Patton Post – March 2021

March 2021

Inside This Issue

Just before finalizing this month’s newsletter we saw an email from Mark Pelletier, the Chief Operating Officer at Joint Commission, indicating that they would be resuming on site surveys again on March 15th. They will no longer be calling ahead of time to screen and verify that conditions on the ground match what they are seeing in data. So, if you are past due for survey and the test positivity data in your county looks good, you should anticipate that TJC will start to catch up and could be visiting your organization in the near future. In addition, we presume that after they do catch up that organizations due in 2021 will begin to be surveyed also.

Suicide Sentinel Events:

The March issue of Perspectives does have a summary of 2020 sentinel event statistics that are informative to understanding the highest priority risk issues. One that we noticed that is disappointing to see, there were still 81 suicide sentinel events reported this past year. Now that everyone has been using evidenced-based tools to screen for suicide risk, providing 1:1 supervision for the highest risk patients and eliminating ligature hazards in the behavioral health environment, we were hopeful that this number would go down.

The article does not identify the outcomes of these events to know if they resulted in death, permanent, severe, or temporary harm, but in theory, 1:1 supervision should have enabled intervention before harm occurred. We also don’t know how many of the reported suicide sentinel events might have been attributable to discharged inpatients who committed suicide within 72 hours of discharge. Nevertheless, it does point out the importance of the standards that were developed to try and prevent this sentinel event.

Supporting Health Care Workers:

Perspectives also reminds us that TJC posted Sentinel Event Alert #62 last month, discussing the pandemic and worker protections. While this alert is not tied to any specific sentinel injury, it does provide an important discussion on ways to help support health care workers during the pandemic. Knowing that at present TJC is temporarily starting surveys with a combined Leadership, Infection Prevention, and Emergency Management session, this Sentinel Event Alert provides useful points for consideration and discussion on how your organization coped with the pandemic emergency. TJC’s Alert identifies five key ways to support health care workers which include:

1. “Foster open and transparent communication to build trust, reduce fears, build morale, and sustain an effective workforce”
2. “Remove barriers to health care workers seeking mental health services and develop systems that support institutional, as well as individual resilience”
3. “Protect workers’ safety using NIOSH Hierarchy of Controls framework” (elimination of the hazard being the most effective and PPE being the least)
4. “Develop a flexible workforce, evaluate the work being performed, and determine if it can be performed remotely”
5. “Provide clinicians and others opportunities to collaborate, lead, and innovate”

The Sentinel Event Alert then discusses each of these issues in greater depth and provides links to useful content including the NIOSH Hierarchy of Controls. We believe that this publication could be useful to your planning for that opening conference, discussing how your organization coped, managed, and addressed the needs of the workforce during the pandemic. There are many important considerations described, many of which you may have already implemented or could implement that would be appropriate to discuss during this opening session. Remember the Sentinel Event Alerts are not mandatory requirements, but you always want to be in the position of being familiar with the content and able to discuss your thoughtful consideration of the recommendations.

For those of you that may not be familiar with the NIOSH Hierarchy of Controls, we have reproduced their graphic. This is also a useful tool when discussing other hazards such as hazardous medications in the workplace.

Eye Wash Station Compliance:

This month’s Consistent Interpretation column addresses a very frequently scored issue relative to management of hazardous chemicals and worker safety features such as eye wash stations. The standard under discussion is EC.02.02.01, EP 5. One interesting piece of guidance from TJC is that “strict compliance with ANSI eyewash standard Z358.1 is not required.” They additionally advise that weekly eyewash checks are not mandatory, but that the organizations risk assessment should determine a time frame.

This is particularly interesting as we have seen many organizations scored out of compliance for failure to adhere to that ANSI standard, even though TJC had an FAQ stating that a risk assessment could determine an alternative frequency. At the same time, we have seen very few organizations choose to develop an alternative frequency for eye wash checks. We do recall one that had risk assessed and decided upon a monthly inspection only to be scored noncompliant by TJC, but successfully clarified this finding after their survey. If you do decide to implement something other than weekly checks, we would encourage you to attach a copy of this Perspectives article to your risk assessment.

A second very clarifying statement in this article is that an eyewash is not required where you simply stored sealed containers of corrosive chemicals, but is required where workers use or mix these chemicals. This article also makes it clear that an eyewash station is not required for a product whose SDS says is an irritant, although we have also seen this scored on survey. The key determinant of what first aid measures must be immediately available is the Safety Data Sheet for the product, and remember staff may be tested to determine if they know how to access your SDS resource.

Dental Services Hazardous Chemicals:

Lastly, this same Consistent Interpretation column discusses a topic of importance to organizations with dental services. It is unrelated to eye wash stations, but still covered by this somewhat generic element of performance which addresses handling, storing, using and disposing of hazardous chemicals.

In dentistry there may be dental amalgam removed from intact teeth or amalgam that is broken off and collected through suction. This amalgam contains mercury which under EPA regulations is a hazardous waste. The EPA does not want this mercury containing amalgam put back into the water system so they have developed regulations for collection and disposal. The link to the EPA notice posted in the Federal Register in 2017.

Deemed Status Home Care Changes:

The March issue of Perspectives provides notice of changes to deemed status home care and hospice standards which were posted February 19^th and become effective March 14^th.

When you access the site be careful as there are three available downloads. The first one for hospices is 19 pages long addressing 8 accreditation manual chapters including HR, IC, LD, MM, PC, PI and RI. The second one for home health is 16 pages long touching on 6 chapters including IM, MM, PC, RC, and RI. The third download is 9 pages from the Joint Commission glossary, providing CMS definitions of different types of practitioners who provide care in home health and hospice organizations.

While many of the modifications are somewhat minor word changes, additions or substitutions for existing language, each change should be reviewed carefully and organizational policies updated where needed. The short notice between posting and implementation is unfortunate, but comes from CMS changes that must be included in the accrediting bodies deemed status survey.

COVID-19 Vaccination Site Tips:

The lead article in the March edition of EC News is a very informative 6-page description of tips and best practices for organizations that are Covid-19 vaccination sites. There are suggestions and links to information on cold storage, expiration date tracking, and security considerations from TJC and organizational leaders who have been providing vaccines.

One of the first links is to a graphic developed by the federal Cybersecurity and Infrastructure Security Agency (CISA) that is also a sad commentary on life in the 21^st century.  It displays six categories of threats to the vaccine supply chain between the point of manufacturing and point of distribution. If you are a point of distribution you will want to download this graphic and share it with your team managing the distribution. The CISA graphic also provides multiple web links to additional guidance for each type of threat.

The EC News article does mention that ASHE has developed guidance for organizations seeking to purchase and place ultracold storage devices.

Internal Flooding:

EC News also has an article on what they call Internal Flooding. They identify that internal flooding may arise from sewer system backups, accidental sprinkler system activation, frozen pipes, roof or wall leaks, or drain lines that become plugged with drywall mud in construction areas.

The authors identify that sewer backups are most commonly caused by cleaning wipes that we use in healthcare and they advise signage and staff education that these must not be flushed. The authors point out that accidental sprinkler system activation can provide up to 5,000 gallons of water in just 10 minutes.

They also point out two risk points with trucks idling at the loading dock building up enough heat to activate sprinklers and a second risk point with a pneumatic-controlled HVAC system that failed and released steam into the room also activating sprinklers. They tie these scenarios back to the standards for having a written plan for managing utility systems and the hazard vulnerability analysis in emergency management planning. This article is worth sharing with your facilities and EM planning teams for their incorporation of this guidance.

NCC Most Frequently Scored EC/LS:

EC News has a review on the most frequently scored EC and LS issues in Nursing Care Center (NCC) accreditation. The two most frequently scored issues in this environment will also sound familiar to hospital readers as they are equally problematic.

LS.02.01.35, EP 5 concerns sprinklers not being damaged in any way such as by corrosion, paint, or missing escutcheons. This is the 4^th most frequently scored issue in NCC accreditation.

EC.02.04.03, EP 2 requires the organization to inspect, test, and maintain all life support equipment including documentation of this effort. This was the 5^th most frequently scored issue in NCC, but a larger percentage of the findings were in the red zone on the SAFER™ Matrix. Since this EP relates to life support equipment that might be on crash carts or other emergency carts, the red zone implications seem logical.

Reducing the Risk of Suicide:

The Joint Commission posted new Heads-Up Reports on the password protected extranet site for its accredited organizations. The hospital accreditation program report addresses reducing the risk of suicide in the physical environment. They report that between July 2019 and September 2020 they performed just under 1100 surveys and 36% of these organizations had high or moderate risk findings on the SAFER™ Matrix relative to reducing suicide risk.

The Heads-Up Report includes a brief summary of sample observations and potential contributing factors associated with those observations. The second page of the report provides 10 suggested steps each organization can take to better prepare their organization for this portion of the survey process and more importantly to provide safe care to patients at risk for suicide. Remember the reference we discussed earlier in this newsletter about 81 suicide sentinel events being reported last year.

Reducing the Risk of Suicide:

The Joint Commission posted new Heads-Up Reports on the password protected extranet site for its accredited organizations. The hospital accreditation program report addresses reducing the risk of suicide in the physical environment. They report that between July 2019 and September 2020 they performed just under 1100 surveys and 36% of these organizations had high or moderate risk findings on the SAFER™ Matrix relative to reducing suicide risk.

The Heads-Up Report includes a brief summary of sample observations and potential contributing factors associated with those observations. The second page of the report provides 10 suggested steps each organization can take to better prepare their organization for this portion of the survey process and more importantly to provide safe care to patients at risk for suicide. Remember the reference we discussed earlier in this newsletter about 81 suicide sentinel events being reported last year.

Medication Errors:

We read a very informative article published in the February edition of Pharmacy Practice News, authored by ISMP describing and categorizing the causation of medication errors reported to them during the past year. There is a link to the article posted on the ISMP website. Studying what types of errors occur elsewhere and why is a very useful tool to determine if you have similar risks and can develop protective strategies to prevent a similar occurrence at your own organization. This is definitely worth a review and discussion by your medication safety team.

Quality and Disparities Report:

The National Healthcare Quality and Disparities Report is an annual report that AHRQ prepares as a report to Congress and the most recent one reflecting 2019 was just published in February. You can download the entire report or portions of the report

The report discusses patient safety measures and some measures such as maternal morbidity. It breaks down the data along race, income, geography, payer source, and age ranges. There are also links to AHRQ toolkits which can help with improvement strategies. The maternal morbidity topic was of particular interest because TJC has new standards in this area that just became effective January 1 that many hospitals are still preparing to implement.