Mac's Safety Space: Critical Access versus Critical Mass

As promised last week, I wanted to take a few more moments of your time to look at the physical environment standards changes for folks managing things at critical access hospitals. I don’t know that there’s anything with the changes that truly give me indigestion from a practical standpoint, but if you should happen to disagree, please let me know at stevemacsafetyspace@gmail.com – I’ll be happy to (anonymously) share any specific concerns to folks. We really are all in this together and I firmly believe that every question, insight, interpretation, etc., can help bring us to a more clearly unified understanding of what is required (and how not to get lost down the rabbit-hole of what is not an actual requirement).

Over the past twenty or so years, I have learned that, oftentimes, compliance is in the eye of the beholder and in the hands of the folks who actually occupy the physical environment at any one time (or multiple times). Most of the stuff that we have to manage doesn’t happen unattended (please notice that I didn’t identify the potential for “accidental” transformations in the environment—we’ve got those to deal with as well—hopefully, your “world” tends towards the former than the latter, but I know that buildings are never more perfect than the moment before you let people in.)

Moving on. You can find the slate of changes coming into play effective August 27, 2023 here: https://www.jointcommission.org/standards/prepublication-standards/revisions-resulting-from-critical-access-hospital-deeming-renewal-application-review/. Running through the changes at a rather rapid clip, we find compliance with the 2012 editions of NFPA 99 Health Care Facilities Code moving from the notes section of its parent standard/performance element into a performance element of its own (I suspect this is mostly an editorial change—NFPA 99 has been in the mix for more than half a decade now—I think the intention is to more clearly reflect the Conditions of Participation).

Next up we find what I consider a consolidation of the performance elements relating to the inspection, testing and maintenance of medical equipment; the specific information regarding Alternative Equipment Management (AEM) programs has been redacted with the additional “caveat” that, whichever method/strategy you choose, your activity rates (remember, that’s not just preventative maintenance activities—it’s inspection, testing and maintenance—make sure you are keeping an eye on that entire continuum) must be at 100%. For me, that means a very clear definition of what compliance looks like for whichever activity you are monitoring. It is the responsibility of the organization to define the frequencies, so make sure that your frequencies are not writing checks that can’t be “cashed” from an operations perspective.

That said, there is a little bit of a disconnect (or it seems so) in that there is no specific completion percentage identified for non-high risk medical equipment; high-risk medical equipment has to be at 100%, but the activities for the “nons” only have to be documented. I suspect that the overall programmatic compliance rates will still be enforceable at 100%, but perhaps there is some wiggle room for the non-high risk (perhaps this might result in some indigestion over time—break out the antacid!)

Likewise, some consolidation of the performance elements relating to the inspection, testing and maintenance of utility systems equipment; again, the highest bar, if you will, is set for the high-risk (and infection control-related) utility systems equipment with 100% compliance being the mark. But the programmatic elements relating to non-high-risk is not as clearly in the 100% completion mix (you’ll have to look at the actual verbiage to see what I mean— I am not in a position to use much verbatim on this stuff). With this subtle difference, I don’t find this one likely to be problematic for folks. Ultimately, I guess it comes down to how much “stuff” you have to manage.

In the section dealing with design and construction, there is a slight change relating to emergency power supply systems and NFPA 99, NFPA 110 and the various Tentative Interim Agreements in that the specific notes were removed from the applicable performance element. It seems likely that this edit is the result of its having been in place for a long enough period to have been adopted across the industry (when it comes to new emergency generator equipment, it’s all about location, location, location, among other things). From a practical standpoint, this will probably be one of those things that gets worked out with whichever AHJ is overseeing the design and construction of anything new or significantly modified.

Finally, there’s the addition of a specific requirement to be in compliance with the 2012 edition of NFPA 101 Life Safety Code^®, with its applicable Tentative Interim Agreements; again, I suspect this is mostly a case of having to specifically call it out as it is specifically called out in the CoPs, so no significant impact on that front, I shouldn’t think (but feel free to disagree).

And that, as they say, is that. I can’t help but think that the 100% compliance targets might be leveraged into additional findings in future surveys, so it becomes a question of carefully managing the inventories of medical and/or utility systems equipment and knowing where you stand relative to inspection, testing and maintenance. If you have an accurate, current inventory, then you should be able to identify any specific vulnerabilities relative to completion and, hopefully, get out the search parties to hunt them down (more for the medical equipment—hopefully your utility systems equipment isn’t too mobile).

Since the end of August is the target date for implementation of these changes, perhaps that’s enough time to take a look at what you have and where things are in the cycle–what better way to spend the summer.

About the Author: Steve MacArthur is a safety consultant with Chartis Clinical Quality Solutions (formerly known as 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.