Compliance News: Reducing Emergency Power Vulnerabilities

 By David Stymiest, PE, CHFM, CHSP, FASHE

Healthcare facility emergency power systems are held to a very high standard.  They are expected to deliver power to what they must, when they must, for as long as they must.  A review of some medical journals will find references to clinical expectations for “uninterrupted power supply” and similar phrases.  In fact uninterrupted power is not guaranteed despite the misconceptions of some clinical personnel.  Hospital power systems are not as robust as large data center power systems, and even data center power systems sometimes fail.  But healthcare facilities can take steps to reduce the probability of emergency power failures. 

Firstly it is helpful to understand the differences between reliability, availability and dependability.  Reliability can be considered the probability that a system operates and gives the same result on successive trials.  Availability on the other hand can be considered the probability that a system will function at any instant required, including the next instant, and for as long as required from that point.  And finally dependability can be considered as the metric that measures availability, reliability & maintenance support.

Compliance News: CMS Issues Categorical Waiver 

 By David Stymiest, PE, CHFM, CHSP, FASHE

The Centers for Medicare & Medicaid Services (CMS) issued a categorical Life Safety Code waiver permitting new and existing ventilation systems supplying hospital and critical access hospital (CAH) anesthetizing locations to operate with a relative humidity (RH) of ≥20%, instead of ≥35%. CMS is also recommending that RH not exceed 60% in these locations.

CMS issued the new Survey & Certification memorandum # S&C: 13-25-LSC & ASC on April 19, 2013.  In its S&C memo, CMS referenced the recent code changes that adopted the lower requirements.  Many hospitals are expected to welcome this change, and it was supported by ASHE.

Organizations will not need to apply for this waiver or wait until they are cited by CMS or by state validation surveyors representing CMS.  However if organizations choose to take advantage of this waiver, they are required to document their decision to do so (such as within Safety Committee meeting minutes) before they start using it.  Organizations are also required to advise every Life Safety Code survey team at the beginning of any survey of their prior decision to use the CMS waiver.  CMS stated that lack of documentation of the prior decision to use the waiver may result in citations that would otherwise have been unnecessary.

The CMS waiver does not overrule more stringent state or local laws or regulations nor does it apply if the reduction of the relative humidity would negatively affect ventilation system performance.

According to CMS, organizations must still monitor relative humidity levels in anesthetizing locations and must take action when needed to ensure that RH levels remain at or above 20%.  Specifically, the CMS S&C memo stated “Facilities must monitor RH levels in anesthetizing locations and be able to provide evidence that the RH levels are maintained at or above 20%. When outdoor humidity and internal moisture are not sufficient to achieve the minimum humidity level, then humidification must be provided by means of the hospital’s or CAH’s ventilation systems. In addition, facilities must provide evidence that timely corrective actions are performed successfully in instances when internal monitoring determines RH levels are below the permitted range.”

The categorical waiver contains 17 pages of details including updated State Operations Manual Appendices A, I, L and W.  All organizations should obtain a copy of the letter and review it closely. 

The URL for the CMS Survey and Certification Memo is:
http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-13-25.pdf

CMS Issues Categorical Waiver to Lower OR Humidity Requirement

Please see below and refer to the URL to obtain your own copy of the just-issued CMS categorical waiver regarding Operating Room minimum allowable relative humidity (RH).

CMS is lowering the humidity requirement for operating rooms from at least 35 percent to at least 20 percent.  In its S&C letter, CMS referenced the recent code changes that adopted the lower requirements.

You will not need to apply for this waiver or wait until you are cited, however if you choose to take advantage of this waiver (and I expect many hospitals will) you must document your decision to do so (such as within your Safety Committee meeting minutes) before you start using it.  You must also advise every Life Safety Code survey team at the beginning of any survey that you have made the prior decision to use the CMS waiver.  CMS stated that lack of documentation of your prior decision to use the waiver may result in your being cited against the 35 percent requirement.

The CMS waiver does not overrule more stringent state or local laws or regulations.

The CMS waiver does not apply if the reduction of the relative humidity would negatively affect ventilation system performance.

According to CMS, you must still monitor relative humidity levels in anesthetizing locations and must take action when needed to ensure that RH levels remain at or above 20 percent.

The URL for the CMS Survey and Certification Memo is:

http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-13-25.pdf

I suggest that you read the entire CMS S&C memo and share it with your staff.

Compliance News: The Power of Tracers

Compliance News:  The Power of Tracers 

by David Stymiest, PE, CHFM, CHSP, FASHE 

The Joint Commission (TJC) discussed the use of a sample hazardous material and waste management environment of care (EOC) tracer in its March 2013 issue of EC News.  The article provided specific examples for conducting the tracer to explore issues related to orientation and training, physical environment, and quality improvement priority focus areas.   

EC News articles also discussed the use of non-patient tracers in June 2011 (sterilizer maintenance) September 2012 (fire safety) and November 2012 (utilities systems).  An earlier Joint Commission International publication also discussed the uses and benefits of a similar tracer methodology approach called System Tracers.  In the writer’s opinion, tracers of this nature have been proven to be extremely powerful in assessing not only compliance with individual TJC Standards and Elements of Performance but also in determining where opportunities for improving the EOC management processes exist within an organization.  As TJC also stated in its November 2012 issue, “Performing mock tracers can help your organization evaluate the effectiveness of its policies, engage staff in looking for opportunities to improve processes, and identify compliance issues that need attention.”

Read more »

Compliance News: Risk Icons Considered as TJC FSA Replaces PPR

Compliance News:  Risk Icons Considered as TJC FSA Replaces PPR

by David Stymiest, PE, CHFM, CHSP, FASHE

Users of The Joint Commission’s (TJC’s) 2012 "Update 2" and 2013 accreditation manuals found a new RISK ICON "R" in selected elements of performance. According to TJC in its September 26, 2012 Joint Commission Online edition, This new icon is related to TJC’s "Replacement of the Periodic Performance Review (PPR) with the Focused Standards Assessment (FSA)" and the "new risk icons denote elements of performance (EPs) assessed through the FSA process, applicable to all except the long term care program." A more comprehensive discussion occurred in TJC’s October 2012 Perspectives.

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Compliance News: EOC Risk Assessments

Compliance News:  EOC Risk Assessments

by David Stymiest, PE, CHFM, CHSP, FASHE 

  

In its March 2013 issues of both Perspectives and EC News The Joint Commission (TJC) continued to promote the use of risk assessments to evaluate whether to accept, mitigate or avoid environmental risks when there not definitive right or wrong answers. The articles by Joint Commission engineering director George Mills reiterated previous TJC guidance on 7-step risk assessments.
  
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Generator Risk Assessments

An ASHE member recently posted on the ASHE Listserv asking if anyone knew of a generator risk assessment.

We responded to the Listerv:   

1. "Log into ASHE's website and go to  
 http://www.ashe.org/resources/management_monographs/mg2009stymiest.html  

2. "Managing Hospital Emergency Power Systems - Testing, Operation, Maintenance and Power Failure Planning".  

3.  A PDF of this document is available for free to all ASHE members.  It can be downloaded from that URL.  

Please feel free to contact me if you have any questions.

After The Storm - Expanding the Concept of Emergency Power Reliability

After The Storm - Expanding the Concept of Emergency Power Reliability

by David Stymiest, PE, CHFM, CHSP, FASHE

As mission-critical equipment, hospital emergency power systems are expected to provide power consistently to what they must, when they must and for as long as they must. This is a tall order, and the impact of an emergency power system failure when normal utility power also has failed is potentially severe for patient care. 

The failure of some facility emergency power systems during and after last fall’s superstorm Sandy already has spawned investigations, which ultimately will result in lessons learned and more knowledge upon which health facilities professionals can base best practices to reduce vulnerabilities.

Read more »

Compliance News: Holiday Decorations

Compliance News:  Holiday Decorations 

by Robert Trotter, BS, MCP and David Stymiest, PE, CHFM, CHSP, FASHE

Many of this newsletter’s readers are regularly confronted with questions concerning holiday decorations. The Joint Commission’s 2012 Hospital Accreditation Standards, Standard LS.02.01.70 EP-1 states: “The hospital prohibits all combustible decorations that are not flame retardant. (For full text and any exceptions, refer to NFPA 101-2000: 18/19.7.5.4.)”

In NFPA 101-2000®, paragraph 18/19.7.5.4 states “Combustible decorations shall be prohibited in any health care occupancy unless they are flame-retardant. Exception: Combustible decorations, such as photographs and paintings, in such limited quantities that a hazard of fire development or spread is not present.”

Compliance News: ECRI Institute Lists 2013's Top 10 Health Technology Hazards

Compliance News:  ECRI Institute Lists 2013's Top 10 Health Technology Hazards 

by David Stymiest, PE, CHFM, CHSP, FASHE

The ECRI Institute recently published a 25-page special report entitled “ECRI Institute 2013 Top 10 Health Technology Hazards” – available at www.ecri.org/2013hazards. In its introduction, ECRI encourages facilities to use the list of generic hazards as a “starting point for patient safety discussions and for setting their health technology safety priorities.” This report is comprehensive with a multitude of useful recommendations along with exhaustive lists of further reference publications. We recommend that our readers use the link above to acquire their own copies of the ECRI publication for review and possible action.

ECRI stated that it considered a number of factors in determining which hazards actually made it to the top 10 list, including potential for harm, frequency/likelihood of the hazard, how widespread is the hazard, whether the problem is difficult to recognize or challenging to rectify, and whether the hazard has a high profile in the media.

Compliance News: ASHE Publishes New Management Monograph "Managing Hospital Electrical Shutdowns"

Compliance News:  ASHE Publishes New Management Monograph "Managing Hospital Electrical Shutdowns" 

by David Stymiest, PE, CHFM, CHSP, FASHE 

ASHE recently published a new management monograph that provides guidance for managing safe electrical shutdowns. It is available free of charge as a downloaded protected PDF to all ASHE members at :

http://www.ashe.org/resources/management_monographs/mg2012stymiest.html.

Hard copies are also available to both ASHE members and non-members in the ASHE Online Store as ASHE catalog # 055978.

This 55-page monograph covers the following major topics in depth:

• Why electrical shutdowns should be planned
• Things to consider before planning a shutdown
• Planning a shutdown
• Electrical system considerations during a shutdown
• After the shutdown
• Planning for future shutdowns
• Numerous appendices with samples and templates to assist hospitals in their shutdown management activities

Our Compliance News readers are welcome to submit comments, suggestions and questions by email to: DStymiest@ssr-inc.com.

Compliance News: TJC Provides More Corridor Clutter Guidance

Compliance News:  TJC Provides More Corridor Clutter Guidance 

by David Stymiest, PE, CHFM, CHSP, FASHE 

  

TJC continued providing corridor clutter clarifications and expectations in the September 2012 edition of The Joint Commission Perspectives®, which is TJC’s official newsletter. In this issue TJC Department of Engineering Director George Mills followed up on his August 2012 column by addressing several additional issues including latching patient room doors, corridor walls, corridors and air supply, corridor projections. He also provided additional guidance related to the CMS waiver policy regarding certain provisions of the 2012 Life Safety Code.

Mr. Mills discussed the differences between the required patient room door latches and the self-closing or automatic closing devices that are not required for patient room doors. He discussed TJC’s expectation that accredited organizations are required to have in their fire response plans a process to ensure that patient room doors close and latch in a fire emergency. Because this requirement must be in the facility fire response plan, staff are accountable for checking patient room doors and closing the open ones during both fire drills and non-drill fire events.

Compliance News: NFPA 110-2013 Edition Addresses Generator Fuel Oil Management

By David L. Stymiest, PE, CHFM, CHSP, FASHE



The 2013 edition of NFPA 110 was recently released by the NFPA Standards Council. Chief among the changes in this edition were several changes, including informational Annex recommendations, intended to improve emergency power supply system (EPSS) reliability through better fuel oil management processes. The excerpts below are only partial excerpts, and readers should review the full text of the updated standard, which is available at www.nfpa.org/110. In the discussion below, note that all Annex language is not mandatory, rather it is advisory only and contains recommendations for user consideration.

Paragraph 7.9.1.3 was modified to stipulate that “tanks shall be sized so that the fuel is consumed within the storage life, or provisions shall be made to remediate fuel that is stale or contaminated or to replace stale or contaminated fuel with clean fuel.” Although these are not in NFPA 110, some popular remediation techniques incorporate filtering of the stored fuel through a series of water separators and media filters, periodic centrifuge cleaning/polishing with high pressure tank agitation and/or mechanical tank cleaning with auxiliary filtration.

RISK + REWARD 

Assessing the need for electrical system shutdowns

By David L. Stymiest, P.E., CHFM, FASHE

Citing concerns for worker safety, tighter insurance requirements and Occupational Safety and Health Administration enforcement actions, most electrical contractors and electrical service companies now do their work in accordance with the National Fire Protection Association (NFPA) 70E, Standard for Electrical Safety in the Workplace.

They are no longer willing to maintain or to modify "hot," or energized, electrical equipment. Consequently, increasing numbers of hospitals have been undertaking the field investigations and electrical system studies necessary for applying those ubiquitous arc flash labels on electrical equipment. What's more, new maintenance requirements have increased the urgency of this process.

Read the entire article at HFM Magazine

Assessing the need for hospital electrical system shutdowns

Risk + Reward - Assessing the need for electrical system shutdowns

By David L. Stymiest, P.E., CHFM, FASHE

Consider conducting Shutdown Risk Assessments

This article first appeared in the August 2012 issue of HFM magazine.

NFPA disclaimer: Although the author is chairman of the NFPA tech­nical committee on emergency power supplies, which is responsible for NFPA 110 and 111, the views and opinions expressed in this article are purely those of the author and shall not be considered the official position of NFPA or any of its technical committees, and shall not be considered to be, nor be relied upon as, a formal interpretation of the discussed standards.

Citing concerns for worker safety, tighter insurance requirements and Occupational Safety and Health Administration enforcement actions, most electrical contractors and electrical service companies now do their work in accordance with the National Fire Protection Association (NFPA) 70E, Standard for Electrical Safety in the Workplace.

They are no longer willing to maintain or to modify "hot," or energized, electrical equipment. Consequently, increasing numbers of hospitals have been undertaking the field investigations and electrical system studies necessary for applying those ubiquitous arc flash labels on electrical equipment. What's more, new maintenance requirements have increased the urgency of this process.

Click here to read more