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Review the little things to help your life safety and emergency preparation readiness game


March 1, 2019

Often in healthcare facilities, it’s the small details missed that can raise the ire of a surveyor or, in worst-case scenarios, lead to accidents that can cause tragic patient deaths. So maybe it’s time to take another look at the little things you can do to help keep your facility ready for the emergencies that may seem small—at least until they become huge.

Do you know where your facility’s fire response plan is? Sure, you’ll probably say that it’s in your computer and if anyone needs to see it, they’ll look there. But what if the power goes out? Would you know where to find the hard copy of the plan? Apparently, surveyors want to know.

According to Steven MacArthur, consultant for the Greeley Company in Danvers, Massachusetts, who also writes the weekly Mac’s Safety Space blog, a quick glance through The Joint Commission’s Environment of Care (EC), Life Safety (LS), and Emergency Management (EM) standards and elements of performance (EP) reveals what he calls “Easter eggs” about the availability of a written copy of your fire response plan.
“That makes sense to me; you can never completely rely on electronic access (it is very reliable, but a hard-copy backup seems reasonable),” he says. “The odd component of the performance element is the specificity of the location for the fire response plan to be available—readily available with the telephone operator or security.”

How do you do this? MacArthur says that in most large hospitals, 24/7 operator and security coverage is a given, and therefore emergency plans could be made available with them, or at least with an on-site nursing supervisor.

“There are smaller, rural facilities that may not have that capacity (I think my personal backup would be the nursing supervisor), so it makes me wonder what the survey risks are for those folks who don’t have 24/7 switchboard or security coverage,” he says. “At the end of the day, I would think that you could do a risk assessment, pass it through your EC committee, [and] then if the topic comes up during survey, you can push back if you happen to encounter a literalist surveyor. As there is no specific requirement to have 24/7 telephone operator or security presence, I think that this should be an effective means of ensuring you stay out of the hot waters of survey. For me, ‘readily available’ is the important piece of this, not so much how you make it happen.”

Make sure you’re up to code. According to the National Fire Protection Association (NFPA), in 2012 there were 99,500 nonresidential fires in businesses, resulting in 65 deaths and 1,525 injuries. While only one of those deaths in that time occurred in a hospital, that’s still one too many. Simply having fire protection equipment in place at your facility isn’t enough. Fire code violations can include anything from improperly installed equipment to a missed service date. Periodic testing, inspection, and maintenance are crucial to guarantee the equipment will function properly in the event of an emergency. By conducting an assessment of your facility and keeping an eye out for common fire code violations, you can improve your fire protection program and avoid unnecessary fines. Common fire code violations include the following:

•    Painted sprinkler heads. Sprinkler heads aren’t meant to be pretty. They should not be painted or covered in any way. In addition to regular inspections, sprinkler systems must be inspected internally every five years to ensure that they are free of corrosion and buildup that would restrict water flow.
•    Fire extinguishers that do not meet requirements for hazard type. Many fire hazards exist within a healthcare facility. However, different hazards require different types of extinguishers, and using the wrong extinguisher can sometimes make the fire worse. Make sure you have the appropriate extinguishers available based on the hazards present in your facility. Those extinguishers must be fully functional, too. Fire extinguishers that have been tampered with or discharged are noncompliant.
•    Failures in emergency lighting and exit signs. Occupational Safety and Health Administration 1910.37 and NFPA 101 require emergency lights and exit signs to be tested for 30 seconds monthly and 90 minutes annually, along with other important but easy-to-miss vitals a trained technician will know to check.
•    Alarm systems not functional/improperly installed. Lives are at stake when a fire occurs, and an alarm system won’t do its job if it’s not properly maintained. Additionally, alarm systems need to be tested regularly to ensure that they will work in the event of a fire. NFPA 72 outlines required testing intervals for automatic fire alarm systems. Proper maintenance of a fire alarm system will greatly improve the chances that it will detect a fire, notify the building occupants, and alert first responders.
•    Burned-out backup batteries. Backup batteries for alarm systems, emergency lighting, and exit signs are meant to ensure that the equipment will work even if the electricity goes out. The NFPA requires that backup batteries be replaced in pairs—this means even the manufacturer and date code must match. Compared to the rest of your fire protection equipment, backup batteries are cheap, so don’t skimp on this small but critical requirement.
•    No inspection paperwork. If no paperwork exists, did the inspection really take place? Work with a fire protection provider that offers complete and easy-to-understand inspection reports. This will help you keep track of all completed inspections and quickly reference them when needed.

Think like a surveyor. As you do your rounds, you should be thinking about what a surveyor will look at—and cite you for. That starts with an understanding of the Joint Commission standards. Too many facility safety professionals don’t read the language of some of the standards, much less understand and follow it, and that’s why they get dinged.

The Joint Commission’s LS and EC standards, while sometimes vague (take EC.02.03.01, which states that a facility “manages fire risks”), are written in such a way that they pretty much give you a script of what surveyors will look for when they visit your facility.

If you’re following the standards, you know that the EC chapter requires you to have a written fire response plan. In addition, utility systems are required to be inspected and maintained, and you need to keep a written record of the intervals of that maintenance (EC.02.05.05). As another example, every 30 days, you need to run a test of your battery-powered exit lights for at least 30 seconds and document those tests (EC.02.05.07). If you keep a binder with all the standards handy, and include all the records that prove you’re checking up on each standard, you’ll look great come survey time.

Do a Hazard Vulnerability Analysis. You can do all the planning, drilling, and data collection you want (which you do, right?), but it won’t help if you don’t first perform a proper assessment and know what you’re up against. The Hazard Vulnerability Analysis (HVA) is known in emergency management circles as the base document that hospitals should develop to help guide their emergency response plans. It’s a document required by The Joint Commission as part of the EM standards (EM.01.01.01, EP 2), and CMS requires an HVA as part of its increasingly stringent survey standards that mandate an “all hazards” approach to emergency planning. By design, the HVA is a flexible document. It should be reviewed annually and revised as needed, used as a planning document for your drills, and improved as you discover weaknesses (or strengths) in your facility’s response plans. Consider the following items when developing your HVA:

•    Historically, what is likely to occur in your area? This is a great starting point, because it helps you prepare for the things that are most likely to happen in your area and require the most resources to deal with. Therefore, if you’re located in Miami, you’ll probably want to plan for how to respond to a major hurricane. Hospitals in Minneapolis will have well-tested plans to hunker down during a blizzard. And in San Francisco, the well-prepared hospital safety officer knows to have those earthquake plans within arm’s reach.
•    What events occurred in the last year? This is where you find the wild cards: the game-changing events that aren’t likely to occur, but do occur every so often. Review the events that happened in your region over the past year to figure these out. Did anything increase in frequency or probability? Did you experience more than the normal number of severe weather events? Did you experience an increase in earthquakes in an area that’s not usually prone to seismic activity?
•    Is there anything new going on? We’ve got one word for you: Ebola. It’s something most hospitals never expected they’d need to think about in their emergency plans—that is, until the events of 2014. All it took was one case to show up at Texas Health Presbyterian Hospital in Dallas, a couple of nurses coming down with the disease from patient contact, and the revelation that staff were not trained or equipped to deal with a disease of Ebola’s magnitude for the CDC to step in and help hospitals reassess and rewrite their emergency readiness plans. Paying constant attention to changing needs around you—and updating plans accordingly—could be the single best tactic to help manage risk to your facility and be ready for the next tragedy.
•    Has anything in your facility changed? Did you acquire new equipment or personnel?  Any changes in your facility are going to affect your ability—or inability—to respond to emergencies quickly and efficiently, so these changes should be taken into account when updating your facility’s HVA. Perhaps you’ve opened a brand-new Level I trauma wing, with an increased number of trauma bays; that’s going to allow you to take in more patients. If your emergency department goes under construction, that will have the opposite effect. Also take into consideration your staff, and the ability to handle a particular number of patients at any one time. You may have added trauma bays, but have you added nurses and physicians to man those bays? Use your HVA to reevaluate your staffing needs.
•    What happened during your last drill? At their core, exercises aren’t so much about identifying your facility’s strengths (although that’s good, too), but rather the weaknesses in your hospital’s response to emergencies. Much like teachers assess their students and makes changes to their lesson plans based on test results, you should be editing your facility response plans based on the outcome of your drills. In fact, your HVA will be the document that helps you plan what the next drill will be. Was your emergency staff a little rusty on working the decontamination tent during your last hazardous chemical drill? Perhaps it’s time to bring the fire department in for a quick tutorial. Maybe your last drill uncovered problems with the radios that you use to communicate with first responders, or issues with triage procedures.
•    What are you NOT capable of? If your facility is small or has limited personnel or resources, it may not be able to help other hospitals in the event of a major catastrophe. It’s a good idea to know this limitation and prepare for it now, rather than in the middle of a crisis when severely injured patients start arriving at your ambulance bays and flooding your waiting rooms. Revelations like this should drive either your plan for improvement or the creation of a contingency plan.

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