A Joint Commission official is warning hospitals to double-check contingency plans they have in place for utility system failures.
George Mills, MBA, FASHE, CEM, CHFM, CHSP, senior engineer at the accrediting organization, said he has seen some medical centers rely too heavily on memorandums of understanding with vendors without truly testing those agreements.
Lacking such tests, healthcare facilities may find themselves competing for scarce contracted resources should a community-wide emergency occur, Mills said during a Joint Commission Resources Webcast earlier this month.
The dilemma showcases the connections between utility performance and disaster planning efforts.
Agreements pulling from the same source
Although memorandums of understanding are great ways to prepare for utility disruptions, they are weakened if several facilities or community organizations have agreements to get the same piece of standby equipment, such as a 25,000-gal. water bladder, Mills said.
Hospital emergency management coordinators should talk to their counterparts at other medical centers about this concern. If, in fact, several parties lay claim to a limited resource or item as part of utility contingency plans, it is time to conduct a drill and see what happens, Mills said.
Let's look at the aforementioned water bladder from a single vendor, for example. An exercise scenario might be for all of the involved hospitals to simultaneously drill for a loss of water, and then have all of the facilities call the vendor to gauge the reaction to multiple sites requesting a single item.
It's possible the vendor has its own contingencies to bring in other water bladders, or the vendor may be forced to simply provide the bladder to the first hospital that requests it.
Only drills can expose potential flaws such as this before an actual emergency, Mills said.
Other avenues to monitor vendor agreements
Expect Joint Commission surveyors to ask hospitals about memorandums of understanding and whether these agreements meeting the accreditor's emergency management requirements.
Beyond the aforementioned drill for vendor items, memorandums are excellent pieces of an escalating disaster drill scenario as called for under emergency management standard EM.03.01.03.
Other standards to review in regards to utility contingencies include:
Emergency management standard EM.02.02.09, which sets provisions for managing utilities during an emergency response
Environment of care standard EC.02.05.01, which discusses general utility risks
The world offers many opportunities for hospital emergency managers to think analytically, and there is plenty of inspiration to be taken from the eruption of the volcano in Iceland.
Ash spewing high into the atmosphere from the volcano has disrupted air traffic across Europe since last Thursday. Aviation officials expect that many airlines will be able to resume flights out of European airports as the ash cloud subsides today.
For ground-based disaster preparation coordinators in healthcare facilities, think about the following issues that the volcanic activity has brought forth:
Creatively planning for escalating incidents. When the Iceland volcano erupted, it's doubtful anyone initially predicted that it would halt most European-based flights. But the eruptions combined with atmospheric conditions and political decision-making, all of which escalated the incident beyond its early stages. Many hospital-related disasters, the most notable being Hurricane Katrina in 2005, follow similar patterns of evolving scenarios. The Joint Commission's emergency management standards require hospitals that offer emergency services to conduct at least one disaster exercise a year that includes some sort of escalating scenario.
Preparing to last at least 96 hours without outside help. The Joint Commission expects emergency operations plans to identify hospital capabilities if the organization can't be supported by the local community for at least 96 hours (note that this doesn't mean the hospital has to survive for 96 hours, but rather determine its ability to do so and then plan accordingly). Although the ash cloud didn't shut down cities and governments, it did demonstrate how a disaster can unexpectedly become drawn out. Another industry, in this case air carriers, had to deal with days' worth of disruptions to their business, and hospitals may be able to learn from the airline reactions.
Getting staff members to your hospital during an emergency. Think of the thousands of passengers who were stranded with little warning at various airports because of the flight delays. Some countries have begun efforts to retrieve their citizens through means other than planes—for example, the British Royal Navy was being considered to transport stranded travels on war ships. Hospitals must also plan for taking unusual steps if an emergency isolates employees at home who need to be at the facility.
Losing money during a disaster. Airline carriers have lost up to $200 million a day during the prolonged crisis, says the International Air Transport Association. Such figures drive home the point that large-scale emergencies can devastate business operations. Hospital emergency planners who haven't already done so should take the Iceland situation as an invitation to coordinate disaster recovery planning with the finance and accounting departments, as well as insurance carriers.
When hospitals think about a fire, it's often in terms of the immediate response to keep patients, staff, and visitors safe.
But for a Maine hospital, the recovery phase became the real story following a recent blaze at a medical practice building.
The fire caused an estimated $6 million to $9 million in damage at the Franklin Health Medical Arts Center in Farmington, ME, which is located 30 yards from Franklin Memorial Hospital and connected to the main building by an enclosed corridor.
Investigators are looking at the building's boilers, chimney, and related placement of roof trusses for clues about an exact cause.
The three-story Medical Arts Center is divided into a trio of sections: east and west wings and a central lobby. The fire did the most damage to the east wing, which needs a new roof, said Gerald Cayer, Franklin's Health's executive vice president.
The surgery and urology practices located directly under the fire scene were significantly damaged. The destruction generally was lesser on lower levels. The east wing could be out of service until the fall, Cayer said.
Finding space quickly for ousted practices
Immediately following the fire, the hospital had to relocate urology, general surgery, OB/GYN, pediatrics, and orthopedics to other buildings while officials surveyed the damage to the Medical Arts Center.
"You scramble [to find space]," Cayer said. Franklin Memorial Hospital is a community medical center licensed for 70 beds.
Urology and general surgery, which were housed in the heavily damaged east wing, relocated to available space within the main hospital. Pediatrics, which was also in the east wing, went back to an empty space that it previously occupied before moving to the Medical Arts Center.
"We had extra space that we were able to bring up," Cayer said. "It took a couple of days to figure all of this out."
One concern with relocating surgery practices is the need for alternate locations to feature adequate sinks and plumbing to handle procedures, Cayer adds.
On February 8, a little more than one week after the fire, the hospital reopened the lobby and west wing, allowing for the resumption of services for OB/GYN and orthopedics.
"We got everything taken care of in a very fast fashion," said Jill Gray, community relations manager for the hospital.
Just prior to reopening the lobby and west wing, the hospital hired an air quality testing firm. "We just wanted to make sure … that the air was clean" for employees and patients, Cayer said.
Hospitals officials were not only worried about smoke residue in the air, but also whether there were any lingering remnants of the cleaning products that had been used. The Medical Arts Building got a clean bill for air quality.
Ozone helps restore smoke-logged items
There were plenty of medical records, furniture, and employees' personal items that suffered smoke damage during a fire.
Franklin Health hired a vendor to restore these materials through the use of ozone, which is a gas that penetrates items and remove odors, Cayer said.
A room was selected in the Medical Arts Building in which to pump ozone using a special generator, and affected items were placed in the room for 12—24 hours. After that period, the smoky smell was gone from them.
"It works. It's remarkable," Cayer said.
Accounting for the cost of clean-up
A final note concerns the HR piece of a recovery phase. Employees involved in the fire aftermath had to report this time in a specific way under the label of "FIRE" on their timesheets.
The designation served as a way of documenting for insurance purposes that staff hours were devoted to dealing with the aftermath of the incident, Cayer said.
Additionally, the insurance carrier assigned a forensic accountant to the case to aid the hospital's finance department in properly documenting fire-related expenses, he said.
When it comes to the physical security of hospital buildings and the well-being of workers, healthcare reform brings with it the likely risk of increased traffic into the nation's ERs.
ERs are among the top locations in medical centers for violence between patients and staff, generally because ERs act as funnels into the rest of the facility.
"You have overcrowded emergency rooms right now," says James Blair, FACHE, president and CEO at the Center for Healthcare Emergency Readiness in Nashville. "You're going to make 30 million people eligible [for insurance]. They won't be coming hat in hand."
But when people believe they have a right to medical care—"And that's what the rhetoric has led everyone to believe, that everyone in America is covered," Blair says—some individuals may be hard to physically control when they find out at the ER that they have to wait until 2014, when many provisions for covering the uninsured kick in.
That dilemma puts ER nurses, physicians, and security officers on the battleground of dealing with potentially upset, confused, or even violent patients who don't fully understand the healthcare reform laws passed last week.
"I think a greater number of folks will show up and push for their 'entitlements,'" which will up the ante for workplace violence in medical centers, says Roll, president and principal consultant at Healthcare Security Consultants, Inc., in Frederick, CO.
There are also patient surge issues, both immediate and long-term, associated with healthcare reform that mirror concerns about an influx of patients from a community emergency.
Although not a potential disaster in the traditional sense, healthcare reform, by bringing more people into hospitals, will challenge facilities by depleting them of supplies more quickly, Blair says.
It's already tricky enough determining just-in-time inventories of surgical masks, latex gloves, food, and other provisions. Hospital planners and emergency managers will soon need to get a firmer grasp on how healthcare reform could tax the supply chain, he says.
The upcoming end of the first quarter may be a time to reflect on your financial performance, but from a building safety perspective, that timeframe also triggers several recurring inspection and testing activities that The Joint Commission mandates.
Most of these requirements fall under the hospital accreditation manual's "environment of care" chapter, which is a series of standards that address how to manage occupational, fire, and building system risks.
Perhaps the biggest quarterly concern that Joint Commission surveyors will zero in on is whether a hospital has successfully completed fire drills. The accrediting group requires hospitals to conduct at least one drill per shift each quarter, which can add up to a sizable task depending on the amount of employees.
At least 50% of required quarterly drills must be unannounced, meaning only selected drill organizers should know about an upcoming exercise. Finally, you must critique your drills, with an eye toward not only how well staff responded, but also whether fire protection features worked properly.
Be sure to check whether any interim life safety measures (ILSMs) are in place that could require extra quarterly drills, given that ILSMs are also high on surveyors' minds. ILSMs help offset life safety deficiencies by providing temporary alternatives to keep staff and patients safe.
Fire safety devices to note
Other environment of care concerns with a quarterly review component include:
Testing fire protection supervisory signal devices, such as valve supervisory switches or water level indicators
Testing fire alarm notification devices for off-site responders, such as the fire department or an alarm monitoring company
Inspecting fire department water supply connections
Testing stored emergency power supply systems, which can take the place of or supplement generator-provided emergency power
There may also be more informal needs to check on a quarterly basis.
For example, some hospitals require the submission of reports every three months to the safety committee from the safety officer or biomedical engineer. Such reporting contributes to monitoring the environment of care, although these reports are not required by The Joint Commission each quarter.
Also, facilities may employ a building maintenance program to track life safety problems that often crop up, but are easily correctable, such as burnt-out exit signs or fire doors that are out of alignment.
A building maintenance program will set specific inspection intervals for problems areas, and quarterly inspections are a common time frame to consider. If your facility has such a program in place, verify that quarterly reviews are being completed as expected.
Many hospitals already have green teams of ecology-minded employees who strategize ways to reduce waste and energy consumption, but some medical centers have taken things a step further by creating a full-time position for the management of environmental initiatives, typically called a "sustainability officer" or "sustainability manager."
The University of Maryland Medical Center (UMMC) in Baltimore and Metro Health Hospital in Wyoming, MI, have set up Web sites discussing their green initiatives and have plugged into national group Practice Greenhealth's initiatives.
The green movement is widespread enough that several universities now offer degree programs specializing in sustainable business practices. John Ebers, LEED AP, CEM, sustainable business officer at Metro Health, graduated from such a program at Aquinas College in Grand Rapids, MI.
Among its green projects, Metro Health put in a vegetative roof for one of its buildings that used plants and not shingles.
That project will pay off in 15 years, Ebers said, and was part of several initiatives that helped the facility earn a 2009 Practice Greenhealth Environmental Leadership Circle Award, the highest honor the ecologically oriented healthcare association gives.
A trio of benefits from sustainability
Denise Choiniere, RN, BSN, sustainability manager at UMMC, said that when someone's tracking sustainability at a hospital, the payoffs can come in three main areas:
Energy conservation. Using less electricity, gas, oil, and water probably is the biggest ways to cut costs and lessen a facility's ecological footprint.
Waste reduction. Sustainability officers have more time to help "sort the trash," creating systems in which fewer truckloads of red bag waste get hauled away. There are also benefits from general trash reduction (e.g., recycling blue sterile wrap instead of tossing it out).
Purchasing practices. Smart purchasing can turn waste into recyclables and cut costs. At UMMC, Choiniere now orders DEHP-free IV tubing that not only gets potentially unhealthy chemicals out of patient care, but also is recyclable whereas the previous tubing wasn't, she said. Therefore, that tubing purchase incurs no disposal cost, saving about $8,000 per year.
The staffers, who have been fired, called in when storms dumped more than 40 inches of snow on the DC area between Feb. 5 and Feb. 11. Hospital officials said they offered transportation for the nurses and also alerted staff beforehand that they should make accommodations, such as staying at the hospital, when the storms hit.
Nurses United of the National Capital Region, a union that represents nurses from Washington Hospital Center, has filed a labor grievance with the facility over the firings.
Joint Commission emergency management standard EM.02.02.07 comes into play with this situation. The standard sets a variety of provisions on how a hospital manages staff roles and responsibilities during a disaster. The idea is that an organization and its workers must be able to adapt from normal routines when dealing with an emergency.
Some specific provisions that might have been considered by area hospitals during the blizzards include the following:
A facility's emergency operations plan must describe how the hospital will handle staff support activities, including housing, transportation, and mental health. In other words, it may fall to an organization to find sleeping quarters for employees who get stranded at the hospital because of inclement weather, and a facility may also need to consider whether it will travel out to workers' homes to pick them up. To accommodate workers who spent the night at Washington Hospital Center during one of the storms, the facility offered 7,300 meal vouchers and found sleeping arrangements for 2,200 workers at various times.
The emergency operations plan must describe how the hospital will support the needs of employees' families, including child care, elder care, communication, and pet care. Clearly babysitting services, which appear to have played a role in at least some of the absenteeism at Washington Hospital Center, are a big concern to address ahead of time in The Joint Commission's eyes. About 250 nurses at Washington Hospital Center didn't arrive for their shifts during the storms, The Washington Post reported. It seems likely some of the nurses who didn't get fired had childcare issues that were taken into consideration, although it's not clear how much leeway was granted in that regard.
Another Joint Commission standard requires hospitals to annually review the findings of their "hazard vulnerability analysis." This analysis weighs the risks of a given emergency against the likelihood of it happening, and then ranks the resulting consequences.
The Washington Hospital Center situation should prompt all medical facilities to reconsider any findings in the hazard vulnerability analysis that hinge on staff members showing up to work. Weather-related emergencies would be one area to review again with a critical eye in the analysis, but also look at terrorist threats that could lead to worried workers either staying with family members or avoiding public areas, such as hospitals, out of fear of follow-up attacks.
When it comes to workplace violence in hospitals, emergency departments (EDs) act as a potential powder keg.
"The emergency department is a funnel into your institution," says Fredrick Roll, MA, CHPA-F, CPP, president of Healthcare Security Consultants, Inc., of Frederick, CO, and one of the country's leading experts on hospital security.
"Patients coming to the ED don't really want to be there in the first place," Roll says. "Something has happened to them to bring them to the hospital."
Undiagnosed psychiatric cases also pose a threat to the 24/7 environment of an ED. Whereas patients with behavioral health issues might have used standalone clinics before, the failings of these "doc-in-a-box" settings during the recession have driven more behavioral patients to the ED, he says.
Annual reviews of security plans and incidents offer hospitals an opportunity to improve the safety of ED workers. Roll provides the following four suggestions for preventing ED violence:
Tighten access control. Evaluate every entrance—such as entries to treatment rooms, reception areas, and outside entrances—and determine if access should be tightened to each. Also, consider whether receptionists and intake nurses should be protected with glass barriers or other measures.
Evaluate lockdown protocols. A key is to know when you initiate an ED lockdown. For example, if a domestic violence victim is brought into the ED and the aggressor is still at large, will that trigger a lockdown? A less drastic measure is to screen people coming into the ED waiting room.
Encourage employees and physicians to discuss incidents. Some physicians and nurses assume that violence comes with the job and don't speak up about it, Roll says. But assessing violence and fully reporting incidents can help your facility get a better grip on what's truly happening and how to enact prevention measures.
Assess patients for their violence potential. As part of the triage and admissions process, educate nurses and physicians to identify a patient's potential for violence. Talk to the emergency medical technicians and police officers who bring patients in about the circumstances surrounding an injury or condition, and enter this information into the patient's record. Often these details are ignored, Roll says, but if the particulars are part of the patient assessment process, providers become more informed and can take steps to begin verbal de-escalation if needed to prevent problems.
One thing is clear when it comes to Joint Commission surveyors reviewing your disaster plans: If people from various departments can speak to their roles in emergency management, you'll be in better graces.
During an emergency management review, surveyors may ask to see your hospital's hazard vulnerability analysis (which ranks the likelihood of disasters occurring against their potential consequences), emergency operations plan, and any mutual aid agreements with outside parties. Some surveyors also conduct a tabletop drill, in which a disaster scenario is role-played in a conference room.
Surveyors often look to various department managers to participate in these discussions, rather than the lead emergency management planner, as a way to test how many people are familiar with the facility's disaster plan.
In fact, George Mills, FASHE, CEM, CHFM, senior engineer at The Joint Commission, has occasionally mentioned that if an emergency manager talks too much during the review, he might ask the manager to make some coffee as a way to force other people in the room to participate.
Having a physician familiar with disaster planning available during The Joint Commission's review is probably the biggest advantage you can obtain. Other important, but perhaps not obvious, representatives might be a nursing supervisor, materials management director, infection control practitioner, pharmacy director, and chief financial officer.
Skaggs Regional Medical Center in Branson, MO, was visited by The Joint Commission last year and completed a tabletop drill that involved a tornado hitting the hospital, said Lou Smith, RN, CHSP, CPHRM, safety and risk manager at the hospital. Smith is in charge of emergency planning.
During the session, she kept quiet and let the emergency management team do the talking. The tornado scenario was no problem, given that staff had drilled on that type of event before.
Smith also makes sure that disaster readiness figure into mundane events too. She recalls activating the emergency operations center when a water main broke outside the hospital.
"That gives people a familiarity of doing it so they get into that mode," she says.
Bill Mangieri, emergency management specialist at St. Luke's Cornwall Hospital in Newburgh, NY, also emphasizes the importance of various staff being familiar with emergency management.
For example, "The surveyor wanted to know about capabilities of our building systems," he wrote. "Make sure you have someone knowledgeable from engineering in the room to discuss back-up generators and alternate sources of water."
After further consideration, the Food and Drug Administration (FDA) has extended the deadline to 18 months for hospitals to transition away from using the Steris System 1® (SS1) processor.
Previously, FDA officials said the transition could be made within three to six months. But after hearing from hospitals and others in the industry, the "FDA now understands that a three-to-six-month transition period may present significant difficulties for some healthcare facilities, which could, in turn, adversely affect patient care," the agency said.
Using the FDA's original December 2009 announcement of the six-month timeframe, the new extension would bring the deadline to August 2011.
Hospitals using the SS1 should be figuring out what their next sterilizer will be and how quickly they can switch over, Steven Silverman, assistant director of the Office of Compliance in the FDA's Center for Drug Evaluation and Research, told HealthLeaders Media's sister publication, Briefings on Hospital Safety.
In an initial safety notice first published in December, the FDA said Steris modified the SS1 and that the agency hasn't approved the modifications yet.
The agency also said that despite discussions with Steris since 2008, the FDA is not satisfied with the company's response to concerns about providing hospitals with adequate replacements to the SS1.
Steris, based in Mentor, OH, has criticized the FDA's assertions, saying there has been no documented case of infection caused by the SS1 when the equipment is used properly.
About 23,000 SS1s have been used in more than 5,000 hospitals and clinics in the country, according to Steris.
Many hospital operating rooms, gastrointestinal laboratories, and ambulatory surgery centers used the SS1 to sterilize or disinfect medical devices, said Rose Seavey, RN, BS, MBA, CNOR, CRCST, CSPDT, president and CEO of Seavey Healthcare Consulting in Arvada, CO.
The processor was the only product of its kind for many years, but in recent memory, several alternatives have come on the market, including one from Steris itself, Seavey said.
The FDA does not expect to enforce the 18-month timeline for hospitals that don't stop using the SS1.
"But these facilities should be aware that the current SS1 is a misbranded and adulterated medical device because it has not been cleared by FDA as safe and effective for its labeled claims," the agency said.
