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Top-cited standard reveals rift with clinical activities


March 1, 2010

Survey monitor

Top-cited standard reveals riff with clinical activities

Like many facilities, Massachusetts General Hospital (MGH) in Boston was cited during its Joint Commission survey for having blood pressure equipment, soiled linen carts, and IV poles stored in corridors on three of its units.

The standard in question, LS.02.01.20, was the most cited one in accredited hospitals during the first half of 2009, according to The Joint Commission. LS.02.01.20 requires facilities to maintain their means of egress, and under element of performance (EP) 13, exits must remain clear of obstructions.

MGH constantly tries to focus attention on the problem of corridor clutter, says Robert Castaldo, director of environmental health and safety at MGH. “[Managing this issue well] takes a lot of work. It’s not just an easy issue to be perfect about.”

The Joint Commission surveyed the 900-bed hospital, which has about 50 patient care units, in August 2009.

Nurses primarily focus on patient care

According to Castaldo, problems with some corridor clutter stem from a conflict of interest between Life Safety Code® (LSC) compliance and clinical care duties.

Clinicians often state that they need to have certain items immediately available; thus, they don’t instinctively monitor corridor obstructions the same way a safety officer might.

“They’re focused on patients, so they’re not focused on equipment in the corridor,” Castaldo says.

The Joint Commission allows wheeled items (e.g., computers on wheels and dietary carts) that are in use by workers to remain in a corridor for up to 30 minutes. After that time limit, the item is considered in storage in the corridor, which violates the LSC.

The commission has two exceptions to this rule: Crash carts can remain in corridors for emergency use at all times, and infection control carts can remain outside active isolation rooms until such time as the isolation patient is moved or discharged.

Steps MGH has taken over the years to improve corridor compliance include the following:

  • Offer refresher training for staff members on units in which clutter recurs. “We also listen to the staff and try to understand clearly what issues they’re having” while working together to improve things, Castaldo says.
  • Encourage staff members to call support services if abandoned carts remain in a corridor.
  • Increase the frequency of equipment pickup from support services.
  • Reconfigure space in a unit for more efficient storage.

Unobstructed corridors are only one aspect of fire protection, which also includes sprinkler protection, smoke detection, and 24/7 staffing on patient care units. Given these precautions, it is unlikely that a fire would spread quickly enough to overwhelm a unit, Castaldo says.

However, he fully acknowledges that items blocking corridors could increase evacuation times from a smoke compartment if patient relocation became necessary, and it remains an important issue to manage well.

Fire drill goals fall short

Surveyors also cited MGH for fire drill performance under EC.02.03.03, EP 1, which requires quarterly drills on each shift.

In the third quarter of 2008, staff member participation in fire drills at MGH was 86%, according to The Joint Commission, a figure that led to the finding. The first two quarters of 2009 saw drill compliance rebound to 100%.

MGH’s internal drill participation target is 95%, Castaldo says. In the third quarter of 2008, administrative changes at the hospital resulted in a temporary lapse, he says.

“These drills don’t happen automatically,” Castaldo says. “It takes somebody to quarterback it so it remains on target.” The lesson in the citation is that organizational changes make hospitals vulnerable to compliance blips, and if surveyors find those blips, citations can result, he says.

“When it did slip up in ’08, we were able to recover quickly” because MGH tracks fire drill activity and recognized the issue right away, Castaldo says.

Emergency plan presentation sets the tone

Surveyors reviewed emergency management planning at MGH but didn’t conduct a tabletop drill.

The hospital employs a multidisciplinary approach to emergency management compliance, and the committee members keep their eyes open for related Joint Commission developments. “This group is extremely active and has a lot of energy, and it does an exceptional job at documenting [emergency planning activities],” Castaldo says.

During the survey, the administrative director of the ED showcased the group’s forward-thinking program and how it aligns with the emergency management standards. The director articulated the emergency operations plan well and spoke the language of surveyors, which is a good style for any hospital to consider, Castaldo says.

The group was able to illustrate how MGH ramped up surge planning efforts in reaction to H1N1 swine flu cases in the Boston area, which satisfied surveyors.

Wrapping up with EC concerns

Surveyors also issued citations under the following standards:

  • EC.02.01.01, EP 1 (identify safety and security risks). In one unit’s bathroom, open hand rails on the wall and a ceiling vent with open rings provided opportunities for distraught patients to hang themselves. Environmental rounds did not address this risk.
  • EC.02.03.05, EP 12 (conduct flow tests for standpipe systems every five years). There were three cases in which the standpipe tests weren’t completed.

Hospital posts its survey report for all to read

Massachusetts General Hospital (MGH) in Boston is one of the few facilities that posts its full Joint Commission accreditation report online for all to see and explains the various findings surveyors issue.

“Our leadership feels it’s a healthy thing,” says Robert Castaldo, director of environmental health and safety at the medical center.

Administrators there believe that if the hospital is open about the accreditation challenges it faces, staff members will feel more comfortable offering suggestions and solutions, Castaldo says.

“I think maybe in the past, folks were reluctant to do that,” he says. “Maybe it was a sense we were airing our dirty laundry in public … [But] it’s better to be up front about the challenges you have.”

To view MGH’s report, go to http://qualityandsafety.massgeneral.org, click the Performance Reports tab, and look in the left column.

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