Carbon-dating compliance: What happened when…

…and how responsible are you for the sins of the past (turns out, quite a bit).

Kind of a mixed bag of things this week, so please bear with me.

First up, in looking back over the last little while of survey activity, I keep looping back around to one (possibly unanswerable) question: How many of the survey findings being generated are the result of conditions that pre-existed the prior survey? I think we can all agree that there are noncompliant conditions lurking throughout our buildings (including that pesky loaded sprinkler head we talked about a couple of weeks ago), some of which (and perhaps quite a few) are the result of actions or inactions occurring a long time ago (in a galaxy almost too close to home). I’m going to guess there are few of us that have not encountered the angst of having a surveyor pop a ceiling tile or wriggle into some crawl space and find some condition that had previously escaped prying eyes (I suspect that the most common previously undetected finding relates to things attached to sprinkler piping and supports, which supports LS.02.01.35 being the most frequently cited Joint Commission standard). And, as onerous as it may be on the face of it (and every other aspect), we are on the hook for all of it (grandfathering of conditions can help in very limited ways, but there’s really very little in the way of grandfathering noncompliant conditions and practices).

For better or worse (likely more the latter than the former), in these increasingly resource-challenged times, it is almost impossible to ferret out every little imperfection. Particularly in the sense that noncompliance happens in three dimensions—square footage just doesn’t work for this process. So, the questions I ask of you, dear readers, are these:

• Do you proactively attempt an exhaustive search of your facility from top to bottom (and all the nooks and crannies)?
• Do you “roll the dice” and correct deficiencies as they appear and if there’s stuff out there, let the surveyors find them?

I’m keen to see how this is going to “split.” I know if we could we would take the higher road of proactivity, but not everyone is in that position.

One other item I’ve been hanging on to for probably longer than I should relates to the management of medical gas and vacuum systems. I would hardly think that this blog is the only resource for information, commentary, etc. (though I do like to think it’s an entertaining and perhaps randomly enlightening one), there is one dedicated to the management of medical gas systems, etc., that I think you’ll find useful (and since it doesn’t publish as often, it’s an easy one to add to your bloggy queue) is sponsored by Compliant Healthcare Technologies (CHT). Recently, Tim Richards at CHT penned a blog post on upcoming changes in NFPA 99 relative to medical gases, etc. As I’ve noted once or twice in the past, I really see NFPA 99 compliance as a likely source of heartburn for facilities and safety folks in the coming survey cycles, so any resource that can increase our operational understanding of what is actually required, etc. gives us a leg up on the survey front. I encourage you to check out the information.

As a final note, it appears that we are gearing up for another wild summer of weather and I wanted to take a moment to send best wishes to those in areas already in the throes of severe weather and those that may find themselves in the same. I do believe that, as an industry, we have done some extraordinary work in the practical preparations to deal with emergencies (I would feel better if appropriate preparedness would “drive” regulatory compliance a little more closely, but perhaps in time) and I trust that we all manage the coming season with minimal impact and disruption.

About the Author: Steve MacArthur is a safety consultant with 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 also a contributing editor for Healthcare Safety Leader. Contact Steve at stevemacsafetyspace@gmail.com.