How regulators are like shingles
No matter what else might be happening, no matter what issues you may be dealing with, when it comes to physical environment compliance as a source of vulnerabilities, the regulators don't care.
As you read this (if you’re partaking during the week of publication), I am taking some time off from the daily grind, so I’m allowing myself (with your permission) a little philosophical ramble. In this particular instance, I had the headline before the rest of the post became clear (which is still kind of the case, but I’m hoping it coalesces by the time I finish).
As a starting point for this conversation, I continue to be fascinated with the many and varied TV ads addressing various physical/health conditions, ailments, etc. Now, I like catchy jingles and a quirky/funny turn of phrase tends to lodge itself in my lizard brain, so the series of ads advertising a shingles vaccine (if you want a gentle reminder of this particular ad, this should suffice) also managed to lodge itself to the point where I had to make use of the headline. And, you might be inclined to agree, the level of pain that can be experienced in the wake of either shingles or a regulatory visit is of a similar order of magnitude.
As I look back to when I started writing in this space (which is about 16 or so years ago), I think the purpose of the Safety Space has been to help folks prepare more effectively for regulatory interactions, as well as being able to give voice to some of the frustrations of having to embrace a completely mad undertaking—the management of the healthcare environment. I’ve certainly witnessed any number of failure modes in the healthcare physical environment. CMS is not incorrect in pointing out that there are very few instances (and I’m paraphrasing here) in which there are not deficiencies in the physical environment. It is merely a question of looking far enough/long enough for those deficiencies to manifest themselves: the dusty sprinkler head, the obstructed access to a zone valve, the network cabling resting on a sprinkler pipe, the rated door that does not close and latch, the missing daily/weekly log entry. Anything that involves the human touch is subject to some level of inconsistency, some level of imperfection.
And sometimes those imperfections can become more critical from a planning perspective when the ground rules are revised. A good example are the new expectations (effective August 2024) from our friends in Chicago relating to compliance with NFPA 101 & 99 in ambulatory surgery care and outpatient surgical department locations. The interesting piece of this (or at least it feels that way at first blush) is the change in language which formerly highlighted the number of patients rendered incapable of self-preservation, but now reads the number of patients served—if you are using accreditation as a means of Medicare certification (which is pretty much everyone that is using accreditation, I would suspect). There are a number of changes that run through the ambulatory occupancy section of the Life Safety chapter, but it looks like this: if you are engaging in surgical processes (I don’t know if you can even limit it as a function of procedures), then you have to comply with the ambulatory healthcare elements of NFPA 101 and 99. This may not be a big deal, but if you happen to have an outpatient surgical department in a facility classified as a business occupancy, this may be a significant vulnerability if you’ve not engaged in some sort of gap analysis. I guess we’ll have to wait and see how this all plays out in the field, but I’m having a difficult time conjuring up a change to regulatory standards that did not result in an increase in survey findings relative to the change. And, as I think about it, there’s no vaccine to prevent that, is there?
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.