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Hospital Safety Center, December 2009

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December 1, 2009

Inside:

Use these 10 tips to tune up your RCRA compliance

Old EC rules may still be useful for today’s compliance

Nationwide debate continues over mandatory flu shots

A new breed of safety fair focuses on data-based trends

Emergency management de-emphasized in Texas survey

Squeeze more energy efficiency out of your buildings

Understand both sides of the H1N1 PPE debate

Computer forensics and information security

Best practices for healthcare security

What are security’s biggest challenges in 2010?



EPA settlement with the VA

Use these 10 tips to tune up your RCRA compliance

As we first noted in November’s “Tip of the month,” the Environmental Protection Agency’s (EPA) actions as part of a $533,570 hospital settlement should give all safety committees a reason to review hazardous waste concerns.

The U.S. Department of Veterans Affairs’ (VA) Eastern Kansas Health Care System settled with the EPA over violations to the Resource Conservation and Recovery Act (RCRA) allegedly found at Dwight D. Eisenhower Veterans Medical Center in Leavenworth, KS, and Colmery O’Neil Veterans Medical Center in Topeka, KS.

Civil fines totaled $51,501. On top of that, the VA agreed to invest nearly $482,069 for new systems to better track and manage chemical wastes in the two hospitals.

The EPA inspection was not triggered by a complaint or accident. Instead, the regional EPA office had identified hospitals as potentially vulnerable to RCRA violations and devoted resources to inspecting facilities randomly.

Some of the alleged violations included no-nos such as incinerating hazardous materials on-site, says Ed Buckner, compliance officer in the RCRA enforcement branch at the EPA’s Region 7 office.

Even though many hospitals probably know better than to incinerate on-site, Buckner says, they still could be vulnerable to similar fines because they don’t know exactly what is hazardous and what isn’t—and how to store and transport hazardous materials properly once they’re identified.

“These are violations we see a lot in hospitals, colleges, any kind of facility that has a lot of people doing a lot of different stuff,” Buckner says. “[The VA facilities] are not unique.”

At presstime in mid-October, the VA’s national headquarters in Washington declined any comment on the record for this article.

Watch your quantity threshold

The main trigger of RCRA is the quantity of waste, say Buckner and colleague Belinda Holmes, senior counsel for the EPA’s Region 7 office.

Here’s a quick refresher: If your facility generates less than 100 kg of RCRA-covered waste in a month, you’re not required to comply with the law. If you have 100–1,000 kg each month, you’re a small-quantity generator. Above 1,000 kg a month, you are a large-quantity generator and subject to more stringent requirements.

Inventorying and reducing your RCRA-covered solid waste can be more than just an environmental gain. If you’re a large-quantity generator but can later get under 1,000 kg per month, that will reduce your facility’s regulatory burden.

The EPA classified the VA hospitals in question as large-quantity waste generators under RCRA, subjecting them to the most stringent rules. RCRA considers solid waste to be discarded material, including solid, liquid, semisolid, or contained gaseous material, resulting from industrial and commercial activities.

Take this advice from the EPA

Buckner offers 10 tips to help you stay ahead of RCRA problems:

  • Do a hazardous waste determination for all solid wastes. The main problem with the Kansas VA hospitals’ handling of wastes was that they didn’t know what was hazardous material under RCRA, Buckner says. Hazardous wastes require special handling and transport. If you don’t know what’s hazardous in your building and covered under RCRA, you may be racking up fines without knowing it.
  • Make certain to ship hazardous wastes using a qualified transporter. Not just anyone can haul away hazardous wastes. Make sure your hauler has a federal ID number.
  • Do not collect chemicals in storerooms and laboratories. Do you know what’s been forgotten about on shelves in the landscaping shed? Labs—especially those connected to universities—are also vulnerable to storing chemicals past their allowed RCRA time frame, usually 90 or 180 days depending on facility size. Abandoning or ignoring stored chemicals past that period is a way of creating waste. Containers of waste oil and gasoline, old batteries in the maintenance sheds, and fluorescent bulbs may fall under RCRA.
  • Inventory all waste streams. Don’t forget to include items such as lead aprons, pharmaceuticals, and paints. Hazardous wastes lurk in many corners of the hospital, and missing the less-than-obvious ones may lead to RCRA violations.
  • Watch for acute hazardous wastes (P-listed). Small quantities of highly toxic chemicals on this RCRA list can turn you into what the regulation deems a large-quantity generator, and subject to more of the rules.
  • Manage containers of hazardous waste appropriately. Make sure containers are properly labeled, dated, and closed. Once a container is received (not opened), it’s considered to be in storage. Know when a chemical comes in, when the container is opened, and if the material falls under RCRA, confirm there’s a disposal plan within mandated time frames for that quantity of chemical.
  • Do not treat hazardous waste on-site. There are other methods of inappropriate self-treatment besides incineration. Examples include dumping chemicals down the drain, flushing them down the toilet, and evaporating them (such as consumers do with latex paint before disposing the cans). Get an idea of what your staff members’ practices are when it comes to getting rid of wastes and train them on proper methods.
  • Create a complete contingency plan. By law, staff members must be prepared and trained on what to do—notification of local authorities included—in the event of a spill or other emergency that would require a response.
  • Seek to reduce use of hazardous materials. It’s simple logic, but the less you use, the less vulnerable you are to RCRA violations. You might also be able to adjust your practices to move from large- to small-quantity generator status, depending on your facility size. Auditing your chemical use will likely present opportunities for less hazardous substitutes. Such environmental management systems can pay off in the form of lower energy bills and reduced chemical quantities.
  • Contact federal or state environmental agencies. Federal and state authorities understand RCRA well and are usually willing to offer compliance tips, answer questions, and even perform site visits in some cases. Hospitals may fear that seeking such advice from authorities will put them on an inspection hit list, but that isn’t the case, Buckner says. “We’re an enforcement-oriented agency, but we’re not going to suddenly turn around and inspect somebody because they’re asking questions in or- der to get into compliance,” he says. “We’ve already got our inspection plan set up for a year in advance.”

Common chemicals can lead to problems

Below are some of the materials that allegedly were improperly handled or disposed of by two hospitals within the U.S. Department of Veterans Affairs’ Eastern Kansas Health Care System:

  • Ether
  • Ethyl acetate
  • Paint sludge
  • Sulfuric acid drain cleaner
  • Paint booth skimming
  • Waste or spent mineral spirits
  • Paint thinner containing mineral spirits
  • Spent aerosol cans

Source: Environmental Protection Agency.



Old EC rules may still be useful for today’s compliance

A Joint Commission official and a well-respected security consultant have separately recommended digging up old copies of the EC standards and using them for guidance.

Current standard EC.03.01.01 requires staff members and physicians to be familiar with their EC-related roles and how to minimize safety risks.

However, EC.03.01.01 doesn’t specify particular areas in which these people should receive training, George Mills, FASHE, CHFM, CEM, senior engineer at The Joint Commission, said during the American Society for Healthcare Engineering’s (ASHE) annual conference in Anaheim, CA, in August.

Staff competency requirements migrated back to the EC standards from the HR standards this year. They had been in the EC standards previously, too, before being taken out of that chapter in 2004.

The prior version of the standard in question was EC.2.8, which required employees to receive education about the EC.

Mills suggested that safety managers check out the 36 items that EC.2.8 required staff members to be able to describe, although to be clear, he didn’t say those items are mandatory today.

For those of you who don’t have EC.2.8 handy anymore, here’s a synopsis of the items that staff members were required to describe or demonstrate, as applicable to their jobs:

  • General EC risks
  • How to report property damage, occupational illnesses, and injuries to patients, workers, or visitors
  • Actions to minimize or eliminate safety risks
  • Fire evacuation routes
  • Staff member roles at a fire’s point of origin and at locations away from a fire’s point of origin
  • Use of the fire alarm system
  • Preparations for building evacuation
  • Use of equipment for transporting patients to safe areas during a fire
  • How to contain smoke and fire using smoke compartment features
  • How to minimize security risks and report incidents
  • Emergency procedures for security incidents
  • Precautions for hazardous materials and waste
  • Emergency and reporting procedures for hazmat spills and exposures, medical equipment failures, and utility system problems
  • Roles in emergency preparedness
  • Emergency backup communication strategies
  • Obtaining supplies and equipment during disasters
  • Safe operating procedures for medical equipment
  • How to perform medical equipment maintenance
  • Utility system capabilities
  • Location and use of emergency shutoff controls
  • Preventive maintenance of utility systems

Meanwhile, security professionals are better off using provisions in the old EC standards related to security planning, said Fredrick Roll, MA, CHPA-F, CPP, president and principal consultant at Healthcare Security Consultants, Inc., in Frederick, CO. Roll spoke at a different ASHE conference session.

Current standard EC.02.01.01 calls for hospitals to manage safety and security risks, with only a few EPs noting specific security duties. However, predecessor EC.1.2 listed a more detailed series of security processes.

Due to space limitations, we can’t run down the list under EC.1.2, but platinum subscribers to our Hospital Safety Center can check out the box below for further details posted online.



New York rule’s fallout

Nationwide debate continues over mandatory flu shots

If H1N1 and seasonal influenza hit hard this season, the legal and ethical rumblings in New York could be a preview of things to come in other states.

After indicating earlier this year that it would require healthcare workers to obtain seasonal and H1N1 swine flu vaccinations as conditions of employment, New York officials backed away from that mandate October 22.

In making the announcement, New York Governor David Paterson said the decision was based on a limited supply of vaccine in the state, forcing the need to prioritize who receives it.

Paterson’s statement said nothing about the legal battles that initially had ensued from nurses suing the state over the forced vaccinations.

However, there is little doubt that opposition to the mandatory vaccinations put pressure on the state government to rethink its position.

Other states are less restrictive

Four other states—Alabama, Arkansas, California, and Kentucky—require healthcare workers to obtain flu shots, according to an article published online September 21 at Medscape Today (www.medscape.com/viewarticle/709080).

For hospital employee safety managers, however, it was the New York mandate that bore watching, as it allowed few exemptions for workers to opt out.

In contrast, the Alabama and Kentucky laws allow workers to decline a flu shot for religious reasons. In California, any reason works, as long as the request is in writing.

New York’s rule, on the other hand, said that any healthcare worker with direct patient contact who refused H1N1 and seasonal flu shots would not be able to practice.

Medical exemptions to the New York rule could have been be requested, but they were few, such as employees allergic to eggs or workers acquiring Guillain-Barre Syndrome within six weeks of the last time they received a seasonal flu shot.

Informing employees is step one

Tucker Woods, DO, emergency medicine chairperson at Long Island College Hospital (LICH) in Brooklyn, NY, said he had hoped the New York rule would boost vaccination rates at his facility.

“I actually think it’s a good law,” Woods said prior to the state pulling back on its mandate. “I think there’s going to be a lot of noise this year, but I predict next year it’s going to be fine. I think other states are going to watch New York and learn from our example.”

LICH sent e-mail notifications about the mandatory vaccination law, posted signs, and held “town meetings” to address worker questions and meet the law’s notification mandates.

Although there had been at least some resistance among staff members, Woods expected 100% compliance among workers because of the consequences of not getting vaccinated under the state’s mandate.

The New York rule would have required hospitals to document when workers received the vaccine, which is important for several reasons:

  • Such paperwork would have confirmed that the clinicians are legally practicing
  • The record would have served as proof for floaters working at multiple hospitals to prove they’ve already been vaccinated
  • The documentation would have allowed for the state to audit the information

The rule’s enforcement was nebulous, but as Woods understood the situation, the state could have scrutinized vaccination records in the event of an outbreak at a hospital. It’s possible state authorities could have assessed penalties if a hospital allowed unvaccinated employees to work.



A new breed of safety fair focuses on data-based trends

For years, employee safety fairs served as inexpensive ways to host informal refreshers about hospital policies and procedures.

However, some facilities now tie their safety fair content to opportunities for improvement, education about new equipment and training, and honed emergency preparedness.

Safety fairs are best when they reflect data and trends the hospital has collected, says Ann Colvin, RN, advanced nursing coordinator at the University of Alabama (UAB) Hospital in Birmingham, whose safety fair in the hospital atrium in April attracted 44 vendors and 1,100 staff participants.

A safety fair doesn’t fill the need for mandated training. However, when you tie the fair’s content to incident data you’ve collected, it shows Joint Commission surveyors that you’re acting upon trouble spots you’ve identified. Further, fairs help refresh earlier safety training in which your facility invests.

“It doesn’t replace the formal training, but it reinforces the training they get ... and gets out some new information,” says William Wilson, CFPS, PEM, fire safety coordinator at Beaumont Hospitals based in Royal Oak, MI. “We really don’t have the time to do new training on all these topics, but [the safety fair] really helps.”

Draw inspiration from the horizon

Beaumont’s safety fair earlier this year in the parking lot not only addressed detailed topics such as radiation safety, hazardous materials handling, and security, but it also hit hard on emergency management, a Joint Commission priority over the past few years.

Wilson and his safety fair planning committee peers got their inspiration for the topics by seeing what Joint Commission standards or OSHA regulations have changed or will be changing, as well as what’s happening in the news (e.g., H1N1 swine flu concerns).

“Basically, we tried to get information out to our staff, but in a fun way,” Wilson says. That included inviting local police and fire departments to set up their equipment: fire extinguishers, decontamination gear, and even a mobile communications trailer for disaster response.

Colvin advises safety managers to involve as many departments as possible in the planning process, which helps identify issues to focus on during the fair. UAB includes the procurement department that deals with supplies and equipment, the infection control office, patient safety representatives, the employee health office, and vendors. Together they determine what internal concerns need the most attention with safety fair content and emphasize equipment training and best practices.

Since UAB’s first fair several years ago, the planners also polled participants on what they learned and what they thought needed to be covered in future fairs. This year’s fair featured a station for the environmental services department, based on suggestions from previous years.

Create incentives for participation

If your safety fair’s content is strong, the next effort must focus on ways to encourage employees to attend. The following are Colvin and Wilson’s suggestions for engaging passersby:

  • Offer prizes. A lot of people like to stick around for door-prize drawings. For example, Beaumont offered home emergency preparation kits and fire extinguishers, which were appropriate to the content of its fair. Items such as cafeteria vouchers or gift shop credits and gear such as stethoscopes also appeal to attendees, Colvin says.
  • Create a game-like atmosphere. Bowling and Jeopardy! with safety-oriented messages attracted a good number of participants at past safety fairs, Wilson says.
  • Give away food. At Beaumont, the hospital’s bake shop made cookies that workers love. At UAB, meals were given to attendees who proved they participated in a certain number of educational activities with stamped cards.
  • Time the activities conveniently. Can your safety fair straddle two shifts? Try early to mid-morning or late afternoon so you can catch staff members both coming and going.

Given the recession, you may face obstacles funding a safety fair. See the tips in the related story below for ideas to cut expenses.

Try these steps to minimize your safety fair’s costs

In this hostile economy, getting funds to hold a safety fair may be a tough sell with your administrator. With that in mind, use the following cost-cutting tips for your next fair:

  • Call for donated prizes. Local businesses, vendors, even in-house sources (e.g., the gift shop) might be willing to pitch in.
  • Hit up local retailers for supplies. Need plywood to build platforms, for example? Ask your local hardware store for donations and give them credit during the fair.
  • Apply for grants. Your local or regional emergency management consortium may have money set aside for education, and having a safety fair with emphasis on your hospital’s disaster preparation might make you eligible. A recent safety fair at Beaumont Hospitals based in Royal Oak, MI, cost less than $1,000—including tent rental and prize purchase—and it was covered in whole by such a grant, says William Wilson, CFPS, PEM, Beaumont’s fire safety coordinator.
  • Ask your marketing and PR offices to help. The marketing and PR folks typically reach out to the community, but chances are they will be happy to devote some bandwidth to your safety fair. Marketing professionals can help sharpen your messages, create materials, and get the word out about the event in printed materials and on the hospital’s Web site.
  • Invite community responders. Local public service–minded partners may be willing to come and offer education on matters germane to their jobs, such as fire safety, patient handling, flu vaccines, and security. Beaumont’s community partners were eager to set up at the safety fair, Wilson says.
  • Involve your vendors. This approach can be tricky, says Ann Colvin, RN, advanced nursing coordinator at the University of Alabama Hospital in Birmingham. The hospital lets outside vendors come and set up tables at its safety fair, provided they are companies with equipment that the hospital has already purchased and is using. The vendors are also required to educate employees who visit their tables and not just give away knick-knacks. For the privilege of participation, Colvin charged a $250 fee for each of the 44 vendors who set up at this year’s fair, which funded the event.

Regarding vendor involvement, don’t be afraid to invite the vendors whose equipment you have the most trouble with or those you call the most for support requests, Colvin says. “We don’t invite people who are looking to get in our doors. They have to be people already supplying us,” she says.

The one exception happened a few years back, when the hospital was considering competing electronic charting systems. Colvin and her peers used the safety fair to solicit employee input about the finalists before making the major equipment purchase.



Survey monitor

Emergency management de-emphasized in Texas survey

The Joint Commission’s survey at East Texas Medical Center (ETMC) in Tyler continued what appears to be a trend, anecdotally at least, of little interest in emergency management tabletop exercises.

The five-day survey began August 17 at the 49-bed rehabilitation hospital. Surveyors gave a few minutes’ discussion about emergency management, but no tabletop disaster drill occurred despite the hospital’s anticipation of an exercise, says William Deitenbeck, director of plant services.

“That’s what we were expecting,” Deitenbeck says. “But we didn’t try to push it and ask for a tabletop or anything.”

In our past two “Survey monitors,” safety and quality professionals have also noted a lack of tabletop drills during their Joint Commission visits.

Magnetic lock tests bring a citation

The life safety specialist came on the first day of the survey and handed down three indirect findings:

  • Although magnetic locks on egress doors had been tested by the hospital alarm vendor, there was no inventory of the mag locks. The alarm company stated that it had tested “all,” but without an inventory, the life safety specialist felt the hospital could not ensure that the alarm company had checked all the locks on egress doors. Generally, this problem can be cited under leadership standard LD.04.01.05, element of performance (EP) 4 (see “Keep your vendor maintenance logs on-site for surveyors” below for more details).
  • The specialist also found four unprotected penetrations in fire barrier walls bordering a gymnasium, which Deitenbeck and his colleagues didn’t think were fire walls. Three of the penetrations were due to holes from cable runs. This was likely cited under LS.02.01.10, EP 9, which requires cables and other penetrating items to be sealed with an approved fire-rated material.
  • At a clinic in a separate building covered under the hospital’s license, a fire extinguisher fell out when the surveyor opened the door to its housing. The citation may have come from EC.02.03.05, EP 15, which requires monthly checks of extinguishers.

On a related note, ETMC has addressed recent reports of fire damper testing scrutiny through the following actions:

  • Documenting damper inspections by having the inspection company representative sign and date reports
  • Attaching repair tickets to the report to demonstrate how and when the hospital acted upon a report of a faulty damper

E-SOC credentials questioned

Surveyors determined that the facility lacked a written document assigning an individual to maintain the electronic Statement of Conditions (SOC) under LS.01.01.01, EP 1. The hospital addressed the issue quickly, creating a memo assigning that job during lunch and getting it signed by the CEO.

This is a somewhat controversial aspect of the e-SOC, as there is no mandate to have such paperwork. In fact, the EP in question isn’t even marked with a D icon to formally indicate documentation is required. The surveyor at ETMC was aware there was no D icon, too.

All that said, it is unwise to assign someone responsibility for the e-SOC without documentation noting this duty to hospital leaders and outlining the individual’s credentials, says Peter Leszczak, Network 3 fire protection engineer at the U.S. Department of Veterans Affairs in West Haven, CT.

“How do you prove someone is qualified if they don’t have any documentation?” Leszczak tells our sister publication, Healthcare Life Safety Compliance.

Surveyor asks for alarm company monitoring

In other life safety tidbits, one of the surveyors suggested that, on occasion, the hospital should notify the fire department—not the alarm company—about its fire drills. Then, after setting off an alarm, the hospital should log how long it takes the alarm company to notify the fire department.

The inspection of door self-closing and latching features caught Deitenbeck’s eye. The life safety specialist would open a door a little, let go, and if the door didn’t latch upon closing, he’d do it again, opening it wider. If it didn’t latch the second time, he’d give it a third try, opening it much wider.

“He gave us the benefit of the doubt,” Deitenbeck says. “That was interesting.”

Also, surveyors were pleased with ETMC’s organization of its documents, such as fire and generator testing, which were referenced by the EP under which they fell, Deitenbeck says.

BMP yields positive results

Although The Joint Commission ended any scoring benefits for hospitals participating in the optional building maintenance program (BMP) at the start of 2009, some hospitals continue to use it, including ETMC.

That dedication paid off with this visit because surveyors found few problems related to common Life Safety Code® deficiencies addressed in the BMP, Deitenbeck says.

One note he passes along to fellow facilities folks at hospitals coming up for a survey: In a recent state association meeting, Joint Commission senior engineer George Mills, FASHE, CHFM, CEM, emphasized that surveyors would take a zero-tolerance stance on cables run along fire sprinkler pipes.

In ETMC’s 60-year-old main hospital building, which wasn’t surveyed this time out, there are bundles of cables running off sprinkler pipes, Deitenbeck says.

In a Joint Commission response to a query from him about the matter, Deitenbeck was advised to put the deficiency on a plan for improvement (PFI) with a six-year time frame. The problem didn’t come up in the rehab hospital survey that’s the subject of this article, although some cables do run along sprinkler pipes there, too.

He also passes on a final procedural hint: ETMC conducts an interim life safety measure assessment for every PFI entered into the e-SOC.

Keep your vendor maintenance logs on-site for surveyors

The Joint Commission’s life safety specialist may apply leadership standards to fire protection deficiencies in certain cases.

For example, LD.04.01.05, element of performance 4, requires hospital leaders to hold their staff members accountable for their responsibilities. This provision can be invoked if a surveyor requests fire protection inspection documentation and the paperwork is not immediately available, but instead arrives late from an off-site vendor, George Mills, FASHE, CHFM, CEM, senior engineer at The Joint Commission, said during the American Society for Healthcare Engineering’s annual conference in Anaheim, CA, in August.

Letting a vendor hold on to your maintenance logs for weeks at a time is not a good practice and probably isn’t a solid career move either, Mills said.

When surveyors cite this problem, “You’re going to have to explain to your boss why you think it’s okay to [not have the logs] for six or eight weeks,” Mills said. “Good luck.”

Survey at a glance

  • Emergency management highlights: Surveyors only conducted a short emergency management review and did not request a tabletop drill.
  • Life safety highlights: Surveyors looked at fire protection requirements for doors, scrutinized barrier penetrations, and requested documentation proving a qualified person was completing the electronic Statement of Conditions (SOC).
  • Standards focused on: EC.02.03.05 (inspection, testing, and maintenance of fire protection equipment), LS.01.01.01 (Life Safety Code® and e-SOC compliance), and LS

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