Safety

Secret Club for Members Only: Some FAQing for your reading pleasure

Hospital Safety Insider, June 6, 2019

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This week finds us (once again) visiting with our friends from Chicago as they stand astride the accreditation world like some ancient colossus. (I am hopeful that my purple prose will subside at this point, but sometimes the fingers take me in odd directions.)

First up, we have some additional guidance relative to how one might go about managing compressed gas cylinders, particularly those pesky oxygen cylinders that can cause so much grief during survey. So now we have a Joint Commission performance element that establishes the expectation that each organization will have a policy regarding the storage of oxygen and other compressed gas cylinders, said policy is to include the amount of gas at which segregation of full and empty cylinders would take place. You may recall that the initial “take” required full cylinders to be segregated from empty and partially full cylinders, but that “interpretation” of NFPA 99 has shifted a bit to allow for the storage of partially full cylinders in the company of full cylinders.

And now, we have a new FAQ that provides some guidance relative to how one might go about determining the amounts representative of full/partial/empty, depending on whether the cylinder(s) you are using have an integral pressure gauge. The FAQ also introduces the concept of “depleted volume content,” which ( as near as I can tell), is the amount of gas left in the cylinder that requires storage with the empty (as opposed to the full) cylinders. There is also a (maybe) handy table that walks you through the various segregatory considerations—I’ll let you parse those in your spare time.

My takeaway is that you need to make sure that if your current policy (if you don’t have one, it is a standards-based requirement, so best get on it) doesn’t pretty closely mirror how things shake out in this FAQ, you should consider modification of current policy/practice or be prepared to discuss how what you’re doing to be in compliance with the NFPA 99-2012 requirements. The other “thing” I noticed is the discussion of the labeling of empty cylinders as a function of the segregation process—if you have the empties in a separate rack that is labeled as such, then you should be fine. But if you have a single rack with full and empty cylinders cohabitating, then the empty cylinders have to be labeled; unfortunately, this does not appear to allow for the marking of the rack itself (I’ve seen red tape and red paint to identify the empty “slots”), so if that’s your practice you might get some pushback from a literalist surveyor looking for the empty cylinders to be labeled.

Next up, we have some information relative to the management of behavioral health patients, in this case, discussions of the various methodologies for determining the risks of each patient to be managed. I do believe that the regulatory focus on environmental considerations will start to diminish somewhat as we kick into the “next” survey cycle,  but I believe that the focus on the management of at-risk patient populations will continue as a function of: now that we have a “safer” environment, how are we making sure that the patients are being appropriately cared for, which is driven by the assessment process. Assessment stuff can be found here.

As an additional piece of the puzzle (I guess time will tell whether it is more piece than puzzle or the reverse…), TJC has established an information portal to assist organizations in compliance with the July 1, 2019 changes to the National Patient Safety Goal on Suicide Prevention, including links to the issues of Perspectives in which the initial (and ongoing) guidance, etc. can be found. As a one-stop-shop, it looks like a pretty useful thing to have in your back pocket. As I’ve noted any number of times (and I think once or twice in this forum), a lot of the TJC surveyor knowledge comes to them the same way it comes to you, so I think it a positively splendid idea to take a gander at the links contained herein.



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