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