2015 SSR, Inc. All rights reserved Constant ... - AHCA Seminar 2015 PDF For Flash...

2015 AHCA Conference: Maintaining

Constant Survey Readiness: Copyright (c)

2015 SSR, Inc. All rights reserved

See Content Disclaimer. David Stymiest,

PE CHFM CHSP FASHE. cell 504.232.1113.

[email protected] 1

AHCA 2015 Fall Conference

Maintaining Constant

Survey Readiness

David Stymiest, P.E., CHFM, CHSP, [email protected], cell 504.232.1113Copyright © 2014, Smith Seckman Reid, Inc.; All rights reserved

Content Disclaimer

• These slides are only meant to be cue

points, which were expounded upon

verbally by the original presenter and are

not meant to be comprehensive

statements of requirements or best

practices, nor represent all the content of

the presentation. Thus, care should be

exercised in interpreting content based

solely on the content of these slides.

Major topics

• How to be survey-ready in times of change

• Why continuous survey readiness is crucial

• Dealing with most troublesome requirements

• Spotting the low-hanging fruit every time

• Pre-survey SWAT vs. daily compliance

• Making your documentation “survey-friendly”

• Conducting and following up EC tracers

• TJC for examples, but issues are generic






[email protected] 2

Most challenging EC/LS requirements

Most challenging requirements

• 56%↑↑↑ EC.02.06.01 (Up from 51%, 39%)

The hospital establishes and maintains a safe,

functional environment. (6 EPs)

– Mostly EP1 Meets patient needs, Safe, Suitable

• Misc. & electrical hazards, unsecured oxygen cylinders,

ligature risks

– EP13 Suitable Ventilation, Temperature, Humidity

• Doors/air pressure, temp., RH>60% - mold growth possible

– EP20 Odors


• 53%↑ EC.02.05.01 (53%, Up from 47%)

The hospital manages risks associated with its utility systems.(16 EPs)– Mostly EP15 – Managing Airborne Contaminants

(pressure relationships, ACH, filter eff.)• CMS Cond. LD, may be reduced to Std. LD under certain

conditions

• May be related to IC.02.02.01 at 50%↑ (Up from 46%)

• High Level Disinfection: Glutaraldehyde: PPE, ventilation, storage

– Also EP2-EP7 – Utilities inventories, ITM activities, ITM intervals [RH monitoring]

– Also EP9-EP13 – Failure procedures






[email protected] 3


• 50%↓ LS.02.01.20 (Down from 52%)

The hospital maintains the integrity of the

means of egress. (32 EPs)

– Mostly EP13 – Corridor Clutter

• Storage if more than 30 minutes

• In use: Crash, Isolation and Chemo Carts

• Risks: patient, staff movement; code team, etc..

– Also suites issues and locked doors in means

of egress


• 48%↓ EC.02.03.05 (Down from 50%, 45%)

The hospital maintains fire safety equipment and

fire safety building features. (21 EPs)

– All EPs (fire safety testing) are problematic. [EC News]

– Inventory requirements are now clearer & tougher

– Lack of inventory = RFI for that EP

– Missing testing records = RFI on that EP

+ RFI on EP25 (records not readily available to AHJ)

– If ≥3: RFI on LD.04.01.05 EP4, holding staff

accountable

EC.02.03.05: Inventories

• Every device required to be tested must be in an inventory – If 300 devices were tested last year,

and 297 were tested this year, which 3 devices were missed?

– Having only the total number of devices (quantity) will get you one or more RFIs.

• Lack of an inventory (written, electronic or other means) results in RFIs






[email protected] 4

Keeping your inventory current

• Fire extinguishers: CMMS or simple spreadsheet

• 12 month rolling window; Record each month:

– Starting total on 1st day

– # added (+) or removed (-) for construction

– Ending total on last day

• Also could list

– Failed, needed recharge – replaced

– Replaced during NFPA 10 multi-year service interval

There are many ways to manage


• 46%↓ LS.02.01.10 (Down from 46%, 48%)

Building and fire protection features are

designed and maintained to minimize the

effects of fire, smoke, and heat. (10 EPs)

– Still mostly EP5-7 – Doors

– Ongoing issues: EP9 Fire barrier penetrations

– Free barrier management symposium events

• TJC, FCIA, UL; ASHE, AWCI,

GI, NCMA, Damper/Glazing






[email protected] 5


• 43%↓ LS.02.01.30 (Down from 46%, 45%)

The hospital provides and maintains building

features to protect individuals from the hazards

of fire and smoke. (25 EPs)

– Mostly EP2 hazardous areas door issues

– Also EP16-EP23 smoke barriers; smoke doors


• 44%↑ LS.02.01.35 (Varies, from 44%, 36%)

Sprinkler system– EP4 stuff on sprinkler piping

– EP5 sprinkler heads (corrosion, paint, other materials)

– EP14 all other sprinkler requirements: (i.e. escutcheons, ceiling tiles, blocked FE, NFPA 13 signage, wrong sprinkler head types mixed)

– EP6: I still see sprinkler 18” rule violations


• 36%↔ EC.02.02.01 (From 36%, 34%)

The hospital manages risks related

to hazardous materials and waste

– 13 EPs

– Mostly EP3-EP5 PPE, process issues,

eyewashes & safety showers

– Also EP6 & EP7, hot lab escorts and

lead aprons






[email protected] 6


• 27%↔ EC.02.05.09 (From 27%, 21%)

• The hospital inspects, tests, and maintains medical gas and vacuum systems.

– Only 3 EPs

– Mostly EP3: zone valve obstructions & NFPA 99 zone valve labeling issues

• NOT UNDER EC.02.05.09:

– Cylinder ft3,qty. storage (fire risk): EC.02.03.01 EP1

– Unsafe cylinders, transfilling O2 EC.02.06.01 EP1


• 21% ↔ EC.02.05.07 (From 21%, 23%)

The hospital inspects, tests, and maintains

emergency power systems.

– Mostly EP6: Missed monthly test of ATS

– EP4-EP7: (EP7: Missed triennial 4-hour test)

– Generator & ATS tests: monthly vs. 20-40 days

• NFPA 110 and TJC: monthly

• NFPA 99 states 20-40 days

• http://www.ssr-inc.com/pressroom/compliance-news-tjc-

modifies-emergency-power-test-intervals-2014/

What about the AEM Program challenges

• Utility Management Plans

• New AEM policy/procedure

• HR records, contractor records

• Determine where mfr-recommended

I/T/M is mandated by new rules

• Maybe split I / T / M – different regs?

• Determine critical / high-risk

• Operating components

• Obtain mfr recommendations for all

• More analyses

• Risk assessments to use AEM

• Justify I/T/M choices

• Justify what you do now or change

• Sources for decisions

• Use of test equipment

• What is a major repair/upgrade?

• Inventory: more records?

• Inventory: equipment definitions

• Inventory: CMS level of detail

• Inventory includes PM records

• Inventory: new reqd categories– Critical (high-risk) equip

– Equipment with AEM

• Monitoring effectiveness

• Utility failure procedures, reports

• Track/analyze failures

• Incident reports

• EOC Committee reports

• Annual reports: AEM effective?

• Training, training, more training

• Internal/external tracers

• Be alert (more clarifications?)






[email protected] 7

Unannounced surveys and inspections

• CMS: Centers for Medicare & Medicaid Services

• TJC: The Joint Commission

• DNV: DNV GL Healthcare, Inc.

• HFAP: Healthcare Facilities Accreditation Program

• CIHQ: Center for Improvement in Healthcare Quality

• AAAHC: Accreditation Association for Ambulatory Health Care

• AAAASF: American Association for Accreditation of Ambulatory Surgery Facilities

• State health departments, federal agencies, etc.

>>> Random Unannounced Surveys

>>> For-Cause Surveys

>>> TJC also has extra surveys for late PFIs

Typical EOC Findings

• Not doing the ILSM Assessment for random LS Deficiencies that occur

• Failure to Implement ILSMs Consistently

• LSC Building Maintenance Issues

• Not Complying with Requirements

• Not Complying w/ Your Own PPPs

• Not Documenting Your Compliance Efforts

Other challenges

• Meeting all applicable NFPA requirements

• Basic utility failure procedures vs. best practices

– i.e. – not addressing vulnerabilities

• New inventory requirements

• New AEM requirements

• Small ongoing changes

• Get ready for new codes & standards






[email protected] 8

“Current Life Safety Drawings” = Accurate

LS.01.01.01 EP-2 A (D) [DIR]

• A legend that clearly identifies features of fire safety

• Areas of the building that are fully sprinklered (if the building is partially sprinklered)

• Locations of all hazardous storage areas

• Locations of all rated barriers

• Locations of all smoke barriers

• Suite boundaries, dimensions, exits of the identified suites—both sleeping and non-sleeping

• Locations of designated smoke compartments

• Locations of chutes and shafts

• Locations of approved equivalencies or waivers

- From TJC’s Feb 2012 EC News

• Also recommended by SSR– Occupancy type(s) & separations

– New vs. existing

– Required exits, including• Exit enclosures (stairs and horizontal)

• Horizontal exits

• Exits directly to the outside

Standard LS.01.02.01 (ILSM)

Protects occupants: LSC is not met or construction• Need a robust process with documentation

EP1. Notifies FD or other ERG: fire watch when FA or sprinkler system out of service >4 in 24 hrs

EP2. Posts signage: location of alternate exits

EP3. ILSM Policy: When LSC deficiencies cannot be immediately corrected or during construction. Criteria for evaluating when and to what extent. “Not performing the ILSM assessment may result in a

finding under standard LS.01.02.01, EP-3” - TJC October 2013

ILSM EPs 4-14 per ILSM Policy

EP4. Inspects exits on a daily basis…

EP5. Temporary but equivalent FA and detection…

EP6. Additional fire-fighting equipment…

EP7. Temporary construction partition reqmts…

EP8. Increases surveillance…

EP9. Enforces storage, housekeeping, debris-removal…

EP10. Provides additional training on fire-fighting equip…

EP11. One additional fire drill /shift /quarter…

EP12. Inspects and tests temporary systems monthly…

EP13. Conducts education to promote awareness…

EP14. Trains those who work in hospital to compensate…






[email protected] 9

Always Being Prepared for Survey

• Obtain most current accreditation manual

• Review assigned chapters

• Look at the changes

• Know the rules

• Ensure PPPs are in place

• Ensure PPPs pass the current reality check,

are implemented and enforced

• Provide adequate staff training

Plans, policies & procedures (PPPs)

• Look at what you do.

• Does it meet all of today’srequirements?

• If not, change it.

• If it does …,

• SAY what you DO.

• Then you will always DO what you SAY.

Survey-friendly filing and retrieval

• Standard & EP-based

• System-based

• Other methods

• Electronic filing systems

• Searchable PDFs

• Paper backup?






[email protected] 10

Risk assessments

• Safety, security, HazMat, ICRA, ILSM, AEM

• “High risk equipment” (CMS: Critical Equipment)

• Identify training issues

• When there is no clear answer

• Justify a need

• Avoid potentially adverse events

• Compare allowable alternatives

• Consider new or changed input from outside

Continuous Survey Readiness

• Always be prepared to prove quickly

that you do what you say you do via:

• Meeting Minutes (e.g. Safety or EOC

Committee, EM Committee, Infection

Control Committee, etc.)

• Documented Risk Assessments

• Records, Logs, Manifests

• Performance Indicators

Why continuous compliance?

• Maintain safe & functional environment

for quality patient care

• Doing the right things for the right reasons

• Effective way to get safe, high-quality care

• Last-minute ramp-ups to survey

are not always realistic and

often do not work as well as

you want.







Learning New Concepts

Teaching Others

Internalize by Repetition (Muscle Memory)

Discussion Groups

Demonstrations

Audio/Visual

Read

Hear

1 hour spent now … is a day saved before survey

Do all compliance

work just before

survey

Or put together a process that

has everyone doing it

regularly

Recipe for continuous compliance

• What is needed to substantiate compliance with

each requirement?

• Get documentation, electronic and/or hard copy

• Identify detailed activity steps, data, etc ... required

to become compliant with any element that is not

fully compliant

• Identify responsible party and completion date

• Identify barriers to compliance

• Develop and implement methods to educate staff

on compliance requirements

• Test staff comprehension







Continuous compliance

Processes

Organization

Presentation

Look at Details

Requirements

ID Deficiencies

Review

Validate

Prioritize

Resolve

Ongoing

Surveillance &

Corrective

Action

Continuous

Improvement

Solvable Bites

Benefits

• Organization of compliance information and presentation

• Looking at the finer details of compliance

• Testing being done per code

• Identify gaps in compliance

• Resolution recommendations

• Regular looks allow facility to digest findings and act on them in a timely manner.

Pre-Survey or Ongoing?

• Construction sites: workers smoking, blocked

exits, dust barriers, ILSMs being followed, etc.

– BUT … what about all the other times?

• Clinical units/areas: non-compliances,

outdated supplies, meds & their security, etc.

• Clinical support areas (pharmacy, dietetics):

medication or food storage compliance issues

• Above-ceiling issues / permit process

• Nonclinical staff: visual walk-through







• Wear your ID badge at all times above the waist

• Know your role in patient safety

• Know the fire and disaster procedures

on your unit.

• Be able to access Material Safety Data Sheets.

• Be familiar with & be able to find PPPs.

• Remove door wedges that hold doors open – fix

the problem, not the symptom

• Clear hallways

Daily compliance tips


• Exit light & stairwell checks

• Laundry & trash chute doors checked

• Fire/smoke doors checked

• Cylinder storage areas:

cleanliness, separation, quantities, secured.

• Check mechanical, generator,

electrical areas

• Check chemical storage areas

• Opening documentation reviewed


• Accreditation = standing agenda item

• Allocate regular funds for accreditation

• Tours, tracers, mock surveys

• Operations assessments include

accreditation

• Due diligence includes

accreditation

• Consider using fresh eyes








• Survey documents updated monthly

– For-Cause Surveys can occur any time.

• SWAT: Survey Walk-thru Assessment

Tactics

• Daily tours during all shifts

• EC dashboard

• Continuous feedback loop

• Barrier Management Program


• Regular educational clutter patrols

• Use WO program or other effective process for ITM reminders

• Check all new storage areas (i.e. old ptrooms) for hazardous location door hardware

• Know & follow manufacturers’ guidelines or AEM – follow the AEM rules

• Educate users about sprinkler head clearances

• Know the NFPA standards


• Units and departments are clean and tidy

• Only clean items in clean utility rooms

• No clean items in soiled utility rooms

• Med refrigerators clean & temps recorded

• Med carts are locked

• Food in patient nutrition refrigerators are

labeled

• Expiration dates are still current








• Doors to clean & soiled utility rooms closed

• Sharps disposal follows all rules

• Only approved materials under sinks

• No staff member food or drink in patient care

area or where specimens are located

• Clean linen follows all rules

• Follow up on LS deficiencies

Staff education is key

• Understand standards; accreditor’s rules

• Your own plans, P&P’s: regular reality check

• Assign accountability for evaluation

• Common survey citations (low-hanging fruit)

• Plans of action for noncompliance

• Evaluate and measure outcomes

• Ongoing education is key

• ASHE Managing Life Safety E-learning

• Focus visits: questions, questions, questions

Front line staff involvement

• PPPs = excellent care

• Daily staff contributions directly affect safe

EOC

• Examples: near misses, adverse or sentinel

events, anecdotes

– Make quality and safety practices real & personal

• Frame discussions:

– Have PPPs to ensure safe, high-quality care –do

right things for right reasons

• Systems/processes ensure safe care and

services







A readiness quiz

• Where are current policies?

• How can staff report incidents or near

misses?

• What steps do you take to respond to a fire?

• What emergency response number do I call?

• What is the best way to prevent the spread of

infection?

• What areas are security-sensitive? What do

they require?

• Good practices of compliance include…?

Regular communications (↓↔↑)

• Newsletter or hospital e-mail

• Understanding & applying standards &

requirements

• Current issues, confusing requirements,

revisions that affect patient safety

• Trends found during evaluations &

analysis, past survey findings, and

current quality/safety initiatives

• Compliance gaps identified by your own process

– Identified Risk Elements

• Recent survey findings, LS deficiencies

• Recent findings by other AHJs

• Findings by external consultants

• Occurrence reports, sentinel events, and near

misses with associated RCAs

• Assessments of mock tracers

• Latest revisions, additions, clarifications, FAQs

• Current list of top 10 or 20 problem areas

Regular evaluations







Follow-up on your own findings

• Treat as if issued by your accreditor

– TJC RFI

– DNV NIAHO non-conformity ruling

– HFAP, CIHQ, others, etc..

• Could even use their forms, deadlines,

follow-up the same way [muscle memory]

• Consider possibility of systemic issue

• Escalate as necessary to resolve

• Report to management

Make documentation “survey-friendly”

• Review documents against your accreditor’s requirements, K-Tags, etc.

– Plans, policies, procedures, forms

– Modify as necessary to get compliant

• Train those who create records

– What is required to satisfy surveyors?

– Never obliterate, tape over, or white-out info

– Pitfalls

• Review all records before accepting and filing

Why do some assessments fail?

• Limited staff resources

• Failure to assess practice in addition to P&Ps

– Actual surveys use tracer methodology

• Easy fixes not prioritized, # is too daunting

• “Friendly” scoring = false sense of security

• Insufficient education: disconnect between

standards/EPs and routine processes

• Inadequate drill-down (EC or PE tracer)







EC tracer for any risk

• Staff demonstrate responsibilities for minimizing risk,

what they are to do if a problem or incident occurs,

and how to report the problem or incident

• Assess / minimize risk (equipment, alarms, building

features)

• Review ITM procedures

• Assess the EM plan for the risk

• Assess utility failure procedures

• If others have a response role, demonstrate that

role; review equipment they use in responding

EC Tracers

• Focusing on 1 standard or EP

– Drill down to the lowest level

• Follow a path and ask questions

– Do not assume the path is being followed

– Ask intuitive questions to identify potential gaps

– Evaluate compliance by exploring all steps

– Evaluate as if you were an outsider

• Examples

– ILSM, Fire alarm system maintenance, BMP

– Emergency power testing & maintenance

Utility system tracers

• Dept. leader tracers– Qualifications (D); Inventory creation; AEM if used;

processes, effectiveness – criteria & completion rates

• Equipment maintainer tracers– Understanding of process, strategies, AEM,

assignments, competencies, repeat WOs, scheduled vs. completed

• Equipment user tracers– Reliability, failure response, emergency response,

user staff safety training, satisfaction

• Contract service tracers– Ensuring qualified personnel; equipment reliability;

process integration







ILSM & PcRA tracers

• Follow any LS deficiency or a project

• Review ILSM & PcRA policy for thoroughness

• Review records to verify total compliance with ILSM & PcRA policies

• Review in field to verify ILSMs, ICRAs, PcRAs were implemented at sites as stated and performed as required

• Interview construction personnel

• Re-trace later to ensure that required improvements were implemented

Continuous Life Safety Management

1. What and where? – Have accurate LS drawings

2. Manage resolution of LS deficiencies

3. Establish priorities based on risk

4. Educate: do the right things for the right reasons

5. Maintain, test, and inspect fire safety equipment

and fire safety building features

6. Manage design/construction to ensure proper LS

feature design, construction & installation

7. Inspect or monitor LS features that are subject to

change or damage

8. Ensure compliance with operational LS elements

Life Safety Code Inspections

• All LS code inspections that identify

deficiencies must be managed and corrected

– Fire marshal

– Insurance company

– CMS surveys and State agency surveys

– Vendor LS / FS system testing

– SOC / LSA inspection

– Internal findings, etc.

• All LS Code deficiencies “that cannot be

immediately corrected” require ILSM analysis.







Managing testing companies

• Frequency of fire safety equipment ITM

– Do not rely on vendor scheduling, be proactive

– Use your WO, CMMS or scheduling system

– Alerts at least a month or more ahead

– Manage multiple vendors for complete scope

• Review the documentation

– Must reflect what & when, by whom, results, etc.

– Documentation: complete & understandable

– Verify tests meet all reqmts. of NFPA, not just the

AO’s stipulated requirements

Manage design/construction

• Evaluate all C/R project impacts

– Ensure existing LS features not made deficient

– New LS features correctly designed/constructed

– Coordination with required pressure relationships

• Give design teams existing LS feature info

• Review drawings/specs for LS features

• Resolve questions / uncertainties about

barriers, horizontal exit passageways,

required exits, or other physical LS features

before construction

LS features subject to change / damage

• Monitor

– Scheduled rounds, ITM, hazard surveillance

• Choose your tools

• Be proactive, go beyond old BMP limitations

– Doors, penetrations

– Emergency lights, exit signs

– Obstructions in corridors & means of egress

– Storage issues







Dozens of specific opportunities to be individually cited

The old “carrot” (a scoring incentive)

Effective BMP-like approach

Safety transcends compliance. Avoid …

• All knowledge with just 1 or 2 individuals

• Just relying on testing/inspection companies

• Just relying on GC to do ILSM analyses

• Just looking for LS deficiencies every 3 yrs

• GC manages LS system shutdowns

• Ignoring the eSOC & PFIs until survey time

• Relying on just incidental discovery

& corrective action rather than

proactively managing LS

Decrease LS deficiencies

• Develop a rated barrier management plan

• Use LS drawings to train staff on barrier locations

• Train staff to protect penetrations

• Educate contractors regarding penetrations

• Establish permit system for above-the-ceiling work

• Educate staff

• Walkthroughs







Disseminate changes as they occur

• CMS S&C Letters

• CMS Categorical Waivers

• CMS notices of proposed changes

• State & local AHJ changes

• Clarifications from AOs

• Changes from Deeming Authority renewals & other AO changes (such as most of the 2014 TJC changes)

Summary

• Inspect what you

expect

• Fresh eyes see

things others miss

• It’s all about the

details

• Without data you

only have

opinions

Thank You!

David Stymiest, P.E., CHFM, CHSP, FASHE

(P.E. in LA, MS, MA)

Senior ConsultantSmith Seckman Reid, [email protected]

www.ssr-inc.com

504.232.1113

Compliance News archives and sign-up available at:

http://www.ssr-inc.com/pressroom/

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