The fight between the blue you once knew…

By Steve MacArthur, Hospital Safety Consultant

In an interesting dichotomy that can only truly exist in bureaucracies of a certain magnitude (enormity?) we have the announcement of the newest iteration of the Standards Improvement Initiative (which first reared its head in 2009) in which our friends in Chicago announce that there’s going to be a comprehensive review of existing standards and performance elements with an eye towards focusing on redundancies and items that don’t necessarily bring a lot to the party (that’s my take – I can’t imagine anyone else using that as an official representation). Things that may exceed what is required by the CMS Conditions of Participation are also in the mix; you can get (pretty much) the whole story in the Modern Healthcare interview with TJC’s new CEO, Dr. Jonathan Perlin: . One note to prepare you, if you’re not already registered with Modern Healthcare, they’ll be looking for you to do so before allowing access to the interview. I think it’s worth doing. (For more on the future of TJC surveys, go here.)

And on the other and, we have the announcement of revisions to some of the standards chapters that we hold nearest and dearest:

I’m not going to steal all the thunder from the announcement, but I do have some thoughts to share – any changes tend to take a bit of time to manifest themselves in the marketplace, so I will reserve the right to take up more of your time in the future to re-think (recant?):

I think the biggest potential disrupt revolves around the requirement to represent the Interim Life Safety Measures assessment process in the ILSM policy (which would seem intuitive, but maybe not so much); we know they’ve been employing the ILSM process for LSC deficiencies that cannot be corrected before the end of the survey, so I suspect this update may be in response to surveyor feedback that a lot of folks don’t have a clearly delineated assessment process. Before, the policy was supposed to identify the criteria, and now it explicitly calls out the assessment process as a specific component. The ILSM  process used to be a big part of the survey process (to the point where it could be a show-stopper), so maybe it’s going to come back into play with a little more authority.

For those of you with patient care services in spaces that you don’t “control” (primarily leased spaces), I can see where managing recalcitrant landlords when it comes to producing documentation (primarily fire alarm and sprinkler system testing activities) might represent an opportunity for gaps – now there’ll be a specific place to cite that (one more line item for the matrix).

If you count your operating room fire drills towards the quarterly fire drill numbers, you should be prepared to demonstrate that it was truly an unannounced; I think if I still had to manage fire drills, I would “count” those fire drills in special environments (OR, MRI, hyperbaric oxygen) as additional drills and not use them as stand-ins for the regular drill schedule. I think these special environments are best served by focused, scheduled events that are purely educational in nature (but that might just be me).

I’ve had any number of discussions over the years regarding the use of expanding foam as a means of sealing gaps and such (and yes, I’ve seen the stuff that purports to be used as firestopping material, but I somehow don’t think that I would hang my hat on that as a strategy during survey), particularly in business occupancies and I think the changes to 5-1-10 are going to be problematic if you can’t verify clearly that the material is not in a fire-rated barrier (can you say “life safety drawings”? Sure you can…) I think you have to employ a find it, fix it strategy for the expanding foam – it will eliminate so many potentials for discussion – and angst.

Let’s see, legible ratings labels on doors in business occupancies – that should be a lot of fun; as an aside, I am fascinated that there are already modifications to the business occupancy section of the LS chapter – more opportunity for mo’ findings…we shall see, my friends, we shall see.

About the Author: Steve MacArthur is a safety consultant with Chartis Clinical Quality Solutions (formerly known as The Greeley Company) in Danvers, Mass. 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 contributing editor for Healthcare Safety Leader. Contact Steve at