You gotta keep one eye looking over your shoulder…

By Steve MacArthur, Hospital Safety Consultant

And so with the onset of Spring, our friends in Chicago are laying out some more fun stuff to deal with over the next 12-18 months. In looking at the April edition of Perspectives, I don’t know that there’s anything I would call a surprise, though I suppose one of the announcements (pronouncements?) might prove to be problematic over the long haul (the “free pass” one sometimes receives for questionable practices in areas designated as suites might be harder to come by, but I think we’ll chat about that next week). But then again, if you have an effective survey management strategy, perhaps not; at worst, probably something to practice…

First up, effective January 2022, we have something of a shift in the requirements for water management programs—a shift to the extent that they done birthed a new standard just for water management. We’ve chatted about this topic in the past will take you to everything from last October back to the very beginning of time (or so it seems), so anyone who has been paying attention, particularly to the CMS stand on such matters, should be in reasonable shape. Here’s what you need:

• A program/plan for managing waterborne pathogens, including Legionella
• The identity of the individual or team charged with the responsibility for the program/plan
• A basic diagram of your water system, including all water supply sources, treatment systems, processing steps, control measures, and end-use points (that will be a lengthy list for most folks—hope you’ve started that)
• Documentation of testing/monitoring activities; corrective actions and procedures when your testing/monitoring results are outside of acceptable limits; documentation of corrective actions when control limits are not maintained
• Review of the program at least annually, including any time there’s a modification to the water system than could add risk, including new equipment or systems

To my eye (and mind), I don’t see anything here that has not already been in the mix and, to be honest, if you haven’t been working through this process, you may be running the risk of bad survey mojo, particularly if the survey is the result of a waterborne pathogen outbreak at your facility. Again, this one isn’t giving me any fits as I look at the details, but we can probably intuit that they’ll be kicking the water management tires a little more frequently (and perhaps with greater vigor).

As we close out this week’s epistle, I wanted to share with you a resource aimed at assisting folks in hospitals with creating programs for sustainable energy use. As we edge ever closer to whatever the “new normal” is going to represent, I have no reason to think that managing energy costs/expenses will fall by the wayside. If you’re starting to look at energy sustainability, this might be right up your alley.

Next week, we’ll talk about communicating spaces in suites and bid adieu (yet again) to the Building Maintenance Program, so until next time, I hope you continue to be well and stay safe!

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 the author of HCPro's Hospital Safety Director's Handbook and is contributing editor for Healthcare Safety Leader. Contact Steve at stevemacsafetyspace@gmail.com.