And the rest, they say, is history: Accreditation 360 launches in the waters of past surveys

We have now reached the furthest end of our countdown. As I think about it, I probably should have done these in the reverse order, leaving the most frequently cited standards for the final installment, though I will freely admit that I’m extrapolating a bit on the ranking, based on the layout of the slides to which I have access. But I feel pretty comfortable, again, based on what I’ve seen and experienced, that these are less frequently cited (perhaps only by degree) than the vulnerabilities discussed in prior weeks. I guess that’s the thing about having a list of frequently cited anything—there’s always going to be some that are more frequently cited than others on that list. It was the issue I always had back in the day with the Press-Ganey reports—there’s always going to be a top 10 things to work on. It’s not like the list will start at 11 (unless it’s the top 10 Spinal Tap songs; that would have to go to 11). At any rate, as this is likely going to be the last time I have to think on this stuff, I suppose the order of things matters less than the acknowledgement of these as the vulnerabilities upon which the greatest amount of report space has been devoted over the last 12ish months. They are not going to come and find nothing, but if you get these covered, they’ll at least have to work harder to find stuff.

Non-Critical Pressure Relationship (E.2.5.1.16)

• Illumination of food and medication prep areas
• Ventilation in non-critical areas (clean/soiled utility rooms, etc.)
• Storage of food and medications in accordance with applicable regulation and manufacturer recommendations

This is one I’d be really keen to see the numbers; though, perhaps, with the growing number of LS surveyor days, this will become more of a focus. In looking at the third description (storage of food and medications, etc.)—I suspect that this standard might be related more to patient tracer activity than a concerted focus on the LS side. I suppose there’s always the potential for an exhaust fan to slip or break a belt, resulting in air pressure issues in a soiled or clean utility room. I’d be curious to see how illumination might have been identified during a survey. I know it’s part of the applicable (Physical Environment) Condition of Participation, so maybe in the aggregate it comes into play. Interesting that this is called out more than fire-rated doors or egress (the absence of egress in this list may be the one legitimate surprise; it used to be a perennial #1 hit).

Fire Rated Door Requirements (L.2.1.10.11)

• Failure of fire doors to latch or close properly
• Improper door conditions affecting fire rating
• Doors propped or wedged open

How many doors do you have? How many carts and other wheeled vehicles (don’t forget portable x-ray machines) are going through those doors? How many door edges does it take to push (or pull) a door out of alignment? How many different ways can a door be wedged open? How many door rating labels are painted over each day? Week? Month? Year? It’s kind of like a roulette wheel—there’s always got to be one number that comes up, it’s just a question of how many the surveyor(s) check(s). The requirement is for annual inspection, but use that data (and work order data) to identify those doors most likely to fail, put them on a list, and give that list to someone capable/competent when you hear the surveyors have arrived. If you manage the performance data correctly, you should be able to keep this down at the bottom of the list.

Sprinkler Maintenance (L.2.1.35.5)

• Missing or improperly installed escutcheon plates
• Accumulation of dust, dirt, or debris on sprinkler heads
• Corrosion, paint, or ice on sprinkler heads

How many sprinklers do you have? How many escutcheon plates are either tossed or put in someone’s pocket because they don’t know what it is? The first question is knowable, the second, much less so. If you have pendant sprinkler heads (as opposed to concealed heads), there is a statistical likelihood that there’s something on one of them. For those of you with pendant sprinkler heads, you really need to lean on your sprinkler inspection, testing & maintenance vendor(s) to identify problem sprinklers—an inspection of the heads is part of the annual inspection process. That doesn’t mean that you have to pay them to clean the heads when they find them (though that is certainly a strategy), but you do want them to tell you which ones need to be cleaned. Everything on this list is a deficiency relative to the applicable code(s), so your vendor should be helping you stay on top of this. Oh—and don’t forget any sprinklered outpatient locations—don’t think they won’t be looking.

Ceiling Membrane Integrity (L.2.1.34.9)

• Ceiling membrane penetrations and gaps
• Impact on fire suppression and smoke detection
• Immediate corrective actions and compliance requirements

How many ceiling tiles do you have? How many conduits do you have running through those ceiling tiles? How many ceiling tiles have holes in them from data drops? This is another one that requires constant vigilance. And please don’t “waste” firestopping if the ceiling isn’t part of a rated assembly. The repair must resist the passage of smoke and/or heat, but don’t make it any harder to fix than it needs to be. Identifying a standard practice and product for repair will serve you well.

Critical Pressure Relationship (E.2.5.1.15)

• Improper pressure relationships in critical areas
• Temperature and humidity non-compliance
• Lack of documentation and corrective action

I’m glad to see that this is less frequently cited (at least I think it is), as this is one of the highest risk findings if you get tagged for it during survey. While I don’t have hard numbers, I suspect that many, if not most, findings in this realm are corrected during the survey (and don’t forget to note that in your plan of correction). I suppose when you come right down to it, particularly with older facilities, air pressures are never a slam dunk in terms of performance, and all you need is a door or two in a space to be propped open and the air pressure dominoes start tumbling. The cadences for monitoring temperature, humidity, and air pressure are tricky to determine; my “catty” response is always: do it as frequently as you need to in order to ensure compliance. But that’s kind of the deal—every place is different, with different occupants, and different activities, which requires every approach to this to be customized to a fair degree. Certainly a building automation system for ventilation helps keep things on an even keel, but even more important is working with the folks in those oh-so-critical environments to ensure there is good communications of excursions, so any interventions can be documented and any risks can be assessed. A solid process is the foundation for success with this one.

Cylinder Handling Policy (E.2.5.9.12)

• Unsecured or improperly secured gas cylinders
• Improper labeling and segregation of cylinders
• Non-compliance with storage environment requirements

First off, please remember that there are (or seem to be) a fair number of clinical surveyors who survey to the notion that you cannot have 13 e-cylinders in a location, period. Which, of course, is not the case; there are restrictions on the circumstances in which you can exceed the magic 300 cubic feet of stored gas, so make sure that if you have areas (don’t forget outpatient) that are pushing the limit, the storage location, etc. is supported by the requirements of NFPA 99-2012. Beyond that, the only thing I can say is to use the data from rounding to determine where your cylinder management is at its most vulnerable and work to try and design your cylinder management policy to reflect actual practice. For instance, segregation of cylinders can be a tall order if there’s not a lot of space for separation; make sure your policy is flexible enough to support compliance in every environment. Yipping at folks because they don’t get it right generally doesn’t result in a sustainable approach. Instead, work with them to figure out how to get it right. It will be one less thing to have to worry about (and, honestly, you could make a similar case for most of the stuff we’ve covered these past few weeks).

Success during survey doesn’t reside in a committee or someone’s office—it resides at the point of care/point of service. Working together to ensure an appropriately compliant environment is the only thing that will give you sustainable results. Rounding is good to help identify vulnerabilities, but use that time to also help educate folks to the possibilities in their environment. Don’t look for anything—look at everything!

About the Author: Steve MacArthur is a safety consultant with The Chartis Group. He brings more than 30 years of healthcare management and consulting experience to his work with hospitals, physician offices, and ambulatory care facilities across the country. He is the author of HCPro's Hospital Safety Director's Handbook and is an advisory board member for Accreditation and Quality Compliance Center. Contact Steve at stevemacsafetyspace@gmail.com.