Keeping things in perspective: Catching up with Chicago, Part 2

As noted last week, I’m taking a trip down memory lane to drop in on a couple of items published in the past few issues of Perspectives. This week, I’m pulling some stuff from the October and December 2024 issues.

Starting with a continuance of concerns relating to emergency management, there was a subsection of hospitals surveyed in 2023 that struggled with the notion of a continuity of operations plan (COOP), which, if I’m honest, kind of puzzles me. My sense is that without a fairly effective COOP (whether you call it that or not), an organization would have had a very difficult time enduring the pandemic.  At first, I was thinking that perhaps it was not so much about having a COOP as it was not having the essential/required elements, which include plans for the following functions and services to continue during and after an emergency:

• Administrative and vital records
• Information technology
• Financial services
• Security systems
• Communications/telecommunications
• Essential and critical building operations

Now, on the face of it, I’m having a difficult time believing that there was any one facility that was missing the whole lot of this, so I figure it’s got to be a gap that is somewhat/somehow more granular – perhaps financial services is not as well represented in the COOP as would have been preferred by a surveyor. It’s tough to say. I guess the advice here is to make sure that your COOP is “tabbed” to include the items noted above so that it is very clear to a surveyor that your organization’s essential functions are accounted for from a continuity standpoint.

The other item called out in Perspectives relates to elements missing from water management plans. The specific call outs were:

• No diagram depicting water sources, treatment systems, and/or plumbing fixtures.
• No plan to address areas of stagnant water.
• No identification of monitoring protocols.
• Plan didn’t address potentially hazardous conditions and/or corrective action plans for resolving monitoring activities that are out of range. (I don’t know that you’d be able to get much more descriptive than taking appropriate actions; what you do will depend on what’s out of range and to what extent).
• No assessment of areas where immuno-compromised patients are housed.

I’m going to guess that the lion’s share of findings related to that last one. I don’t know that we always do the best job of identifying the most vulnerable—most of the time we do—but not always. So, I’m thinking my advice would be the same here as for the COOP: tab your plan so it is clear to the surveyor where each component lives. Although there is usually someone to help guide the surveyor through documentation review, I suppose clearly tabbing critical program components helps folks less familiar with the process navigate it. Even if you maintain things electronically, individually tabbed folders helps in the finding of information—never a waste pursuit!

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.