. Just sayin…

These last two titles I have not yet read (they’re in my pile), but heard mention of them on the radio (unfortunately, I cannot recall exactly which program might have been the one that planted the seeds of interest). The first, “Games People Play: The Basic Handbook of Transactional Analysis” by Dr. Eric Berne (originally published in 1964—thankfully I was born at that point) rang some bells with me, particularly an example of how certain individuals collect slights against them to be used in the future when they have slighted someone else. The example that sprang to mind was a department director to whom I had to speak about a recalcitrant employee (I think it was a parking issue), with the director responding that “well, a couple of months ago, we found a member of your staff asleep in an exam room,” with the intent that my sleeping staff person was far worse than whatever parking issue was at hand. Of course, I did ask as to why I hadn’t been notified at the time, but the response was somewhat vague and not particularly helpful. I guess it’s kind of like saving things for a “rainy day,” but I am a firm believer in taking care of things now if there is an issue. At any rate, I think it’s kind of interesting to see the various scenarios laid out in a scholarly fashion. I think you’ll find more than a little of the information to represent familiar interactions with folks.

The last title for our little book club is of a little more recent vintage; “Mistakes Were Made (but not by me)” would be interesting if only for the title alone, but the subtitle “Why We Justify Foolish Beliefs, Bad Decisions, and Hurtful Acts” is probably a little more timely than at any other time in recent history. That said, as we in healthcare move ever closer to the vision of just culture (and all the accompanying acts of finger-pointing along the way), I think this is worth a read.

If any of you folks out there check any of these out, please feel free to provide feedback as to whether or not I should stay away from book recommendations.

Stay Calm and Read A Good Book!

Survey Preparation—When do you start kicking the tires?

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

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

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

Keep calm and stock up on emergency supplies

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

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

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

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

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

In other news

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

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

Any world that I’m welcome to…

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

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

• September 6, 2016: “And to the surprise of absolutely no one…“
• August 31, 2015: “Same as it ever was… same as it ever was… same as it ever was…“
• September 11, 2014: “Make sure you go on (okay, over) the papers!“
• October 2, 2012: “We’re number 2! We’re number 2!“

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

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

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

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

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

Thoughts and prayers for Houston; plus, thoughts on required ‘policies’

First off, thoughts and prayers going out to the embattled folks in Texas; I do a fair amount of work in Texas, including the Houston area, and while I have absolute confidence in folks’ ability to respond to and recover from catastrophic events, I also know that this is going to be a very tough next little while for that part of the world. Hurricane Harvey will likely fade from the headlines, but the impact will linger past the news cycle, so don’t forget about these folks in the weeks to come. Thanks!

As I was casting about for a subject for this week’s missive, I happened upon a news item in Health Facilities Management This Week (HFMTW) that outlines some of the pending changes to the ambulatory care / office-based surgery medication management standards and the potential further impact of those changes on some of the EC performance elements in those environments. The changes are pretty much focused on emergency power as a function of being able to provide medication dispensing and refrigeration during emergencies.

Now, I have absolutely no issue with making provisions for the safe physical management of medications during power outages, etc.—it is a critical part of the delivery of safe and appropriate care to patients in any setting, and the more we can do to prepare for any outages, etc., the greater the likelihood of continuity of services if something does happen. What really caught my eye in the TJC blog entry cited in HFMTW (you can find the blog here) is something about half-way down the page titled “Emergency Back-Up Policies.”

At the outset of this discussion, I will tell you that, in most instances, I am no big fan of “policies.” In my mind, mostly what a policy represents is an opportunity to get into trouble for not following said policy. So, the question I wrestle with is whether we need to be mandated to have specific policies in order to appropriately manage our facilities, including preparing to respond to emergencies. For example, I am not entirely certain that a policy is going to make the difference in how well hospitals in the Houston area are responding to Hurricane Harvey (at the time of this writing, there are hospitals facing evacuation), though I would be happy to hear otherwise. I just have a hard time believing that having a policy is the answer to life’s problems; I am absolutely fine with requiring hospitals and other healthcare organizations to have a process in place to ensure appropriate management of medications during power outages, etc.—and I’m reasonably confident that those processes already exist in most, if not all, applicable environments.

I don’t know, maybe some folks do need to be told what to do, but I can’t help but think that those folks are fairly limited in number. And the blog even indicates that “there is no specific direction on the content of the policy”, but publishing this blog is going to force the issue during survey. I don’t know, when you look at the Conditions of Participation, etc., there are really very few policies that are required. It seems a bit odd to think that introducing new requirements for policy will somehow address some heretofore unresolved issue (or something). This one just doesn’t feel “right” to me…

I said you’ll pay for this mischief…

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

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

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

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

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

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

You are so beautiful, to me…

In the interest of a little summertime reading, I wanted to diverge a bit from the usual rant-a-minute coverage (rest assured, the ranting will continue next week—too much going on in the world) and cover a couple of “lighter” topics (though one does have to do with my favoritest topic—risk assessments).

First up, we have Soliant Healthcare’s list of the 20 most beautiful hospitals in the U.S. (as a music lover, I find that I am an absolute sucker for lists—go figure!); while I have not had the opportunity to do any work at the listed facilities (and have done some work at places I think measure up pretty well from a design perspective, etc.), I can say that the buildings represented on the list are pretty easy on the eye. I don’t know if anyone out there in the Mac’s Safety Space blogosphere works at any of the listed facilities, but congratulations to you if you do or did!

The other item for this week focuses on the pediatric environment; from my experiences, a lot of community hospitals have really scaled back their pediatric care facilities, mostly because demand is not quite what it used to be. Where there might once have been dedicated pediatric units, now there are a handful of rooms used for pediatric patients when they need in-hospital care, but not much in the way of dedicated spaces.

If you happen to be in a position in which your dedicated pedi spaces are not quite as dedicated as they once were, you might find it useful to perform a little risk assessment based on a toolkit provided by the University of California, San Francisco, and endorsed by a couple of professional groups. While the focus is more towards the home environment, I think it’s helpful to simply ask the questions and be able to rule out the concerns outlined in the toolkit. Any time you have to “run” with an environment that has to function for different patients, risk factors, etc., it never hurts to be able to pull a risk assessment out of your back pocket when a surveyor starts jumping ugly because they don’t agree with what they’re seeing or how you’re managing something.

The National Center for Missing & Exploited Children used to provide some risk assessment guidance for healthcare professionals, but in looking at their website, it appears to me that they are confining guidance to law enforcement, media, and families. (Some of the stuff for families is interesting and worth sharing in general.) Since they’re an at-risk patient population, you never know when your efforts to provide an appropriate environment for infants, children, and teens will come under survey scrutiny—and it never hurts to periodically review your efforts to ensure that your plan is current.