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A P R I L 2 0 1 9
AGENDA
• Meeting Sponsors
• OC CSHE President Update
• Industry Update
• Educational Event: Medical Gas; Preparing for the Worst
– presented by Dale Terry
• CSHE Member Update
• Upcoming Education & Events
• Roundtable
RISK ASSESSMENTS
• The Joint Commission addresses proactive risk assessments at Standard
LD.04.04.05 EP 10, which requires hospitals to select one high-risk process
and conduct a proactive risk assessment at least every 18 months.
• Hospitals should recognize that this standard represents a minimum
requirement. Hospitals working to become learning organizations are
encouraged to exceed this requirement by constantly working to proactively
identify risk.
To comply with The Joint Commission, organizations must regularly assess and respond
to risks in the healthcare environment.
RISK ASSESSMENTS
WHEN TO CONDUCT RISK
ASSESSMENTS
• When new machines, substances,
processes or procedures are
introduced which could lead to new
hazards.
• On-going to identify unidentified
changes in the environment.
• When unable to meet
recommendations or requirements.
7 STEPS WHEN CONDUCTING
RISK ASSESSMENTS
1. Hazard identification.
2. Develop argument to support issue.
3. Develop argument to oppose issue.
4. Evaluate both arguments.
5. Reach a conclusion.
6. Document Process.
7. Monitor and Reassess conclusion.
RISK ASSESSMENTS
TYPES OF RISK
ASSESSMENTS
• Root Cause Analysis
• Failure Mode Analysis
• Plan / Do / Check / Act
STRATEGIES FOR AN EFFECTIVE
RISK ASSESSMENT
1. Describe chosen process
2. Identify failure modes / break down points
3. Identify risk of failures
4. Prioritize potential failures
5. Determine how potential failure may occur
6. Design/redesign process to minimize risk
7. Test and implement revised process
8. Monitor effectiveness & redesign, as needed.
RISK ASSESSMENTS
RISK ASSESSMENT APPLICATIONS
• Wet Location Risk Assessment ASHE Wet Location Tool
• Hazard Vulnerability Assessment Kaiser HVA Tool
• Interim Life Safety Measures Joint Commission ILSM Revisited
• Patient Self-Harm Risk Assessment VA Mental Health EOC Checklist
• Job Hazard Assessment OSHA Job Hazard Analysis
• Facility Risk Assessments ASHE Risk Assessment Tool
• Clinical Activities Center for Health Design Tool
INDUSTRY UPDATE
CMS UPDATES EMERGENCY
PREPAREDNESS RULE
CDC ISSUES EBOLA
PREPAREDNESS REMINDER TO
US HOSPITALS
INDUSTRY UPDATE
CAL/OSHA PROPOSED
EMERGENCY REGULATION ON
SMOKE-PROTECTION
2 HEALTHCARE EMPLOYERS
MAKE 2019 DIRTY DOZEN LIST
INDUSTRY
UPDATE
The Centers for Medicare & Medicaid Services (CMS) is requesting public comments
regarding Ligature Risk Interpretive Guidelines by June 17, 2019. The proposed
guidance includes several updates to the December 8, 2017 S&C Letter Clarification on
Ligature Policy. Noteworthy recommended updates are:
– The addition and clarification of the use of video monitoring for the purposes of 1:1
monitoring with continuous visual observation
– Clarification of environmental risk assessment tool contents which include evaluating
solid versus drop ceilings
– That waivers for Ligature Risk findings are not permissible
The draft revised guidelines are intended to provide increased direction, clarity and
guidance regarding what constitutes a ligature risk and clarify the expectations that
hospitals achieve a "ligature-resistant" environment in locked psychiatric units within
acute care hospitals and psychiatric hospitals, as well as emergency departments with
dedicated psychiatric beds within a locked unit. The requirements to create a ligature-
resistant environment do not apply to unlocked psychiatric units and general acute-care
beds designated for the treatment of physical diseases and disorders units of hospitals.
CMS will review submitted comments before issuing a final version of this policy
memorandum, Appendix A and Chapter 2 of the SOM. Once finalized, these interpretive
guidelines will be implemented by CMS and become the guidance for surveyors.
ASHE is requesting that members share their concerns and comments regarding the
proposed guidance. A link to the CMS Memorandum requesting information can be
found on the ASHE Patient Safety webpage along with a link to a survey to share your
concerns with ASHE. Please complete the survey by May 17, 2019. The ASHE Patient
Safety webpage also contains several additional tools and resources addressing the
environmental risks associated with the care of patients at risk for suicide and self-harm.
Ligature Risk Interpretive
Guidelines Public Information
Request
INDUSTRY
UPDATE
Building Automation Alarm
Management Tool
ASHE has developed a tool to help members
make the decisions necessary for an alarm
management plan. The plan will define the
risk, response and escalation required for
each alarm type. This will allow operators to
prioritize the alarms as they arrive and take
appropriate action for each, while providing a
clear path for escalation when an alarm goes
unacknowledged.
Medical Gas: Preparing for the Worst
Dale Terry, CEO
FS Medical Technology
Medical Gas: Preparing for the Worst
• Since the 2012 edition, NFPA 99 has greatly increased emphasis on healthcare facility emergency preparedness.
• Medical gases are an area which requires some thought and preparation for any interruptions of service.
• With preplanning, a variety of options and strategies exist which can make assuring resistance, continuity and substitution of medical gases during an emergency relatively easy – while assuring fast and uncomplicated restoration of normal operations after the event.
A side benefit
• By ensuring resistance to failure in a disaster, we also ensure systems are better at resisting ordinary problems.
• We can actually avert many of the small crisis that can otherwise be an irritating part of operating these systems.
Supply and continued demand
Medical gas suppliers may not
have medical gas availability when
emergency quantities are
required.
Critically ill patients must have a
continuous supply of medical gas
to survive.
1. The big two gases are
oxygen and vacuum.
2. With neonatal populations
medical air will be a close
second priority.
3. Trauma surgeries may
require nitrogen or
instrument air.
Design for resistance
Continuity during the worst times
Recovery and restoration to normal
Three specific medical gas considerations
Fundamental resistance1
Supply in depth2
Substitution3
Restoration4
Start here
Four fundamental concepts
Location Toughness Redundancy
Resistance
Are systems located where they will be least
impacted by the events of concern.
Will systems survive the event intact.
Systems should be “backed up” so that no
partial failure should cut off supply to the patients.
Oxidizers
Copper theft of live pipelines and vandalism
Valve security measures.
CCT surveillance.
Entry/exist gate security.
Nitrous oxide theft
Auto racing
Party buzz – promethazine + alcohol > “sizzurp” + N2O
Street resale value
Valve position switch warning
Reduces threat of valve tampering.
Point of valve closure is identified.
MAP indicators.
Bulk pad restricted entry and parking
Oxygen pad maintenance issues
Excessive icing on pipelines can cause cracks to occur.
Only indirect heating is allow to defrost evaporators – not hammers, broomsticks, water hoses, etc.
Oxygen safety should be taken seriously
Oxygen is a rapid oxidizer
Oxygen safety should be taken seriously
Oxygen is a rapid oxidizer
Longer lead times for supplies
Praxair nitrous oxide plant explosion in Florida
Rural and remote areas without regular transport availability
Accidents happen
Accidents happen
Emergency oxygen supply connection –the front line of oxygen defense
Do you test the connection periodically?
Are you sure it works?
What connections do you have should the need arise?
Emergency oxygen supply connection
Is the connection ready for use?
Is the connection easily accessible?
What areas of coverage are provided?
Simple oxygen back feed using dewars
Requires connection hoses and fittings.
Must be ordered from gas supplier since due to normal evaporation rate (NER) liquid will warm and activate PRV if dewar is stored for any length of time.
Emergency oxygen supply connection
Same requirement around the world.
Emergency connection test kit availability.
Tested annually.
Emergency oxygen supply connection
Functional test easy to perform.
Connection kit stored for up to 5 years before re-certification.
Self contained package – hard shell case.
Preparation
Oxygen pad construction
Horizontal vs. vertical vessels.
Adequate security fencing.
Medical Surgical Vacuum
Vacuum cannot be stored – produced at time of use.
Outage impacts hospital productivity, scheduling and revenue.
No really good solution for loss of vacuum.
Vacuum continuity
1. One of the most complex
continuity problems.
2. Portable suction units.
3. Compressed air or oxygen
venturi – only with good
advance preparation.
Medical Surgical Vacuum sizing
Smaller multiple units rather than giant 25 to 50 hp models.
Designs moving away from single point failure potential.
Bare pump availability on site – ready for install.
Keeping Vacuum pump oil clean
Dirty oil and excessive heat lead to vane failure.
Excessive heat + oxidizer + oil = fire
NFPA 99 limits oxidizer content in vacuum stream.
Medical Air
• Single dew point sensor for system
• Probe requires air flow over sensor.
Medical Air
• Potential for moisture entering pipeline.
• Sensors control dryer cycling.
Medical Air
• Training in FDA requirements for drug production – good manufacturing practices.
Visible water in medical air lines
Water in medical air lines can require complete shutdown of medical air system which impacts vents and anesthesia machines.
Visible moisture removed by compressor aftercoolers and receiver tank – not by dryers. Dryers only remove moisture vapor.
Failed auto-drains and deficient engineering rounds not checking moisture removal equipment.
Medical air redundancy
MA is not compressed – it is blendedHave extra cylinders on hand
Continuity
Highest risk patients
Keep ‘em
running
Prioritization
How long?
1. Assumes systems will resist and
survive initial event – now we
must keep them operating.
2. Timeframes – how long must
the facility be able to operate on
it’s own?
3. It may be necessary to reduce
usage by limiting gas to only the
most at risk patients.
4. Not all areas of the hospital
merit the same level of concern –
ICU, NICU
THE BIG ONE!
LOTS OF CYLINDERS!!
Large oxygen back feed using dewars and cylinders
Requires careful monitoring for correct pressure and flowrate to facility.
Should involve a qualified medical gas verification company with experience in large facility support.
Oxygen generation
O2 generation
93% O2 generation
MA Continuity aid – ventilator with on-board compressor and power supply
Puritan Bennett 840
Continuity aids include …
Riser diagram which locates key service valves and coverage areas.
Provides quick access to potential back feed locations.
Includes numbered tags to correctly identify valves.
Restoration
PreparationPreparation
Preparation
1. Poor preparation can delay
or even prevent restoration
of normal service.
2. Cut lines to make
connections may require a
shutdown/back feed to
restore service.
3. Dramatic actions will need
to be reversed.
How will we
restore normal service?
1
4
5
2 6
3
What might happen?
Is the necessary hardware within easy reach?
Are auxiliary connection points installed?
What continuity and substitution strategies
will be used?
How long will the systems be out of
normal?
Which systems could be affected?
In summary
4
2
1 3
Do an emergency drill
It can be an eye opener!
See if your preparations actually work
Actually simulate an emergency scenario.
Consider something radical!
CSHE MEMBER UPDATEA N D R I N I L A L O P U AA C C O U N T R E P R E S E N T A T I V E
• Social Event Feedback
• Membership Committee
• Events Committee
• Sponsorship Opportunities
• Educational Speaker Arrangements
M A G G I E C A S TA N E D A - S C O T T, H E MM A N A G E R , F A C I L I T I E S , S E C U R I T Y, S A F E T Y, E M
• New Member Highlight
• Membership Inquiries
• Topic Requests for Education
• Recent Surveys or Inspections
• Career Opportunities
UPCOMING
CSHE
EVENTS
UPCOMING
EDUCATIONAL
EVENTSEDUCATIONAL EVENT INFORMATION
Southern California Facilities Expo
May 1 & 2, Anaheim, CASCFE Website
IAHSS Annual Conference
May 19-22, Orlando, FLIAHSS.org
NFPA Annual Conference & Expo
June 17-20, San Antonio, TXNFPA.org
ASHE Annual Conference,
July 14-17, Baltimore, MDASHE.org/Annual
NFPA Classroom Training Week
July 15-19, San Francisco, CANFPA.org
JOIN US AT OUR NEXT MEETING
Date Location Sponsor Presentation
May CSHE Annual Institute – No OC CSHE Meeting
June 28th
Panel Discussion Topics: Vendor & Hospital Facility Relationships
The Future Hospital Facilities Mechanic
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