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Briefings on Hospital Safety, September 2015


September 1, 2015

FEMA helps hospitals keep the lights on

Manual offers guidelines, tools for maintaining reliable emergency electrical systems during emergencies


For most of us, a prolonged power outage is at worst a major nuisance. For hospitals, it's quite another story. Without power, a hospital can't provide the life support that many of its patients need.

By design, necessity, and regulatory oversight, hospital facilities are required to have generators and other emergency contingencies in place. Yet as the folks in the greater New York area will tell you after their experiences with Superstorm Sandy in 2012, that's easier said than done. Many facilities that had emergency generators in place as well as emergency fuel stores still lost their power due to flooded basements and supply vendors that couldn't get to the facilities to help keep them going.

"We designate [hospitals] as critical like police, fire, and emergency shelters because they need to operate always, and particularly during weather events, because that's when they're needed the most," said Robert Bachman, SE, director of Tobolski Watkins Engineering, Inc., a structural engineering firm in San Diego.

Bachman was one of several experts on a panel who spoke to a group of hospital engineers and facility managers about hospital resilience and emergency electrical power in early July at the annual conference of the American Society of Healthcare Engineers (ASHE) in Boston. In the session, Bachman and a panel of experts introduced and explained a new guideline document released by FEMA last year designed specifically to assist hospital engineers in developing contingency plans that help keep the power on when disaster strikes.

The 170-page book, Emergency Power Systems for Critical Facilities: A Best Practices Approach to Improving Reliability, is also known as FEMA P-1019 in the industry and was completed in September 2014 and last updated in February 2015. You can check out and download the entire publication by visiting www.fema.gov/media-library-data/1424214818421-60725708b37ee7c1dd72a8fc84a8e498/FEMAP-1019_Final_02-06-2015.pdf.

Coincidentally, the guidelines were published around the same time that the U.S. Department of Health and Human Services' Office of Inspector General released a report criticizing hospitals' response to Sandy. The report, taken from a survey of 174 Medicare-certified hospitals and 10 site visits to facilities in the tri-state area of New York, New Jersey, and Connecticut, found that facilities were largely unprepared for a major hurricane that flooded major metropolitan areas. ASHE panelists said that hospitals need to be ready for it to happen again.

"We must prepare for the climate changes we are already seeing across the country," said Chad Beebe, AIA, SASHE, CHFM, CFPS, CBO, deputy executive director of advocacy for ASHE. "Some of the healthcare impacts are already being felt across the U.S. Some expectations of the public way supersede the minimum requirements, and this means we need to go above and beyond the minimum code and increase public understanding of what to expect after a major event."

In other words, keep your power on and go above and beyond what the regulators tell you to do?note, too, that this isn't just about getting bigger generators to pump out more power.

"Your physical facility may have limitations," Bachman said. It makes no sense to put more power into a building that can't handle it."

The Joint Commission and CMS may say that you need to prove you can keep your facility running for 96 hours after a major disaster, but in reality, you need to be planning for a much longer time frame than that and have contingencies for your contingencies. In addition, as hospitals on the Gulf Coast experienced during the response to Hurricane Katrina in 2005, help from the government may not be quick to come.

"We're not 911, and we don't take over," said Michael Mahoney, a senior geophysicist with FEMA, about the agency's role in emergency planning and response. "We come in and help the states when they need it. Our job is to do what we can to make disasters less of a disaster."


Protect yourself

FEMA P-1019 appears to be written to prepare hospitals to face the same challenges that facilities in the New York area faced; it deals solely with electrical power requirements and how to keep them operational during natural disasters that are most likely to knock out utilities, such as a flood or an earthquake.

Specifically, the first couple chapters deal with explaining electrical requirements from a code perspective under the NFPA 70 standard, which has been adopted throughout the U.S.; they also explain the need for emergency power to be available within 10 seconds of an outage and independent of municipal power supply.

The rest of the book explains the different types of electrical distribution systems, hazards that can affect them, and how to conduct a risk assessment on a facility's electrical contingency system.

Lastly, the book delves into developing an emergency plan that involves working with local authorities to make sure all bases are covered?including making sure vendors can get to the facility.

"Superstorm Sandy was obviously a very large disaster for the U.S.," said Mahoney. "This is not a design document designed to tell contractors exactly what to do."

For an example of the checklists that FEMA offers in the new guidelines, check out the emergency operations checklist on p. 4.

One of the biggest issues that hospitals in the New York area dealt with during Sandy was closed roads, which prevented trucks from getting through to resupply hospital generators with fuel and oil. As a result, some hospitals have begun constructing seemingly excessive contingency plans, such as parking tanker trucks in their parking lots during weather disasters or signing agreements with fuel stations that allow them to take ownership of the station's reserves should there be an emergency need.

"You have to be sure you have reliable on-site fuel, because it can be aged and unusable," Mahoney said.

Bachman said hospitals need to work with police and other public resources to help ensure that vendors can get through to resupply during disasters. "Areas get cordoned off, and fuel trucks won't be able to refuel your generators if they can't get there."

And while many contingencies are focused around weather disasters that can prepared for ahead of time with some warning, emergency electrical planning should also take into consideration unpredictable occurrences in everyday operations. Take, for example, the hospital in Virginia that had its entire basement flooded when a behavioral health patient locked himself in a room and proceeded to tear out all the water pipes inside.

FEMA's P-1019 guidelines also cover new construction considerations and offer advice to facilities looking to build with emergency contingencies in mind. As always, it starts with knowing what hazards are likely to strike your area. As an example, Bachman showed pictures of a hospital in California that had its emergency generator located in the upper floors of the building, constructed in the 1970s before much more stringent seismic standards were developed. When the Northridge earthquake of 1994 struck, the upper floors of the hospital collapsed, literally spilling the generator out of the side of the building. Similarly, Bachman said, hospitals in flood-prone areas should take their specific geographic location into account when weighing design considerations.

"Layout is key. You need to be very careful where your generator is located," he noted, adding that many older hospitals, including several affected during Hurricane Sandy, have their emergency generators in the basement. "Local codes may call for generators in the basement, but that may not be a good idea in a flood zone."


The emergency drill as a teaching tool

Your exercise went as planned, and you gathered plenty of information. Here's what to do with it.


Editor's note: This story is part three of a series exploring how to plan, conduct, and measure results of an emergency exercise at your facility. In this installment, discover how to take information gathered, learn from your mistakes, and apply your knowledge to future emergency planning.


If you've already planned out and executed a successful emergency drill in your hospital, congratulations. Not only are you on point with what The Joint Commission and government regulators require of you, but you are taking some great steps toward gathering important information that can educate your staff and improve your facility's emergency preparedness.

If you've served as a hospital safety official for any length of time, you know about the requirement for two major exercises a year that test your hospital's readiness in the event of a major incident. One of those exercises must be a live-action drill that includes a surge of patients that overwhelms your resources enough to require bringing in outside help.

Because of this requirement, live-action drills are usually dramatic and include many different players. For many facilities, they can disrupt daily activities and cost a significant amount of money. Plus, such a drill can be intimidating the first time you do it.

"We know it takes time, it takes money, and it takes manpower to conduct these exercises, and we want to make sure we get the greatest return on investment from that," said Christopher Sonne, CHEC, assistant director of emergency management solutions for HSS, Inc., in Denver, a company that provides emergency management training, facilitation, and subject matter expertise for hospitals and healthcare providers throughout the United States.

Sonne and his colleague, Tracy Buchman, DHA, CHPA, CHSP, national director of emergency management for HSS, teamed up to coordinate an informative April 28 HCPro live program, "Emergency Planning: Conducting an Effective Preparedness Exercise."

More than 50% of the participants in the webinar indicated they had designed, conducted, and evaluated more than five emergency exercises. About 42% indicated that they do tabletop exercises where emergency responses are talked through, and another 42% perform internal disaster scenarios. If you're a large facility?especially an acute care hospital?you're required to do a large-scale mass casualty drill that tests your ability to handle a major crisis.

"This means you've been in your role for a long time or you're a big exercise junkie and have done a lot of exercises in a brief amount of time," Sonne said about the participant responses. "Either way, congrats to those doing the five-plus."

Those that conduct a combination of many small- and large-scale exercises will get the most out of the drills, mainly because they will get good at performing them and learn from the mistakes and weaknesses that will inevitably come to light while conducting a drill.

It's one thing to do what the regulators require of you, but it's another thing to use the information you gather to learn something from the experience and apply the data to your future emergency planning. Here are some takeaways for performing emergency drills better in the future:

  • Talk things out. This is the step in your exercise process that should be taken right after the drill ends. Experts recommend doing what is called a "hot wash." Get all the major players?including hospital staff and first responders?into a room, feed them sandwiches or pizza to help them wind down (and get their minds off how hungry and tired they are), and give them a chance to talk about what happened, including what went right and what went wrong. This is a crucial step, because it allows participants to get their thoughts out while the information is fresh in their heads. If the communication protocols between emergency crews in the field and the hospital emergency rooms broke down, for instance, this is where you'll hear it first. Ideally, the hot wash should take place immediately following the end of the drill, and it shouldn't last more than an hour. Your participants have already had a long day, and their enthusiasm will wear off quickly. But make sure you're taking plenty of notes: You'll use them to figure out what mistakes were made and how to learn from them.

"A lot of times we will do the hot wash discussion, but sometimes people don't want to be that person that brings something up in front of the group," said Buchman, adding that there should always be an opportunity for participants to give feedback later, either verbally or in written form. Develop a feedback form that can be turned in confidentially at any time. For an example of a participant feedback form from the Homeland Security Exercise and Evaluation Program, see pp. 7?9. Other forms and information can be found at www.fema.gov/media-library-data/20130726-1914-25045-8890/hseep_apr13_.pdf.

  • Write about the experience. The next thing to do is to take the information and data you've gathered and put it into some sort of written form. This way, not only do you have a formal documentation for the drill (the ever-important paper trail), but you also have a tool to work with to know where to go next.

"The after-action report is a document that summarizes key information that kind of ties back to our exercise objectives and the capabilities that we're looking to accomplish, and overall performance review," said Sonne.

Just like you would write an incident report after any major event, the after-action report should focus on documenting the exercise, and include any analysis and opinion about what went right or wrong with protocols and recommendations for improvement.

"Be sure that if we start to put the time and effort into writing our after-action report and improvement plan, we use them for what they truly are," Sonne said. "These are great tools to identify trends in our emergency management program, not just for exercises but for real-world events, too. If you start to pick up a lot of small issues withstanding with the command team, having folks know what their role and responsibility is, we can work to address these in training and exercises and planning before we have larger events that can truly impact the safety of our staff, our patients, our visitors, and our communities."

Another thing to remember, Buchman said, is that while there are no hard and fast rules as to what forms you should use during a drill, FEMA and other government agencies will be expecting forms from the Hospital Incident Command System filled out after an actual disaster?think about the paperwork generated after 9/11 and Hurricane Katrina. These are the forms that will be used when you will seek disaster reimbursement funds from the government. As such, you should probably know where to find them and how to fill them out.

"If you're not filling out the form in a real-world event, you're not going to get reimbursement; therefore, integrating them into your exercises is going to be key," she said. "If we have infrastructure failures such as a water break and we have some carpet that needs to come up or some drywall that needs to come out, there's a number of forms to document how much we're expending in resources, including staff and materials. Include them in exercise scenarios so that when the real thing comes, we know how to use those forms and we can get back the reimbursement that we have coming to us. They're not required, but remember, exercises are practice for game day."

  • Show off a bit. One of the biggest complaints heard from safety officials in hospitals is that it's hard to get buy-in from the top, mainly because security tends to take a back seat when it comes to other more pressing budgetary items. If your CEO believes in only doing the minimum required by regulators, it might be difficult to convince him or her that there is a need for more life-like (and expensive) drills without evidence backing you up. If you have documentation from a tabletop exercise showing that your communication system might need some strengthening or your decontamination team needs some practice, that might be enough to convince the CEO to spend some money on a real-life scenario.

Also, if you did a great drill and got good feedback (positive media coverage doesn't hurt), you'll get a pat on the back and probably obtain funding for the next drill you want to hold. Own the moment, both you and your team, and get to work on an improvement plan.

  • If you've been walking, run a little. Maybe this was your first time running a drill, or perhaps your facility did a successful tabletop exercise. Like any other exercise, you get better by challenging yourself. So next time, use your added confidence to slip in an extra element that challenges your facility?maybe by including a surprise in the next drill. Instead of allowing your emergency managers to simply talk through the motions of what their role would be in an emergency (boring!), what would happen if the power went out all of a sudden, cutting power to the emergency radios? You might simulate the ER being flooded during a hurricane, cutting off a major access point to the facility, or a sudden surge of patients after a major accident on the local highway. These wild card simulations not only add an element of fun to your drills, but they also test your staff's ability to think on their feet, develop their own confidence, and solve problems as they occur?which is exactly what will happen in a real-life event.
  • Next time, dress up for the occasion. Most safety experts say the best way to do an emergency exercise is to make it as life-like as possible, so the next step is to add some real-life scenarios, complete with collaboration with first responders and actors dressed up with moulage to simulate real wounds. This takes some expense, practice, and a good relationships with community resources, so do it a little at a time. And as always, design the drill around your weaknesses. If your staff noted a lack of experience running the decontamination procedures, for instance, maybe it's time to do an exercise with the fire department that simulates a mass casualty incident after a chemical spill to give them some practice and education.
  • Own up to your mistakes. Instead of hiding from mistakes, use them as the objective of your next drill. The whole point of doing a drill is to expose the weak point in your emergency response plans. The smart safety coordinator knows they are there and uses each drill's mistakes to build the next exercise. That's the point of the improvement plan, which is written as documentation that you know what your flaws are and what will be done to work on them.

"When you look at your after-action reports and your improvement plans, you shouldn't be having the same items come up time and time again because that means that we're not taking this seriously," said Sonne. "Just because you said that communications has been an issue for the past 15 years does not give you carte blanche to continue to put it down without addressing it. So we do need to make sure we take the time [and] close the loop with our improvement plan, which is going to be a part of that after-action report."

In other words, if you know communication is a problem, do something about it. Run a drill that tests your radios, ability to communicate with staff and outside resources, and getting information to the public. The more you practice, the better you'll become.


The top survey violations of 2014

Straight from the surveyors themselves, The Joint Commission explains the top-cited standards


It sounds somewhat like a broken record. No matter how many times the experts tell us how to avoid getting hammered by The Joint Commission during a hospital survey, the same problems always seem to make the list of top violations.

Published in the April issue of The Joint Commission Perspectives, the 2014 list includes the top 10 standards for which hospitals received Requirements for Improvement citations during the 2014 calendar year. Compiled from 1,278 surveys, the 2014 list was dominated by violations of Environment of Care (EC) and Life Safety (LS) standards. But some safety experts say that's more or less to be expected.

"Since 2007, there has been a steady increase in findings in the physical environment, because that has been the single greatest focus of the survey process," says Steve MacArthur, consultant for The Greeley Company, Inc., in Danvers, Massachusetts, and a former hospital safety officer in nearby Brockton. "By the time 2009?2010 rolled around, it wasn't just the life safety surveyors that were looking at conditions in the physical environment, it was pretty much the entire survey team?physician, nurse, administrative, ambulatory, behavioral health, etc. So, when you have more eyes on a specific set of standards, it is only natural that there would be more findings."

Topping the list of the top-cited standards is EC.02.06.01 (maintenance of a safe environment) with 56% of hospitals cited, followed by EC.02.05.01 (management of utility system risks), with 53%, and IC.02.02.01 (reduction of infection risk from equipment, devices, and supplies), with 52%. The rest of the list is as follows:

  • LS.02.01.20 (maintenance of egress integrity), 50%
  • RC.01.01.01 (maintenance of accurate, complete medical records for all patients), 49%
  • EC.02.03.05 (maintenance of fire safety equipment and building features), 48%
  • LS.02.01.10 (minimization of fire, smoke, and heat damage via building and fire protection features), 46%
  • LS.02.01.30 (building features provided and maintained to protect from fire and smoke hazards), 43%
  • LS.02.01.35 (fire extinguishment features provided and maintained), 43%
  • EC.02.02.01 (management of hazardous materials and waste risks), 36%


The secrets to success

Joint Commission officials gave rare insight into the standards and offered some tips about how hospitals can avoid some of the top citations during an informative session of the annual conference of the American Society of Hospital Engineers (ASHE) in Boston in early July.

"We are very non-prescriptive," said George Mills, MBA, FASHE, CEM, CHFM, director of the Department of Engineering for The Joint Commission. "We on purpose make these standards flexible to fit your situation."

Mills was one of three panelists who spoke during sessions addressing some of the top Joint Commission findings; the others were Susan McLaughlin, MBA, FASHE, CHFM, CHSP, managing director of MSL Healthcare Consulting, Inc., in Barrington, Illinois, and a former associate director of standards interpretation at The Joint Commission, and Dale Woodin, CHFM, FASHE, senior executive director of ASHE.

Here are some of their recommendations for avoiding some of the top citations:

  • Be seen. A Joint Commission survey can be a very stressful time for hospital officials, and Mills?who emphasized that his primary concern is patient safety and care?explained that the best thing that hospital safety officials and facility managers can do to avoid some of the most common violations is to get out of their offices and walk around.

"There is unfortunately no such thing as a perfect healthcare environment, just like there is no perfect building," he said. "The key is to identify risks proactively, look for deficiencies, and take steps to fix it."

Don't ever think you won't find anything. Your facility is not perfect.

"What is frequently cited are what I can only describe as 'imperfections' and fairly minor ones at that," says MacArthur. "Buildings are never more perfect than in the moment before they are officially occupied. There will always be penetrations in walls, doors that do not close and latch, stuff in exit corridors, missed log entries, obstructed access to emergency equipment, and on and on."

  • Grow more eyes. The most seasoned hospital safety coordinators say the key to their success is recognizing that they can't do the job alone; now you've heard it from the surveyors themselves.

"Do you have a system in place where anyone can report a safety risk so you can get multiple sets of eyes out there?" said McLaughlin. "What do they see walking around your facility? You want to know so you can analyze and correct them."

  • Exercise some common sense. Some of the most common citations are for violations related to fire doors and smoke barriers, ducts, and blocked egress points. These are things that should be easily avoided with a quick tour through the facility. Is there a cart blocking an exit door? Move it. Does a physician have a fish tank in his office with an air tube running into the ceiling tiles to tie into the hospital's air system? It's happened before?and it's a major hazard, as it creates another hole through which smoke can penetrate.

"You're looking for things that are broken, and staff complaints identify environmental deficiencies and unsafe practices," Mills said.

  • Collect data. And do something with it. You shouldn't wait until a surveyor finds something wrong to start fixing it. The well-prepared facilities know what their biggest problems are?and they make a plan to fix them. If the surveyors see you being proactive, they are more likely to give you a break, in the form of a categorical waiver. Do a risk assessment every year?ideally, every department should do its own?and use it to make a plan to fix the problems, whether it be the fire doors that won't close right, the copiers in front of the oxygen shutoff valves at the nurses' station, or the fish tank in the physician's office.

"Risks don't pop up once a year," said McLaughlin. "They pop up much more frequently, and you need to decide how to manage them."

  • Document and have a paper trail. You may say that you have a plan in place to fix whatever problems your facility has, but that means nothing if the surveyors can't read it. Write it down, and make sure there is a clear paper trail.

"We expect to be able to trace that through things like meeting minutes until there is a conclusion," said McLaughlin. "We have to be able to follow that thread. Once there is an issue identified, it can't just fall off the table."

For your reference, take good notes at all meetings and training sessions; have a written record of all hazard assessments and inspections, and any plans of action that are taken. Better yet, make sure everyone else is doing this as well and keeping the results in binders. If you can't lead the surveyor to the records, you will have problems.

"It's a great opportunity for the 'deer in the headlights look,' I can tell you that," said McLaughlin.

  • Make schedules for tests. Mills said that about 21% of facilities get cited for seemingly simple things, such as missed generator tests. These tests, he said, should be scheduled, commonplace events. "I have no answer for this," he said. "I know we miss anniversaries and things, but a monthly frequency test? How do you just flat out miss it?"


Book excerpt: Creating a surveillance team

Editor's note: In this excerpt from the new HCPro book, The Hospital Safety Professional's Handbook, Fifth Edition, author Cindy Taylor, ARM, CSPHP, director of environmental health and safety for University of North Carolina Hospitals, Chapel Hill, discusses the importance of sharing the responsibility of security rounds and shares some new information covered in the updated edition of the book. Visit http://hcmarketplace.com for more information.

It is a good idea to conduct surveillance rounds as an interdisciplinary process by including representatives from the different departments that provide and support patient care. It is also important to involve the department managers in the planning and scheduling of visits to their departments or units and encourage their active participation in the visit. Also, it is important to involve them when it comes time to evaluate findings and report results. You don't want the manager to be caught by surprise in front of leadership when asked about a certain condition on their unit. Collaboration goes a long way in these types of situations.


The surveillance team

The surveillance team needs to be large enough to include an effective cross-section of support departments. Yet if the team is too large, it could impair the effectiveness and efficiency of the surveillance rounds. Surveillance teams are typically a subcommit


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